Urology — MCQs

Urology Indian Medical PG Practice Questions and MCQs

Question 81: What is the first line of intervention in symptomatic varicoceles?

A. Embolization (Correct Answer)
B. Conservative management
C. Ligation of testicular vein
D. Orchidectomy

Explanation: **Explanation:** The management of symptomatic varicoceles has evolved with the advancement of interventional radiology. While surgical ligation was historically the standard, **Embolization (Option A)** is now frequently considered the first-line intervention, especially in centers with interventional expertise. It is minimally invasive, performed under local anesthesia, and offers a quicker recovery time with success rates comparable to open surgery. It involves the percutaneous occlusion of the internal spermatic vein using coils or sclerosing agents. **Analysis of Incorrect Options:** * **B. Conservative management:** This includes scrotal support and NSAIDs. While used for asymptomatic or subclinical cases, it is not the definitive "intervention" for patients who are already symptomatic (pain or infertility). * **C. Ligation of testicular vein (Varicocelectomy):** This is a definitive surgical treatment (e.g., Palomo’s or Ivanissevich procedure). While highly effective, it is more invasive than embolization and carries risks like hydrocele formation or accidental arterial ligation. * **D. Orchidectomy:** This involves the removal of the testis. It is never indicated for a benign condition like varicocele, as the goal is to preserve fertility and hormonal function. **High-Yield Clinical Pearls for NEET-PG:** * **"Bag of worms"** appearance is the classic clinical description. * **Left-sided predominance:** 90% occur on the left due to the left testicular vein entering the left renal vein at a **right angle**, leading to higher hydrostatic pressure. * **Sudden onset/Right-sided varicocele:** Always rule out a retroperitoneal tumor (e.g., **Renal Cell Carcinoma**) obstructing the IVC. * **Gold Standard for Surgery:** Microsurgical subinguinal varicocelectomy (lowest recurrence and complication rates).

Question 82: Prehn sign is seen in which of the following conditions?

A. Acute orchitis
B. Chronic orchitis
C. Testicular torsion (Correct Answer)
D. None of the above

Explanation: **Explanation:** The **Prehn sign** is a clinical diagnostic maneuver used to differentiate between acute scrotum etiologies. It is considered **positive** when the manual elevation of the testis relieves scrotal pain and **negative** when it does not. 1. **Why Option C is correct:** In **Testicular Torsion**, the Prehn sign is **negative**. Elevating the testis does not relieve the pain; in fact, it often exacerbates it. This occurs because the pain in torsion is due to ischemia and the mechanical twisting of the spermatic cord, which is not alleviated by repositioning. 2. **Why Options A and B are incorrect:** In **Acute Epididymo-orchitis**, the Prehn sign is typically **positive**. Lifting the scrotum relieves the gravitational pull on the inflamed epididymis and suspensory structures, providing symptomatic relief. Chronic orchitis is generally not an acute presentation where this sign is clinically utilized. 3. **Why Option D is incorrect:** Since the sign is a classic clinical marker used specifically to rule out torsion (negative sign) versus epididymitis (positive sign), "None of the above" is inaccurate. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** While Prehn sign is a useful bedside tool, **Color Doppler Ultrasonography** is the investigation of choice to confirm absent blood flow in torsion. * **Cremasteric Reflex:** This reflex is typically **absent** in testicular torsion but present in epididymo-orchitis. * **Time Window:** Testicular salvage rates are nearly 100% if detorsion occurs within **6 hours**, dropping to <10% after 24 hours. * **Management:** Testicular torsion is a surgical emergency requiring bilateral orchidopexy (to prevent future torsion on the contralateral side).

Question 83: What is the sentinel lymph node for carcinoma of the penis called?

A. Delphian node
B. Darwin's node
C. Cloquet's node (Correct Answer)
D. Virchow's node

Explanation: **Explanation:** **Correct Answer: C. Cloquet’s node** The lymphatic drainage of the penis primarily occurs via the superficial and deep inguinal lymph nodes. The **sentinel lymph node** for carcinoma of the penis is **Cloquet’s node** (also known as Rosenmüller’s node). It is the highest of the deep inguinal lymph nodes, located within the femoral canal, medial to the femoral vein and just below the inguinal ligament. It serves as a critical clinical marker; if this node is involved, it indicates a high likelihood of spread to the pelvic (iliac) lymph nodes. **Analysis of Incorrect Options:** * **A. Delphian node:** This is a midline prelaryngeal lymph node located on the cricothyroid membrane. It is the sentinel node for **carcinoma of the thyroid** and larynx. * **B. Darwin’s node:** This is not a lymph node. It is a congenital ear condition (Darwin's tubercle), a cartilaginous protuberance on the helix of the ear. * **C. Virchow’s node:** Also known as the "Signal node," this is a left supraclavicular lymph node. Its enlargement (Troisier’s sign) is classically associated with **metastatic gastric cancer** and other abdominal malignancies. **High-Yield Clinical Pearls for NEET-PG:** * **Drainage Pattern:** Glans penis and distal urethra drain directly to **deep inguinal nodes** (including Cloquet’s), while the skin of the penis drains to **superficial inguinal nodes**. * **Cabanas' Node:** Historically, a specific superficial inguinal node was called the sentinel node by Cabanas, but modern surgical practice identifies the **deep inguinal nodes (Cloquet’s)** as the more reliable sentinel indicators. * **EAU Guidelines:** In penile cancer, if inguinal nodes are non-palpable (cN0), Dynamic Sentinel Node Biopsy (DSNB) is the gold standard for staging.

