Urology Basics US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Urology Basics. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Urology Basics US Medical PG Question 1: A 97-year-old man visits the urology clinic 5 days after experiencing urinary retention at an emergency department visit. The patient has a history of hypertension, type II diabetes mellitus, stroke, dyslipidemia, a past myocardial infarction, and severe osteoarthritis in his right hip. He is not compliant with his medications and his multiple comorbidities are poorly managed. In the hospital, the patient’s urinary retention was treated with Foley catheterization. At clinic, the patient’s serum-specific prostate-specific antigen (PSA) is 6.0 ng/mL (normal is < 4 ng/mL). Digital rectal examination (DRE) demonstrates a nontender prostate with several rock hard nodules. The patient's Foley is removed and he is able to urinate on his own. Which is the most appropriate next step in management?
- A. Repeat PSA test
- B. CT abdomen and pelvis
- C. Cystourethroscopy
- D. Reassurance
- E. Transrectal prostate biopsy (Correct Answer)
Urology Basics Explanation: ***Transrectal prostate biopsy***
- The combination of an elevated **PSA** (6.0 ng/mL) and **palpable, rock-hard nodules** on digital rectal examination is highly suspicious for **prostate cancer**.
- A definitive diagnosis requires a **tissue biopsy** to determine the presence of malignancy and its Gleason score.
*Repeat PSA test*
- While a repeat PSA can sometimes be useful to confirm a trend or rule out transient elevation, the presence of **palpable prostatic nodules** on DRE makes a repeat PSA insufficient given the high suspicion of malignancy.
- Delaying definitive workup, such as a biopsy, could be detrimental if cancer is present.
*CT abdomen and pelvis*
- A CT scan would be more appropriate for **staging** if prostate cancer were confirmed, to assess for metastasis, rather than for initial diagnosis.
- It would not provide the definitive **tissue diagnosis** needed to confirm prostate cancer.
*Cystourethroscopy*
- **Cystourethroscopy** is used to visualize the urethra and bladder, often for issues like hematuria, strictures, or bladder masses.
- It is not the primary diagnostic tool for **prostate cancer** originating in the peripheral zone given the DRE findings.
*Reassurance*
- Given the patient's elevated **PSA** and **palpable rock-hard nodules** on DRE, providing reassurance is inappropriate and could lead to delayed diagnosis and treatment of potentially aggressive prostate cancer.
- These findings are highly indicative of prostate pathology requiring further investigation.
Urology Basics US Medical PG Question 2: A previously healthy 22-year-old man presents to the university clinic with increasing scrotal pain and swelling over the past 5 days. He also has dysuria and urinary frequency. He has never felt this type of pain before. The young man considers himself generally healthy and takes no medications. He is sexually active with one partner and uses condoms inconsistently. At the clinic, his temperature is 36.7℃ (98.1℉), the blood pressure is 115/70 mm Hg, the pulse is 84/min, and the respirations are 14/min. On examination, he has swelling and tenderness of the right scrotum, especially over the posterior aspect of the right testicle. The Prehn sign is positive. The remainder of the physical exam is unremarkable. Doppler sonography shows increased blood flow to the testis. Which of the following is the most appropriate next step in management?
- A. Oral metronidazole for patient and sexual partner
- B. IV ceftriaxone and oral doxycycline (Correct Answer)
- C. Radical orchiectomy
- D. Surgical exploration
- E. Manual detorsion guided by Doppler sonography
Urology Basics Explanation: **IV ceftriaxone and oral doxycycline**
- The patient's symptoms (scrotal pain, swelling, dysuria, urinary frequency), positive **Prehn's sign**, and **increased testicular blood flow** on Doppler sonography are highly suggestive of **epididymitis**, most likely caused by sexually transmitted infections (STIs) in a young, sexually active male.
- **Empiric antibiotic treatment** for probable gonococcal and chlamydial infection (common causes of epididymitis in this age group) is the most appropriate next step, with **ceftriaxone** covering gonorrhea and **doxycycline** covering chlamydia.
*Oral metronidazole for patient and sexual partner*
- **Metronidazole** is primarily used to treat anaerobic bacterial infections and parasitic infections (e.g., *Trichomonas vaginalis*).
- While *Trichomonas* can cause urethritis, it is not a common cause of epididymitis, and metronidazole would not cover the more likely bacterial etiologies of epididymitis such as *Neisseria gonorrhoeae* or *Chlamydia trachomatis*.
*Radical orchiectomy*
- **Radical orchiectomy** is the surgical removal of the testicle, typically reserved for confirmed cases of **testicular cancer**.
- There are no indications of malignancy in this patient's presentation; the symptoms are inflammatory and infectious in nature.
