Urology — MCQs

Urology Indian Medical PG Practice Questions and MCQs

Question 531: What is the most common cause of calcium oxalate stones?

A. Hyperparathyroidism
B. Idiopathic hypercalciuria (Correct Answer)
C. High intake of dietary oxalate
D. Renal tubular acidosis type 1

Explanation: **Explanation:** Calcium oxalate is the most common constituent of renal calculi (approx. 75–80%). Among the various metabolic abnormalities associated with its formation, **Idiopathic Hypercalciuria** is the most common identifiable cause. It is defined as hypercalciuria (urinary calcium >4 mg/kg/day) in the absence of hypercalcemia. It is primarily categorized into three types: absorptive (increased intestinal absorption), renal (impaired tubular reabsorption), and resorptive. **Analysis of Options:** * **Idiopathic Hypercalciuria (Correct):** It is found in nearly 50% of patients with calcium oxalate stones. The normocalcemic state distinguishes it from secondary causes like hyperparathyroidism. * **Hyperparathyroidism:** While a classic cause of calcium stones due to resorptive hypercalciuria, it accounts for only about 5% of cases. It is characterized by hypercalcemia and elevated PTH. * **High intake of dietary oxalate:** While dietary oxalate contributes to stone formation, most urinary oxalate is endogenous (metabolic). Enteric hyperoxaluria (e.g., in Crohn’s disease or malabsorption) is a more significant risk factor than simple dietary intake. * **Renal Tubular Acidosis (RTA) Type 1:** Distal RTA causes hypocitraturia and alkaline urine, leading primarily to **Calcium Phosphate** stones rather than pure calcium oxalate. **High-Yield Clinical Pearls for NEET-PG:** * **Most common stone overall:** Calcium oxalate (specifically Calcium oxalate monohydrate/Whewellite). * **Most common metabolic abnormality:** Idiopathic hypercalciuria. * **Dietary Advice:** Patients should **not** restrict dietary calcium; a low-calcium diet actually increases oxalate absorption and stone risk. Instead, restrict sodium and animal protein. * **Drug of choice:** Thiazide diuretics (e.g., Chlorthalidone) are used to reduce urinary calcium excretion in recurrent cases.

Question 532: Which of the following is not a component of the classic triad associated with renal cell carcinoma?

A. Mass
B. Pain
C. Hematuria
D. Pyrexia (Correct Answer)

Explanation: **Explanation:** The classic clinical triad of **Renal Cell Carcinoma (RCC)**, also known as Guyon’s triad, consists of **Hematuria, Flank Pain, and a Palpable Abdominal Mass**. **Pyrexia (Option D)** is the correct answer because, while it is a common systemic symptom of RCC (occurring in about 20% of cases as a paraneoplastic phenomenon due to IL-6 production), it is **not** part of the "classic triad." **Analysis of Options:** * **Hematuria (Option C):** The most common presenting symptom (approx. 40-50%). It is typically gross, painless, and intermittent. * **Pain (Option B):** Usually described as a dull ache in the flank region, caused by the stretching of the renal capsule. * **Mass (Option A):** A palpable, firm, non-tender mass in the loin. **Clinical Pearls for NEET-PG:** 1. **The "Too Late" Triad:** The classic triad is now seen in only **10% of patients** and usually indicates advanced or metastatic disease. Most RCCs today are detected incidentally via imaging ("incidentalomas"). 2. **Paraneoplastic Syndromes:** RCC is known as the **"Internist's Tumor"** because it produces various hormones. Common findings include erythrocytosis (EPO), hypercalcemia (PTHrP), and hypertension (Renin). 3. **Stauffer’s Syndrome:** Reversible hepatic dysfunction (elevated LFTs) in the absence of liver metastases. 4. **Left-sided Varicocele:** May occur if the tumor obstructs the left gonadal vein entry into the left renal vein.

Question 533: What is the most common cause of acute retention of urine in a 2-year-old child?

