Urology — MCQs
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A 13-year-old boy presents with acute onset right scrotal pain. The pain is not relieved on elevation of the scrotum, and he has no fever or dysuria. The testis is enlarged and tender. His routine urinary examination is normal, and there is no history of trauma. Which of the following is the most appropriate management?
Which of the following is NOT a feature of ectopia vesicae?
All are features of Fournier's gangrene except?
What is the commonest endocrine tumor of the pancreas?
What is an indication for percutaneous nephrostomy?
A 40-year-old male presented with severe pain in the left upper abdomen radiating to the groin. Urine routine examination shows 6-8 pus cells and 15-20 RBCs. A CT scan was performed. What is the most likely diagnosis?
During urethral catheterization in male patients, resistance is encountered at which of the following sites EXCEPT?
Which of the following are indications for percutaneous nephrostomy?
Recovery is complete in which of the following types of nerve injuries?
Which of the following is a complication of total parenteral nutrition?
Urology Indian Medical PG Practice Questions and MCQs
Question 601: A 13-year-old boy presents with acute onset right scrotal pain. The pain is not relieved on elevation of the scrotum, and he has no fever or dysuria. The testis is enlarged and tender. His routine urinary examination is normal, and there is no history of trauma. Which of the following is the most appropriate management?
- A. Immediate exploration (Correct Answer)
- B. Antibiotics
- C. Psychiatric evaluation
- D. Antibiotics and scrotal elevation
Explanation: **Explanation:** The clinical presentation of acute, spontaneous scrotal pain in an adolescent is **Testicular Torsion** until proven otherwise. This is a surgical emergency where the spermatic cord twists, leading to ischemia and potential necrosis of the testis. **Why Immediate Exploration is Correct:** The diagnosis of torsion is primarily clinical. The "Golden Period" for testicular salvage is **6 hours** from the onset of pain; delay beyond this significantly increases the risk of orchidectomy. The negative **Prehn’s sign** (pain not relieved by scrotal elevation) and the absence of urinary symptoms (normal urinalysis) strongly point away from inflammatory causes and toward torsion. Immediate surgical exploration is mandatory to detorse the testis and perform bilateral orchidopexy (fixation) to prevent recurrence. **Why Other Options are Incorrect:** * **Antibiotics / Antibiotics and Scrotal Elevation:** These are treatments for *Epididymo-orchitis*. While this also causes scrotal pain, it usually presents with fever, dysuria, and a positive Prehn’s sign. In a 13-year-old, waiting for antibiotics to work in a suspected torsion case would lead to a dead testis. * **Psychiatric Evaluation:** This is irrelevant as the symptoms are clearly organic and acute. **Clinical Pearls for NEET-PG:** * **Age Distribution:** Bimodal peaks (neonatal period and puberty). * **Prehn’s Sign:** Negative in Torsion (pain persists/worsens); Positive in Epididymitis (pain relieved). * **Cremasteric Reflex:** Usually absent in testicular torsion (High sensitivity). * **Investigation of Choice:** Color Doppler Ultrasound (shows decreased/absent blood flow), but **surgery should never be delayed** for imaging if clinical suspicion is high. * **Anatomical Predisposition:** "Bell-clapper deformity" (high tunica vaginalis attachment).
Question 602: Which of the following is NOT a feature of ectopia vesicae?
