Urology Practice Questions

Q: A 65-year-old patient presents with sudden pain in the scrotum associated with prostration, pallor and pyrexia. What could be the most probable diagnosis?

Fournier's gangrene. **Fournier's gangrene** - **Fournier's gangrene** is a rapidly progressive, necrotizing fasciitis of the perineum and genital region, often presenting with sudden severe pain, prostration, pallor, and **fever (pyrexia)** in elderly patients. - The image likely shows extensive tissue necrosis and inflammation consistent with **Fournier's gangrene**, as the described symptoms and the patient's age (often associated with comorbidities like diabetes) increase suspicion for this life-threatening condition. *Torsion testis* - Testicular torsion typically presents with **acute, severe scrotal pain** and is more common in adolescents and young adults. - While it causes acute pain and possibly pallor from severe pain, it is less likely to cause widespread systemic symptoms like **pyrexia and prostration** in an elderly patient and does not involve the diffuse skin and subcutaneous tissue necrosis seen in the image. *Spermatocele* - A spermatocele is a **benign cyst** in the epididymis that usually presents as a painless mass. - It does not cause sudden pain, prostration, pallor, or pyrexia, nor does it involve tissue destruction. *Varicocele* - A varicocele is an **enlargement of veins within the scrotum** (pampiniform plexus), often described as feeling like a "bag of worms." - It typically causes a **dull ache** or heaviness, but not sudden severe pain, prostration, pallor, or pyrexia, and is not associated with the necrotic appearance.

Q: All are true about the conditions shown in the figure except?

Painless intermittent hematuria. ***Painless intermittent hematuria*** - While hematuria **can occur** with vesical calculus, the **classic teaching** emphasizes that **painless hematuria should raise suspicion for bladder malignancy** rather than benign calculus. - In bladder stones, hematuria is typically **associated with other symptoms** such as dysuria, frequency, suprapubic pain, and urgency, making it part of a **symptomatic complex** rather than an isolated painless finding. - The **key distinguishing feature** is that isolated, painless intermittent hematuria without other urinary symptoms is **more characteristic of bladder cancer** than vesical calculus. - Therefore, while hematuria occurs with bladder stones, **"painless intermittent hematuria" as an isolated finding** is NOT the typical presentation pattern. *Vesical calculus* - The image shows a large **radio-opaque shadow** in the bladder region, consistent with a **vesical calculus** (bladder stone). - Bladder stones result from urinary stasis, infection, bladder outlet obstruction (BPH), or foreign bodies. - Symptoms include dysuria, frequency, urgency, suprapubic pain, and hematuria. *Holmium laser* - **Holmium:YAG laser lithotripsy** is an effective endoscopic treatment for bladder stones. - The laser fragments stones into small pieces that can be irrigated out or extracted. - It has advantages of being minimally invasive with excellent stone-free rates. *Litholapaxy* - **Litholapaxy** is the standard endoscopic procedure for bladder stone removal. - Involves mechanical fragmentation using a **lithotrite** followed by evacuation of fragments. - Performed through a cystoscope under vision, making it safe and effective for most bladder stones.

Q: The following instrument is used for:

Bladder wash when urinary catheter gets blocked. ***Bladder wash when urinary catheter gets blocked*** - The image shows a **rubber bulb syringe**, also known as an **irrigation syringe** or **bulb syringe**. This instrument is commonly used to create suction or to instill fluid, making it ideal for procedures like bladder irrigation. - In cases where a **urinary catheter becomes blocked** by mucus plugs, clots, or debris, a bladder wash (irrigation) with sterile saline can help clear the obstruction and restore drainage. This syringe would enable a nurse or physician to manually flush the catheter. *Dilate urethral stricture* - **Urethral stricture dilation** requires specialized instruments such as **urethral dilators** or **balloon catheters**, which are designed to gradually widen the narrowed part of the urethra. - The flexible, bulb-type syringe shown is not rigid enough nor designed with the specific shape or size increments required for urethral dilation. *Relieve bladder outlet obstruction temporarily* - Temporary relief of **bladder outlet obstruction** (BOO) typically involves inserting a **urinary catheter** (e.g., Foley catheter) to drain urine directly from the bladder. - While a syringe can connect to a catheter for drainage, the syringe itself is not the primary instrument for relieving the obstruction; the catheter is. This syringe is for irrigation purposes, not direct catheterization to relieve obstruction. *Perform uroflowmetry* - **Uroflowmetry** is a diagnostic test that measures the **rate of urine flow** during voiding. It requires a specialized device called a **uroflowmeter**, which is typically a funnel or toilet-like apparatus connected to a sensor that measures flow rate and volume. - The pictured syringe plays no role in measuring the natural flow of urine during micturition.

Q: What is the most likely diagnosis based on the clinical image?