A. Posterior urethral valve
B. Duplication of renal pelvis
C. Meatal ulceration with scabbing (Correct Answer)
D. Urethral stones

Explanation: **Explanation:** Acute retention of urine (ARU) in pediatric patients has a different etiology compared to adults. In a **2-year-old child**, the most common cause is **Meatal ulceration with scabbing**. 1. **Why Meatal Ulceration is Correct:** This condition typically occurs in circumcised male toddlers. Friction against diapers leads to ulceration at the external urethral meatus. When the ulcer heals, it forms a dry scab or crust. This scab mechanically obstructs the narrow meatus, and the intense pain/stinging during micturition leads to voluntary withholding of urine, resulting in acute retention. 2. **Analysis of Incorrect Options:** * **Posterior Urethral Valve (PUV):** While PUV is the most common *congenital* cause of lower urinary tract obstruction in male infants, it usually presents in the **neonatal period** or early infancy with a poor stream or overflow incontinence, rather than sudden acute retention at age 2. * **Duplication of Renal Pelvis:** This is often an asymptomatic anatomical variant. While it may predispose to VUR or UTIs, it does not cause acute urinary retention. * **Urethral Stones:** These can cause ARU, but they are significantly less common than inflammatory/traumatic causes like meatal ulcers in this specific age group. **Clinical Pearls for NEET-PG:** * **Most common cause of ARU in elderly males:** Benign Prostatic Hyperplasia (BPH). * **Most common cause of ARU in young adult males:** Urethral stricture or Urethral trauma. * **PUV Diagnosis:** The gold standard investigation is **Voiding Cystourethrogram (VCUG)**, which shows a dilated posterior urethra ("spinning top" appearance). * **Management of Meatal Ulcer:** Usually involves warm sitz baths (to soften the scab) and application of local antibiotic/analgesic ointments.

Question 534: Which of the following investigations is NOT used for the diagnosis of renal stones?

A. Intravenous pyelogram (IVP)
B. Magnetic resonance imaging (MRI)
C. Positron emission tomography-CT scan (PET-CT) (Correct Answer)
D. Ultrasound (USG)

Explanation: **Explanation:** The diagnosis of renal stones relies on imaging techniques that can visualize calcified structures or the resulting anatomical obstruction. **Why PET-CT is the correct answer:** **Positron Emission Tomography (PET-CT)** is a functional imaging modality used primarily in oncology to detect metabolic activity (glucose uptake via FDG). It is **not** used for diagnosing renal stones because stones are metabolically inert and do not take up radiopharmaceuticals. While the CT component of a PET-CT could technically see a stone, the procedure is prohibitively expensive, involves high radiation, and offers no diagnostic advantage over standard imaging for urolithiasis. **Why the other options are incorrect:** * **Intravenous Pyelogram (IVP):** Historically the gold standard, it uses contrast to visualize the collecting system and identify filling defects or obstructions caused by stones. * **Ultrasound (USG):** The preferred initial screening tool, especially in children and pregnant women. It is excellent for detecting radiolucent stones and secondary signs like hydronephrosis. * **Magnetic Resonance Imaging (MRI):** While not the first line, MRI (specifically MR Urography) can be used to detect stones as signal voids or to visualize hydronephrosis in cases where radiation must be avoided. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Non-Contrast Computed Tomography (**NCCT**) of the abdomen and pelvis (KUB) is currently the investigation of choice for acute flank pain/suspected urolithiasis. * **Most Radiopaque Stone:** Calcium oxalate/phosphate. * **Most Radiolucent Stone:** Uric acid stones (visible on NCCT but invisible on plain X-ray). * **Indinavir Stones:** These are the only stones that may be "lucent" even on a CT scan.

Question 535: The Bascom technique is employed in the surgical management of which condition?

