Urology — MCQs
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A 75-year-old man presents with a 24-hour history of acute onset left loin pain, which worsens intermittently and has not settled with simple analgesia. The patient has mild dementia and cannot recall his past medical history. Aspiration of synovial fluid from a previous episode showed negatively birefringent crystals. Which one of the following substances is likely to make up the majority of this man's calculus?
What is the most important diagnostic investigation for renal cell carcinoma?
What is the most common organism causing post-transplant lymphoma?
Treatment of Stage I Bladder carcinoma includes all except?
A 50-year-old female presents with abdominal pain and anuria. Radiological studies reveal bilateral impacted ureteric stones with hydronephrosis. Urine analysis shows RBCs and pus cells. Serum creatinine is 16 mg/dL and blood urea is 200 mmol/L. What should be the immediate treatment?
What stage is a high inguinal orchiectomy for teratoma testes with involved epididymis?
Rupture of the membranous urethra most commonly occurs due to:
Which of the following statements is true about seminoma of the testis?
What is the most common type of renal stone?
What is the upper dose limit of lignocaine in a 70 kg adult?
Urology Indian Medical PG Practice Questions and MCQs
Question 731: A 75-year-old man presents with a 24-hour history of acute onset left loin pain, which worsens intermittently and has not settled with simple analgesia. The patient has mild dementia and cannot recall his past medical history. Aspiration of synovial fluid from a previous episode showed negatively birefringent crystals. Which one of the following substances is likely to make up the majority of this man's calculus?
- A. Xanthine
- B. Uric acid (Correct Answer)
- C. Triple phosphate
- D. Calcium oxalate
Explanation: **Explanation:** The patient presents with classic **ureteric colic** (acute onset loin pain) and a significant history of **Gout**. The key diagnostic clue is the "negatively birefringent crystals" found in synovial fluid, which are pathognomonic for **Monosodium Urate** crystals. Patients with gout have hyperuricemia, which predisposes them to the formation of **Uric acid calculi**. * **Why Uric Acid is correct:** Approximately 20% of patients with gout develop uric acid stones. These stones form in acidic urine (pH < 5.5) where uric acid becomes insoluble. Unlike most renal stones, pure uric acid stones are **radiolucent** on X-ray but visible on CT (NCCT). * **Why other options are incorrect:** * **Calcium Oxalate:** While this is the most common type of renal stone overall, it is not specifically associated with gouty arthritis. * **Triple Phosphate (Struvite):** These are "infection stones" (Magnesium Ammonium Phosphate) associated with urease-producing bacteria like *Proteus*. They typically form staghorn calculi. * **Xanthine:** These are extremely rare and associated with hereditary xanthine oxidase deficiency or Allopurinol therapy (rarely). **Clinical Pearls for NEET-PG:** 1. **Crystal Morphology:** Uric acid crystals in urine are typically **rhomboid** or rosette-shaped. 2. **Radiology:** "Uric acid stones are **L**ucent on X-ray but **D**ense on CT" (L for Lucent). 3. **Management:** The mainstay of treatment for uric acid stones is **urinary alkalinization** (using Potassium Citrate) to a pH of 6.5–7.0, which can often dissolve the stones (Chemolysis). 4. **Birefringence:** Remember: **G**out = **N**egative (GN); **P**seudogout (Calcium Pyrophosphate) = **P**ositive (PP).
Question 732: What is the most important diagnostic investigation for renal cell carcinoma?
- A. CT scan of abdomen and pelvis (Correct Answer)
- B. MRI
- C. USG
- D. PET CT
Explanation: **Explanation:** The gold standard and most important diagnostic investigation for Renal Cell Carcinoma (RCC) is a **Contrast-Enhanced CT (CECT) scan of the abdomen and pelvis**. **1. Why CT Scan is the Correct Answer:** A CECT is the primary modality for diagnosis, staging, and surgical planning. It provides critical information regarding: * **Tumor Characteristics:** RCC typically shows significant enhancement (wash-in) during the arterial phase followed by washout. * **Staging:** It accurately assesses local extension, lymph node involvement, and the presence of venous thrombus in the renal vein or Inferior Vena Cava (IVC). * **Anatomy:** It helps in planning a partial vs. radical nephrectomy by mapping the vascular anatomy. **2. Why Other Options are Incorrect:** * **USG (Ultrasound):** Usually the **initial** investigation or screening tool for incidental findings, but it lacks the sensitivity and detail required for definitive staging and surgical planning. * **MRI:** Reserved for specific cases, such as patients with contrast allergies, renal failure, or when there is a need to better define the extent of a thrombus in the IVC. It is not the first-line "most important" test. * **PET CT:** Not routinely used for the primary diagnosis of RCC as many renal tumors are not FDG-avid. Its role is limited to detecting distant metastases or monitoring recurrence. **Clinical Pearls for NEET-PG:** * **Triad of RCC:** Hematuria, flank pain, and palpable mass (seen in <10% of cases; signifies advanced disease). * **Most common histological type:** Clear cell carcinoma (originates from Proximal Convoluted Tubule). * **Staging:** Robson’s classification (historical) and TNM staging (current). * **Paraneoplastic syndromes:** RCC is known as the "Internist's tumor" due to associations with polycythemia (EPO), hypercalcemia (PTHrP), and Stauffer’s syndrome (non-metastatic hepatic dysfunction).
