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Urology MCQs PDF
Urology MCQs PDF
1- 80-year-old man presented with dull aching pain in the loins. Investigations showed high
urea and creatinine. Ultrasound of the abdomen showed bilateral hydronephrosis. Most
common cause is:
A. Stricture of urethral meatus
B. Neoplasm of the bladder
C. Prostatic enlargement
D. Pelvic CA
E. Retroperitoneal fibrosis
Hydronephrosis and hydroureter can range from benign processes, such as the physiologic hydroureteronephrosis of
pregnancy, to potential life-threatening situations, such as infected hydronephrosis or pyonephrosis. Although patients
usually present with some signs or symptoms, hydronephrosis can be an incidental finding encountered during the
evaluation of an unrelated process. If unrecognized or left untreated, hydronephrosis and hydroureter secondary to
obstruction can lead to hypertension, loss of renal function, and sepsis. Consequently, all patients found to have
hydronephrosis or hydroureter should undergo a thorough evaluation and should be referred to a urologist.
Sex
In women, gynecologic cancers and pregnancy are common causes. As such, among younger patients (aged
20-60 y), the frequency of hydronephrosis is higher in women than in men.
In men, obstruction secondary to prostatic hypertrophy and prostate cancer are the major causes of
hydronephrosis. Consequently, among older patients (>60 y), the frequency of hydronephrosis is higher in men
than in women.
Age
In young adults, calculi are the most common causes of hydroureter and hydronephrosis.
In children, reflux and ureteropelvic junction obstruction are common causes.
Clinical
History
Physical
A multitude of causes exist for hydronephrosis and hydroureter. Classification can be made according to the level
within the urinary tract and whether the etiology is intrinsic, extrinsic, or functional.
Ureter
o Intrinsic
Ureteropelvic junction stricture
Ureterovesical junction obstruction
Papillary necrosis
Ureteral folds
Ureteral valves
Ureteral stricture (iatrogenic)
Blood clot
Benign fibroepithelial polyps
Ureteral tumor
Fungus ball
Ureteral calculus
Ureterocele
Endometriosis
Tuberculosis
Retrocaval ureter
o Functional
Gram-negative infection
Neurogenic bladder
o Extrinsic
Retroperitoneal lymphoma
Retroperitoneal sarcoma
Cervical cancer
Prostate cancer
Retroperitoneal fibrosis
Aortic aneurysm
Inflammatory bowel disease
Ovarian vein syndrome
Retrocaval ureter
Uterine prolapse
Pregnancy
Iatrogenic ureteral ligation
Ovarian cysts
Diverticulitis
Tuboovarian abscess
Retroperitoneal hemorrhage
Lymphocele
Bladder
o Intrinsic
Bladder carcinoma
Bladder calculi
Bladder neck contracture
Cystocele
Primary bladder neck hypertrophy
Bladder diverticula
o Functional
Neurogenic bladder
Vesicoureteral reflux
o Extrinsic - Pelvic lipomatosis
Urethra
o Intrinsic
Urethral stricture
Urethral valves
Urethral diverticula
Urethral atresia
Labial fusion
o Extrinsic - Benign prostatic hyperplasia and prostate cancer
-IVP study done for a male & showed a filling defect in the renal pelvis non-radio opaque. U/S
shows echogenic structure & hyperacoustic shadow. The most likely diagnosis is:
a. Blood clot
b. Tumor
C. Uric acid stone
d. ???
- a non opaque renal pelvis filling defect is seen on IVP.Ultrasound reveals dense echoes and
acoustic shadowing.The MOST likely diagnosis is:
a)blood clot
b)tumor
c)sloughed renal papilla
d)uric acid stone
e)crossing vessel
Causes
Most research on the etiology and prevention of urinary tract stone disease has been directed toward the role of
elevated urinary levels of calcium, oxalate, and uric acid in stone formation, as well as reduced urinary citrate
levels.
Hypercalciuria is the most common metabolic abnormality. Some cases of hypercalciuria are related to
increased intestinal absorption of calcium (associated with excess dietary calcium and/or overactive calcium
absorption mechanisms), some are related to excess resorption of calcium from bone (ie,
hyperparathyroidism), and some are related to an inability of the renal tubules to properly reclaim calcium in
the glomerular filtrate (renal-leak hypercalciuria).
Magnesium and especially citrate are important inhibitors of stone formation in the urinary tract. Decreased
levels of these in the urine predispose to stone formation.
A low fluid intake, with a subsequent low volume of urine production, produces high concentrations of stone-
forming solutes in the urine. This is an important, if not the most important, environmental factor in
kidney stone formation.
The exact nature of the tubular damage or dysfunction that leads to stone formation has not been characterized.
