Urology Practice Questions

Q: A patient presents with urinary symptoms due to benign prostatic hyperplasia. Which of the following is used to manage the urinary symptoms in the initial stage of this condition?

Tamsulosin. ***Tamsulosin*** - **Alpha-1 adrenergic blocker** that relaxes smooth muscle in the prostate and bladder neck - Provides **rapid symptom relief** within days to weeks for moderate-to-severe LUTS (Lower Urinary Tract Symptoms) - **First-line medical therapy** for symptomatic BPH requiring treatment - Improves urinary flow rate and reduces obstructive symptoms (hesitancy, weak stream, incomplete emptying) *Finasteride* - 5-alpha reductase inhibitor that shrinks prostate size over time - Takes **6+ months** to show clinical benefit, not ideal for initial symptom relief - More appropriate for patients with large prostates (>40g) or as combination therapy *TURP (Transurethral Resection of Prostate)* - **Surgical intervention** reserved for refractory cases, complications, or failure of medical management - Not appropriate as initial management - Indications: recurrent retention, refractory hematuria, bladder stones, renal insufficiency due to BPH *Observation* - Appropriate for **asymptomatic or mildly symptomatic** patients (watchful waiting) - This patient presents with urinary symptoms requiring active management - Not suitable when symptoms are bothersome enough to prompt medical consultation

Q: A 60-year-old patient presents with painless hematuria. He is diagnosed with bladder cancer involving the muscle layer. What is the next best step in the treatment of this patient?

Radical cystectomy. ***Radical cystectomy***- Because this tumor involves the **muscle layer**, it is classified as **muscle-invasive bladder cancer (MIBC)** (T2 stage or higher), for which radical cystectomy is the gold standard treatment for patients who are surgical candidates.- This procedure involves complete removal of the bladder and adjacent pelvic lymph nodes, followed by urinary diversion, offering the best survival and curative rates for localized MIBC.*Intravesical administration of BCG*- This immunotherapy is used primarily for **high-risk non-muscle-invasive bladder cancer (NMIBC)**, particularly carcinoma in situ (CIS) or high-grade T1 tumors, to reduce recurrence.- It cannot achieve adequate penetration or tumor clearance in tumors that have already invaded the **detrusor muscle**.*Radiotherapy*- Radiotherapy is typically used as part of a **bladder-preserving trimodality therapy** (TMT) when the patient is unable or unwilling to undergo surgery.- For fit patients with MIBC, **radical cystectomy** generally provides superior long-term survival rates compared to radiotherapy alone.*Neoadjuvant chemotherapy with Mitomycin C*- **Mitomycin C** is an agent used *intravesically* for NMIBC, similar to BCG, to prevent recurrence after TURBT.- Standard **neoadjuvant chemotherapy** for MIBC (given before cystectomy) consists of **systemic platinum-based regimens** (like Gemcitabine/Cisplatin) and not local Mitomycin C.

Q: Which of the following will have unilateral hydronephrosis?

Retrocaval ureter. ***Retrocaval ureter*** - This is a rare congenital anomaly where the **right ureter** passes behind the inferior vena cava (IVC), causing extrinsic compression and obstruction. - Since only the right ureter is involved in this pathway abnormality, it inherently results in **unilateral hydronephrosis** of the right kidney. *Phimosis* - Phimosis is the inability to retract the foreskin; severe cases can cause distal urinary outflow obstruction. - If obstruction is severe enough to cause hydronephrosis, the resulting high intravesical pressure would be transmitted equally to both kidneys, usually causing **bilateral hydronephrosis**. *Posterior urethral valves* - **Posterior urethral valves (PUV)** are congenital folds in the posterior urethra, causing obstruction distal to the bladder neck. - This obstruction leads to high intravesical pressure, which impairs drainage from both kidneys, inevitably resulting in **bilateral hydronephrosis**. *Urethral strictures* - Urethral strictures are narrowings of the urethra, usually acquired, which obstruct urine flow distal to the bladder. - Significant obstruction at this level causes increased back pressure in the bladder and ureters, usually leading to pressure effects and subsequent **bilateral hydronephrosis**.

Q: A 44-year-old lady presents to the hospital with a ballotable flank mass. On CT imaging, the mass measures 4cm. Urine examination shows malignant cells. What is the most appropriate management for her condition?

