Urology — MCQs

Urology Indian Medical PG Practice Questions and MCQs

Question 681: Which of the following is NOT an obstructive cause of acute renal failure?

A. Bilharzia
B. Duplex ureter (Correct Answer)
C. Retroperitoneal fibrosis
D. Renal calculi

Explanation: **Explanation:** Acute Renal Failure (ARF), or Acute Kidney Injury (AKI), can be classified into pre-renal, intrinsic renal, and post-renal (obstructive) causes. Post-renal ARF occurs when there is a physical blockage to the flow of urine, leading to increased retrograde pressure and decreased GFR. **Why Duplex Ureter is the correct answer:** A **Duplex Ureter** is a congenital anatomical variation where the kidney has two separate ureters. While it can be associated with complications like vesicoureteral reflux (VUR) or ureteroceles, the presence of a double ureter itself does **not** cause obstruction or renal failure. It is an anatomical anomaly rather than an obstructive pathology. **Analysis of Incorrect Options (Obstructive Causes):** * **Bilharzia (Schistosomiasis):** Chronic infection by *Schistosoma haematobium* leads to inflammation and fibrosis of the ureteric walls (ureteritis cystica) and bladder, causing strictures and obstructive uropathy. * **Retroperitoneal Fibrosis (Ormond’s Disease):** This condition involves the proliferation of fibrous tissue in the retroperitoneum, which characteristically encases and compresses the ureters medially, leading to bilateral obstruction. * **Renal Calculi:** Stones lodged in the ureter or renal pelvis are the most common cause of acute post-renal obstruction. Bilateral calculi or a stone in a solitary kidney can precipitate acute renal failure. **Clinical Pearls for NEET-PG:** * **Post-renal ARF** typically requires bilateral obstruction (or unilateral obstruction in a patient with a single functioning kidney) to cause a significant rise in serum creatinine. * **Retroperitoneal Fibrosis** is often idiopathic but can be associated with drugs like **Methysergide** or Ergotamine. * On imaging, retroperitoneal fibrosis classically causes **medial deviation** of the ureters.

Question 682: Mucus strings in urine are suggestive of:

A. Urethritis
B. Cystitis
C. Prostatitis (Correct Answer)
D. Pyelonephritis

Explanation: **Explanation:** The presence of **mucus strings** (also known as "shreds" or "Furbringer's crystals") in the urine is a classic clinical sign of **Chronic Prostatitis**. **Why Prostatitis is correct:** In chronic prostatitis, the prostatic ducts become inflamed and congested. This leads to the accumulation of inflammatory exudate, desquamated epithelial cells, and prostatic secretions within the ducts. When the patient voids, especially during the initial part of the stream or after prostatic massage, these accumulated secretions are flushed out as elongated, thread-like structures known as mucus strings. These are highly characteristic of chronic prostatic inflammation. **Why other options are incorrect:** * **Urethritis:** Typically presents with a purulent or mucoid urethral discharge and pyuria (pus cells), but not organized mucus strings. * **Cystitis:** Characterized by frequency, urgency, and dysuria. While the urine may appear cloudy due to bacteria and WBCs, mucus strings are not a hallmark feature. * **Pyelonephritis:** This is an upper urinary tract infection. It typically presents with systemic symptoms (fever, chills), flank pain, and **WBC casts** in the urine, rather than mucus strings. **Clinical Pearls for NEET-PG:** * **Stamey-Meares Test (4-glass test):** The gold standard for localizing the site of infection in prostatitis. * **Prostatic Massage:** Contraindicated in *Acute* Prostatitis (risk of bacteremia) but used in *Chronic* Prostatitis to obtain expressed prostatic secretions (EPS). * **Common Organism:** *E. coli* is the most common cause of bacterial prostatitis. * **Key differentiator:** Remember, **Casts** suggest renal origin (Pyelonephritis), while **Strings/Shreds** suggest prostatic origin.

