Urology Practice Questions

Q: In which condition is the Prehn sign typically positive?

Acute epididymitis. ***Acute epididymitis*** - **Prehn sign** is positive when lifting the scrotal sac alleviates pain, as it reduces pressure on the inflamed epididymis. - This sign is commonly used to differentiate **epididymitis** from **testicular torsion**, where pain typically worsens or remains unchanged with elevation. *Chronic epididymitis* - While potentially painful, **chronic epididymitis** usually presents with persistent, dull pain that is less likely to be acutely relieved by scrotal elevation. - The **Prehn sign** is primarily a diagnostic tool for **acute inflammatory conditions** of the epididymis. *Testicular torsion* - In **testicular torsion**, the pain is often sudden, severe, and typically **not relieved** by elevating the testicle; in fact, it may worsen. - This condition is a **surgical emergency** where blood flow to the testicle is compromised. *Acute scrotal pain due to other causes* - Other causes of **acute scrotal pain**, such as **trauma** or **incarcerated hernias**, generally do not exhibit a positive Prehn sign. - The **Prehn sign** is quite specific to the **inflammatory process** of epididymitis affecting pain perception.

Q: Circumcision is contraindicated in

Hypospadias. ***Hypospadias*** - In **hypospadias**, the **urethral opening** is located on the underside of the penis, and the foreskin is **essential** for **reconstructive surgery** (urethroplasty) to correct the defect. - Removing the foreskin via circumcision would eliminate this vital tissue, making surgical repair extremely difficult or impossible. - This is the **most absolute contraindication** to circumcision in pediatric urology. *Balanitis* - **Balanitis** is inflammation of the glans penis, often due to poor hygiene or infection. - Circumcision is actually a **treatment** for recurrent balanitis, not a contraindication. - It represents an **indication** for circumcision, not a contraindication. *Paraphimosis* - **Paraphimosis** is a urological emergency where the retracted foreskin becomes trapped behind the glans, causing vascular compromise. - Immediate management involves manual reduction or dorsal slit procedure. - Once the acute condition is resolved, elective circumcision can be performed to prevent recurrence—**not a contraindication**. *Exstrophy of bladder* - **Bladder exstrophy** is a severe congenital anomaly involving the epispadias-exstrophy complex, where the bladder is exposed outside the body. - The foreskin is typically **preserved for penile reconstruction** during complex staged repairs. - While this is also considered a **contraindication to circumcision** in most cases, **hypospadias** remains the **classic and most absolute contraindication** taught in medical education and is the expected answer for this question.

Q: What is the most reliable diagnostic tool to differentiate between psychological and organic erectile dysfunction?

Nocturnal penile tumescence. ***Nocturnal penile tumescence*** - This diagnostic tool assesses whether a man experiences erections during sleep, which are naturally occurring physiological events. The presence of normal nocturnal erections indicates intact **neurovascular pathways** necessary for erection, suggesting that any daytime erectile dysfunction is likely due to **psychological factors** [2]. - Conversely, the absence of nocturnal erections points towards an **organic cause** for erectile dysfunction, as the physiological mechanism itself is impaired [1]. *Squeeze technique* - The squeeze technique is a behavioral therapy used to treat **premature ejaculation**, not erectile dysfunction. It involves stopping stimulation at the point of impending ejaculation and applying pressure to the glans to reduce arousal. - This technique does not provide any diagnostic information regarding the underlying cause (psychological vs. organic) of erectile dysfunction. *Sildenafil induced erection* - While sildenafil (Viagra) can induce an erection in many men with erectile dysfunction, its response does not reliably differentiate between psychological and organic causes. Sildenafil works by enhancing the effects of **nitric oxide**, leading to increased blood flow to the penis. - Both men with psychological erectile dysfunction and some with organic causes (e.g., mild vascular compromise) may respond to sildenafil, so a positive response does not rule out an **organic etiology**. *PIPE therapy* - "PIPE therapy" is not a recognized medical or diagnostic term for erectile dysfunction. It may be a typo or a misnomer. - Therefore, it does not serve as a diagnostic tool for differentiating between psychological and organic causes of erectile dysfunction.

