Urology Practice Questions

Q: A man is brought to the emergency after he fell into a man hole and injured his perineum. He feels the urge to micturate but is unable to pass urine and there is blood at the tip of the meatus with extensive swelling of the penis and scrotum. What is the location of the injury?

Bulbar urethra. ***Bulbar urethra*** - Injury to the **bulbar (spongy) urethra** in the perineum, often from a straddle injury or fall into a manhole, typically causes the extravasation of urine and blood into the **superficial perineal pouch**. - This leads to **extensive swelling of the penis and scrotum** (butterfly hematoma) because the superficial perineal fascia (Colles' fascia) is continuous with dartos fascia of the penis and scrotum, preventing blood from extending into the thighs or abdominal wall, combined with an inability to micturate with blood at the meatus. *Membranous urethra* - Injury to the **membranous urethra** is usually associated with **pelvic fractures** and tends to cause extravasation into the **deep perineal space** and then the retroperitoneum, leading to swelling in the lower abdomen or around the anus, not primarily the penis and scrotum. - While it can cause inability to micturate and blood at the meatus, the characteristic extensive swelling of the penis and scrotum points away from this location. *Prostatic urethra* - Injuries to the **prostatic urethra** are rare and typically occur with **severe pelvic crush injuries** given its protected position deep within the pelvis. - While it would cause inability to urinate, the nature of the fall and the distribution of swelling (predominantly penis and scrotum) are not typical for prostatic urethral injury. *Bladder* - A bladder injury from a fall would likely present with suprapubic pain and hematuria, but the inability to urinate combined with **blood at the meatus** and extensive swelling limited to the penis and scrotum is not characteristic of isolated bladder trauma. - **Blood at the meatus** is a classic sign of urethral, not typically bladder, injury.

Q: A 70-year-old male presents with difficulty urinating. Examination reveals a mass in the pelvis. Which structure is most likely to be enlarged?

Prostate. ***Prostate*** - In a 70-year-old male presenting with **difficulty urinating** and a pelvic mass, an enlarged prostate is the most likely cause. This is indicative of **benign prostatic hyperplasia (BPH)**, a common condition in older men. - The enlarged prostate can compress the **urethra**, leading to symptoms like **urinary hesitancy, weak stream, nocturia, and incomplete bladder emptying** [1]. *Bladder* - While bladder distension can occur secondary to **urinary outflow obstruction**, the bladder itself is not typically the structure that *enlarges* as the primary cause of the obstruction in this scenario. - A palpable bladder mass would usually indicate a **distended bladder** due to urinary retention rather than a primary bladder enlargement causing the obstruction. *Seminal vesicle* - Enlargement of the seminal vesicles is generally **not associated with urinary obstruction** and is usually asymptomatic unless there is inflammation or a rare malignancy. - The seminal vesicles are located posterior to the bladder and do not typically exert pressure on the urethra in a way that causes significant urinary symptoms or a palpable pelvic mass in the context of voiding difficulty. *Urethra* - The urethra is a **tube-like structure**; it does not "enlarge" to form a mass in the pelvis. - Instead, the urethra can be **compressed or strictured**, leading to obstruction, but its anatomical structure prevents it from forming a palpable mass.

Q: A 45-year-old man presents with gross hematuria and a palpable abdominal mass. A CT scan reveals a renal mass with metastasis to the lungs. What is the most appropriate treatment strategy for this patient?