- A. Epispadias
- B. Bifid clitoris
- C. Undescended testis
- D. X-linked dominant inheritance (Correct Answer)
Explanation: **Explanation:** **Ectopia vesicae (Bladder Exstrophy)** is a complex congenital malformation resulting from the failure of the infraumbilical anterior abdominal wall and bladder neck to fuse. **Why Option D is the correct answer:** Ectopia vesicae is **not** an X-linked dominant disorder. Most cases occur **sporadically** with no clear inheritance pattern. While there is a slightly higher risk in siblings (approx. 1 in 100), it does not follow Mendelian genetics. The etiology is primarily attributed to the failure of mesenchymal migration between the ectoderm and endoderm of the cloacal membrane. **Analysis of incorrect options (Features of Ectopia Vesicae):** * **Epispadias (Option A):** This is a hallmark feature. In males, the urethra opens on the dorsal aspect of the penis. The penis is typically short and broad with a dorsal chordee. * **Bifid Clitoris (Option B):** In females, the clitoris is bifid (split), the labia are widely separated, and the vaginal orifice is displaced anteriorly. * **Undescended Testis (Option C):** Cryptorchidism and inguinal hernias are frequently associated with bladder exstrophy due to the widening of the bony pelvis and defects in the inguinal canal. **High-Yield Clinical Pearls for NEET-PG:** * **Bony Defect:** Widening of the **symphysis pubis** (diastasis) is a classic radiological finding. * **Associated Malignancy:** Patients have a significantly increased risk (up to 400-fold) of developing **Adenocarcinoma** of the bladder due to chronic irritation and glandular metaplasia of the exposed mucosa. * **Umbilicus:** The umbilicus is typically low-set, immediately above the exstrophied bladder. * **Management:** The primary goal is functional closure of the bladder, reconstruction of the bladder neck for continence, and repair of the epispadias.
Question 603: All are features of Fournier's gangrene except?
- A. Testicles are involved (Correct Answer)
- B. Obliterative arteritis seen
- C. Haemolytic streptococci, E.coli, Staphylococci, Cl. welchi can be isolated
- D. Necrotising fasciitis
Explanation: **Fournier’s gangrene** is a life-threatening, rapidly progressive polymicrobial necrotizing fasciitis of the perineal, perianal, and genital regions. ### **Explanation of Options** * **Option A (Correct Answer):** The **testicles are typically spared** in Fournier’s gangrene. This is because the blood supply to the testes originates from the **internal spermatic (testicular) arteries**, which arise directly from the abdominal aorta. In contrast, the scrotum and perineal skin are supplied by the external and internal pudendal arteries. Since the infection spreads along the fascial planes (Colles’, Dartos, and Scarpa’s fascia), the deep-seated testes remain protected. * **Option B:** The hallmark pathophysiology is **obliterative arteritis** of the subcutaneous arterioles. This leads to local ischemia, which further promotes the growth of anaerobic bacteria and leads to rapid tissue necrosis. * **Option C:** It is a **polymicrobial infection**. Common isolates include aerobes (E. coli, Klebsiella, Staphylococci, Streptococci) and anaerobes (Bacteroides, Clostridium species like *C. welchii*). * **Option D:** By definition, it is a form of **necrotizing fasciitis** specifically involving the male genitalia and perineum. ### **Clinical Pearls for NEET-PG** * **Risk Factors:** Diabetes mellitus (most common), chronic alcoholism, and local trauma/surgery. * **Clinical Sign:** **Crepitus** on palpation (due to gas-forming organisms) and "woody" induration of the skin. * **Management:** This is a surgical emergency. Treatment involves **aggressive surgical debridement**, broad-spectrum intravenous antibiotics, and hemodynamic stabilization. * **Anatomical Spread:** The infection is limited by the attachments of **Colles' fascia** (to the perineal body and ischiopubic rami), but it can spread upward to the abdominal wall via **Scarpa’s fascia**.
Question 604: What is the commonest endocrine tumor of the pancreas?