The most common findings on 24-hour urine studies include hypercalciuria, hyperoxaluria, hyperuricosuria,
hypocitraturia, and low urinary volume. Other factors, such as high urinary sodium and low urinary
magnesium concentrations, may also play a role. To identify these risk factors, a 24-hour urine profile,
including appropriate serum tests of renal function, uric acid, and calcium, is needed. Such testing is available
from various commercial laboratories. A finding of hypercalcemia should prompt follow-up with an intact
parathyroid hormone study to evaluate for primary and secondary hyperparathyroidism.
Imaging Studies
3- a 75 year olf man came to the ER complaining of acute urine retention what will be your
initial management:
a)send patient immediately to OR for prostatectomy
b)empty urinary bladder by folley’s catheter and tell him to come back to the clinic
c)give him antibiotics because retention could be from sort of infection
d)insert folly’s catheter and tell him to come back to the clinic (b & d are repeated)
e)admission, investigation which include cystoscopy then..
- A 82 years old patient present with urinary retention. What is the most proper treatment in
ER?
-Insert Folly’s Cath then send to clinic.
-Insert Folly’s Cath then send to home.
-O.R. for prostatectomy.
-Admission, Investigation, then do cystoscope or TRUP.
- In an 82 years old patient with acute urinary retention,the management is:
a) To empty the bladder by Foley’s catheter and follow up in the clinic.
b) To insert a Foley’s catheter then send the patient home to come back in the clinic.
c) To admit and investigate by TURP.
d) Immediate prostatectomy
6- A 20 yr old female present with fever, loin pain & dysuria, management include all of the
following except:
a) urinanalysis and urine culture
b) blood culture
c) IVU (IVP)
d) Cotrimexazole
7- Old male came with urine retention, dilated ureter and hydronephrosis, Dx is:
a) Benign prostatic hyperplasia.
b) Ureteric stone impaction.
c) bladder tumor.
Clinical
History
History includes a sudden onset of severe unilateral scrotal pain.
Onset of pain can occur more slowly, but this is an uncommon presentation of torsion.
Torsion can occur with activity, can be related to trauma in 4-8% of cases,2 or can develop during sleep.
The historical features suggestive of testicular torsion include the following:
o Acute onset of unilateral scrotal pain
o Scrotal swelling
o Nausea and vomiting: In the pediatric population, nausea and vomiting more commonly accompany
acute testicular torsion and have a positive predictive value of greater than 96%. 4
o Abdominal pain (20-30%)
o Fever (16%)
o Urinary frequency (4%)
Many patients have a history of recurrent scrotal pain that has resolved spontaneously. This history is highly
suggestive of intermittent torsion and detorsion of the testicle. Patients who complain of what sounds like
torsion-detorsion should be referred promptly to a urologist since patients with symptoms of intermittent
torsion who electively have surgical exploration are less likely to develop subsequent torsion and loss of the
testicle.5 Creagh et al reported that acute torsion developed in 10% of patients with intermittent torsion while
they waited for surgery.6
Physical
The physical examination is useful, but imperfect, in diagnosing acute testicular torsion. 7
The physical examination, moreover, may be difficult to perform, as the testicle is typically very tender and
patients are often in significant discomfort.
The involved testicle is painful and is frequently elevated in position when compared with the other side.
Horizontal lie of the testicle - While abnormal lie can help diagnose testicular torsion, fewer than 50% of cases
demonstrated true horizontal lie.7
Enlargement and edema of the testicle; edema involving the entire scrotum
Scrotal erythema
Ipsilateral loss of the cremasteric reflex - The cremasteric reflex is almost always absent in patients with
testicular torsion, and its presence may help to distinguish other causes of acute scrotal pain from testicular
torsion. Case reports, however, have noted the opposite to be true. 8,9,7
Usually, no relief of pain upon elevation of scrotum (elevation may improve the pain in epididymitis [Prehn
sign])
Fever (uncommon)
Causes
Congenital anomaly; bell clapper deformity
Undescended testicle
Sexual arousal and/or activity
Trauma
Testicular tumor
Exercise
Treatment
Emergency Department Care
Early diagnosis and prompt urologic consultation is essential since time is critical in salvage of the testicle.
Analgesic pain relief should be administered as testicular torsion is typically very painful.
Attempt manual detorsion with pain relief as the guide for successful detorsion. The procedure is similar
to the "opening of a book" when the physician is standing at the patient's feet.
