Urology Practice Questions

Q: A 70-year-old man underwent the procedure shown below. 3rd day he develops seizures. What is the diagnosis?

Water intoxication. ***Water intoxication*** - The image depicts a **transurethral resection of the prostate (TURP)** using a resectoscope. During TURP, large volumes of **hypotonic irrigation fluid** are used. - If excess fluid is absorbed into the systemic circulation, it can lead to **dilutional hyponatremia** and subsequent **cerebral edema**, causing neurological symptoms like **seizures** post-operatively. *Anesthetic over-dosage* - Anesthetic overdose would typically manifest during or immediately after the procedure with respiratory and cardiovascular depression, not delayed seizures on the third day. - The patient's presentation of seizures several days post-operatively does not align with acute anesthetic toxicity. *Mismatched blood transfusion* - A mismatched blood transfusion would present with acute symptoms like fever, chills, hemoglobinuria, and hypotension, usually *during* or immediately after the transfusion, not delayed neurological symptoms. - Blood transfusions are not routinely part of a TURP procedure unless significant bleeding occurs. *Malignant hyperthermia* - Malignant hyperthermia is a rare, life-threatening **hypermetabolic state** triggered by certain general anesthetics, characterized by rapid onset of high fever, muscle rigidity, and tachycardia. - It occurs *during* or very soon after anesthesia and would not typically present as seizures on the third post-operative day.

Q: A 60-year-old male smoker presents with discoloration of urine and has brought a sample to your clinic. He denies any pain or discomfort while passing urine. No history of fever is present. IVU of the patient is shown. Which is the next best investigation to be done?

Cystoscopy. ***Cystoscopy*** - The patient presents with **painless hematuria** and a history of smoking, which are classic indicators of **bladder cancer**. The IVU may also suggest filling defects or abnormalities in the bladder. - Cystoscopy offers **direct visualization of the bladder and urethra**, allowing for biopsy of any suspicious lesions, which is crucial for diagnosis and staging of bladder cancer. *Urine cytology* - While urine cytology can detect malignant cells, its **sensitivity for low-grade tumors is limited**, and it cannot pinpoint the exact location or extent of the lesion. - A definitive diagnosis of bladder cancer requires **histopathological confirmation**, which cytology alone cannot provide. *USG abdomen* - USG can detect some renal and bladder abnormalities, but it is **not as sensitive or specific as cystoscopy** for detecting small or flat bladder lesions. - It's a good initial screening tool but **lacks the diagnostic precision** needed to investigate painless hematuria suspected to be from the bladder. *DMSA scan* - A DMSA scan is primarily used to assess **renal cortical function** and identify cortical scarring or anomalies, not for investigating hematuria or bladder pathologies. - It provides no information about the **urethra or bladder lumen**, which are critical for evaluating the cause of painless hematuria in this patient.

Q: A person could not pass urine after a fall shown below. On examination vitals are stable but bladder is palpable. What is the probable diagnosis? (NEET Pattern 2018)

Anterior urethra rupture. ***Anterior urethra rupture*** - The mechanism of injury - a **fall causing straddle trauma** (man falling into manhole) - is the classic cause of **bulbar urethral injury**, affecting the anterior urethra where it passes through the urogenital diaphragm. - Inability to pass urine with **palpable bladder** indicates urinary retention from complete urethral disruption, with the classic triad of **inability to void, blood at urethral meatus, and distended bladder**. *Posterior urethra rupture* - Requires **high-energy trauma** causing **pelvic fractures** (like road traffic accidents), not the straddle injury mechanism shown in the fall. - Associated with **membranous urethral injury** above the urogenital diaphragm, typically seen with **symphysis pubis or sacroiliac joint disruption**. *Penile avulsion* - Involves **complete or partial tearing** of penile skin or deeper structures, presenting with **obvious external hemorrhage and tissue loss**. - Would not primarily present as urinary retention without visible **external genital trauma or bleeding**. *Recto-urethral injury* - Results from **penetrating trauma** or severe **crush injuries** affecting both rectum and urethra simultaneously. - Would present with additional signs like **rectal bleeding, fecaluria, or pneumaturia**, which are not described in this case.