- A. A cells
- B. B cells (Correct Answer)
- C. Delta cells
- D. VIPoma
Explanation: **Explanation:** Pancreatic Neuroendocrine Tumors (PanNETs) arise from the multipotent stem cells of the pancreatic ductal epithelium. The correct answer is **B cells (Beta cells)** because **Insulinomas** (which arise from B cells) are the most common functional endocrine tumors of the pancreas. * **B cells (Insulinoma):** These represent approximately 70-75% of all functional PanNETs. They are typically benign (90%), solitary, and present with the classic **Whipple’s Triad** (hypoglycemic symptoms, low blood glucose, and relief of symptoms upon glucose administration). * **A cells (Glucagonoma):** These arise from Alpha cells. They are much rarer and are clinically characterized by the "4Ds": Diabetes, Dermatitis (Necrolytic Migratory Erythema), Deep Vein Thrombosis, and Depression. * **Delta cells (Somatostatinoma):** These are extremely rare. They present with an inhibitory syndrome consisting of diabetes, cholelithiasis (due to inhibition of CCK), and steatorrhea. * **VIPoma:** Arising from non-beta islet cells, these produce Vasoactive Intestinal Peptide. They cause **WDHA Syndrome** (Watery Diarrhea, Hypokalemia, Achlorhydria), also known as Verner-Morrison syndrome. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most common overall PanNET:** Non-functioning tumors (often asymptomatic until large). 2. **Most common functional PanNET:** Insulinoma. 3. **Most common PanNET in MEN-1:** Gastrinoma (Zollinger-Ellison Syndrome) is frequently cited as the most common *symptomatic* or *malignant* endocrine tumor in MEN-1, though non-functional tumors are also prevalent. 4. **Rule of 10s for Insulinoma:** 10% are malignant, 10% are multiple, and 10% are associated with MEN-1.
Question 605: What is an indication for percutaneous nephrostomy?
- A. Stone removal
- B. Ureteral obstruction (Correct Answer)
- C. Anterograde renography
- D. Renal tumor resection
Explanation: **Explanation:** **Percutaneous Nephrostomy (PCN)** is a procedure where a catheter is inserted through the skin into the renal pelvis to provide external drainage of the collecting system. **Why Ureteral Obstruction is Correct:** The primary indication for PCN is **supravesical urinary tract obstruction**. When the ureter is blocked (by stones, strictures, or extrinsic malignancy) and retrograde stenting (Double-J stent) fails or is contraindicated, PCN is performed to relieve pressure. This prevents hydronephrosis, protects renal function, and is life-saving in cases of **pyonephrosis** (infected obstructed system) or urosepsis. **Analysis of Incorrect Options:** * **A. Stone removal:** While PCN provides access for procedures like Percutaneous Nephrolithotomy (PCNL), the nephrostomy tube itself is a drainage device, not a tool for stone removal. * **C. Anterograde renography:** This is a diagnostic imaging study. While PCN access is used to perform an **Antegrade Pyelogram** or a **Whitaker test**, "renography" typically refers to nuclear medicine scans (like DTPA/MAG3) which are non-invasive. * **D. Renal tumor resection:** PCN has no role in the resection of renal tumors. Malignant tumors are managed via partial or radical nephrectomy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common indication:** Acute ureteral obstruction with infection (Urosepsis). * **Access point:** Usually through **Brodel’s line** (the avascular plane on the posterolateral border of the kidney) to minimize hemorrhage. * **Contraindication:** Uncorrected coagulopathy is the most significant absolute contraindication. * **Urgency:** In a patient with "Pus under pressure" (obstructed infected kidney), PCN is the definitive emergency management.
Question 606: A 40-year-old male presented with severe pain in the left upper abdomen radiating to the groin. Urine routine examination shows 6-8 pus cells and 15-20 RBCs. A CT scan was performed. What is the most likely diagnosis?
- A. Aortic aneurysm
- B. Acute cholecystitis
- C. Left ureteric calculus (Correct Answer)
- D. Acute colitis
Explanation: ***Left ureteric calculus*** - **Severe colicky pain** in the left upper abdomen radiating to the **groin** is classic for ureteric stone, following the path of the ureter. - **Hematuria** (15-20 RBCs) on urine analysis is a key finding, along with **pyuria** (6-8 pus cells) due to associated inflammation. *Aortic aneurysm* - Typically presents with **tearing back pain** radiating to the abdomen, not specifically to the groin. - **No hematuria** would be expected, and pain is usually constant rather than colicky. *Acute cholecystitis* - Pain is typically in the **right upper quadrant** radiating to the **right shoulder**, not to the groin. - **No hematuria** or pyuria would be present, and pain is usually related to **fatty meals**. *Acute colitis* - Presents with **diarrhea**, **blood in stool**, and **lower abdominal cramping**, not upper abdominal pain. - **No hematuria** would be expected, and pain doesn't radiate to the groin.