*Surgical exploration*
- **Surgical exploration** is indicated if **testicular torsion** cannot be ruled out or if there are signs of **testicular abscess** or other surgical emergencies.
- The positive **Prehn's sign** (relief of pain with scrotal elevation) and **increased blood flow** on Doppler argue against torsion and support epididymitis, making immediate surgical exploration unnecessary.
*Manual detorsion guided by Doppler sonography*
- **Manual detorsion** is a treatment for **testicular torsion**, a condition characterized by sudden, severe scrotal pain, an absent cremasteric reflex, a negative Prehn's sign, and **decreased or absent blood flow** on Doppler.
- This patient's symptoms, especially the positive Prehn's sign and increased blood flow, are inconsistent with testicular torsion, making manual detorsion an inappropriate intervention.
Urology Basics US Medical PG Question 3: A 75-year-old woman presents to the physician with a complaint of a frequent need to void at nighttime, which has been disrupting her sleep. She notes embarrassingly that she is often unable to reach the bathroom in time, and experiences urinary leakage throughout the night as well as during the day. The patient undergoes urodynamic testing and a urinalysis is obtained which is normal. She is instructed by the physician to perform behavioral training to improve her bladder control. Which of the following is the most likely diagnosis contributing to this patient’s symptoms?
- A. Urinary tract infection
- B. Stress incontinence
- C. Urge incontinence (Correct Answer)
- D. Overflow incontinence
- E. Total incontinence
Urology Basics Explanation: ***Urge incontinence***
- The patient's symptoms of a **frequent need to void**, inability to reach the bathroom in time (urgency), and **nocturnal leakage** (nocturia with incontinence) are classic for urge incontinence.
- This condition is characterized by **detrusor overactivity**, leading to sudden, strong urges to urinate that are difficult to defer.
*Urinary tract infection*
- While UTIs can cause urgency and frequency, the patient's **normal urinalysis** rules out an active infection as the cause of her symptoms.
- UTIs typically present with dysuria, hematuria, or suprapubic pain, which are not mentioned.
*Stress incontinence*
- This type of incontinence is characterized by **involuntary urine leakage with increased intra-abdominal pressure**, such as coughing, sneezing, or laughing.
- The patient's description of sudden urges and inability to reach the bathroom in time does not align with stress incontinence.
*Overflow incontinence*
- This condition is due to **incomplete bladder emptying**, leading to a constantly full bladder and continuous leakage.
- It often presents with weak stream, hesitancy, and a feeling of incomplete voiding, which are not described here.
*Total incontinence*
- Total incontinence involves the **continuous and unpredictable leakage** of urine, day and night, without any discernible pattern.
- While the patient experiences significant leakage, her symptoms point more specifically to the urge component rather than a complete absence of bladder control.
Urology Basics US Medical PG Question 4: A 75-year-old male presents to the emergency room complaining of severe lower abdominal pain and an inability to urinate. He reports that he last urinated approximately nine hours ago. When asked to urinate, only a few drops dribble from the tip of his penis. Further questioning reveals that the patient has experienced progressively worsening difficulty with urinating over the past two years. He has lived alone for five years since his wife passed away. He has not seen a doctor in that time. His temperature is 98.8°F (37.1°C), blood pressure is 145/90 mmHg, pulse is 115/min, and respirations are 22/min. He appears to be in severe pain. Physical examination reveals a distended bladder and significant tenderness to palpation over the inferior aspect of his abdomen. Which of the following sets of lab values would most likely be found in a urinalysis of this patient?
- A. Urine osmolality 550 mOsmol/kg H2O, Urine Na+ 15 mEq/L, FENa 0.9%, red blood cell casts
- B. Urine osmolality 400 mOsmol/kg H2O, Urine Na+ 25 mEq/L, FENa 1.5%, no casts
- C. Urine osmolality 300 mOsmol/kg H2O, Urine Na+ 45 mEq/L, FENa 5%, no casts (Correct Answer)
- D. Urine osmolality 200 mOsmol/kg H2O, Urine Na+ 35 mEq/L, FENa 3%, muddy brown casts
- E. Urine osmolality 600 mOsmol/kg H2O, Urine Na+ 15 mEq/L, FENa 0.8%, hyaline casts
Urology Basics Explanation: ***Urine osmolality 300 mOsmol/kg H2O, Urine Na+ 45 mEq/L, FENa 5%, no casts***
- The patient's presentation with acute urinary retention due to **benign prostatic hyperplasia (BPH)** and subsequent obstructive uropathy leads to **postrenal acute kidney injury (AKI)**. If the obstruction is prolonged, it can lead to kidney damage and an inability to concentrate urine effectively, resulting in an **isosthenuric** urine (osmolality near plasma, ~300 mOsmol/kg H2O) and a higher fractional excretion of sodium (**FENa > 2-3%**).