Question 683: Which of the following does not occur in unilateral renal trauma?

A. Hypertension
B. Uraemia (Correct Answer)
C. Clot formation
D. Perinephric haematoma

Explanation: **Explanation:** The correct answer is **Uraemia (Option B)**. **Why Uraemia does not occur:** Uraemia (elevated blood urea and creatinine) is a clinical manifestation of renal failure. In the case of **unilateral** renal trauma, the contralateral (opposite) kidney is typically healthy and functioning. A single normal kidney possesses sufficient reserve capacity (approximately 50% of total nephron mass) to maintain effective glomerular filtration and electrolyte balance. Therefore, as long as one kidney remains functional, systemic uraemia will not develop. Uraemia in trauma suggests either bilateral renal injury, injury to a solitary kidney, or pre-existing chronic kidney disease. **Analysis of Incorrect Options:** * **Hypertension (Option A):** Can occur due to the "Page Kidney" phenomenon, where a subcapsular or perinephric hematoma compresses the renal parenchyma, leading to activation of the Renin-Angiotensin-Aldosterone System (RAAS) due to ischemia. * **Clot formation (Option C):** Hematuria is a hallmark of renal trauma. Blood in the collecting system or ureter can form clots, which may lead to "clot colic" (ureteric obstruction). * **Perinephric haematoma (Option D):** This is a common finding in blunt renal trauma (Grades II-V) where bleeding occurs into the retroperitoneal space between the renal capsule and Gerota’s fascia. **High-Yield Clinical Pearls for NEET-PG:** * **Most common organ injured** in blunt abdominal trauma is the Spleen; however, the **Kidney** is the most common organ injured in the genitourinary system. * **Gold Standard Investigation:** Contrast-Enhanced CT (CECT) is the investigation of choice for stable patients with suspected renal trauma. * **Management:** Most renal injuries (Grades I-III and many Grade IV) are managed conservatively. Absolute indications for surgery include hemodynamic instability or an expanding/pulsatile hematoma.

Question 684: A 67-year-old chronic heavy smoker presents with a 2-week history of frank hematuria. Ultrasound of the pelvis shows a filling defect. What is the most probable diagnosis?

A. Bladder diverticula
B. Adenocarcinoma of the bladder
C. Squamous cell carcinoma of the bladder
D. Transitional cell carcinoma of the bladder (Correct Answer)

Explanation: **Explanation:** The clinical presentation of **painless frank hematuria** in an elderly male with a significant **smoking history** is the classic triad for **Transitional Cell Carcinoma (TCC)**, also known as Urothelial Carcinoma. 1. **Why TCC is correct:** TCC is the most common primary malignancy of the urinary bladder (accounting for >90% of cases). Smoking is the most significant risk factor, increasing the risk 3–4 fold due to alpha and beta-naphthylamines. On imaging (Ultrasound or CT), a bladder tumor typically appears as a **fixed filling defect** or an intraluminal mass. 2. **Why other options are incorrect:** * **Bladder Diverticula:** These are outpouchings of the bladder wall. While they can cause urinary stasis or stones, they do not typically present with frank hematuria unless complicated by a tumor within the diverticulum. * **Adenocarcinoma:** This is rare (<2% of bladder cancers). It is usually associated with urachal remnants (at the dome of the bladder) or cystitis glandularis. * **Squamous Cell Carcinoma (SCC):** This accounts for ~5% of cases. It is strongly associated with **chronic irritation**, such as Schistosomiasis (common in Egypt), long-term indwelling catheters, or chronic bladder stones, rather than smoking alone. **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Cystoscopy with biopsy is the definitive diagnostic tool. * **Most common site:** Lateral walls of the bladder. * **Field Change Effect:** The entire urothelium (from renal pelvis to urethra) is at risk; therefore, patients with bladder TCC need evaluation of the upper tracts. * **Occupational Risks:** Exposure to arylamines in rubber, dye, and leather industries.

Question 685: What is the most common type of hypospadias?