Question 607: During urethral catheterization in male patients, resistance is encountered at which of the following sites EXCEPT?
- A. Base of navicular fossa (Correct Answer)
- B. Mid-penile urethra
- C. Urogenital diaphragm
- D. Bulbomembranous junction
Explanation: In male urethral catheterization, resistance is typically encountered at specific anatomical narrowings or angulations. The **base of the navicular fossa** is the correct answer because it is a site where the catheter may "catch" on a mucosal fold (the **Valve of Guérin**), but it is not a site of physiological resistance or narrowing. ### **Anatomical Basis of Resistance:** 1. **Mid-penile urethra (Option B):** This is a common site of resistance due to the **pendulous nature** of the penis. If the penis is not held upright (stretched) to straighten the "S-shaped" curve of the urethra, the catheter can buckle here. 2. **Urogenital diaphragm (Option C):** This contains the **external urethral sphincter** (skeletal muscle). In anxious patients, voluntary contraction of this sphincter creates significant resistance. 3. **Bulbomembranous junction (Option D):** This is the most common site of resistance and potential injury. The urethra turns upwards to enter the fixed membranous portion. If the catheter is forced against the floor of the bulbous urethra, it can lead to a **false passage**. ### **Why "Base of Navicular Fossa" is the exception:** While the **Valve of Guérin** (a mucosal fold on the roof of the navicular fossa) can snag a fine-tipped catheter, the fossa itself is a **dilated** segment of the urethra. It does not provide the structural or muscular resistance seen in the other options. ### **High-Yield Clinical Pearls for NEET-PG:** * **Narrowest part of the male urethra:** External urethral meatus. * **Most dilatable part:** Prostatic urethra. * **Least dilatable part:** Membranous urethra. * **Most common site of iatrogenic trauma:** Bulbomembranous junction. * **Technique Tip:** To bypass resistance at the urogenital diaphragm, ask the patient to take deep breaths or attempt to void, which relaxes the external sphincter.
Question 608: Which of the following are indications for percutaneous nephrostomy?
- A. Stone removal, ureteral obstruction, renal tumor resection, ischemic renal failure
- B. Stone removal, ureteral obstruction, renal tumor resection, antegrade renography (Correct Answer)
- C. Stone removal, renal tumor resection, ischemic renal failure, antegrade renography
- D. Stone removal, ureteral obstruction, ischemic renal failure, antegrade renography
Explanation: **Explanation** Percutaneous Nephrostomy (PCN) is a minimally invasive procedure involving the placement of a catheter into the renal pelvis through the skin under radiological guidance. It is primarily used for **drainage, access, or diagnostic imaging.** **1. Why Option B is Correct:** The indications for PCN are broadly categorized into: * **Relief of Obstruction:** Most common indication (e.g., ureteral stones, strictures, or extrinsic compression by pelvic tumors). * **Access for Interventions:** Essential for **stone removal** (Percutaneous Nephrolithotomy - PCNL) [1] and occasionally for **renal tumor resection** (e.g., endourologic ablation of small transitional cell carcinomas in the upper tract). * **Diagnostic Testing:** Used for **antegrade renography** (Whitaker test) to differentiate between an obstructed and a non-obstructed dilated system. **2. Why Other Options are Incorrect:** Options A, C, and D include **Ischemic Renal Failure**. PCN is indicated for **Post-renal (obstructive) acute renal failure**. It has no therapeutic role in Pre-renal causes (like ischemia/hypovolemia) or Intrinsic renal causes (like Acute Tubular Necrosis). Relieving a non-existent obstruction will not improve renal function in ischemic failure. **High-Yield Clinical Pearls for NEET-PG:** * **Most common indication:** Supravesical obstruction with infection (Urosepsis) [2]. * **Preferred site of puncture:** Brodel’s line (posterolateral border of the kidney), as it is the relatively avascular plane between the anterior and posterior divisions of the renal artery. * **Contraindications:** Uncontrolled coagulopathy (Absolute) and uncontrolled hypertension. * **Complication:** Hemorrhage is the most common significant complication.