Q: A 25-year-old gentleman complains of dragging pain in the scrotum. The examination reveals the scrotum full of bag of worms which disappear on lying down. The usual first line option for relief is :

Surgical varicocelectomy (ligation of testicular veins). ***Surgical varicocelectomy (ligation of testicular veins)*** - The "bag of worms" sensation that disappears on lying down is **pathognomonic for varicocele**, representing dilated pampiniform plexus veins - **Varicocelectomy** (surgical ligation of the internal spermatic/testicular veins) is the **gold standard first-line treatment** for symptomatic varicoceles causing pain or infertility - Common approaches include **open (Palomo or Ivanissevich technique)**, **laparoscopic**, or **microscopic subinguinal** varicocelectomy with success rates of 90-95% - The procedure involves **ligation** (tying off) the dilated veins, not excision of the entire pampiniform plexus *Radio frequency ablation of testicular veins* - **Radiofrequency ablation** is not a standard treatment modality for varicoceles - The testicular veins are not amenable to standard RFA techniques used for other venous insufficiencies - This is **not considered a first-line option** in clinical practice *Percutaneous embolization of gonadal veins* - **Percutaneous embolization** is an alternative **minimally invasive first-line treatment** option for symptomatic varicoceles, particularly in resource-rich settings - Success rates are comparable to surgery (90-95%) with potentially lower complication rates and faster recovery - However, in the context of **traditional Indian surgical practice** and most PG examinations, **surgical varicocelectomy remains the conventional first-line answer** - Embolization involves retrograde catheterization and occlusion of the testicular vein with coils or sclerosants *Laparoscopic excision of affected testes* - **Orchiectomy** (testicular excision) is completely inappropriate for varicocele management - This radical procedure is reserved for **testicular malignancy**, severe trauma with non-viable testis, or torsion with necrosis - **Never a treatment option** for simple symptomatic varicocele

Q: Extracorporeal Shock Wave Lithotripsy (ESWL) is most commonly used for the treatment of

urinary tract stones. ***Urinary tract stones*** - **Extracorporeal Shock Wave Lithotripsy (ESWL)** is a non-invasive procedure primarily used to break down **kidney stones** and **ureteral stones** into smaller fragments. - The shock waves are generated outside the body and focused on the stone, allowing the fragments to be passed naturally in the urine. *Gallbladder stones* - **Gallbladder stones (cholelithiasis)** are typically treated with **cholecystectomy** (surgical removal of the gallbladder) or medications for dissolution, not ESWL. - While some research has explored ESWL for gallbladder stones, it is not the most common or preferred treatment due to high recurrence rates and limited efficacy. *Abdominal stony-hard tumour* - ESWL is designed to fragment **calcifications or stones**, not cellular masses or tumors. - Abdominal tumors, regardless of their consistency, require **biopsy for diagnosis** and subsequent treatment such as surgery, chemotherapy, or radiation, specialized based on pathophysiology. *Salivary gland stones* - **Sialolithiasis** (salivary gland stones) can sometimes be treated with **lithotripsy**, but this typically involves specific techniques like **endoscopic lithotripsy** or **interventional removal**, distinct from the general application of ESWL for urinary stones. - The most common treatments for salivary gland stones focus on hydration, massage, and, if necessary, surgical removal of the stone or gland.

Q: Which of the following statements are correct regarding renal cell carcinoma? 1. It arises from the epithelium of the proximal convoluted tubule. 2. It has a female preponderance. 3. Major subtypes are clear cell, papillary and chromophobe. 4. Surgery is the mainstay of treatment for organ-confined disease. Select the answer using the code given below.

1, 3 and 4. ***1, 3 and 4*** - **Renal cell carcinoma (RCC)** most commonly arises from the **epithelium of the proximal convoluted tubule**, particularly the clear cell subtype [1]. This makes statement 1 correct. - The major subtypes of RCC are indeed **clear cell, papillary, and chromophobe carcinomas**, accounting for the vast majority of cases [1]. This validates statement 3. - For **organ-confined renal cell carcinoma**, **surgical resection (nephrectomy)** remains the primary and most effective treatment modality, making statement 4 correct. [1] *1, 2 and 3* - This option incorrectly includes statement 2, which claims a female preponderance for RCC. **Renal cell carcinoma is more common in males** than females, not the reverse [1]. - While statements 1 and 3 are correct regarding the origin and major subtypes of RCC, the inclusion of an incorrect epidemiological fact makes this option wrong. *1, 2 and 4* - This option falls short by incorrectly including statement 2, which asserts a female predominance for RCC. **RCC has a male predominance**, with a male-to-female ratio of about 2:1 [1]. - This option also omits statement 3, which correctly identifies the major subtypes (clear cell, papillary, and chromophobe), even though statements 1 and 4 are correct. *2, 3 and 4* - This option incorrectly includes statement 2, which states a female preponderance for RCC; **renal cell carcinoma is actually more prevalent in males** [1]. - While statements 3 and 4 are correct regarding the major subtypes and the role of surgery in organ-confined disease, the factual error in statement 2 invalidates this option.