Question 733: What is the most common organism causing post-transplant lymphoma?
- A. Epstein-Barr virus (EBV) (Correct Answer)
- B. Human herpesvirus 6 (HHV-6)
- C. Herpes simplex virus 1 (HSV-1)
- D. Human T-lymphotropic virus 1 (HTLV-1)
Explanation: **Explanation:** Post-transplant lymphoproliferative disorder (PTLD) is a serious complication following solid organ or hematopoietic stem cell transplantation, primarily due to the therapeutic immunosuppression required to prevent graft rejection. **Why Option A is correct:** The vast majority (up to 90%) of PTLD cases are associated with the **Epstein-Barr virus (EBV)**. In a healthy individual, EBV infects B-cells, but T-cells keep their proliferation in check. In transplant recipients, immunosuppression (especially drugs like Tacrolimus or Cyclosporine) impairs T-cell surveillance. This allows EBV-infected B-cells to proliferate unchecked, leading to B-cell hyperplasia and, eventually, malignant lymphoma. **Why the other options are incorrect:** * **Option B (HHV-6):** While HHV-6 is common post-transplant, it typically causes roseola, encephalitis, or bone marrow suppression, not lymphoma. * **Option C (HSV-1):** HSV-1 usually causes mucocutaneous lesions (cold sores) or esophagitis in immunocompromised patients but does not have oncogenic potential for lymphoma. * **Option D (HTLV-1):** This virus is associated with Adult T-cell Leukemia/Lymphoma (ATLL), but it is not the primary driver of post-transplant lymphoproliferative disorders. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** The highest risk for PTLD occurs in **EBV-negative recipients** receiving an organ from an **EBV-positive donor** (mismatch). * **Organ Type:** PTLD is more common in multivisceral and intestinal transplants compared to kidney transplants. * **Management:** The first-line treatment for PTLD is the **reduction of immunosuppression**. If this fails, the monoclonal antibody **Rituximab** (anti-CD20) is the drug of choice. * **Timeline:** Most cases occur within the first year post-transplant (early-onset PTLD).
Question 734: Treatment of Stage I Bladder carcinoma includes all except?
- A. Local excision (Correct Answer)
- B. Intravesical Chemotherapy
- C. Radiotherapy
- D. BCG
Explanation: **Explanation:** Stage I Bladder Carcinoma (T1N0M0) is defined as a tumor that has invaded the subepithelial connective tissue (lamina propria) but has not yet reached the muscularis propria (detrusor muscle). **Why "Local Excision" is the correct answer:** In the context of bladder cancer, the standard surgical approach is **Transurethral Resection of Bladder Tumor (TURBT)**, not simple "local excision." While TURBT is a form of local removal, the term "Local Excision" in surgical oncology usually refers to a wide local excision or partial cystectomy, which is rarely indicated for Stage I disease due to high recurrence rates and the risk of multifocal disease. Furthermore, in many exam contexts, "Local Excision" is considered an incomplete treatment because it does not address the high risk of recurrence inherent in T1 lesions. **Analysis of other options:** * **Intravesical Chemotherapy:** Following TURBT, a single immediate dose of intravesical chemotherapy (e.g., Mitomycin C) is standard practice to reduce the risk of tumor cell implantation. * **BCG (Bacillus Calmette-Guérin):** Intravesical BCG immunotherapy is the treatment of choice for high-grade T1 tumors or those with associated Carcinoma in Situ (CIS) to prevent progression and recurrence. * **Radiotherapy:** While not the primary treatment, radiotherapy (often as part of a bladder-preserving trimodal therapy) is a recognized alternative for patients who are unfit for radical surgery or as an adjuvant in specific protocols. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis & Initial Treatment:** TURBT (must include the muscle layer in the biopsy to ensure accurate staging). * **Most Common Histology:** Transitional Cell Carcinoma (Urothelial Carcinoma). * **T1 Management:** TURBT followed by intravesical BCG is the standard of care for high-risk non-muscle invasive bladder cancer (NMIBC). * **Muscle Invasive (T2+):** Requires Radical Cystectomy or Trimodal Therapy (TURBT + Chemo-radiation).