Question 84: Which of the following is not an appropriate investigation for anterior urethral stricture?

A. Magnetic Resonance Imaging (Correct Answer)
B. Retrograde urethrogram
C. Micturating cystourethrogram
D. High frequency ultrasound

Explanation: **Explanation:** The diagnosis and evaluation of an **anterior urethral stricture** focus on defining the location, length, and depth of the stricture. **Why MRI is the correct answer (Not appropriate):** While MRI (specifically MR Urethrography) can provide detailed images of the pelvic anatomy, it is **not** a routine or appropriate investigation for anterior urethral strictures. It is expensive, time-consuming, and offers no significant advantage over conventional imaging for the anterior segment. MRI is generally reserved for complex **posterior** urethral distractions (e.g., pelvic fracture urethral injuries) to assess prostatic displacement and fibrosis. **Analysis of other options:** * **Retrograde Urethrogram (RGU):** This is the **gold standard** for evaluating anterior urethral strictures. It accurately defines the site and length of the stricture by injecting contrast through the meatus. * **Micturating Cystourethrogram (MCU/VCUG):** While RGU shows the distal end of a stricture, MCU is essential to visualize the **proximal** extent of the stricture and the posterior urethra during voiding. A combination of RGU + MCU is often used to map the stricture completely. * **High-frequency Ultrasound (Sonourethrography):** This is highly effective for the anterior urethra. It is the best modality to assess the degree of **spongiofibrosis** (scarring of the corpus spongiosum), which helps in planning the type of urethroplasty. **Clinical Pearls for NEET-PG:** * **Gold Standard for diagnosis:** Retrograde Urethrogram (RGU). * **Best for Spongiofibrosis:** Sonourethrography (USG). * **Most common site of post-inflammatory stricture:** Bulbar urethra. * **Most common cause of stricture (overall):** Iatrogenic (e.g., catheterization, transurethral surgery). * **Definitive Management:** Urethroplasty (End-to-end anastomosis for <2cm; Substitution urethroplasty using Buccal Mucosa Graft for >2cm).

Question 85: Which of the following conditions is characterized by a "golf-hole ureter"?

A. Genitourinary Tuberculosis (Correct Answer)
B. Ureterocele
C. Vesicoureteric reflux
D. Carcinoma of the bladder

Explanation: **Explanation:** **Genitourinary Tuberculosis (GUTB)** is the correct answer. The "golf-hole ureter" is a classic cystoscopic finding in chronic renal tuberculosis. It occurs due to extensive fibrosis and cicatrization of the peri-ureteric tissues and the ureter itself. This scarring leads to a shortened, thickened, and rigid ureter that pulls the ureteric orifice upward and outward into a fixed, gaping, and dilated position, resembling a golf hole. **Analysis of Incorrect Options:** * **Ureterocele:** This is a cystic dilatation of the distal intramural ureter. On imaging (IVP), it typically presents with a **"Cobra-head"** or "Adder-head" appearance, not a gaping orifice. * **Vesicoureteric Reflux (VUR):** While VUR involves an incompetent ureterovesical junction, the characteristic cystoscopic finding is often a **"Stadium" or "Horseshoe"** shaped orifice, rather than the rigid, retracted "golf-hole" appearance of TB. * **Carcinoma of the Bladder:** This typically presents as a papillary or solid mass. While it can involve the ureteric orifice causing obstruction, it does not classically produce the specific retracted "golf-hole" morphology. **High-Yield Clinical Pearls for GUTB:** * **Most common site:** Kidney (via hematogenous spread); however, the **Epididymis** is the most common site of clinical presentation in males. * **Urinalysis:** Characterized by **"Sterile Pyuria"** (pus cells present, but routine cultures are negative). * **Putty Kidney:** Refers to autonephrectomy where the kidney becomes a small, shrunken, calcified sac. * **Thimble Bladder:** A small-capacity, fibrotic bladder resulting from chronic TB cystitis.

Question 86: Staghorn calculi are associated with which type of infection?