A. Glandular (Correct Answer)
B. Penile
C. Scrotal
D. Perineal

Explanation: **Explanation:** Hypospadias is a congenital anomaly characterized by the failure of the urethral folds to fuse, resulting in the urethral meatus opening on the ventral aspect of the penis. **Why Glandular is correct:** Hypospadias is classified based on the anatomical location of the ectopic meatus. Statistically, the most common types are the **distal varieties**, which account for approximately **65-70%** of all cases. Among these, the **glandular (coronal)** type is the most frequent. In this form, the opening is located on the glans penis or at the coronal sulcus. **Analysis of Incorrect Options:** * **B. Penile:** These are intermediate types (mid-shaft) and are less common than distal varieties. * **C. & D. Scrotal and Perineal:** These are classified as **proximal hypospadias**. While they are the most severe forms and often associated with significant chordee (ventral curvature) and bifid scrotum, they are the least common, representing only about 10-15% of cases. **Clinical Pearls for NEET-PG:** * **Triad of Hypospadias:** Ectopic urethral meatus, Chordee (ventral curvature), and Hooded prepuce (deficient ventral foreskin). * **Contraindication:** Circumcision is **strictly contraindicated** in newborns with hypospadias because the prepuce is required for future surgical reconstruction (urethroplasty). * **Ideal Age for Surgery:** Usually performed between **6 to 12 months** of age. * **Associated Anomalies:** Cryptorchidism (undescended testis) and inguinal hernias are the most common associated findings. If a patient has hypospadias and undescended testes, a workup for Disorders of Sex Development (DSD) is mandatory.

Question 686: When a horseshoe kidney develops, the ascent of the kidney is restricted by which structure?

A. Internal iliac artery
B. External iliac artery
C. Common iliac artery
D. Inferior mesenteric artery (Correct Answer)

Explanation: **Explanation:** **1. Why the Inferior Mesenteric Artery (IMA) is correct:** Horseshoe kidney is the most common renal fusion anomaly. It occurs when the lower poles of the kidneys fuse across the midline, forming a "parenchymal isthmus." During embryogenesis, the kidneys originate in the pelvis and normally ascend to the lumbar region (T12–L3). In a horseshoe kidney, as the fused organ ascends, the **isthmus** gets trapped by the **Inferior Mesenteric Artery (IMA)**, which arises from the aorta at the level of **L3**. This prevents the kidney from reaching its normal adult position, resulting in an ectopic, lower-lying kidney. **2. Why the incorrect options are wrong:** * **Internal, External, and Common Iliac Arteries (A, B, C):** These vessels are located more inferiorly in the pelvis. While the kidneys pass these vessels during the very early stages of ascent, they do not act as a definitive anatomical barrier to the isthmus. The ascent is only halted when the isthmus meets the IMA, which acts as a "hook" over the midline bridge. **3. High-Yield Clinical Pearls for NEET-PG:** * **Isthmus Position:** Usually lies anterior to the aorta and IVC at the level of L3–L5. * **Ureteric Course:** Ureters pass **anterior** to the isthmus, often leading to high insertion points and a risk of **Pelviureteric Junction (PUJ) obstruction**. * **Associated Risks:** Increased incidence of nephrolithiasis (due to stasis), urinary tract infections, and a specific predisposition to **Wilms tumor** (in children) and **Renal Cell Carcinoma**. * **Vascularity:** The blood supply is highly anomalous, often receiving multiple branches directly from the aorta or common iliacs. * **Radiology:** On IVP, the characteristic finding is the **"Handshaking sign"** (lower poles pointing medially).

Question 687: Moure's sign is seen in which of the following conditions?