A. Rectal prolapse
B. Anal incontinence
C. Pilonidal sinus (Correct Answer)
D. Fistula-in-ano

Explanation: **Explanation:** The **Bascom technique** is a specialized surgical approach used for the management of **Pilonidal Sinus Disease (PNS)**. It is based on the principle that pilonidal disease is not a congenital cyst but an acquired condition caused by hair follicles being sucked into the midline pits due to negative pressure created by the movement of the buttocks. The technique involves two main components: 1. **Bascom I (Pit Picking):** Simple excision of the midline pits with lateral drainage of the secondary tracks. 2. **Bascom II (Cleft Lift Procedure):** A more definitive procedure for recurrent or complex cases where the deep natal cleft is flattened by mobilizing a skin flap. This reduces the friction and anaerobic environment that promotes sinus formation. **Analysis of Incorrect Options:** * **A. Rectal Prolapse:** Managed by procedures like Wells rectopexy, Frykman-Goldberg procedure, or Delorme’s procedure. * **B. Anal Incontinence:** Treated via sphincteroplasty, sacral nerve stimulation, or the Gracialis muscle wrap (Pickrell’s procedure). * **C. Fistula-in-ano:** Managed by techniques such as LIFT (Ligation of Intersphincteric Fistula Tract), VAAFT, or Seton placement. **High-Yield Clinical Pearls for NEET-PG:** * **Karydakis Flap:** Another common lateral advancement flap for pilonidal sinus to move the scar away from the midline. * **Z-plasty and Limberg Flap:** Other transposition flaps used to flatten the natal cleft in PNS. * **Lord’s Procedure:** While Lord’s is used for hemorrhoids (dilatation), it is also a historical term for a specific "tuft excision" in pilonidal disease; however, **Bascom** is the more frequently tested eponym for modern PNS surgery.

Question 536: Torsion of the testes may be due to which of the following?

A. Trauma to testes
B. Full coverage of the testis with tunica vaginalis
C. Long mesorchium
D. All of the above (Correct Answer)

Explanation: **Explanation:** Testicular torsion is a surgical emergency caused by the twisting of the spermatic cord, leading to venous congestion and eventual arterial occlusion. The primary underlying mechanism is **abnormal mobility** of the testis within the scrotum. 1. **Full coverage of the testis with tunica vaginalis (Option B):** This is the most common predisposing factor, known as the **"Bell-clapper deformity."** Normally, the tunica vaginalis attaches to the posterior aspect of the testis. In this deformity, the tunica covers the testis, epididymis, and cord completely, allowing the testis to hang freely and rotate like a clapper inside a bell. 2. **Long mesorchium (Option C):** The mesorchium is the fold of visceral tunica vaginalis connecting the testis to the epididymis. A pathologically long mesorchium increases the space between these structures, facilitating axial rotation. 3. **Trauma to testes (Option D):** While anatomical defects are the "predisposing" factors, trauma or sudden physical activity (including the cremasteric reflex during sleep) acts as the **"precipitating" factor** that initiates the actual twist. Since all three factors contribute to the etiology—either as anatomical predispositions or clinical triggers—**Option D (All of the above)** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Golden Period:** Salvage rate is nearly 100% if detorsion occurs within **6 hours**; it drops to <20% after 12 hours. * **Prehn’s Sign:** Negative in torsion (pain is not relieved by elevating the scrotum), helping differentiate it from epididymo-orchitis. * **Angel’s Sign:** The affected testis lies higher and in a horizontal lie. * **Management:** Immediate surgical exploration. Since the anatomical defect is usually bilateral, **bilateral orchidopexy** (fixation) must be performed to prevent recurrence on the contralateral side.

Question 537: Which of the following is NOT true about varicocele?

A. It is common on the right side. (Correct Answer)
B. It can present as a late sign of renal cell carcinoma.
C. It has a 'bag of worms' like feeling.
D. It can lead to infertility.