Q: What are the metabolic consequences of ureterosigmoidostomy?

Hyperchloremic with hypokalemic acidosis. ***Hyperchloremic with hypokalemic acidosis*** - In ureterosigmoidostomy, the reabsorption of urinary constituents like **chloride** and **urea** from the bowel mucosa leads to **hyperchloremia**. - The exchange of **chloride** for **bicarbonate** and the concomitant loss of **potassium** from the colon results in **hypokalemic metabolic acidosis**. *Hyperkalemia* - Colonic reabsorption of urinary products typically causes **potassium wasting** and **hypokalemia**, not hyperkalemia. - While some potassium is reabsorbed, the overall effect due to the exchange for hydrogen ions and fluid loss from the colon is a net decrease in serum potassium. *Metabolic alkalosis* - Metabolic alkalosis involves an increase in **bicarbonate**, which is the opposite of what occurs in ureterosigmoidostomy where bicarbonate is lost. - The increased reabsorption of urea and chloride from the urine in the colon leads to an **acidic state** due to increased **hydrogen ion production** and **bicarbonate depletion**. *Hyponatremia* - Although some **sodium** reabsorption can occur, the primary electrolyte imbalances are related to chloride, potassium, and bicarbonate. - While some intestinal urinary diversion procedures can lead to hyponatremia due to volume changes or syndrome of inappropriate antidiuretic hormone (SIADH), it is not the most characteristic or direct metabolic consequence of ureterosigmoidostomy itself.

Q: What is the first-line intervention for acute symptomatic hydroureter with ureteral obstruction requiring urgent decompression?

Endoscopic ureteral stenting. ***Endoscopic ureteral stenting*** - **Endoscopic ureteral stenting** is the primary intervention for **acute symptomatic ureteral obstruction** requiring urgent decompression when the obstruction causes **hydroureter**. - This minimally invasive procedure provides immediate drainage from the kidney to the bladder, preventing further renal damage, managing pain, and relieving obstruction. - **Indications for urgent stenting** include: infected hydronephrosis, impaired renal function, intractable pain, solitary kidney with obstruction, or bilateral obstruction. - Alternative to stenting is **percutaneous nephrostomy**, particularly when retrograde stent placement fails or in infected systems. *Antibiotic prophylaxis alone* - While antibiotics are essential when infection complicates obstruction (pyonephrosis), **antibiotics alone cannot relieve the mechanical obstruction**. - The physical blockage must be addressed to prevent progressive renal damage and sepsis. *Immediate ureterolithotomy* - **Open ureterolithotomy** is a definitive surgical treatment but is **not first-line** for acute obstruction. - It is more invasive and typically reserved for failed endoscopic management, large impacted stones, or anatomical abnormalities preventing endoscopic access. - Modern approach favors initial decompression followed by definitive treatment (ureteroscopy, ESWL, or surgery). *Urinary alkalization* - **Urinary alkalization** may help dissolve **uric acid stones** over time but does not provide immediate relief of acute obstruction. - This is an adjunctive measure for specific stone types, not an emergency intervention for symptomatic hydroureter.

Q: Which condition is commonly associated with complications arising from phimosis?

Inflammation of the glans and foreskin. ***Inflammation of the glans and foreskin*** - **Phimosis** (the inability to retract the foreskin) can lead to poor hygiene under the foreskin, creating an environment for bacterial or fungal growth. - This often results in **balanitis** (inflammation of the glans) or **balanoposthitis** (inflammation of both the glans and foreskin) due to retained secretions and microorganisms. *Inability to retract the foreskin* - This is the **definition** of phimosis, not a complication arising from it. - While it is the primary characteristic, it directly describes the condition itself rather than a subsequent problem. *Urethral opening on the underside of the penis* - This condition is known as **hypospadias**, a congenital anomaly of the urethra. - Hypospadias is a developmental issue and is unrelated to phimosis or its complications. *Narrowing of the urethral opening* - This condition is called **meatal stenosis** and refers to the narrowing of the external opening of the urethra. - While it can cause urinary symptoms, it is a distinct condition and not a direct complication of phimosis, although severe phimosis might indirectly impact urinary hygiene.