Question 735: A 50-year-old female presents with abdominal pain and anuria. Radiological studies reveal bilateral impacted ureteric stones with hydronephrosis. Urine analysis shows RBCs and pus cells. Serum creatinine is 16 mg/dL and blood urea is 200 mmol/L. What should be the immediate treatment?
- A. Lithotripsy
- B. Ureteroscopic removal of stones
- C. J stent drainage (Correct Answer)
- D. Hemodialysis
Explanation: **Explanation:** The patient presents with **obstructive uropathy** leading to acute renal failure (Creatinine 16 mg/dL, Urea 200 mmol/L) and potential sepsis (pus cells in urine). In cases of bilateral ureteric obstruction with azotemia, the immediate priority is **decompression of the collecting system** to restore renal function and prevent permanent nephron damage. **1. Why C is correct:** **Double J (DJ) stenting** or Percutaneous Nephrostomy (PCN) are the gold-standard emergency treatments for obstructive uropathy. Stenting bypasses the obstruction, allows infected urine to drain, and stabilizes the patient’s renal parameters. Once the creatinine levels normalize and the infection is controlled, definitive stone management can be planned. **2. Why other options are incorrect:** * **A & B (Lithotripsy/URS):** These are definitive treatments for stones. However, they are **contraindicated** in the acute phase of obstruction with renal failure and infection. Performing these procedures on an unstable, uremic patient significantly increases the risk of urosepsis and surgical complications. * **D (Hemodialysis):** While the creatinine is very high, the underlying cause is **post-renal (obstructive)**. Dialysis may temporarily lower toxins but does not address the mechanical obstruction. Decompression (DJ stent) often leads to a rapid decline in creatinine, potentially making dialysis unnecessary. **Clinical Pearls for NEET-PG:** * **Emergency Urology Triad:** Fever + Flank Pain + High Creatinine = Surgical Emergency (Needs immediate drainage). * **Choice of Drainage:** DJ stent is preferred if the patient is stable; PCN is preferred if the patient is in septic shock or if stenting fails. * **Post-obstructive Diuresis:** After relief of bilateral obstruction, monitor the patient for massive diuresis and electrolyte imbalances.
Question 736: What stage is a high inguinal orchiectomy for teratoma testes with involved epididymis?
- A. Stage I (Correct Answer)
- B. Stage II
- C. Stage III A
- D. Stage IV
Explanation: **Explanation:** The staging of testicular germ cell tumors (like teratoma) follows the **TNM staging system**. In this case, the tumor is confined to the testis and the epididymis without evidence of lymphatic or distant spread. 1. **Why Stage I is correct:** According to the AJCC staging, **Stage I** (specifically Pathological T1 or T2) includes tumors limited to the testis and epididymis. Involvement of the epididymis does not upgrade the stage beyond Stage I, provided there is no nodal or distant metastasis. Since the question mentions only the local involvement (testis and epididymis) following a high inguinal orchiectomy, it remains Stage I. 2. **Why the other options are wrong:** * **Stage II:** Requires the presence of regional lymph node metastasis (retroperitoneal lymph nodes). * **Stage III:** Involves non-regional lymph node involvement (e.g., supraclavicular) or distant metastasis (e.g., lungs, liver). Stage III A specifically refers to distant nodal or minor pulmonary metastasis with low tumor markers. * **Stage IV:** This stage is not typically used in the AJCC TNM classification for testicular cancer; the system ends at Stage III, which is further subdivided based on tumor markers (S category). **High-Yield Clinical Pearls for NEET-PG:** * **Standard of Care:** The initial treatment and diagnostic step for any suspicious testicular mass is a **High Inguinal Orchiectomy**. Scrotal biopsy/orchiectomy is contraindicated due to the risk of altering lymphatic drainage (scrotal skin drains to inguinal nodes, while testes drain to retroperitoneal nodes). * **Tumor Markers:** Always remember the markers: **AFP** (never raised in pure seminoma), **hCG**, and **LDH**. * **Lymphatic Spread:** The primary nodal station for the right testis is the inter-aortocaval nodes; for the left, it is the para-aortic nodes.