Explanation: ### Explanation **1. Why Option A is the Correct Answer (The False Statement):** Varicocele is significantly more common on the **left side** (approximately 90% of cases). This is due to the unique anatomy of the left testicular vein: * **Length:** The left testicular vein is longer than the right. * **Angle of Insertion:** It enters the left renal vein at a **90-degree (perpendicular) angle**, which increases hydrostatic pressure. * **Nutcracker Phenomenon:** The left renal vein can be compressed between the Superior Mesenteric Artery and the Aorta, leading to venous backflow. In contrast, the right testicular vein drains directly into the Inferior Vena Cava (IVC) at an oblique angle, making right-sided varicoceles rare. **2. Analysis of Incorrect Options (True Statements):** * **Option B:** A sudden-onset or right-sided varicocele in an older patient can be a clinical sign of **Renal Cell Carcinoma (RCC)**. This occurs if a tumor thrombus obstructs the renal vein or the IVC, blocking venous drainage from the testis. * **Option C:** On palpation, the dilated pampiniform plexus of veins feels like a **"bag of worms."** This sensation typically disappears or diminishes when the patient lies down. * **Option D:** Varicocele is the most common reversible cause of **male infertility**. It leads to increased scrotal temperature and oxidative stress, which results in decreased sperm count and motility (oligoasthenozoospermia). **3. High-Yield Clinical Pearls for NEET-PG:** * **Grading:** Grade I (palpable only with Valsalva), Grade II (palpable standing), Grade III (visible through scrotal skin). * **Surgery Indication:** Indicated if there is testicular atrophy, abnormal semen analysis, or severe pain. * **Gold Standard Investigation:** Color Doppler Ultrasound. * **Surgical Approach:** Sub-inguinal (Marmar) microsurgical varicocelectomy has the lowest recurrence and complication rates.

Question 538: A 28-year-old white male presents with asymptomatic testicular enlargement. Which of the following statement(s) is/are true concerning his diagnosis and management?

A. Tumour markers, beta-fetoprotein (AFP) and human chorionic gonadotropin (HCG) will both be of value in the patient regardless of his ultimate tissue type
B. The diagnosis of seminoma should be followed by postoperative radiation therapy (Correct Answer)
C. Orchiectomy should be performed via a scrotal approach
D. With current adjuvant chemotherapy regimens, retroperitoneal lymphadenectomy is no longer indicated for non-seminomatous testicular tumours

Explanation: ### Explanation **1. Why Option B is Correct:** Seminomas are highly **radiosensitive**. In Stage I seminoma (confined to the testis), the standard of care historically involves radical orchidectomy followed by low-dose adjuvant radiotherapy to the para-aortic lymph nodes to prevent occult micrometastatic spread. While surveillance and single-agent Carboplatin are modern alternatives, the statement remains a fundamental oncological principle for seminoma management. **2. Why the Other Options are Incorrect:** * **Option A:** AFP is **never** elevated in pure seminomas. If AFP is elevated, the tumor must be treated as a non-seminomatous germ cell tumor (NSGCT), regardless of the histology. HCG is elevated in only 10-15% of seminomas. * **Option C:** A **Radical Inguinal Orchidectomy** is the gold standard. A scrotal approach is strictly contraindicated as it disrupts the lymphatic drainage of the testis (which goes to para-aortic nodes), potentially leading to tumor seeding in the inguinal lymph nodes. * **Option D:** Retroperitoneal Lymph Node Dissection (RPLND) remains a critical tool. It is indicated for staging in Stage I NSGCT (if surveillance is not chosen) and as a therapeutic measure for residual masses >1 cm following chemotherapy in NSGCT. **Clinical Pearls for NEET-PG:** * **Most common presentation:** Painless testicular swelling in a young male. * **Lymphatic Spread:** Testis drains to **Para-aortic nodes** (except if scrotal skin is involved, then Inguinal nodes). * **Tumor Markers:** * **AFP:** Elevated in Yolk sac tumors; *Never* in Seminoma. * **HCG:** Elevated in Choriocarcinoma and some Seminomas. * **LDH:** Correlates with overall tumor burden. * **Investigation of Choice:** Scrotal Ultrasound (initial) followed by Contrast-Enhanced CT (staging).

