Urology Practice Questions

Q: A patient with pelvic fracture presents with suprapubic pain, difficulty in passing urine, and hematuria. Cystography reveals findings suggestive of bladder injury. What are the indications for surgical repair of a bladder injury?

All of the above. Bladder injuries are broadly classified into **extraperitoneal (60-85%)** and **intraperitoneal (15-40%)**. While most uncomplicated extraperitoneal ruptures can be managed conservatively with catheter drainage, specific complications necessitate surgical intervention. **Explanation of Options:** * **A. Repeated blockage of the urinary catheter:** Persistent hematuria with clot formation can lead to catheter obstruction. If the bladder cannot be effectively drained, it remains distended, preventing the wound edges from apposing and healing, thus requiring surgical evacuation and repair. * **B. Projecting bone fragment:** In pelvic fractures, a sharp spicule of bone may penetrate or remain embedded in the bladder wall. This prevents spontaneous closure and carries a high risk of persistent leakage or infection if not surgically addressed. * **C. Tear extending to the bladder neck:** The bladder neck contains the internal sphincter mechanism. Injuries here rarely heal spontaneously with a catheter and often lead to future incontinence or strictures if not precisely repaired. **Why "All of the above" is correct:** Each of these scenarios represents a "complicated" extraperitoneal injury. Other mandatory indications for surgery include **intraperitoneal rupture** (due to risk of peritonitis), concomitant rectal/vaginal injury, or when the patient is already undergoing laparotomy for other pelvic injuries. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Retrograde Cystography (showing "flame-shaped" extravasation in extraperitoneal and "bowel loop outlining" in intraperitoneal tears). * **Management Rule:** Intraperitoneal = **Always Surgery**; Extraperitoneal = **Catheter first** (unless complicated). * **Associated Fracture:** Bladder rupture is most commonly associated with **pubic symphysis diastasis** or rami fractures.

Q: Which is the best investigation for prostate cancer?

PSA velocity. **Explanation:** In the context of diagnosing and monitoring prostate cancer, **PSA Velocity (PSAV)** is considered a superior marker compared to a single static PSA value. 1. **Why PSA Velocity is the Correct Answer:** PSA velocity refers to the **rate of change in PSA levels over time**. While a single PSA measurement can be elevated due to benign conditions (like BPH or prostatitis), a rapid rise in PSA (typically >0.75 ng/mL/year) is highly suggestive of malignancy. It increases the specificity of the PSA test, helping to differentiate between benign prostatic hyperplasia and aggressive prostate cancer, making it a "better" diagnostic and prognostic tool in clinical practice. 2. **Analysis of Incorrect Options:** * **Prostate Specific Antigen (A):** While PSA is the most common screening tool, a single value lacks specificity. It can be elevated in non-cancerous conditions, leading to false positives. * **Acid Phosphatase (B):** Historically used as a marker for prostate cancer, it is now obsolete because it is only elevated in advanced, metastatic stages and lacks the sensitivity of PSA. * **Alkaline Phosphatase (D):** This is a non-specific marker for bone turnover. In prostate cancer, it is used to screen for **osteoblastic bone metastases**, not to diagnose the primary cancer itself. **Clinical Pearls for NEET-PG:** * **Gold Standard for Diagnosis:** Transrectal Ultrasound (TRUS) guided biopsy (specifically Multiparametric MRI-TRUS fusion biopsy). * **Most Common Site:** Peripheral zone (70%). * **PSA Density:** PSA value divided by prostate volume; >0.15 is suspicious. * **Free-to-Total PSA Ratio:** A ratio 25% suggests BPH.

Q: Which electrolyte abnormality is commonly observed following a Transurethral Resection of the Prostate (TURP)?