- **No casts** are typically seen in pure postrenal AKI unless superimposed intrinsic renal damage has occurred. The increased urine Na+ and FENa reflect tubular dysfunction due to prolonged obstruction.
*Urine osmolality 550 mOsmol/kg H2O, Urine Na+ 15 mEq/L, FENa 0.9%, red blood cell casts*
- This profile suggests **prerenal azotemia** with a low FENa and concentrated urine, indicating appropriate kidney response to hypoperfusion, which is not the primary issue here. **Red blood cell casts** indicate glomerulonephritis, typically seen in intrinsic renal disease, which is not supported by the patient's presentation of obstructive uropathy.
*Urine osmolality 400 mOsmol/kg H2O, Urine Na+ 25 mEq/L, FENa 1.5%, no casts*
- This urine profile suggests an intermediate state, possibly early or resolving prerenal injury, but not classic for established postrenal AKI. The **FENa is still relatively low**, indicating some preserved tubular function, which would be compromised in prolonged obstruction leading to AKI.
*Urine osmolality 200 mOsmol/kg H2O, Urine Na+ 35 mEq/L, FENa 3%, muddy brown casts*
- **Muddy brown casts** are characteristic of **acute tubular necrosis (ATN)**, and while ATN can be a complication of prolonged postrenal obstruction, it is not the initial or most direct finding for postrenal AKI. Also, an osmolality of 200 mOsmol/kg H2O would suggest significant inability to concentrate urine, common in ATN, but the presence of muddy brown casts is the key differentiating feature.
*Urine osmolality 600 mOsmol/kg H2O, Urine Na+ 15 mEq/L, FENa 0.8%, hyaline casts*
- This profile is highly suggestive of **prerenal azotemia**, characterized by a **highly concentrated urine** (high osmolality) and **low urinary sodium and FENa**, indicating robust renal sodium and water reabsorption in response to perceived hypovolemia. While hyaline casts can be seen in prerenal states, the overall picture does not fit the obstructive cause of AKI described.
Urology Basics US Medical PG Question 5: A 37-year-old woman presents to the Emergency Department after 8 hours of left sided flank pain that radiates to her groin and pelvic pain while urinating. Her medical history is relevant for multiple episodes of urinary tract infections, some requiring hospitalization, and intravenous antibiotics. In the hospital, her blood pressure is 125/83 mm Hg, pulse of 88/min, a respiratory rate of 28/min, and a body temperature of 36.5°C (97.7°F). On physical examination, she has left costovertebral tenderness and lower abdominal pain. Laboratory studies include a negative pregnancy test, mild azotemia, and a urinary dipstick that is positive for blood. Which of the following initial tests would be most useful in the diagnosis of this case?
- A. Urine osmolality
- B. Fractional excretion of sodium (FeNa+)
- C. Renal ultrasonography (Correct Answer)
- D. Contrast abdominal computed tomography
- E. Blood urea nitrogen (BUN): serum creatinine (SCr) ratio
Urology Basics Explanation: ***Renal ultrasonography***
- This is the most appropriate initial imaging test to evaluate for **kidney stones** (given the flank pain radiating to groin and hematuria) and **hydronephrosis** (which can indicate obstruction) and assess for signs of **pyelonephritis** (given the history of recurrent UTIs and CVA tenderness).
- It is **non-invasive**, readily available, and avoids radiation exposure, making it suitable as a first-line diagnostic tool in this setting.
*Urine osmolality*
- This test primarily assesses the kidney's ability to **concentrate urine**, which is more relevant for evaluating fluid balance, diabetes insipidus, or other renal tubular disorders.
- It would not directly diagnose the cause of acute flank pain or urinary tract obstruction.
*Fractional excretion of sodium (FeNa+)*
- FeNa+ is used to differentiate between **prerenal azotemia** and **acute tubular necrosis**, indicating the kidney's response to hypoperfusion.
- While the patient has mild azotemia, FeNa+ would not identify the underlying cause of the flank pain, hematuria, or potential obstruction.
*Contrast abdominal computed tomography*
- While highly sensitive for diagnosing kidney stones and other renal pathologies, **contrast CT** exposes the patient to **ionizing radiation** and risks associated with contrast agents (e.g., contrast-induced nephropathy), especially with pre-existing azotemia.
- It is often reserved for cases where ultrasound is inconclusive or more detailed anatomical information is needed.
*Blood urea nitrogen (BUN): serum creatinine (SCr) ratio*
- This ratio is primarily used to differentiate between **prerenal** causes of acute kidney injury (high ratio, e.g., >20:1) and **intrinsic renal** causes (lower ratio, e.g., <15:1).
- While it can provide insight into the etiology of azotemia, it does not directly identify the cause of the patient's acute flank pain or potential urinary tract obstruction.
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