Hydrocele. **Hydrocele** - The image shows a **swollen scrotum** that is likely **non-tender** and **transilluminable**, characteristic findings of a hydrocele, which is a collection of fluid around the testis. - The swelling appears smooth and confined to the scrotum, consistent with fluid accumulation within the **tunica vaginalis**. *Direct inguinal hernia* - A direct inguinal hernia typically presents as a bulge in the **inguinal region** that protrudes directly through the posterior wall of the inguinal canal (Hesselbach's triangle). - It usually **does not extend into the scrotum** or cause such a generalized scrotal enlargement as seen here. *Indirect inguinal hernia* - An indirect inguinal hernia protrudes through the **deep inguinal ring** and often descends into the scrotum, alongside the spermatic cord. - Unlike a hydrocele, it is typically **reducible** bulge of bowel or omentum, thus feeling more solid and not transilluminating. *Varicocele* - A varicocele is characterized by a "bag of worms" feeling due to **dilated pampiniform plexus veins** in the scrotum. - It often appears as an irregular, soft mass that is more prominent when standing and typically **does not transilluminate**.

Q: Which is incorrect about the swelling shown below?

Possible to get above swelling. ***Possible to get above swelling*** - The image shows a **transilluminating scrotal swelling**, characteristic of a **hydrocele**. - A hydrocele originates from within the scrotum (testicular origin), so you **CANNOT get above the swelling** during physical examination. - The statement "Possible to get above swelling" is **INCORRECT** for a hydrocele - this is the key distinguishing feature. - In contrast, an **inguinoscrotal hernia** descends from the inguinal canal, so you **CAN get above it** and feel the neck of the hernia. - Since the question asks "which is incorrect," this option is the **correct answer**. *Fluctuation positive* - Hydroceles contain clear fluid, making them **fluctuant** on palpation. - A wave-like impulse can be transmitted through the fluid from one side to the other. - This statement is **correct** about hydroceles. *Fluid aspiration* - **Aspiration of fluid** from a hydrocele is possible for diagnostic or therapeutic purposes. - The aspirated fluid is typically straw-colored and clear if uncomplicated. - This statement is **correct** about hydroceles. *Transillumination positive* - The image clearly shows **positive transillumination**, where light passes through the swelling. - This indicates the swelling is **fluid-filled** and not solid. - This is a hallmark sign of hydrocele, distinguishing it from hernia or tumor. - This statement is **correct** about hydroceles.

Q: What does the following image show?

Stenting for pyeloplasty. ***Stenting for pyeloplasty*** - The image shows a **double J stent** placed in the ureter, which is commonly used to ensure **urine drainage** and **prevent stricture** after reconstructive surgeries like pyeloplasty. - The stent extends from the renal pelvis (upper coiled end) down into the bladder (lower coiled end), typical positioning for urinary tract procedures. *Stenting for bile duct obstruction* - Stents for **bile duct obstruction** are placed within the biliary system, which is anatomically distinct from the urinary tract shown. - These stents would be visible in the upper abdomen, associated with the liver and pancreas, not spanning the kidney and bladder as seen here. *Stenting for ESWL* - **Extracorporeal Shock Wave Lithotripsy (ESWL)** is a procedure to break up kidney stones; stents may be placed before or after to facilitate stone fragment passage or relieve obstruction. - While a stent might be placed after ESWL, the image itself shows the placement and course of the stent, which is a common intervention following reconstructive procedures such as pyeloplasty. *Stenting for PCNL* - **Percutaneous Nephrolithotomy (PCNL)** is a surgical procedure to remove large kidney stones directly from the kidney. - After PCNL, a **nephrostomy tube** or a **ureteral stent** may be placed, but the primary indication shown in the image (a long-term indwelling stent from kidney to bladder) is most consistent with facilitating healing and drainage after reconstruction such as pyeloplasty.

Q: During evaluation of a male child with recurrent UTI, VCUG is performed and the following finding is observed. What is the diagnosis?

Posterior urethral valves. ***Posterior urethral valves*** - The image shows a **dilated and elongated posterior urethra** which is characteristic of posterior urethral valves (PUV). Also evident is **trabeculation of the bladder wall** and significant **bilateral vesicoureteral reflux (VUR)**, with a dilated and tortuous left ureter. - PUV frequently cause **recurrent UTIs** in male infants and children due to urinary obstruction and stasis, leading to bladder and upper tract damage. *Ureterocele* - A ureterocele would appear as a **cystic dilation of the distal ureter** into the bladder, typically visualized as a lucent defect within the opaque bladder on VCUG. The image does not show this specific finding. - While it can cause obstruction and VUR, the obstruction pattern observed in the image (especially the posterior urethra) is not consistent with a ureterocele. *Ectopic ureter* - An ectopic ureter involves the ureter inserting into an abnormal location, such as the vagina, urethra, or seminal vesicle, often bypassing the bladder. This would lead to a more direct drainage outside the bladder or into another structure without the gross changes seen in the posterior urethra. - While an ectopic ureter can lead to reflux or obstruction affecting the kidney, the primary obstruction in the **posterior urethra** with characteristic valve morphology is absent with an ectopic ureter. *Hydronephrosis* - **Hydronephrosis** refers to the swelling of a kidney due to a backup of urine, often caused by an obstruction or VUR. While hydronephrosis is a *consequence* of conditions like PUV, it is not the *diagnosis* explaining the direct VCUG findings in the bladder and urethra. - The VCUG directly visualizes the obstruction in the posterior urethra and associated reflux/bladder changes, which are the primary diagnostic features, rather than just the renal swelling.