Q: Diversion of urine is best done at

Ileum. ***Ileum*** - The **ileum** is the most commonly used segment for urinary diversion due to its **mobility**, adequate vascular supply, and low complication rates. - Its relatively **low absorptive capacity** for electrolytes, particularly urea and ammonia, minimizes metabolic disturbances. *Jejunum* - The **jejunum** has a high absorptive capacity, which can lead to significant **electrolyte imbalances** (e.g., hypochloremic, hypokalemic metabolic acidosis) when urine is diverted into it. - It is also more prone to **stomal stenosis** and bowel obstruction compared to the ileum. *Colon* - While the colon can be used, particularly in continent diversions, it has a **thicker wall** and can be less mobile, making surgical creation of a conduit more challenging. - Similar to the jejunum, it has a **higher absorptive capacity** than the ileum, which can lead to electrolyte disturbances. *Caecum* - The **caecum** is a possible site for continent urinary diversions (e.g., cecal pouch), but it is not typically used for simple incontinent conduits due to its **anatomical position** and surgical complexity. - Its use often requires additional procedures to ensure continence and prevent reflux.

Q: Which of the following statements is true regarding acute epididymitis?

Typically presents with pain. ***Typically presents with pain*** - **Acute epididymitis** characteristically causes sudden onset of **unilateral scrotal pain**, which can range from mild to severe. - The pain often radiates to the **inguinal area** or lower abdomen and is accompanied by tenderness of the epididymis. *Commonly associated with urinary tract infections* - While acute epididymitis can occur secondary to **UTIs**, especially in older men or those with obstructive uropathy, it is more commonly associated with **sexually transmitted infections (STIs)** in younger, sexually active men [1]. - In children and prepubertal boys, non-bacterial causes or congenital anomalies are more prevalent. *Scrotum size is usually enlarged* - While the **epididymis** itself becomes **swollen** and tender, leading to a palpable mass, the scrotum itself is not typically described as generally enlarged in its overall size. - The swelling is localized to the affected epididymis and sometimes the testicle (epididymo-orchitis). *Can mimic testicular torsion* - Although both conditions present with acute scrotal pain, **epididymitis pain** usually has a more gradual onset, and fever or urinary symptoms may be present. - **Testicular torsion** typically causes sudden, severe pain with an absent or high-riding cremasteric reflex and requires urgent surgical intervention.

Q: Most common site of urethral carcinoma in men is:

Bulbomembranous urethra. ***Bulbomembranous urethra*** - The **bulbomembranous (bulbar) urethra** is the **most common site** of primary urethral carcinoma in men, accounting for approximately **60% of cases**. - This region is lined by **pseudostratified columnar epithelium** and is often associated with **chronic irritation, strictures, or history of sexually transmitted infections**. - The most common histological type in this location is **squamous cell carcinoma**, followed by transitional cell carcinoma. *Penile urethra* - The **penile (anterior) urethra** is the second most common site, accounting for approximately **30% of urethral carcinomas**. - This region is lined by **stratified squamous epithelium**, making it susceptible to squamous cell carcinoma. - Often associated with **urethral strictures** or chronic inflammation. *Prostatic urethra* - The **prostatic urethra** is the **least common site** for primary urethral carcinoma, accounting for only about **10% of cases**. - Cancers in this region are more often **extensions from bladder cancer or prostate cancer** rather than primary urethral tumors. - When primary tumors occur here, they are typically **transitional cell carcinomas** (urothelial carcinomas). *Fossa navicularis* - The **fossa navicularis** is the distal-most portion of the **penile urethra**, not a separate anatomical site. - While it can be affected as part of penile urethral involvement, it is not considered separately in epidemiological data. - Tumors here are typically **well-differentiated squamous cell carcinomas**.