Partial nephrectomy. ***Partial nephrectomy*** - For localized renal tumors measuring **≤ 4 cm (T1a)**, such as the one described, partial nephrectomy is the gold standard treatment, aiming to preserve renal function. - This approach, also known as **nephron-sparing surgery**, offers equivalent cancer control to radical nephrectomy for small tumors but with a lower risk of long-term **chronic kidney disease (CKD)** and associated cardiovascular morbidity. *Partial nephrectomy + neoadjuvant chemotherapy* - **Renal cell carcinoma (RCC)**, the most common type of kidney cancer, is notoriously resistant to conventional chemotherapy, so neoadjuvant chemotherapy is not a standard treatment for localized disease. - Neoadjuvant approaches for RCC, when used, typically involve **targeted therapy** or **immunotherapy** in the context of clinical trials for larger or more advanced tumors, not for a small 4cm mass. *Radical nephrectomy* - **Radical nephrectomy**, the removal of the entire kidney, is considered overtreatment for a small 4cm mass and is generally reserved for larger tumors (**>7 cm**) or when a partial nephrectomy is not technically feasible. - Performing a radical nephrectomy when a partial is possible unnecessarily sacrifices nephrons, increasing the patient's risk of developing **CKD** in the future. *Radical nephrectomy + postoperative radiotherapy* - RCC is largely **radioresistant**, and adjuvant radiotherapy after surgery has not been shown to improve survival or prevent recurrence for non-metastatic disease. - Radiotherapy is typically reserved for palliative care in cases of metastatic RCC, for example, to control symptoms from **bone** or **brain metastases**.

Q: How long should a couple use contraception post-vasectomy?

12-16 weeks. ***12-16 weeks***- Contraception is mandatory post-vasectomy until a follow-up semen analysis confirms **azoospermia** (complete absence of sperm).- The 12-16 week period accounts for the time needed for all existing sperm distal to the occlusion site to be ejaculated and cleared from the system.*4-6 weeks*- This time frame is generally too short to ensure complete clearance of all viable **sperm** stored in the **vas deferens** and related structures.- Relying on this duration significantly increases the risk of early **contraceptive failure** before azoospermia is achieved.*9-11 weeks*- While many men achieve clearance by the 9-week mark, the standard clinical protocol usually mandates waiting until **12 weeks** for the first definitive **semen analysis**.- Stopping contraception prematurely based on an estimated time frame, rather than laboratory confirmation, increases the hazard of unwanted pregnancy.*16-20 weeks*- Although safe, this duration unnecessarily exceeds the typical time required for the successful confirmation of **azoospermia**.- If the semen analysis at 12 weeks confirms **azoospermia**, contraception can typically cease immediately, making further delay unwarranted.

Q: What is incorrect about the image shown?

Microaerophilic hemolytic streptococci. ***Microaerophilic hemolytic streptococci*** - **For Fournier's gangrene**, the primary causative agents are typically a **polymicrobial infection (aerobic and anaerobic bacteria)**, not specifically microaerophilic hemolytic streptococci. - While streptococci can be involved, it is the synergistic action of multiple bacteria, especially gram-positive, gram-negative, and anaerobes, that characterizes the infection. *Gangrene of testis* - The image shows **Fournier's gangrene**, a severe form of necrotizing fasciitis affecting the perineum and genitals. - While the infection can spread and critically affect the scrotal tissues, the **testes themselves are often spared** due to their separate blood supply. *Seen in diabetics* - **Diabetics** are at significantly **increased risk** for developing Fournier's gangrene due to their impaired immune response and microvascular complications. - Approximately 30-60% of patients with Fournier's gangrene have underlying diabetes mellitus. *Obliterative arteritis* - **Obliterative endarteritis** is a key pathological feature of Fournier's gangrene, leading to **thrombosis of small vessels** and subsequent tissue necrosis and gangrene. - This vascular compromise is crucial in the rapid progression and tissue destruction seen in this condition.

Q: What is the clinical diagnosis?

Paraphimosis. ***Paraphimosis*** - The image shows the **glans penis** to be swollen and erythematous, with the **retracted foreskin** forming a tight constricting band behind it. - This condition occurs when the foreskin, once retracted, cannot be pulled back to its normal position, leading to **venous congestion** and edema of the glans. *Epispadias* - This is a congenital defect where the **urethral opening** is located on the **dorsal (upper) side** of the penis. - It would present as an abnormally placed urethral meatus, not foreskin entrapment. *Hypospadias* - This is a congenital condition where the **urethral opening** is located on the **ventral (underside)** of the penis. - The image does not show an abnormally placed urethral opening, but rather constriction of the glans by the foreskin. *Phimosis* - This condition involves the **inability to retract the foreskin** from the glans penis due to a tight opening. - The image depicts the foreskin *after* being retracted and then getting stuck, which is characteristic of paraphimosis, not phimosis.

Q: An 18-year-old patient presents with sudden agonizing pain in the groin and the lower abdomen. On physical examination, the testis seems high. The cremasteric reflex is lost. What is the most possible cause?