A. Uric acid stones
B. Triple phosphate stones (Correct Answer)
C. Calcium oxalate stones
D. Cysteine stones

Explanation: **Explanation:** Staghorn calculi are large, branching stones that occupy the renal pelvis and extend into at least two calyces, resembling the antlers of a deer. **Why Triple Phosphate is Correct:** Triple phosphate stones (also known as **Struvite** or **Infectious stones**) are composed of Magnesium Ammonium Phosphate. They are directly associated with **Urinary Tract Infections (UTIs)** caused by **urea-splitting organisms** (e.g., *Proteus mirabilis*, *Klebsiella*, *Pseudomonas*). These bacteria produce the enzyme **urease**, which hydrolyzes urea into ammonia and carbon dioxide. This process increases urinary pH (alkaline urine), providing the ideal environment for triple phosphate crystals to precipitate and rapidly grow into large staghorn shapes. **Analysis of Incorrect Options:** * **Uric acid stones:** These form in persistently **acidic urine**. They are typically radiolucent on X-ray and are associated with gout or high cell turnover. * **Calcium oxalate stones:** The most common type of renal calculi overall. They are usually small, hard, and spiculated, but they do not typically form staghorn configurations. * **Cysteine stones:** These are caused by an autosomal recessive defect in amino acid transport. While they can occasionally form "partial" staghorn shapes, they are much rarer than triple phosphate stones and are not primarily driven by infection. **High-Yield Clinical Pearls for NEET-PG:** * **Organism:** *Proteus* is the most common urea-splitter associated with these stones. * **Radiology:** Triple phosphate stones are **radio-opaque** (though less dense than calcium oxalate). * **Microscopy:** They show characteristic **"Coffin-lid"** appearance crystals. * **Management:** The gold standard treatment for large staghorn calculi is **Percutaneous Nephrolithotomy (PCNL)**. Medical management alone is insufficient as the stone acts as a nidus for persistent infection.

Question 87: Low and fixed specific gravity of urine is seen in which condition?

A. Diabetes mellitus
B. Diabetes insipidus
C. Chronic renal failure (Correct Answer)
D. Acute glomerulonephritis

Explanation: **Explanation:** The correct answer is **Chronic Renal Failure (CRF)**. This phenomenon is known as **Isosthenuria**. **1. Why Chronic Renal Failure is correct:** In advanced chronic renal failure, there is a progressive loss of functioning nephrons. The remaining nephrons undergo compensatory hypertrophy and are under a constant state of solute diuresis. This results in the loss of the kidney's ability to either concentrate urine (under the influence of ADH) or dilute it. Consequently, the urine osmolality becomes fixed to that of the plasma (approx. 285–295 mOsm/kg), which corresponds to a **fixed specific gravity of 1.010**. **2. Analysis of Incorrect Options:** * **Diabetes Mellitus:** Characterized by glycosuria. Glucose increases the osmotic pressure, leading to a **high specific gravity** despite polyuria. * **Diabetes Insipidus:** Due to a lack of ADH (Central) or resistance to it (Nephrogenic), the kidneys cannot reabsorb water. This results in very dilute urine with a **persistently low specific gravity** (usually <1.005), but it is not "fixed" at the plasma level. * **Acute Glomerulonephritis:** Typically presents with oliguria and **high specific gravity** as the kidneys attempt to conserve sodium and water in response to decreased perfusion and glomerular filtration. **Clinical Pearls for NEET-PG:** * **Isosthenuria:** Specific gravity fixed at **1.010**. It is a hallmark of end-stage renal disease. * **Hyposthenuria:** Specific gravity **<1.008** (seen in Diabetes Insipidus). * **Hypersthenuria:** Specific gravity **>1.030** (seen in Dehydration or DM). * The **Fishberg Concentration Test** was historically used to assess this tubular function, though it is rarely used in modern practice.

Question 88: Which of the following features are NOT seen in a case of carcinoma of the penis?

A. Circumcision is protective
B. Lesion is painless to begin with
C. Commonest site is glans penis
D. Distant metastasis is common (Correct Answer)