Most torsions twist inward and toward the midline; thus, manual detorsion of the testicle involves twisting
outward and laterally.
o For example, in a suspected torsion of the right testicle, the physician is in front of the standing or
supine patient and holds the patient's right testicle with the left thumb and forefinger.
o The physician then rotates the right testicle outward 180° in a medial to lateral direction.
o Rotation of the testicle may need to be repeated 2-3 times for complete detorsion and to provide pain
relief to the patient.
o For the patient's left testicle, the physician uses the right thumb and forefinger and rotates the patient's
left testicle in an outward direction 180° from medial to lateral.
o Manual detorsion is successful in 26.5% to greater than 80% of patients based upon a number of
reviewed studies.2
Consultations
If the clinical diagnosis of torsion is suspected, early urologic consultation is mandatory since definitive treatment is
surgery for detorsion and orchiopexy or possible orchiectomy.
- Epidydimitis:
A-Common at the age 12-18 years
B-Iliac fossa pain
C-Scrotal content does not increase in size.
D-Ultrasound will confirm the diagnosis.
E-All of above
Acute scrotal pain is a common complaint in the emergency room, and the diagnosis of epididymitis must be
differentiated from testicular torsion, a true scrotal emergency.1 Ultrasonography is noninvasive and can help
differentiate between the pathologies. One area under investigation is the ability of emergency physicians to use bedside
ultrasonography to accurately diagnose patients with acute scrotal pain.
Epididymitis is most often due to the retrograde extension of organisms from the vas deferens and is rarely the result of
hematogenous spread. Bacterial infection results in the infiltration of WBCs into the epididymal connective tissue, with
resultant congestion and edema. This inflammation can rapidly spread to the tubules, with the risk of abscess formation
and necrosis of the epididymis.4,5 The causative organism is identified in 80% of patients and varies according to the age
of the patient.
Age
Epididymitis is primarily a disease of adults, most commonly affecting males aged 19-40 years.
Clinical
History
The progression of epididymitis usually is gradual in nature, with symptoms often peaking within 24 hours of onset.
Initially, the patient may note abdominal or flank pain because cellular inflammation typically begins in the vas
deferens. As the inflammation descends to the lower segment of the epididymis, the patient notes discomfort localized
to the scrotum. Younger patients or any patient with a sexually transmitted epididymitis may note symptoms related to
urethritis. A recent history of endourethral instrumentation or urinary tract infection is more common in older patients.
Symptoms include the following:
Scrotal pain and edema
Urinary frequency, urgency, or dysuria
Urinary retention from bladder outlet obstruction in older patients
Nausea
Fever and chills
Abdominal or flank pain
Bilateral epididymal involvement (10%)
Urethral discharge
Physical
Edematous tender epididymis: Early on, in cases without significant testicular involvement, tenderness may be
clearly localized to the epididymis.
Erythematous edematous scrotum
Scrotal abscess
o Scrotal fluctuance
o Scrotal fixation to underlying epididymis
Reactive hydrocele
Prehn sign: This has been used to distinguish epididymitis from testicular torsion. Classically, scrotal elevation
decreases pain in epididymitis and not in torsion. However, the Prehn sign is not reliable for distinguishing
epididymitis from testicular torsion.
Urethral discharge (10%)
Fever or other constitutional symptoms with progression of disease
Causes
Epididymitis most often is due to the retrograde extension of bacterial organisms from the vas deferens.
o Prepubertal males - Coliform bacteria (E coli)
o Sexually active males -C trachomatis is the most common organism followed by N gonorrhoeae
o Older males - Coliform bacteria most common, sexually transmitted diseases less common
Less common causes of epididymitis include the following:
o Chemical epididymitis due to the reflux of sterile urine
o Boys with epididymitis due to a postinfectious inflammatory reaction to pathogens, such as M
pneumoniae, enteroviruses, and adenoviruses
o Candidal epididymitis in immunocompromised patients (AIDS)
o Epididymitis as an extrapulmonary manifestation of tuberculosis
o Epididymitis secondary to exposure to amiodarone therapy or prostate brachytherapy
Screening
Advances in transrectal ultrasound (TRUS) and prostate-specific antigen (PSA) monitoring have
allowed for enhanced detection of nonpalpable tumors. Much controversy currently exists over
whether men over age 50 should be encouraged to undergo screening. While available data show a
decrease in the mortality rate of prostate cancer, there is as yet little evidence that screening has
been the cause of this change. Even so, the realities of clinical practice are that the combination of
digital rectal examination and serum PSA monitoring is the most effective screening protocol.
15- 35 Y/O presented with left iliac pain and dysuria, management include all the following
except:
• blood C+S.
• microscopy of urine.
• IVP.
• urine C+S.
• norfloxacin.
Treatment
Prehospital Care
Address acute life-threatening conditions. Be very aware that the amount of force necessary to cause a
significant pelvic fracture is likely to have caused other significant injuries.
Application of an external compression device to a grossly unstable pelvis will provide mechanical
stabilization while controlling hemorrhage from the fracture site. A sheet or one of a variety of inexpensive,
commercial products may be used.10
Avoid excessive movement of the pelvis.