Total nephrectomy and immunotherapy. **Total nephrectomy and immunotherapy** - The presence of a **palpable abdominal mass**, gross hematuria, and **pulmonary metastases** indicates advanced renal cell carcinoma, making **total nephrectomy** essential for tumor burden reduction. - **Immunotherapy** (e.g., PD-1 inhibitors) is the first-line systemic treatment for metastatic renal cell carcinoma, offering improved survival outcomes compared to traditional chemotherapy. *Partial nephrectomy and radiation therapy* - **Partial nephrectomy** is typically reserved for smaller, localized renal masses to preserve renal function, which is not indicated in the presence of **metastatic disease**. - **Radiation therapy** has a limited role in the primary treatment of renal cell carcinoma and is mostly used for **palliative care** for bone or brain metastases, not as a primary treatment for the renal tumor. *Transplantation with immunosuppression* - **Kidney transplantation** is only considered in patients with end-stage renal disease (ESRD) and no malignancy, or in highly selected cases of small, localized renal tumors in the explanted kidney, not for **metastatic cancer**. - **Immunosuppression** in the context of transplantation would actually be detrimental in a patient with metastatic cancer as it could accelerate tumor growth. *Chemotherapy only* - **Renal cell carcinoma** is notoriously **chemotherapy-resistant**, making it ineffective as a primary treatment for metastatic disease. - Targeted therapies or **immunotherapy** have largely replaced chemotherapy in the management of advanced renal cell carcinoma due to superior efficacy.

Q: A 70-year-old woman presents with recurrent urinary tract infections and a palpable pelvic mass. An ultrasound shows a large, irregular mass on the anterior wall of the bladder. What is the most likely diagnosis?

Bladder cancer. ***Bladder cancer*** - The combination of **recurrent UTIs**, a **palpable pelvic mass**, and an **irregular mass on the anterior bladder wall** on ultrasound is highly suggestive of bladder cancer, which can present with these non-specific symptoms. - Bladder cancer is more common in older individuals and can lead to symptoms like recurrent infections due to compromised bladder integrity or obstruction. *Uterine fibroids* - While uterine fibroids can present as a **pelvic mass**, they typically arise from the **uterus**, not the bladder wall. - They are less likely to cause recurrent UTIs unless they are very large and compress the bladder or ureters. *Cystocele* - A cystocele is a **prolapse of the bladder** into the vagina, manifesting as a bulge or pressure, not typically an irregular mass *on* the bladder wall seen on ultrasound. - While it can cause recurrent UTIs due to incomplete bladder emptying, the description of an "irregular mass" points away from this condition. *Bladder diverticulum* - A bladder diverticulum is an **outpouching of the bladder wall**, which can be congenital or acquired. - While it can be associated with recurrent UTIs due to urinary stasis, it is generally a **smooth-walled pouch** and not typically described as a large, "irregular mass" on the anterior bladder wall, which suggests a solid or infiltrative lesion.

Q: A 45-year-old man presents with a painless, enlarged scrotum. The transillumination test reveals a cystic mass. What is the most likely diagnosis?

Hydrocele. ***Hydrocele*** - A **hydrocele** is a collection of fluid in the **tunica vaginalis**, which typically presents as a **painless, enlarged scrotum** that transilluminates. - The **transillumination test** is positive because the fluid within the hydrocele allows light to pass through. *Inguinal hernia* - An **inguinal hernia** usually presents as a scrotal swelling that does not transilluminate and may be **reducible**. - It involves the protrusion of abdominal contents, not fluid, into the scrotum. *Varicocele* - A **varicocele** is an enlargement of the **pampiniform plexus veins** within the scrotum, often described as feeling like a "bag of worms." - It does not transilluminate and is more commonly associated with a dull ache or heaviness, and can be associated with infertility. *Testicular torsion* - **Testicular torsion** is an acute, painful condition caused by the twisting of the **spermatic cord**, leading to inadequate blood flow to the testis. - It is characterized by sudden, severe pain and tenderness, and is a medical emergency that does not transilluminate.

Q: A 30-year-old male presents with an acute onset of severe scrotal pain. The scrotum is swollen and tender. What is the most likely diagnosis?

Testicular torsion. ***Testicular torsion*** - The sudden onset of **severe scrotal pain** in a young male, accompanied by **swelling and tenderness**, is highly suggestive of testicular torsion. - Testicular torsion is a **surgical emergency** requiring prompt intervention to preserve testicular viability. *Epididymitis* - While epididymitis also causes scrotal pain and swelling, its onset is typically more **gradual** and is often associated with **dysuria or fever**. - Physical examination may reveal a **positive Prehn's sign** (pain relief with elevation of the testicle), which is usually absent in torsion. *Hydrocele* - A hydrocele is a collection of fluid around the testis, usually presenting as a **painless scrotal swelling** that can be transilluminated. - It does not typically cause acute, severe pain unless it becomes infected or acutely enlarges due to trauma. *Inguinal hernia* - An inguinal hernia can cause scrotal swelling, but the pain is often described as a **dull ache** or a feeling of heaviness, especially with straining, rather than acute severe pain. - A hernia typically presents as a **reducible mass** that may extend into the scrotum.