Hyponatremia. **Explanation:** The correct answer is **Hyponatremia**. This electrolyte imbalance is the hallmark of **TURP Syndrome**, a potentially life-threatening complication occurring due to the systemic absorption of large volumes of non-conductive irrigation fluid (traditionally 1.5% Glycine) through opened prostatic venous sinuses. **Why Hyponatremia occurs:** During the procedure, the irrigation fluid is absorbed into the intravascular compartment. This leads to **dilutional hyponatremia** (hypervolemic hyponatremia). As the serum sodium levels drop, patients may experience neurological symptoms (confusion, seizures, coma) and cardiovascular instability. If Glycine is used, its metabolism into ammonia can also contribute to encephalopathy and transient visual loss. **Analysis of Incorrect Options:** * **Hypokalemia & Hyperkalemia:** While minor fluctuations in potassium can occur due to hemodilution or cell lysis, they are not the primary or "classic" electrolyte abnormality associated with TURP. * **Hypernatremia:** This would imply a loss of free water or an excess of sodium, which is the opposite of the fluid overload and dilution seen in TURP syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **Prevention:** Use of **Bipolar TURP** is now preferred as it allows the use of **Normal Saline (0.9% NaCl)** as an irrigant, significantly reducing the risk of hyponatremia. * **Risk Factors:** Resection time >60 minutes, prostate size >60g, and high height of the irrigation bag (>60cm above the patient). * **Management:** Treatment of severe symptomatic hyponatremia involves fluid restriction, diuretics (Furosemide), and cautious administration of **3% Hypertonic Saline**. * **Triad of TURP Syndrome:** Hypertension (early), Bradycardia, and Mental status changes.

Q: Sterilization is commonly performed at which site of the fallopian tube?

Isthmus. **Explanation:** The **isthmus** is the preferred site for female sterilization (tubal ligation) because it is the narrowest, straightest, and most muscular part of the fallopian tube. Its anatomical characteristics make it ideal for the application of mechanical devices like clips (Filshie or Hulka-Clemens) or rings (Falope rings), as well as for segmental resection (Pomeroy’s technique). Performing the procedure here ensures minimal damage to the blood supply and provides the highest success rate for potential future surgical reversal (tubal re-anastomosis). **Analysis of Options:** * **Ampulla (A):** This is the widest and longest part of the tube where fertilization occurs. It is highly vascular and thin-walled, making it unsuitable for ligation due to a higher risk of hematoma and failure. * **Infundibulum (B):** This is the funnel-shaped distal end containing fimbriae. While fimbriectomy (Kroener technique) is a method of sterilization, it is not the "common" site and is irreversible. * **Cornua (D):** This is the intramural portion where the tube enters the uterus. Surgery here carries a high risk of uterine bleeding and interstitial pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Pomeroy’s Method:** The most common surgical technique used worldwide; it involves creating a loop in the **isthmus**, ligating it, and excising the knuckle. * **Failure Rates:** The failure rate of tubal ligation is approximately 0.5%. If pregnancy occurs after sterilization, there is a high suspicion of **ectopic pregnancy**. * **Timing:** "Mini-lap" tubal ligation is ideally performed 24–48 hours postpartum when the fundus is near the umbilicus.

Q: A newborn presents with a mid-anterior abdominal wall defect that characteristically disappears spontaneously by age 4 years. What is the most likely diagnosis?

Umbilical hernia. ### **Explanation** **Correct Option: D. Umbilical hernia** The clinical hallmark of a congenital **umbilical hernia** is its high rate of spontaneous resolution. It occurs due to a failure of the umbilical ring to close after birth. In most infants, the defect closes as the rectus abdominis muscles grow and fuse in the midline. Statistically, approximately **80–90% of umbilical hernias disappear spontaneously by the age of 3 to 4 years**. Surgery is generally deferred until after age 4 unless the defect is exceptionally large (>1.5–2 cm) or complications like strangulation occur (which is rare). **Why other options are incorrect:** * **A. Patent urachus:** This is a persistent communication between the bladder and the umbilicus. It presents with continuous or intermittent **leakage of urine** from the umbilicus and requires surgical excision; it does not resolve spontaneously. * **B. Omphalocele:** This is a major midline defect where abdominal viscera protrude through the umbilical ring, **covered by a peritoneal sac**. It is a surgical emergency and never resolves on its own. * **C. Ectopia vesicae (Bladder Exstrophy):** This involves a defect in the lower abdominal wall and anterior bladder wall, leaving the bladder mucosa exposed. It is a severe structural malformation requiring complex reconstructive surgery. **High-Yield Clinical Pearls for NEET-PG:** * **Management Rule:** "Wait and watch" for umbilical hernias until age 4. * **Associations:** Umbilical hernias are more common in **premature infants**, infants with **Down syndrome**, and those with **congenital hypothyroidism**. * **Umbilical Hernia vs. Gastroschisis:** Remember that umbilical hernia and omphalocele occur *through* the ring (midline), whereas gastroschisis typically occurs to the *right* of the umbilical cord and has no covering sac.