Question 609: Recovery is complete in which of the following types of nerve injuries?
- A. Neurotmesis
- B. Axonotmesis
- C. Neuropraxia (Correct Answer)
- D. Nerve avulsion
Explanation: **Explanation:** The classification of nerve injuries is based on the **Seddon Classification**, which categorizes injuries into three types based on the severity of damage to the nerve components. **Why Neuropraxia is correct:** Neuropraxia is the mildest form of nerve injury. It involves a **physiological conduction block** (usually due to focal demyelination) without any physical disruption of the axon or the connective tissue sheath (endoneurium, perineurium, or epineurium). Since the axon remains intact, there is no Wallerian degeneration. Recovery is spontaneous and **complete**, typically occurring within days to a few weeks once the inciting cause (like compression) is removed. **Why the other options are incorrect:** * **Axonotmesis:** This involves the disruption of the **axon**, but the supporting connective tissue framework (endoneurium) remains intact. While regeneration is possible (at a rate of 1 mm/day) because the sheath guides the regrowing axon, recovery is often prolonged and may be incomplete depending on the distance to the target organ. * **Neurotmesis:** This is the most severe form, involving **complete transection** of both the axon and the entire connective tissue sheath. Spontaneous recovery is impossible; surgical intervention (nerve repair or grafting) is mandatory, and even then, functional recovery is rarely 100%. * **Nerve Avulsion:** This occurs when the nerve is forcibly torn away from its origin (e.g., brachial plexus roots from the spinal cord). It is a permanent injury with no chance of spontaneous recovery. **High-Yield Clinical Pearls for NEET-PG:** * **Wallerian Degeneration:** Occurs in Axonotmesis and Neurotmesis, but **NOT** in Neuropraxia. * **Tinel’s Sign:** It is **absent** in Neuropraxia (as there is no axonal regeneration) but becomes **positive** in Axonotmesis as the nerve regrows. * **Sunderland Classification:** An expansion of Seddon’s; it divides injuries into 5 degrees (1st degree = Neuropraxia; 5th degree = Neurotmesis).
Question 610: Which of the following is a complication of total parenteral nutrition?
- A. Congestive heart failure (CHF)
- B. Hypochloremia
- C. Metabolic acidosis (Correct Answer)
- D. Leukopenia
Explanation: **Explanation:** Total Parenteral Nutrition (TPN) is associated with several metabolic complications. **Metabolic acidosis** is a well-recognized complication, primarily occurring due to the high concentration of cationic amino acids (such as arginine, histidine, and lysine) in older TPN formulations. When these amino acids are metabolized, they release hydrogen ions. Additionally, the presence of acetate or chloride salts in the solution can influence the acid-base balance; an excess of chloride relative to sodium can lead to **hyperchloremic metabolic acidosis**. **Analysis of Options:** * **A. Congestive Heart Failure (CHF):** While fluid overload can occur if TPN is administered too rapidly, CHF is not a direct metabolic complication of the TPN constituents themselves. * **B. Hypochloremia:** TPN is more likely to cause **hyperchloremia** (due to high chloride content in certain formulations), which contributes to the metabolic acidosis mentioned above. * **D. Leukopenia:** TPN does not typically cause a decrease in white blood cell counts. In fact, catheter-related bloodstream infections (CRBSI) are a common complication, which would lead to leukocytosis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common metabolic complication:** Hyperglycemia (due to high glucose infusion rates). * **Refeeding Syndrome:** Characterized by **Hypophosphatemia** (most important), hypokalemia, and hypomagnesemia when feeding is restarted in a malnourished patient. * **Hepatobiliary complications:** Cholestasis, steatosis, and cholelithiasis (gallstones) are common with long-term TPN use due to lack of enteral stimulation. * **Trace element deficiency:** Zinc deficiency is common, presenting as perioral dermatitis and alopecia.
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