Testicular torsion. ***Testicular torsion*** - The sudden onset of **agonizing pain**, a **high-riding testis**, and a **lost cremasteric reflex** are classic signs of testicular torsion. - This condition is an acute surgical emergency that requires prompt intervention to preserve testicular viability. *Epididymo-orchitis* - Typically presents with a more **gradual onset of pain** and symptoms of inflammation, often associated with a urinary tract infection or sexually transmitted infection. - The cremasteric reflex would usually be present, and the testis would not typically be high-riding. *Mumps orchitis* - This condition is preceded by **parotitis (mumps)**, which is not mentioned in the patient's history. - While it causes testicular pain and swelling, it generally occurs several days after the onset of mumps and does not present with a high-riding testis or absent cremasteric reflex. *Idiopathic scrotal edema* - This is characterized by **swelling of the scrotal wall** without significant testicular pain upon palpation. - It usually presents with diffuse, non-pitting edema of the scrotum, with a preserved cremasteric reflex and normal testicular position.

Q: A 24-year-old male patient complains of painful and involuntary erection. Which of the following statement is false regarding this patient?

Relieved by ejaculation. ***Relieved by ejaculation*** - Priapism, especially **ischemic priapism**, is characterized by persistent erection **unrelated to sexual stimulation or desire** and is not relieved by ejaculation. Ejaculation does not resolve the underlying vascular issue causing the prolonged erection. - The pain associated with priapism often intensifies over time and is a key distinguishing feature from normal erections. *Due to defective venous drainage* - **Ischemic priapism**, the most common form, results from impaired venous outflow from the corpora cavernosa. This leads to **venous congestion** and trapping of deoxygenated blood. - This defective drainage causes **hypoxia and acidosis** within the cavernous tissue, contributing to pain and potential long-term damage. *Corpus spongiosum and glans penis are not involved* - In priapism, particularly ischemic priapism, the **corpora cavernosa** are primarily affected and become engorged. - The **corpus spongiosum** (which contains the urethra) and glans penis typically remain soft or less engorged because they have a separate venous drainage system which is not usually obstructed. *Intracavernosal injection of phenylephrine is used for low flow priapism* - **Phenylephrine** is an alpha-1 adrenergic agonist that causes **vasoconstriction** of the penile arterioles and venules leading to detumescence. - It is a common first-line treatment for **ischemic (low-flow) priapism**, helping to re-establish venous drainage and resolve the erection.

Question 1

A patient presents with urinary symptoms due to benign prostatic hyperplasia. Which of the following is used to manage the urinary symptoms in the initial stage of this condition?

Accepted Answer

Tamsulosin

Answer

Finasteride

Answer

Observation

Answer

TURP-Transurethral resection of prostate

Question 2

A 60-year-old patient presents with painless hematuria. He is diagnosed with bladder cancer involving the muscle layer. What is the next best step in the treatment of this patient?

Accepted Answer

Radical cystectomy

Answer

Radiotherapy

Answer

Neoadjuvant chemotherapy with Mitomycin C

Answer

Intravesical administration of BCG

Question 3

Which of the following will have unilateral hydronephrosis?

Accepted Answer

Retrocaval ureter

Answer

Phimosis

Answer

Posterior urethral valves

Answer

Urethral strictures

Question 4

A 44-year-old lady presents to the hospital with a ballotable flank mass. On CT imaging, the mass measures 4cm. Urine examination shows malignant cells. What is the most appropriate management for her condition?

Accepted Answer

Partial nephrectomy

Answer

Partial nephrectomy + neoadjuvant chemotherapy

Answer

Radical nephrectomy + postoperative radiotherapy

Answer

Radical nephrectomy

Question 5

How long should a couple use contraception post-vasectomy?

Accepted Answer

12-16 weeks

Answer

4-6 weeks

Answer

9-11 weeks

Answer

16-20 weeks

Question 6

A 35-year-old patient presents with colicky pain and is diagnosed with a ureteric stone. Which of the following is the best diagnostic investigation in this case?

Accepted Answer

Non-contrast CT KUB

Answer

Ureteroscopy

Answer

Ultrasonography KUB

Answer

Contrast-enhanced CT KUB

Question 7

What is incorrect about the image shown?

Accepted Answer

Microaerophilic hemolytic streptococci

Answer

Gangrene of testis

Answer

Seen in diabetics

Answer

Obliterative endarteritis

Question 8

What is the clinical diagnosis?

Accepted Answer

Paraphimosis

Answer

Epispadias

Answer

Hypospadias

Answer

Phimosis

Question 9

An 18-year-old patient presents with sudden agonizing pain in the groin and the lower abdomen. On physical examination, the testis seems high. The cremasteric reflex is lost. What is the most possible cause?

Accepted Answer

Testicular torsion

Answer

Epididymo-orchitis

Answer

Mumps orchitis

Answer

Idiopathic scrotal edema

Question 10

A 24-year-old male patient complains of painful and involuntary erection. Which of the following statement is false regarding this patient?

Accepted Answer

Relieved by ejaculation

Answer

Due to defective venous drainage

Answer

Corpus spongiosum and glans penis are not involved

Answer

Intracavernosal injection of phenylephrine is used for low flow priapism

Urology — MCQs

Urology — MCQs

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