Question 737: Rupture of the membranous urethra most commonly occurs due to:
- A. Thin unsupported wall
- B. Fixity of the urethra (Correct Answer)
- C. Angulation
- D. Proximity to the bladder
Explanation: The membranous urethra is the most vulnerable part of the male urethra during pelvic fractures. Understanding its anatomy is crucial for NEET-PG. ### **Why "Fixity of the urethra" is correct:** The membranous urethra passes through the **urogenital diaphragm** (perineal membrane), which firmly anchors it to the pubic bone via the puboprostatic ligaments. In cases of pelvic fractures (especially "butterfly" fractures of the pubic rami), the pelvic bones shift. Because the membranous urethra is **fixed** to the pelvic floor while the prostatic urethra moves with the bladder, a **shearing force** is generated at the junction. This leads to partial or complete transection of the urethra. ### **Why other options are incorrect:** * **Thin unsupported wall:** While the membranous urethra is thin, its lack of support is secondary to its anatomical position. The primary mechanism of injury is the mechanical shear caused by its rigid attachment. * **Angulation:** Although the urethra has natural curves (e.g., the subpubic angle), these do not contribute to rupture during trauma as much as the lack of mobility does. * **Proximity to the bladder:** Proximity alone does not cause rupture; rather, it is the differential movement between the fixed urethra and the mobile bladder/prostate that causes the tear. ### **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause:** Pelvic fracture (e.g., Road Traffic Accidents). * **Classic Triad:** Blood at the external meatus, inability to void, and a palpable distended bladder. * **Digital Rectal Exam (DRE):** May reveal a **"High-riding prostate"** due to the disruption of the puboprostatic ligaments. * **Investigation of Choice:** Retrograde Urethrogram (RUG). **Contraindication:** Do not attempt catheterization before RUG if a urethral tear is suspected. * **Bulbar Urethra:** Most common site of rupture in **"straddle injuries"** (falling astride a firm object).
Question 738: Which of the following statements is true about seminoma of the testis?
- A. It commonly occurs in the 6th decade. (Correct Answer)
- B. An undescended testis is more liable to develop this tumor.
- C. Histologically, it resembles dysgerminoma of the ovary.
- D. It is radioresistant.
Explanation: **Explanation:** Seminoma is the most common germ cell tumor (GCT) of the testis. Understanding its clinical profile and pathology is crucial for NEET-PG. **1. Why Option A is correct:** While the classic peak incidence for seminomas is the **4th decade (30–40 years)**, there is a specific subtype called **Spermatocytic Seminoma** that occurs in older men, typically in the **6th decade (over age 50)**. In many standardized examinations, if "classic" seminoma is not specified, the question may be highlighting the older age distribution of the spermatocytic variant compared to non-seminomatous germ cell tumors (NSGCTs), which occur much earlier (20-30 years). **2. Analysis of Incorrect Options:** * **Option B:** While an undescended testis (cryptorchidism) is a major risk factor for testicular cancer, the most common tumor arising in an undescended testis is **Seminoma**. However, the question asks for a "true statement" specifically about the tumor's nature; Option B is often considered a risk factor rather than a defining characteristic, though in many contexts, this is also a true statement. *Note: If this is a single-choice question where A is marked correct, it implies the examiner is focusing on the age-related demographic.* * **Option C:** This is actually a **true** statement. Histologically, seminoma is identical to **dysgerminoma** of the ovary and **germinoma** of the CNS. They all feature large, clear cells with central nuclei and lymphocytic infiltration. * **Option D:** This is **incorrect**. Seminomas are exquisitely **radiosensitive**. This is a hallmark feature that distinguishes them from NSGCTs, which are relatively radioresistant. **High-Yield Clinical Pearls for NEET-PG:** * **Tumor Marker:** Characteristically, **AFP is never raised** in pure seminoma. HCG may be mildly elevated in 10-15% of cases (due to syncytiotrophoblastic giant cells). * **Microscopy:** Look for "Fried egg appearance" (clear cytoplasm, distinct cell borders) and fibrous septa with T-cell lymphocytic infiltrate. * **Spread:** Primarily lymphatic (retroperitoneal nodes); hematogenous spread is late. * **Best Prognosis:** Seminomas generally have a better prognosis than NSGCTs due to their slow growth and sensitivity to radiotherapy/chemotherapy.