A. Carcinoma (Correct Answer)
B. Appendicitis
C. Varicose vein
D. Pancreatitis

Explanation: **Explanation:** **Moure’s sign** (also known as the "click sign") is a clinical sign used in the evaluation of **laryngeal or hypopharyngeal carcinoma**. It refers to the loss of the normal **post-cricoid crepitus**. In a healthy individual, when the larynx is moved laterally across the cervical spine, a palpable "click" or grating sensation is felt as the cricoid cartilage rubs against the vertebrae. In cases of malignancy involving the post-cricoid region or the posterior pharyngeal wall, the tumor mass acts as a "cushion," separating the larynx from the spine and causing this crepitus to disappear. Therefore, a **negative Moure’s sign** (loss of crepitus) is highly suggestive of a space-occupying lesion like carcinoma. **Analysis of Incorrect Options:** * **Appendicitis:** Associated with signs like McBurney’s point tenderness, Rovsing’s sign, Psoas sign, and Obturator sign. * **Varicose Veins:** Associated with signs like Trendelenburg test, Perthes test, and Fegan’s sign. * **Pancreatitis:** Associated with signs of retroperitoneal hemorrhage such as Cullen’s sign (periumbilical ecchymosis) and Grey Turner’s sign (flank ecchymosis). **High-Yield Clinical Pearls for NEET-PG:** * **Moure’s Sign:** Specifically associated with **Post-cricoid Carcinoma** (often seen in females with long-standing Plummer-Vinson syndrome). * **Trotter’s Triad:** Associated with Nasopharyngeal Carcinoma (conductive deafness, palatal paralysis, and trigeminal neuralgia). * **Boyce’s Sign:** Gurgling sound on pressing the neck in Zenker’s Diverticulum. * **Milian’s Ear Sign:** Helps differentiate Erysipelas (involves pinna) from Cellulitis (spares pinna).

Question 688: Imatinib mesylate, used in the treatment of GIST, is an inhibitor of which of the following?

A. IL-12
B. TNF-alpha
C. Tyrosine kinase (Correct Answer)
D. VEGF

Explanation: **Explanation:** **Imatinib mesylate** is a revolutionary targeted therapy that acts as a selective **Tyrosine Kinase Inhibitor (TKI)**. In the context of Gastrointestinal Stromal Tumors (GIST), it specifically targets the **KIT (CD117)** proto-oncogene, which encodes a type II receptor tyrosine kinase. In most GIST cases, a gain-of-function mutation leads to constitutive activation of this receptor, driving uncontrolled cell proliferation. Imatinib binds to the ATP-binding site of the kinase domain, effectively "switching off" the signaling pathway. **Analysis of Options:** * **Option A (IL-12):** Interleukin-12 is a cytokine involved in T-cell differentiation. Inhibitors like Ustekinumab target IL-12/IL-23 and are used in Psoriasis/Crohn’s disease, not GIST. * **Option B (TNF-alpha):** Tumor Necrosis Factor-alpha inhibitors (e.g., Infliximab, Adalimumab) are used in inflammatory conditions like Rheumatoid Arthritis and IBD. * **Option D (VEGF):** Vascular Endothelial Growth Factor inhibitors (e.g., Bevacizumab) target angiogenesis. While some TKIs (like Sunitinib) have anti-VEGF activity, Imatinib’s primary mechanism in GIST is KIT and PDGFR inhibition. **High-Yield Clinical Pearls for NEET-PG:** * **GIST Marker:** The most sensitive and specific marker for GIST is **CD117 (c-KIT)**. **DOG1** is another highly specific marker. * **Other Indications:** Imatinib is also the first-line treatment for **Chronic Myeloid Leukemia (CML)**, where it targets the **BCR-ABL** tyrosine kinase (Philadelphia chromosome). * **Resistance:** If a GIST patient becomes resistant to Imatinib, the second-line drug of choice is **Sunitinib**, followed by **Regorafenib**. * **Origin:** GIST arises from the **Interstitial Cells of Cajal (ICC)**, the pacemakers of the GI tract.

Question 689: Carcinoma of the penis is rarest among which population group?