Q: Anderson-Hynes plasty is a type of repair of

ureteropelvic junction. ***ureteropelvic junction*** - The **Anderson-Hynes pyeloplasty** is a widely used surgical procedure for the correction of a **ureteropelvic junction (UPJ) obstruction**. - It involves **excision of the stenotic or obstructed UPJ segment** and **reconstruction** to create a wide, funnel-shaped connection between the renal pelvis and the ureter. *lower ureter* - Repairs of the lower ureter, such as for distal ureteral strictures or reflux, typically involve procedures like ureteral re-implantation into the bladder or ureteroureterostomy, not the Anderson-Hynes plasty. - While these can address obstruction, the specific technique of Anderson-Hynes is designed for the UPJ. *glans penis* - The glans penis is part of the male external genitalia, and surgical repairs in this area, such as for hypospadias or strictures, are entirely unrelated to the ureter or kidney. - Surgical procedures for the glans penis would involve plastic and reconstructive techniques specific to the urethra and foreskin. *urinary bladder* - Repairs of the urinary bladder involve procedures for conditions like bladder diverticula, fistulae, or augmentation cystoplasty, which are distinct from managing obstructions in the upper urinary tract. - These procedures aim to restore bladder function and integrity, not to address blockages at the junction of the kidney and ureter.

Q: Which method of vasectomy has the highest failure rate ?

Open ended vasectomy with granulation formation. ***Open ended vasectomy with granulation formation*** - This method involves either leaving the testicular end of the **vas deferens** open or allowing the formation of a **sperm granuloma**, which is believed to reduce post-vasectomy pain and congestion. - However, this approach carries a higher risk of **recanalization** and failure because sperm can potentially find a pathway through the granuloma or the open end, leading to unintended pregnancy. *Use of hemoclips with 1-4 cm gap after cutting proximal and distal ends* - The use of **hemoclips** with a significant gap (1-4 cm) between the clipped ends of the vas deferens is a common and generally effective method. - While failure is possible due to clip displacement or recanalization, the gap and mechanical obstruction provided by the clips make it more reliable than open-ended techniques. *Cutting and ligating vas to occlude the proximal and distal lumen* - **Cutting and ligating** both the proximal and distal ends of the vas deferens creates a clear physical barrier, preventing sperm transport. - This method is considered highly effective as it involves both severance and occlusion, significantly reducing the chance of recanalization. *Cutting the vas and turning the ends backwards and ligating with suture material* - This technique, often referred to as **fascial interposition** or burying the ends, involves cutting the vas, turning one or both ends back, and ligating them into the fascial sheath. - This creates an additional anatomical barrier, further separating the cut ends and making recanalization much more difficult, thus offering a very high success rate.

Q: The most frequent complication of fracture pelvis is injury to :

membranous urethra. ***membranous urethra*** - The membranous (posterior) urethra is the **most frequently injured genitourinary structure** in pelvic fractures, occurring in **10-20% of major pelvic fractures** in males. - It is particularly vulnerable due to its **relatively fixed position** between the urogenital diaphragm and prostate, making it susceptible to shearing forces during anteroposterior compression or straddle-type injuries. - **Associated with pubic rami fractures and diastasis of the pubic symphysis** - the "pie in the sky" bladder sign on cystography suggests associated posterior urethral injury. - Clinical signs include **blood at the urethral meatus, high-riding prostate, and inability to void**. *urinary bladder* - Bladder injury occurs in approximately **5-10% of pelvic fractures**, making it less common than posterior urethral injuries. - Can present as **intraperitoneal rupture** (dome injury from increased intravesical pressure) or **extraperitoneal rupture** (base injury from bone fragments). - More common with pubic rami fractures, but still **less frequent than urethral injury overall**. *penile urethra* - Injury to the penile (anterior) urethra is **rarely associated with pelvic fractures** as it is mobile and not in direct proximity to pelvic bones. - More commonly injured by **straddle injuries, instrumentation, or direct penile trauma**. *rectum* - Rectal injury is a **rare complication** occurring in less than 1-5% of pelvic fractures. - Typically seen with **open pelvic fractures, open-book fractures with severe displacement**, or penetrating injuries where sharp bone fragments lacerate the rectum. - Much less common than genitourinary injuries.