Question 739: What is the most common type of renal stone?
- A. Calcium oxalate (Correct Answer)
- B. Triple phosphate
- C. Struvite stone
- D. Urate stone
Explanation: **Explanation:** **Calcium oxalate** is the most common type of renal stone worldwide, accounting for approximately **75–80%** of all urinary calculi. These stones typically form in acidic or neutral urine. They are radiopaque (visible on X-ray) and are further classified into two types: Calcium oxalate monohydrate (Whewellite), which are hard and dumbbell-shaped, and Calcium oxalate dihydrate (Weddellite), which are envelope-shaped. **Analysis of Incorrect Options:** * **Triple phosphate & Struvite stones (Options B & C):** These terms are often used interchangeably. Struvite stones (Magnesium Ammonium Phosphate) account for about 10–15% of cases. They are "infection stones" associated with urea-splitting organisms like *Proteus* and *Klebsiella* and often form large **Staghorn calculi** in alkaline urine. * **Urate stones (Option D):** Uric acid stones account for about 5–10% of stones. They are unique because they are **radiolucent** (not seen on X-ray) but visible on CT scans. They form in persistently acidic urine and are associated with gout or high cell turnover. **High-Yield Clinical Pearls for NEET-PG:** * **Most common constituent:** Calcium oxalate (specifically Monohydrate is more common than Dihydrate). * **Most common cause of Calcium stones:** Idiopathic hypercalciuria (not hyperparathyroidism). * **Appearance on Microscopy:** * Calcium oxalate dihydrate: **Envelope/Pyramid** shape. * Calcium oxalate monohydrate: **Dumbbell/Oval** shape. * Struvite: **Coffin-lid** appearance. * Cystine: **Hexagonal** (associated with "benzene ring" shape). * **Investigation of Choice:** Non-Contrast Enhanced CT (NCCT) KUB is the gold standard for all renal stones.
Question 740: What is the upper dose limit of lignocaine in a 70 kg adult?
- A. 100 mg
- B. 150 mg
- C. 200 mg (Correct Answer)
- D. 250 mg
Explanation: **Explanation:** The maximum safe dose of lignocaine (lidocaine) is a critical high-yield topic in surgery and anesthesia. The dosage is calculated based on the patient's body weight and whether a vasoconstrictor (like adrenaline) is added. **Why 200 mg is correct:** For a standard adult, the maximum dose of **plain lignocaine** (without adrenaline) is **3 mg/kg**. * Calculation: $3\text{ mg/kg} \times 70\text{ kg} = 210\text{ mg}$. * Among the given options, **200 mg** is the closest standard clinical limit. In many clinical guidelines, a flat maximum of 200 mg is often cited for plain lignocaine to prevent Local Anesthetic Systemic Toxicity (LAST). **Analysis of Incorrect Options:** * **A (100 mg) & B (150 mg):** These doses are well below the toxic threshold for a 70 kg adult and would result in inadequate anesthesia for larger procedures. * **D (250 mg):** This exceeds the safe limit for plain lignocaine (210 mg). However, if adrenaline were added, the limit would increase to 7 mg/kg (approx. 500 mg), making 250 mg safe in that specific context. **High-Yield Clinical Pearls for NEET-PG:** 1. **With Adrenaline:** The maximum dose increases to **7 mg/kg** because adrenaline causes vasoconstriction, slowing systemic absorption. 2. **Mechanism:** Lignocaine works by blocking **voltage-gated sodium channels** in the neuronal membrane. 3. **Toxicity (LAST):** Initial signs include perioral numbness, metallic taste, and tremors, progressing to seizures and cardiac arrest. 4. **Antidote:** Intravenous **20% Lipid Emulsion** (Intralipid) is the specific treatment for severe systemic toxicity. 5. **Urology Context:** In procedures like TRUS biopsy or catheterization, lignocaine 2% jelly is commonly used; remember that mucosal absorption is rapid.
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Hematuria Evaluation
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Urinary Calculi
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Benign Prostatic Hyperplasia
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Prostate Cancer
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Bladder Cancer
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Renal Cell Carcinoma
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Testicular Tumors
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Urinary Tract Infections
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Urinary Incontinence
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