Q: Which hormone is NOT given for palliative care of carcinoma of the prostate?

Progesterone. **Explanation:** The primary objective in the palliative management of advanced or metastatic **Carcinoma of the Prostate** is **Androgen Deprivation Therapy (ADT)**. Since prostate cancer cells are typically androgen-dependent, reducing testosterone levels to "castrate levels" (<50 ng/dL) inhibits tumor growth. **Why Progesterone is the correct answer:** Progesterone (Option B) has no established role in the standard hormonal manipulation of prostate cancer. While some progestational agents (like Cyproterone acetate) have antiandrogenic properties, pure progesterone itself does not effectively lower serum testosterone or block androgen receptors in a clinical setting for palliative care. **Analysis of incorrect options:** * **Estrogens (Option A):** Historically, Diethylstilbestrol (DES) was used to suppress the hypothalamic-pituitary-gonadal axis via negative feedback, reducing LH and testosterone. Its use has declined due to cardiovascular side effects (thromboembolism). * **LHRH Agonists/Antagonists (Option C):** These are the current "gold standard" for medical castration. Agonists (e.g., Leuprolide, Goserelin) initially cause a testosterone flare followed by downregulation of receptors, while Antagonists (e.g., Degarelix) cause an immediate drop in testosterone. * **Antiandrogens (Option D):** These drugs (e.g., Flutamide, Bicalutamide, Enzalutamide) compete with dihydrotestosterone (DHT) for the androgen receptor, preventing the tumor from utilizing circulating androgens. **High-Yield Clinical Pearls for NEET-PG:** * **Combined Androgen Blockade (CAB):** Refers to the use of an LHRH agonist plus an antiandrogen to prevent the "testosterone flare" phenomenon. * **Orchidectomy:** Bilateral subcapsular orchidectomy is the surgical gold standard for rapid androgen deprivation. * **Castration-Resistant Prostate Cancer (CRPC):** Defined as disease progression despite testosterone levels being at castrate levels (<50 ng/dL).

Q: Nelson syndrome is seen following which surgical procedure?

Adrenalectomy. **Explanation:** **Nelson Syndrome** is a clinical condition characterized by the rapid enlargement of a pre-existing ACTH-secreting pituitary adenoma following a **bilateral total adrenalectomy**. **Why Adrenalectomy is the correct answer:** In patients with Cushing’s disease (pituitary-driven hypercortisolism), the high levels of circulating cortisol normally provide negative feedback to the pituitary gland. When a bilateral adrenalectomy is performed to control symptoms, this negative feedback is abruptly removed. In the absence of cortisol, the underlying pituitary microadenoma undergoes aggressive growth and hypersecretion of ACTH. This leads to the classic triad of: 1. **Hyperpigmentation** (due to high ACTH levels stimulating melanocytes). 2. **Mass effect symptoms** (headaches, visual field defects like bitemporal hemianopia). 3. **Very high serum ACTH levels.** **Why other options are incorrect:** * **Cholecystectomy:** Removal of the gallbladder; associated with Post-cholecystectomy syndrome, not endocrine feedback loops. * **Splenectomy:** Removal of the spleen; associated with OPSI (Overwhelming Post-Splenectomy Infection) and Howell-Jolly bodies. * **Duodenectomy:** Part of a Whipple’s procedure; associated with malabsorption or dumping syndrome, but has no direct effect on the pituitary-adrenal axis. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnostic Marker:** Markedly elevated plasma ACTH levels and MRI evidence of an enlarging pituitary mass. * **Prevention:** Prophylactic pituitary irradiation or careful monitoring of ACTH levels post-adrenalectomy. * **Treatment:** Transsphenoidal surgery (TSS) or radiotherapy to the pituitary gland. * **Key Association:** Always remember: **Bilateral Adrenalectomy → Loss of Negative Feedback → Nelson Syndrome.**

Q: What is the commonest presentation of bilateral ureteric stones?

