Urology Practice Questions

Q: A 20-year-old male presented to the emergency department with acute onset of pain in the right scrotum. On examination, the testes were swollen, and the transillumination test was negative. What could be the probable diagnosis based on the ultrasound of the scrotum?

Testicular torsion. ***Testicular torsion*** - The ultrasound image shows a significant **lack of blood flow** (absent or markedly decreased color flow signals) in the right testis compared to the left, which is characteristic of **testicular torsion**. - **Acute onset of pain**, swollen testis, and a **negative transillumination test** in a young male are clinical signs highly suggestive of testicular torsion, requiring urgent intervention. *Fournier's syndrome* - This is a severe form of **necrotizing fasciitis** of the perineum and genitals, typically presenting with crepitus, gangrene, and systemic symptoms, which are not described. - Ultrasound would show gas in the soft tissues and possibly fluid collections, not primarily compromised testicular blood flow within the testis itself. *Acute epididymitis* - Acute epididymitis would typically show **increased blood flow** (hyperemia) in the affected epididymis and potentially the testis on Doppler ultrasound. - While it causes acute scrotal pain and swelling, the key differentiator here is the **absent/decreased blood flow** on the ultrasound, which rules out epididymitis. *Hydrocele* - A hydrocele is a collection of **fluid around the testis**, which would appear as an anechoic (black) fluid collection on ultrasound. - A hydrocele typically would yield a **positive transillumination test** and does not usually cause acute, severe pain or lead to a significant change in testicular blood flow on Doppler like torsion does.

Q: Which of the following structures in the spermatic cord is typically preserved (not divided) during vasectomy surgery?

Testicular artery. ***Testicular artery*** - The goal of a vasectomy is to interrupt sperm transport, not the blood supply to the testis. The **testicular artery** is the most critical structure to preserve as it provides the primary blood supply to the testis. - Preserving the **testicular artery** ensures continued blood flow to the testis, preventing ischemia and maintaining both spermatogenesis (though sperm won't exit) and endocrine function (testosterone production). - Surgeons carefully isolate and preserve the testicular artery while dividing only the vas deferens. *Vas deferens* - The **vas deferens** is the target structure that is deliberately divided and ligated during vasectomy. - Cutting the **vas deferens** interrupts the pathway for sperm transport from the epididymis to the ejaculatory duct, achieving permanent contraception. - This is the only structure within the spermatic cord that is intentionally divided during the procedure. *Autonomic nerves* - While **autonomic nerves** (sympathetic postganglionic fibers) are present in the spermatic cord and innervate the vas deferens, they may be inadvertently damaged during the vasectomy procedure. - The primary function of these **autonomic nerves** related to the vas deferens is smooth muscle contraction for sperm transport, which becomes irrelevant once the vas deferens is divided. - These nerves are not actively preserved as their division doesn't significantly impact testicular function. *Testicular vein* - The **testicular vein** (pampiniform plexus) drains blood from the testis and is also typically preserved during vasectomy, along with the testicular artery. - However, the **testicular artery** is considered more critical as arterial blood supply is essential for tissue viability, whereas venous drainage has collateral pathways through cremasteric and deferential veins. - Both vessels are preserved, but the arterial supply takes priority in surgical technique.

Q: Pelvic fracture is most commonly associated with which type of bladder injury?

Extraperitoneal bladder rupture. ***Extraperitoneal bladder rupture*** - **Pelvic fractures** are most commonly associated with **extraperitoneal bladder ruptures** (85-90% of bladder injuries from pelvic fractures). The tear in the bladder often occurs at the neck or anterior wall. These ruptures result from bone fragments from the pelvic fracture directly puncturing the bladder or from shearing forces. - Urine extravasates into the **retropubic space** and other extraperitoneal pelvic tissues, causing symptoms like suprapubic pain, hematuria, and difficulty voiding. - **Posterior urethral injuries** are also commonly associated with pelvic fractures (particularly pubic rami fractures), but among bladder injuries specifically, extraperitoneal rupture is most characteristic. *Intraperitoneal bladder rupture* - **Intraperitoneal bladder ruptures** are less common with pelvic fractures (10-15% of pelvic fracture-related bladder injuries) and typically occur from a direct blow to a **distended bladder**, causing rupture of the bladder dome. - Urine extravasates into the **peritoneal cavity**, leading to generalized abdominal pain, peritonitis, and potentially a larger volume of fluid accumulation. *Anterior urethral injury* - **Anterior urethral injuries** (e.g., bulbous or pendulous urethra) are usually caused by a **straddle injury** or direct trauma to the perineum. - They are generally **not associated with pelvic fractures**, which typically affect the **posterior urethra** (membranous portion) in males, particularly with pubic rami fractures.

Question 1

A 20-year-old male presented to the emergency department with acute onset of pain in the right scrotum. On examination, the testes were swollen, and the transillumination test was negative. What could be the probable diagnosis based on the ultrasound of the scrotum?

Accepted Answer

Testicular torsion

Answer

Acute epididymitis

Answer

Fournier's syndrome

Answer

Hydrocele

Question 2

Which of the following structures in the spermatic cord is typically preserved (not divided) during vasectomy surgery?

Accepted Answer

Testicular artery

Answer

Autonomic nerves

Answer

Testicular vein

Answer

Vas deferens

Question 3

Pelvic fracture is most commonly associated with which type of bladder injury?

Accepted Answer

Extraperitoneal bladder rupture

Answer

Intraperitoneal bladder rupture

Answer

Anterior urethral injury

Answer

Posterior urethral injury

Urology — MCQs

Urology — MCQs

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