Q: The radiographic image shows a stent in the urinary tract. This type of stenting is most commonly performed following which procedure?

Pyeloplasty. ***Pyeloplasty*** - **Double J stents** are routinely placed in virtually all pyeloplasties (Anderson-Hynes dismembered pyeloplasty for **UPJO - Ureteropelvic Junction Obstruction**) to stent the anastomosis and ensure proper **urine drainage**. - The stent prevents **PUJ stricture** formation and supports healing of the surgical anastomosis, making it a standard postoperative measure. *ESWL* - **Extracorporeal Shock Wave Lithotripsy (ESWL)** rarely requires routine stenting unless there is **large stone burden** or risk of steinstrasse (stone fragment obstruction). - Stenting after ESWL is **selective**, not universally performed, unlike the routine nature implied by the question. *PCNL* - **Percutaneous Nephrolithotomy (PCNL)** primarily uses **nephrostomy tube** for drainage rather than double J stents as the first-line drainage method. - DJ stent placement after PCNL is **optional/selective**, not the most common stenting indication compared to pyeloplasty. *Ureteroscopy (URS)* - **Ureteroscopy** may require stenting in cases of **ureteral injury**, significant edema, or large stone burden, but it's placed **selectively**. - Unlike pyeloplasty, stenting after URS is **not universal** and depends on specific procedural factors and complications.

Q: Which of the following uroflowmetry recording indicates BPH?

Curve 3. ***Curve 3*** - Curve 3 shows a **low, flattened peak flow rate** (around 5 mL/sec) and a **prolonged voiding time**, which is characteristic of significant bladder outlet obstruction due to BPH. - The **sustained low flow** indicates constant effort to overcome resistance, a common finding in BPH. *Curve 1* - Curve 1 depicts a **high peak flow rate** (around 30 mL/sec) and a **short voiding time**, representing a normal and efficient urinary flow pattern. - This pattern is inconsistent with BPH, which is characterized by obstructed flow. *Curve 2* - Curve 2 indicates a **moderately reduced peak flow rate** (around 15 mL/sec) and a somewhat prolonged voiding time compared to normal. - While reflecting some degree of obstruction or weaker detrusor function, it is less severe than curve 3 and may represent early BPH or other conditions. *Curve 4* - Curve 4 shows an **intermittent or staccato flow pattern**, which typically indicates detrusor-sphincter dyssynergia or abdominal straining during voiding. - This pattern is not characteristic of BPH, which typically shows a continuous low flow rather than intermittent flow.

Question 1

A 65-year-old patient presents with sudden pain in the scrotum associated with prostration, pallor and pyrexia. What could be the most probable diagnosis?

Accepted Answer

Fournier's gangrene

Answer

Torsion testis

Answer

Spermatocele

Answer

Varicocele

Question 2

All are true about the conditions shown in the figure except?

Accepted Answer

Painless intermittent hematuria

Answer

Vesical calculus

Answer

Holmium laser

Answer

Litholapaxy

Question 3

The following instrument is used for:

Accepted Answer

Bladder wash when urinary catheter gets blocked

Answer

Dilate urethral stricture

Answer

Relieve bladder outlet obstruction temporarily

Answer

Perform uroflowmetry

Question 4

What is the most likely diagnosis based on the clinical image?

Accepted Answer

Hydrocele

Answer

Direct inguinal hernia

Answer

Indirect inguinal hernia

Answer

Varicocele

Question 5

Which is incorrect about the swelling shown below?

Accepted Answer

Possible to get above swelling

Answer

Fluctuation positive

Answer

Fluid aspiration

Answer

Transillumination positive

Question 6

Which is incorrect about the procedure shown in the patient with right flank pain?

Accepted Answer

No anesthesia is required

Answer

Done as outpatient procedure

Answer

Contraindicated in hard stones

Answer

Shockwaves pass through a water bath

Question 7

What does the following image show?

Accepted Answer

Stenting for pyeloplasty

Answer

Stenting for bile duct obstruction

Answer

Stenting for ESWL

Answer

Stenting for PCNL

Question 8

During evaluation of a male child with recurrent UTI, VCUG is performed and the following finding is observed. What is the diagnosis?

Accepted Answer

Posterior urethral valves

Answer

Ureterocele

Answer

Ectopic ureter

Answer

Hydronephrosis

Question 9

The radiographic image shows a stent in the urinary tract. This type of stenting is most commonly performed following which procedure?

Accepted Answer

Pyeloplasty

Answer

ESWL

Answer

PCNL

Answer

Ureteroscopy (URS)

Question 10

Which of the following uroflowmetry recording indicates BPH?

Accepted Answer

Curve 3

Answer

Curve 1

Answer

Curve 2

Answer

Curve 4

Urology — MCQs

Urology — MCQs

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