A. Americans
B. Indians
C. Swedes
D. Jews (Correct Answer)

Explanation: **Explanation:** The correct answer is **Jews**. The rarity of penile carcinoma in this population is attributed to the practice of **neonatal circumcision**. **1. Why Jews?** Penile carcinoma is strongly associated with chronic irritation caused by **smegma** (a byproduct of desquamated epithelial cells and bacteria) accumulating under the prepuce in uncircumcised males. Smegma acts as a potential carcinogen. In the Jewish community, ritual circumcision (Brit Milah) is performed on the **8th day of life**. Early circumcision prevents the accumulation of smegma and significantly reduces the risk of Human Papillomavirus (HPV) infection (specifically types 16 and 18), which are major risk factors for the disease. **2. Why other options are incorrect:** * **Americans and Swedes:** While these populations have lower incidences compared to developing nations, circumcision is not universal or performed as early as in the Jewish faith. In these regions, the incidence is roughly 1 per 100,000. * **Indians:** India has a higher incidence of penile cancer, particularly in rural areas where hygiene may be poor and circumcision is not a routine practice among the majority population. **High-Yield Clinical Pearls for NEET-PG:** * **Protective Factor:** Circumcision is only protective if performed in **neonatal life/infancy**. Circumcision performed in adulthood does not provide the same level of protection against penile cancer. * **Risk Factors:** Phimosis (present in ~25-75% of cases), HPV 16 & 18, smoking, and poor hygiene. * **Premalignant Lesions:** Erythroplasia of Queyrat (on the glans), Bowen’s disease (on the shaft), and Balanitis Xerotica Obliterans (BXO). * **Most Common Histology:** Squamous Cell Carcinoma (SCC). * **Lymphatic Spread:** Usually follows a step-wise pattern to the **superficial inguinal nodes** first.

Question 690: Sipuleucel-T is a vaccine indicated for which condition?

A. Renal cell carcinoma
B. Testicular tumor
C. Prostate carcinoma (Correct Answer)
D. Bladder carcinoma

Explanation: **Explanation:** **Sipuleucel-T** is a revolutionary immunotherapy, specifically an **autologous cellular immunotherapy**, used in the management of advanced prostate cancer. **Why Prostate Carcinoma is Correct:** Sipuleucel-T is the first "cancer vaccine" approved by the FDA for the treatment of **asymptomatic or minimally symptomatic metastatic castrate-resistant prostate cancer (mCRPC)**. The process involves collecting a patient's own peripheral blood mononuclear cells (including antigen-presenting cells) via leukapheresis. These cells are activated ex-vivo with a recombinant fusion protein (PA2024) consisting of **Prostatic Acid Phosphatase (PAP)** linked to Granulocyte-Macrophage Colony-Stimulating Factor (GM-CSF). When re-infused, these "primed" cells stimulate a T-cell immune response against prostate cancer cells expressing PAP. **Why Other Options are Incorrect:** * **Renal Cell Carcinoma (RCC):** While RCC is highly immunogenic, standard immunotherapies involve Tyrosine Kinase Inhibitors (TKIs) or Checkpoint Inhibitors (Nivolumab/Pembrolizumab), not Sipuleucel-T. * **Testicular Tumor:** These are primarily treated with surgery (Radical Orchidectomy) and platinum-based chemotherapy (BEP regimen). * **Bladder Carcinoma:** Intravesical BCG is the standard immunotherapy for non-muscle invasive bladder cancer; Sipuleucel-T has no role here. **High-Yield Clinical Pearls for NEET-PG:** * **Indication:** Metastatic Castrate-Resistant Prostate Cancer (mCRPC) that is asymptomatic/minimally symptomatic. * **Target Antigen:** Prostatic Acid Phosphatase (PAP). * **Mechanism:** Active cellular immunotherapy (not a preventive vaccine). * **Survival:** It has been shown to improve overall survival (OS) but does not typically result in a decrease in PSA levels or tumor shrinkage on imaging.

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Renal Cell Carcinoma

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Urology — MCQs

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