Q: A young male presents with a painless testicular mass suspicious for germ cell tumor. Which of the following tumor markers would be most useful for initial evaluation?

Alpha-Fetoprotein (AFP). ***Alpha-Fetoprotein (AFP)*** - **AFP** is a key tumor marker in **germ cell tumors**, particularly in **non-seminomatous** testicular tumors such as **yolk sac tumors** [1]. - It is often elevated in patients with a **painless testicular mass**, aiding in the diagnosis and management of these tumors [1]. *CA-125* - **CA-125** is primarily used as a tumor marker for **ovarian cancer** rather than testicular tumors, making it less relevant here. - It is often elevated in **pelvic inflammatory disease** and **endometriosis**, not specific to male genital tract tumors. *Carcinoembryonic Antigen (CEA)* - **CEA** is mostly associated with **colorectal** and **lung cancers**, and is not typically involved in testicular tumor diagnosis [1]. - While it may have some role in gastrointestinal malignancies, it does not serve as a useful marker for **testicular masses** [2]. *Prostate-Specific Antigen (PSA)* - **PSA** is specific for **prostate disorders**, including cancer, but does not provide relevant information for testicular tumors [1] [2]. - Its elevation is indicative of conditions related to the **prostate gland**, which is not involved in the context of a testicular mass [2].

Q: Which type of renal stone is known to have less satisfactory results with extracorporeal shock wave lithotripsy (ESWL)?

Cystine stone. ***Cystine stone*** - **Cystine stones** are known for their high **elasticity** and durable molecular bonds, making them resistant to fragmentation by **extracorporeal shock wave lithotripsy (ESWL)**. - Their physical properties result in **less satisfactory fragmentation rates** compared to other stone types, often requiring multiple ESWL sessions or alternative treatments. *Oxalate stone* - **Calcium oxalate stones** are generally **amenable to ESWL**, especially smaller ones, as they tend to fragment well. - They are the **most common type of kidney stone**, and ESWL is a primary treatment modality for many of these. *Phosphate stone* - **Calcium phosphate stones** (e.g., brushite, apatite) and **struvite stones** also tend to respond reasonably well to ESWL. - While sometimes harder than oxalate stones, they usually **fragment effectively** with shock waves. *Urate stone* - **Uric acid stones** are typically **radiolucent** but generally respond well to ESWL, often fragmenting into small pieces. - They can also be dissolved with **urinary alkalinization**, which is a unique therapeutic option for this stone type.

Q: Radical nephrectomy involves resection of the following structures, which one is not typically resected?

Proximal para-aortic lymph nodes. ***Proximal para-aortic lymph nodes*** - **Proximal para-aortic lymph nodes** are NOT routinely resected during radical nephrectomy unless there is evidence of gross nodal involvement on imaging or intraoperatively. - The extent of lymph node dissection is tailored to individual disease burden; hilar and regional nodes are addressed, but distant nodal groups like proximal para-aortic nodes are only resected when clearly involved. - Extended lymphadenectomy to proximal para-aortic regions is not part of standard radical nephrectomy. *Gerota's fascia* - **Gerota's fascia** (perirenal fascia) is **always resected** in radical nephrectomy as it encases the kidney and perirenal fat. - En bloc resection of Gerota's fascia with the kidney ensures complete tumor removal, clear margins, and prevents tumor spillage. - This is a defining component of "radical" versus "simple" nephrectomy. *Ipsilateral adrenal gland (in classical approach)* - In **classical radical nephrectomy** (Campbell-Walsh traditional description), the ipsilateral adrenal gland was routinely removed due to proximity and concern for tumor extension. - **Modern practice** has shifted to adrenal-sparing nephrectomy as the standard, with adrenalectomy reserved for upper pole tumors with direct invasion, bulky tumors, or imaging abnormalities. - For this question's context of "classical radical nephrectomy," the adrenal gland **IS typically resected** in the traditional approach. *Surrounding hilar lymph nodes* - **Hilar lymph nodes** are routinely resected during radical nephrectomy for staging and regional disease control. - These nodes are the first-line lymphatic drainage sites and their removal is integral to proper oncologic surgery. - Hilar lymphadenectomy is a standard component of radical nephrectomy.