Question 539: What causes ureteric colic due to a stone?

A. Stretching of the renal capsule due to back pressure
B. Increased peristalsis of the ureter to overcome the obstruction (Correct Answer)
C. Irritation of the intramural ureter
D. Extravasation of urine

Explanation: **Explanation:** The pain of ureteric colic is primarily a result of **increased peristaltic activity** of the ureteral smooth muscle. When a stone obstructs the lumen, the ureter attempts to propel the stone forward by generating hyperperistaltic waves. This intense, spasmodic contraction against a fixed obstruction leads to an increase in intraluminal pressure and ischemia of the muscular wall, which triggers the characteristic "colicky" pain (waxing and waning in intensity). **Analysis of Options:** * **Option A (Incorrect):** Stretching of the renal capsule causes **Renal Pain (Dull ache)**, not ureteric colic. This occurs due to hydronephrosis and increased pressure within the collecting system, typically felt at the T10-L1 distribution (loin pain). * **Option C (Incorrect):** Irritation of the intramural ureter (the portion within the bladder wall) specifically causes **vesical irritability**, leading to symptoms like frequency, urgency, and pain radiating to the tip of the penis or labia majora. * **Option D (Incorrect):** Extravasation of urine (urinoma) is a complication of severe obstruction or trauma; it causes localized inflammation or peritonitis rather than the rhythmic pain of colic. **NEET-PG High-Yield Pearls:** * **Pain Distribution:** Ureteric colic typically radiates from **"Loin to Groin"** (following the genitofemoral and ilioinguinal nerves). * **Nerve Roots:** The ureter is supplied by T11-L2 segments. * **Narrowest Point:** The **vesicoureteric junction (VUJ)** is the most common site for a stone to lodge. * **Management:** The first-line medical management for acute colic is **NSAIDs** (e.g., Diclofenac), as they reduce ureteral edema and prostaglandin-mediated contractions more effectively than opioids.

Question 540: Which of the following surgeries is indicated for the removal of a 3cm ameloblastoma involving the inferior border of the mandible?

A. Enucleation
B. Fulgration
C. Cryosurgery
D. Resection (Correct Answer)

Explanation: **Explanation:** **Ameloblastoma** is a benign but locally aggressive odontogenic tumor with a high rate of recurrence. The management of this tumor is a high-yield topic for NEET-PG, focusing on the distinction between conservative and radical treatments. **Why Resection is Correct:** For a large (3cm) lesion involving the **inferior border of the mandible**, radical surgery in the form of **Segmental or Marginal Resection** is the treatment of choice. Because ameloblastoma tends to infiltrate the surrounding trabecular bone beyond its apparent radiological margins, a "safety margin" of 1–1.5 cm of healthy bone is required. Since the inferior border is involved, a segmental resection is often necessary to ensure complete removal and prevent recurrence, which can be as high as 50–90% with conservative methods. **Why Other Options are Incorrect:** * **Enucleation:** This involves "shelling out" the tumor. It is only considered for very small, unicystic variants. For a 3cm multicystic lesion, it carries an unacceptably high recurrence rate. * **Fulguration & Cryosurgery:** These are adjunctive treatments sometimes used after enucleation to kill residual cells. However, they are not primary treatments for a 3cm lesion involving the mandibular border, as they cannot guarantee the removal of deep infiltrative components. **Clinical Pearls for NEET-PG:** * **Most common site:** Posterior mandible (molar-ramus area). * **Radiological appearance:** "Soap bubble" or "Honeycombed" multilocular appearance. * **Histopathology:** "Vickers-Gorlin" criteria (palisading basal cells with reverse polarity). * **Gold Standard:** Wide local excision/Resection with 1–1.5 cm margins.

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Renal Cell Carcinoma

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Testicular Tumors

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