Q: Regarding varicocele, all of the following are true except :

Varicosity of cremasteric veins. ***Varicosity of cremasteric veins*** - A varicocele is specifically the **dilation of the pampiniform plexus** of testicular veins, not the cremasteric veins. - The cremasteric veins are a separate venous system, and their varicosity is not what defines a varicocele. *May lead to infertility* - Varicoceles can **impair spermatogenesis** due to increased scrotal temperature and reflux of adrenal/renal metabolites, leading to reduced sperm count and motility. - This is a well-established complication and a common cause of **male factor infertility**. *Left side is affected usually* - The left side is more commonly affected because the **left testicular vein drains into the left renal vein** at a perpendicular angle, leading to higher hydrostatic pressure and a longer course. - The right testicular vein drains directly into the inferior vena cava (IVC) at an acute angle, which is less prone to reflux and dilation. *Feels like a bag of worms* - The characteristic palpation of a varicocele is described as a **"bag of worms"** due to the palpable dilated and tortuous veins within the pampiniform plexus. - This sensation is a key diagnostic clinical finding on physical examination.

Question 1

A 70-year-old man underwent the procedure shown below. 3rd day he develops seizures. What is the diagnosis?

Accepted Answer

Water intoxication

Answer

Anesthetic over-dosage

Answer

Mismatched blood transfusion

Answer

Malignant hyperthermia

Question 2

A 60-year-old male smoker presents with discoloration of urine and has brought a sample to your clinic. He denies any pain or discomfort while passing urine. No history of fever is present. IVU of the patient is shown. Which is the next best investigation to be done?

Accepted Answer

Cystoscopy

Answer

Urine cytology

Answer

USG abdomen

Answer

DMSA scan

Question 3

A person could not pass urine after a fall shown below. On examination vitals are stable but bladder is palpable. What is the probable diagnosis? (NEET Pattern 2018)

Accepted Answer

Anterior urethra rupture

Answer

Posterior urethra rupture

Answer

Penile avulsion

Answer

Recto-urethral injury

Question 4

A 25-year-old gentleman complains of dragging pain in the scrotum. The examination reveals the scrotum full of bag of worms which disappear on lying down. The usual first line option for relief is :

Accepted Answer

Surgical varicocelectomy (ligation of testicular veins)

Answer

Radio frequency ablation of testicular veins

Answer

Percutaneous embolization of gonadal veins

Answer

Laparoscopic excision of affected testes

Question 5

Extracorporeal Shock Wave Lithotripsy (ESWL) is most commonly used for the treatment of

Accepted Answer

urinary tract stones

Answer

gallbladder stones

Answer

abdominal stony-hard tumour

Answer

salivary gland stones

Question 6

Which of the following statements are correct regarding renal cell carcinoma?

1. It arises from the epithelium of the proximal convoluted tubule.
2. It has a female preponderance.
3. Major subtypes are clear cell, papillary and chromophobe.
4. Surgery is the mainstay of treatment for organ-confined disease. Select the answer using the code given below.

Accepted Answer

1, 3 and 4

Answer

1, 2 and 3

Answer

1, 2 and 4

Answer

2, 3 and 4

Question 7

Anderson-Hynes plasty is a type of repair of

Accepted Answer

ureteropelvic junction

Answer

lower ureter

Answer

glans penis

Answer

urinary bladder

Question 8

Which method of vasectomy has the highest failure rate ?

Accepted Answer

Open ended vasectomy with granulation formation

Answer

Use of hemoclips with 1-4 cm gap after cutting proximal and distal ends

Answer

Cutting and ligating vas to occlude the proximal and distal lumen

Answer

Cutting the vas and turning the ends backwards and ligating with suture material

Question 9

The most frequent complication of fracture pelvis is injury to :

Accepted Answer

membranous urethra

Answer

penile urethra

Answer

rectum

Answer

urinary bladder

Question 10

Regarding varicocele, all of the following are true except :

Accepted Answer

Varicosity of cremasteric veins

Answer

May lead to infertility

Answer

Left side is affected usually

Answer

Feels like a bag of worms

Urology — MCQs

Urology — MCQs

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