Pain. **Explanation:** **1. Why Pain is the Correct Answer:** Pain is the most common presenting symptom of ureteric calculi, whether unilateral or bilateral. The pain is typically described as **ureteric colic**—a sudden, severe, spasmodic pain originating in the loin and radiating to the groin. This occurs due to the sudden increase in intraluminal pressure and hyperperistalsis of the ureteric smooth muscle in an attempt to bypass the obstruction. Even in bilateral cases, it is rare for both ureters to obstruct simultaneously and silently; patients usually present due to the acute distress caused by the colic. **2. Why Other Options are Incorrect:** * **Chronic Renal Failure (CRF):** While bilateral obstruction can lead to post-renal azotemia and eventually renal failure if left untreated, it is usually a late consequence rather than the initial "presentation." * **Urinary Tract Infection (UTI):** Stasis of urine due to stones predisposes a patient to infection (pyelonephritis or pyonephrosis), but this is a secondary complication. * **Hematuria:** This is a very common associated sign (found in ~90% of cases on microscopy), but it is rarely the primary reason a patient seeks medical attention compared to the agonizing nature of the pain. **3. Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Non-contrast Computed Tomography (NCCT) KUB is the investigation of choice for ureteric stones. * **Narrowest Point:** The most common site for a stone to impact is the **Vesicoureteric Junction (VUJ)**, which is the narrowest part of the ureter. * **Management:** Stones <5 mm usually pass spontaneously. For bilateral obstructing stones with rising creatinine, the priority is urgent decompression via **DJ stenting** or percutaneous nephrostomy (PCN).

Question 1

A patient with pelvic fracture presents with suprapubic pain, difficulty in passing urine, and hematuria. Cystography reveals findings suggestive of bladder injury. What are the indications for surgical repair of a bladder injury?

Accepted Answer

All of the above

Answer

Repeated blockage of the urinary catheter due to bleeding

Answer

A projecting bone fragment impinging on the bladder wall

Answer

A tear extending to the bladder neck

Question 2

Which is the best investigation for prostate cancer?

Accepted Answer

PSA velocity

Answer

Prostate Specific Antigen

Answer

Acid Phosphatase

Answer

Alkaline phosphatase

Question 3

Which electrolyte abnormality is commonly observed following a Transurethral Resection of the Prostate (TURP)?

Accepted Answer

Hyponatremia

Answer

Hypokalemia

Answer

Hyperkalemia

Answer

Hypernatremia

Question 4

Sterilization is commonly performed at which site of the fallopian tube?

Accepted Answer

Isthmus

Answer

Ampulla

Answer

Infundibulum

Answer

Cornua

Question 5

A newborn presents with a mid-anterior abdominal wall defect that characteristically disappears spontaneously by age 4 years. What is the most likely diagnosis?

Accepted Answer

Umbilical hernia

Answer

Patent urachus

Answer

Omphalocele

Answer

Ectopia vesicae

Question 6

Which hormone is NOT given for palliative care of carcinoma of the prostate?

Accepted Answer

Progesterone

Answer

Estrogen

Answer

LHRH

Answer

Antiandrogens

Question 7

Nelson syndrome is seen following which surgical procedure?

Accepted Answer

Adrenalectomy

Answer

Cholecystectomy

Answer

Spleenectomy

Answer

Duodenectomy

Question 8

Which LASER can be used in the treatment of ureteric calculi?

Accepted Answer

Holmium laser

Answer

CO2 laser

Answer

Nd-Yag laser

Answer

All of the above

Question 9

Which of the following is NOT a cause of acute retention of urine?

Accepted Answer

Herniorraphy

Answer

Meatal ulcer with scabbing in children

Answer

Haemorrhoidectomy

Answer

Fecal impaction

Question 10

What is the commonest presentation of bilateral ureteric stones?

Accepted Answer

Pain

Answer

Chronic renal failure

Answer

Urinary tract infection

Answer

Hematuria

Urology — MCQs

Urology — MCQs

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