Obtain large-bore intravenous (IV) access, and administer analgesia and fluids in accordance with local
protocols.
Closely monitor vital signs.
19- A patient with gross hematuria after blunt abdominal trauma has a normal-appearing
cystogram after the intravesical instillation of 400 ml of contrast. You should next order:
a. A retrograde urethrogram.
b. An intravenous pyelogram.
c. A cystogram obtained after filling, until a detrusor response occurs.
d. A voiding cystourethrogram.
e. A plain film of the abdomen after the bladder is drained.
General Considerations
Renal injury is uncommon but potentially serious and often accompanied by multisystem trauma. The most common
causes are athletic, industrial, or automobile accidents. The degree of injury may range from contusion to laceration of
the parenchyma or disruption of the renal pedicle.
Clinical Findings
Symptoms and Signs
1. Gross hematuria following trauma means injury to the urinary tract.
2. Pain and tenderness over the renal area may be significant but could be due to musculoskeletal injury.
3. Hemorrhagic shock may result from renal laceration and lead to oliguria.
4. Nausea, vomiting, and abdominal distention (ileus) are the rule.
5. Physical examination may reveal ecchymosis or penetrating injury in the costovertebral angle or flank.
6. Extravasation of blood or urine may produce a palpable flank mass.
7. Other injuries should be sought.
Laboratory Findings
1. Serial hematocrit determinations will give clues to persistent bleeding.
2. Hematuria is to be expected, but the absence of hematuria does not exclude renal injury (as in renal vascular
injury).
Imaging Studies
1. A plain film may reveal obliteration of the psoas shadow; this suggests the presence of a retroperitoneal hematoma
or urinary extravasation. Bowel gas may be displaced from the area. Evidence of transverse vertebral process
fractures or rib fracture may be noted.
In the past the excretory urogram was used for evaluating renal trauma. Excretory urograms may show a normal
kidney if it is mildly contused or may show extravasation of contrast medium if the kidney is lacerated.
Nonfunction suggests injury to the vascular pedicle. The excretory urogram should demonstrate that the
contralateral kidney is normal.
2. CT scan with intravenous contrast medium is now the method of choice for staging a patient with
hemodynamically stable renal trauma. CT scans may miss urinary extravasation if performed too rapidly
following intravenous contrast administration—before the contrast is excreted into the collecting system and ureter.
3. If renal vascular damage is suspected and the patient's condition is stable, preoperative renal angiography may
facilitate planning of renovascular reconstruction or permit arterial stenting. In special circumstances, selective
renal artery embolization may control segmental arterial bleeding.
Differential Diagnosis
Bony fractures or contusion of soft tissues in the region of the kidney may cause confusion.
Hematuria might be secondary to vesical injury. The absence of a perirenal mass (ie, hematoma or urinoma) or contrast
extravasation on urograms or CT scan would rule out significant trauma.
Complications
Early
1. The most serious complication is continued perirenal hemorrhage, which may be fatal. Serial hematocrit, blood
pressure, and pulse determinations are essential. Serial CT scans may also be useful. Evidence of an enlarging flank
mass implies persistent bleeding. In most cases, bleeding stops spontaneously, probably as a result of tamponade by
the perirenal fascia.
2. Delayed bleeding 1 or 2 weeks later is rare.
3. Infection of the perirenal hematoma may occur.
Late
Ultrasound should be obtained 1–3 months after surgery to look for progressive hydronephrosis from ureteral
obstruction. The blood pressure should be checked at regular intervals, because hypertension may be a late sequela.
Treatment
1. Treat shock and hemorrhage with fluids and transfusion.
2. Most patients with blunt renal trauma stop bleeding and heal spontaneously.
3. Bed rest is indicated until hematuria resolves.
4. If bleeding persists, laparotomy is indicated.
5. Penetrating renal trauma requires exploration.
6. Lacerations may be sutured, the collecting system closed, and urinary extravasation drained.
7. Nephrectomy or partial nephrectomy may be necessary to remove devitalized tissue and secure the collecting
system.
8. Late complications may occur.
9. Perinephric abscess should be drained.
10. Hypertension due to renal ischemia requires vascular reconstruction or nephrectomy.
Prognosis
Most injured kidneys heal spontaneously, though the patient must be examined at intervals for the onset of hypertension
due to renal ischemia or progressive hydronephrosis due to secondary ureteral stricture. Many patients with
genitourinary trauma have associated injuries. In most cases, death is due to associated injury rather than renal injury.
20- The most likely cause of gross hematuria in a 35-year-old man is:
a) cystitis
b) ureteral calculi
c) renal carcinoma
d) prostatic carcinoma
e) bladder carcinoma