Explanation: **Explanation:** **Carcinoma of the penis** is primarily a **Squamous Cell Carcinoma (SCC)**. Understanding its natural history is crucial for NEET-PG. **Why Option D is the correct answer:** Distant metastasis is actually **uncommon** in penile cancer, especially in the early stages. The disease primarily spreads via **lymphatic channels** to the inguinal lymph nodes. When distant metastasis does occur (late stages), it typically involves the lungs, liver, or bones, but this is seen in less than 10% of cases at presentation. **Analysis of other options:** * **Option A (Circumcision is protective):** This is a well-established fact. Neonatal circumcision significantly reduces the risk of penile cancer by preventing **phimosis** and the accumulation of **smegma**, which acts as a chronic irritant and carcinogen. * **Option B (Lesion is painless to begin with):** Most penile cancers present as a painless ulcer or a fungating growth. Pain usually develops only if there is secondary infection or deep invasion into the corpora cavernosa. * **Option C (Commonest site is glans penis):** The glans is the most frequent site of origin (approx. 48%), followed by the prepuce (21%). **Clinical Pearls for NEET-PG:** 1. **Lymphatic Spread:** The first site of spread is the **Inguinal Lymph Nodes** (Horizontal group of superficial nodes). 2. **Sentinel Node:** The **Sentinel node of Cabanas** (located near the superficial epigastric vein) was historically considered the first node involved. 3. **Etiology:** Strongly associated with **HPV types 16 and 18**. 4. **Staging:** The most important prognostic factor is the presence and extent of inguinal lymph node metastasis.

Question 89: Which of the following is the most common presentation of a colovesical fistula?

A. Pneumaturia (Correct Answer)
B. More common in females
C. Most commonly caused by colon cancer
D. Readily diagnosed on barium enema

Explanation: **Explanation:** A **colovesical fistula** is an abnormal communication between the colon (usually the sigmoid) and the urinary bladder. **1. Why Pneumaturia is correct:** **Pneumaturia** (passage of gas in urine) is the most common and pathognomonic symptom of a colovesical fistula, occurring in over 70-90% of cases. It occurs because the pressure gradient allows intestinal gas to enter the bladder. The second most common symptom is **fecaluria** (passage of stool in urine). Patients often present with "recurrent UTIs" that do not resolve with standard antibiotics. **2. Why the other options are incorrect:** * **B. More common in females:** Incorrect. It is actually **more common in males** (ratio approx. 3:1). In females, the uterus and broad ligaments act as a protective anatomical barrier between the sigmoid colon and the bladder. * **C. Most commonly caused by colon cancer:** Incorrect. The most common cause is **Diverticulitis** (accounting for ~65-75% of cases). Malignancy is the second most common cause, followed by Crohn’s disease. * **D. Readily diagnosed on barium enema:** Incorrect. Barium enema has a low sensitivity (approx. 30%) for detecting the fistula tract itself. The **investigation of choice is a CT scan with oral/rectal contrast** (but not IV contrast initially, as it may mask the contrast entering the bladder from the colon). **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** CT Scan (shows air in the bladder, bladder wall thickening, or contrast in the bladder). * **Bourne Test:** A simple test where the patient's urine is centrifuged after a barium enema; the presence of barium in the sediment confirms the fistula. * **Gouverneur’s Sign:** Suprapubic pain, frequency, urgency, and dysuria (heralds the impending rupture of an inflammatory bowel mass into the bladder).

Question 90: A 33-year-old woman presents with severe right flank pain that started 3 hours ago. The pain occasionally radiates to her right iliac fossa. She also reports nausea and a low-grade fever. What is the most appropriate investigation?

A. Abdominal x-ray
B. Magnetic resonance imaging (MRI) scan
C. Intravenous urography
D. Abdominal ultrasound (US) scan (Correct Answer)

Explanation: **Explanation:** The clinical presentation of acute-onset severe flank pain radiating to the iliac fossa (ureteric colic) in a young woman strongly suggests **urolithiasis**. **1. Why Option D is Correct:** In the context of NEET-PG and standard clinical guidelines (like EAU/AUA), **Non-Contrast Computed Tomography (NCCT) KUB** is generally the gold standard for diagnosing renal stones. However, in female patients of reproductive age, **Abdominal Ultrasound (USG)** is the preferred initial investigation to avoid ionizing radiation and to rule out differential diagnoses like ovarian torsion or ectopic pregnancy. USG is highly effective at detecting hydronephrosis (secondary to obstruction) and stones in the pelvic-ureteric or vesico-ureteric junctions. **2. Why Other Options are Incorrect:** * **Abdominal X-ray (KUB):** While useful for follow-up of radiopaque stones, it misses radiolucent stones (uric acid) and small stones obscured by bowel gas. It has low sensitivity for acute diagnosis. * **MRI Scan:** MRI is excellent for soft tissue but poor at visualizing calcified stones. It is reserved only for specific cases, such as pregnant patients where USG is inconclusive. * **Intravenous Urography (IVU):** Historically the gold standard, it is now obsolete in acute settings due to the risk of contrast-induced nephropathy and the time required for the procedure. **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** NCCT KUB (highest sensitivity and specificity). * **First-line in Pregnancy/Children:** Ultrasound. * **Most common site of stone impaction:** Vesico-ureteric junction (VUJ) — the narrowest part of the ureter. * **Radiolucent stones on X-ray:** "Pure" Uric acid, Xanthine, and Matrix stones (Mnemonic: **U**n**X**-rayable).

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