Q: Ectopic ureter may be frequently associated with which of the following conditions?

Paradoxical incontinence. ***Paradoxical incontinence*** - Ectopic ureters in females often insert distal to the external sphincter (e.g., vagina, vestibule), leading to **continuous leakage of urine** despite periods of normal voiding. This is known as paradoxical incontinence, where the bladder fills and empties normally, but urine also constantly dribbles from the ectopic opening. - In males, ectopic ureters usually insert proximal to the external sphincter (e.g., prostatic urethra, seminal vesicle) and therefore rarely cause incontinence but rather present with **ureteral obstruction** or **epididymitis**. *Oliguria* - **Oliguria** refers to a decreased urine output and is typically associated with **renal failure**, dehydration, or severe obstruction, not directly or frequently with an ectopic ureter itself. - An ectopic ureter may cause obstruction leading to **hydronephrosis** or renal damage, which could eventually lead to oliguria, but it is not the immediate or frequent direct association. *Dysuria* - **Dysuria** means painful urination, most commonly associated with **urinary tract infections (UTIs)**, urethritis, or bladder inflammation. - While an ectopic ureter can predispose to UTIs, dysuria is a symptom of infection rather than a direct, frequent consequence of the anatomical anomaly itself. *Bilateral hydroureter* - **Bilateral hydroureter** suggests obstruction of both ureters, often at the level of the bladder or urethra, or a systemic condition affecting both kidneys. - An ectopic ureter is usually a unilateral anomaly, causing **unilateral hydroureter** if it is obstructed, not typically bilateral.

Question 1

In which condition is the Prehn sign typically positive?

Accepted Answer

Acute epididymitis

Answer

Chronic epididymitis

Answer

Testicular torsion

Answer

Acute scrotal pain due to other causes

Question 2

Circumcision is contraindicated in

Accepted Answer

Hypospadias

Answer

Paraphimosis

Answer

Exostrophy of bladder

Answer

Balanitis

Question 3

What is the most reliable diagnostic tool to differentiate between psychological and organic erectile dysfunction?

Accepted Answer

Nocturnal penile tumescence

Answer

PIPE therapy

Answer

Sildenafil induced erection

Answer

Squeeze technique

Question 4

What are the metabolic consequences of ureterosigmoidostomy?

Accepted Answer

Hyperchloremic with hypokalemic acidosis

Answer

Hyperkalemia

Answer

Metabolic alkalosis

Answer

Hyponatremia

Question 5

What is the first-line intervention for acute symptomatic hydroureter with ureteral obstruction requiring urgent decompression?

Accepted Answer

Endoscopic ureteral stenting

Answer

Antibiotic prophylaxis alone

Answer

Immediate ureterolithotomy

Answer

Urinary alkalization

Question 6

Which condition is commonly associated with complications arising from phimosis?

Accepted Answer

Inflammation of the glans and foreskin

Answer

Inability to retract the foreskin

Answer

Urethral opening on the underside of the penis

Answer

Narrowing of the urethral opening

Question 7

Diversion of urine is best done at

Accepted Answer

Ileum

Answer

Jejunum

Answer

Colon

Answer

Caecum

Question 8

Which of the following statements is true regarding acute epididymitis?

Accepted Answer

Typically presents with pain

Answer

Commonly associated with urinary tract infections

Answer

Scrotum size is usually enlarged

Answer

Can mimic testicular torsion

Question 9

Most common site of urethral carcinoma in men is:

Accepted Answer

Bulbomembranous urethra

Answer

Prostatic urethra

Answer

Fossa navicularis

Answer

Penile urethra

Question 10

Ectopic ureter may be frequently associated with which of the following conditions?

Accepted Answer

Paradoxical incontinence

Answer

Dysuria

Answer

Bilateral hydroureter

Answer

Oliguria

Urology — MCQs

Urology — MCQs

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