Question 1

A man is brought to the emergency after he fell into a man hole and injured his perineum. He feels the urge to micturate but is unable to pass urine and there is blood at the tip of the meatus with extensive swelling of the penis and scrotum. What is the location of the injury?

Accepted Answer

Bulbar urethra

Answer

Membranous urethra

Answer

Prostatic urethra

Answer

Bladder

Question 2

A 10-year-old boy came to emergency with complaints of severe pain in right scrotum that is not relieved for the past 1 hour. On examination, testicular torsion of the right side is suspected. The surgical intervention should be:

Accepted Answer

Immediate exploration of the affected side and operate opposite side even if asymptomatic

Answer

Delayed exploration on the affected side along with the opposite side even if asymptomatic

Answer

Immediate scrotal exploration of the affected side and operate opposite side if symptomatic

Answer

Delay exploration and operate opposite side if symptomatic

Question 3

A 70-year-old male presents with difficulty urinating. Examination reveals a mass in the pelvis. Which structure is most likely to be enlarged?

Accepted Answer

Prostate

Answer

Bladder

Answer

Seminal vesicle

Answer

Urethra

Question 4

A 45-year-old man presents with gross hematuria and a palpable abdominal mass. A CT scan reveals a renal mass with metastasis to the lungs. What is the most appropriate treatment strategy for this patient?

Accepted Answer

Total nephrectomy and immunotherapy

Answer

Partial nephrectomy and radiation therapy

Answer

Transplantation with immunosuppression

Answer

Chemotherapy only

Question 5

A 70-year-old woman presents with recurrent urinary tract infections and a palpable pelvic mass. An ultrasound shows a large, irregular mass on the anterior wall of the bladder. What is the most likely diagnosis?

Accepted Answer

Bladder cancer

Answer

Uterine fibroids

Answer

Cystocele

Answer

Bladder diverticulum

Question 6

A 45-year-old man presents with a painless, enlarged scrotum. The transillumination test reveals a cystic mass. What is the most likely diagnosis?

Accepted Answer

Hydrocele

Answer

Inguinal hernia

Answer

Varicocele

Answer

Testicular torsion

Question 7

A 30-year-old male presents with an acute onset of severe scrotal pain. The scrotum is swollen and tender. What is the most likely diagnosis?

Accepted Answer

Testicular torsion

Answer

Epididymitis

Answer

Hydrocele

Answer

Inguinal hernia

Question 8

A young male presents with a painless testicular mass suspicious for germ cell tumor. Which of the following tumor markers would be most useful for initial evaluation?

Accepted Answer

Alpha-Fetoprotein (AFP)

Answer

Prostate-Specific Antigen (PSA)

Answer

Carcinoembryonic Antigen (CEA)

Answer

β-hCG (beta-human chorionic gonadotropin)

Question 9

Which type of renal stone is known to have less satisfactory results with extracorporeal shock wave lithotripsy (ESWL)?

Accepted Answer

Cystine stone

Answer

Oxalate stone

Answer

Phosphate stone

Answer

Urate stone

Question 10

Radical nephrectomy involves resection of the following structures, which one is not typically resected?

Accepted Answer

Proximal para-aortic lymph nodes

Answer

Gerota's fascia

Answer

Surrounding hilar lymph nodes

Answer

Ipsilateral adrenal gland (in classical approach)

Urology — MCQs

Urology — MCQs

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