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UROLOGY
(Total Questions - 137)Q.1. A 58 year old man has renal colic for the past 12 hours. In the last two years, he has presented with three episodes of acute onset of pain in his right knee. What is the most likely cause of his renal colic?
Correct Answer : A
Hyperuricaemia is the only one of the choices that has links to both gouty arthritis and the formation of renal stones which causes renal colic.
Q.2. An 85 year old war veteran complains of loss of appetite and says that he has lost weight over the past few months. He says that he has passed some blood in his urine however, there was no pain. He finds it difficult to empty his bladder completely and complains of having to urinate more often than usual. He also states that he has worsening pelvic pain over the past 3 months. A recent report shows that PSA is 9.5 ng/ml. What is the most likely reason for his symptoms?
Correct Answer : C
These are the features of prostate cancer.
The raised PSA would be a reason to investigate further for prostate cancer. The pelvic pain could be a sign of bone metastasis or it could be obstructive symptoms due to prostate cancer.
PROSTATE CARCINOMA :
Risk factors :
• Increasing age is the most important risk factor
• Men of black African-Caribbean family origin
• First-degree relative with prostate cancer
Presentation :
• Lower urinary tract symptoms (LUTS) do not particularly raise suspicion of prostate cancer because LUTS are common in older men and are rarely the presenting symptom of prostate cancer. However, locally advanced prostate cancer may cause obstructive LUTS.
Local disease:
• Raised PSA on screening
• Weak stream, hesitancy, the sensation of incomplete emptying, urinary frequency, urgency, urge incontinence
• Urinary tract infection
Locally invasive disease:
• Haematuria, dysuria, incontinence
• Haematospermia
• Perineal and suprapubic pain
• Obstruction of ureters, causing loin pain, anuria, symptoms of acute kidney injury or chronic kidney disease
Metastatic disease:
• Bone pain or sciatica
• Paraplegia secondary to spinal cord compression
• Lymph node enlargement
• Lethargy (anaemia, uremia)
• Weight loss
Q.3. An 81 year old Afro-Caribbean man presents with pain in his lower back and hip. He complains of waking up in the middle of the night to go to the washroom and often he wets himself before reaching the toilet. He also has to urinate much more frequent than in the past and has terminal dribbling. What is the most likely underlying diagnosis?
Correct Answer : C
His age, ethnicity, and urgency point toward a prostatic pathology. Metastasis to the bones could explain the pain in his back and hips. Frequency, urgency, and terminal dribbling are features of prostate cancer. Black men are at greatest risk for prostate cancer.
The most frequent sites of metastasis for prostate carcinoma are bone and lymph nodes of the obturator fossae, internal, external, and common iliac arteries, and presacral regions.
Q.4. A 14 year old boy presents with a 3 hour history of severe left testicular pain. He has no urinary symptoms and is otherwise well. On examination, the right testis looks normal but the left hemiscrotum is swollen and acutely tender. The pain is not eased by elevation of the testes. What is the most appropriate initial step?
Correct Answer : A
This boy is having a testicular torsion.
Key features of testicular torsion include :
• Severe, sudden onset testicular pain
• Typically affects adolescents and young males
• On examination testis is tender, and pain is not eased by elevation.
Remember: In testicular torsion, lifting the testis over the symphysis increases pain, whereas in epididymitis this usually relieves pain.
• Urgent surgery is indicated.
Management:
• Urgent exploratory surgery is needed to prevent ischemia of the testicle.
Colour Doppler USS shows reduced arterial blood flow in the testicular artery and radionuclide scanning shows decreased radioisotope uptake can be used to diagnose testicular torsion, but in many hospitals, these tests are not readily available and the diagnosis is based on symptoms and signs.
Scrotal exploration should be undertaken as a matter of urgency.
Delay in relieving the twisted testis results in permanent ischaemic damage to the testis, causing atrophy.
This is a very high-yield question and in most cases, if you suspect testicular torsion the answer would be exploratory surgery (or urgent surgery).
REMEMBER: if clinical suspicion is high, surgical intervention should not be delayed for the sake of further investigation!
Q.5. A 22 year old sexually active male comes into the hospital with a 2 day history of fever with increasing pain in the scrotal area. He also describes painful micturition. There is no history of trauma. On examination, the scrotal skin is red and tender. He has a temperature of 37.8 C. What is the most likely diagnosis?
Correct Answer : D
The history here is of epididymal-orchitis.
The two major things you need to look out for when someone presents with testicular / scrotal pain are epididymo-orchitis and testicular torsion.
Epididymo-orchitis would have a more gradual onset of symptoms like in this case. It is quite clear that this is epididymo-orchitis, especially with the gradual onset and the fever. Remember, dysuria is also a symptom of acute epididymo-orchitis although not very frequently seen.
Epididymo-orchitis describes an infection of the epididymis with or without an infection of the testes resulting in pain and swelling.
It is most commonly caused by local spread of infections from the genital tract such as Chlamydia trachomatis and Neisseria gonorrhoeae where there is a retrograde spread from the prostatic urethra and seminal vesicles.
The most important differential diagnosis is testicular torsion. This needs to be excluded urgently to prevent ischaemia of the testicle. Epididymo-orchitis has similar presenting symptoms as testicular torsion.
Tenderness is usually localized to the epididymis, absence of testicular tenderness may help to distinguish epididymal-orchitis from testicular torsion, but in many cases, it is difficult to distinguish between the two.
Another feature that can help distinguish epididymo-orchitis from testicular torsion is that the tenderness may be relieved by elevating the scrotum (positive Prehn’s sign) in epididymo-orchitis. Whereas this same action would exacerbate pain or show no relief in pain if one had a testicular torsion (negative Prehn’s sign)
Features :
• unilateral testicular pain and swelling
• urethral discharge may be present, but urethritis is often asymptomatic
• factors suggesting testicular torsion include patients < 20 years, severe pain, and an acute onset
Management :
• Antibiotics.
One important differential is testicular torsion. Look out for factors suggestive of testicular torsion which includes patients under the age of 20 years having severe testicular pain and an acute onset.
Q.6. A 74 year lady who has had a stroke in the past has an indwelling catheter for 10 months. She presents with bluish-purple discolouration of the catheter bag. What is the most likely explanation for this?
Correct Answer : C
Purple urine bag syndrome is a medical syndrome where purple discoloration of urine occurs in people with urinary catheters and co-existent urinary tract infections. It is a rare phenomenon. Bacteria in the urine produce the enzyme indoxyl phosphatase.
This converts indoxyl sulfate in the urine into the red and blue-colored compounds indirubin and indigo. One of the most common bacteria implicated is Providencia stuartii.
Q.7. A 72 year old man brought to the emergency department with onset of paraplegia following a trivial fall. He was treated for prostatic malignancy in the past. What is the most likely diagnosis?
Correct Answer : D
As the patient had prostatic malignancy, pathological fracture from secondary metastasis to bone is more likely the option.
Q.8. A 33 year old woman complains of having urinary urgency for the past year. She urinates more than 8 times a day. She gives a history of having suprapubic pain if her bladder is full, resulting in the need to urinate frequently as suprapubic pain is relieved by voiding. A urine culture was sent and results have come back negative. On cystoscopy, Hunner’s ulcers were seen on the bladder wall. What is the most likely diagnosis?
Correct Answer : B
Interstitial cystitis :
• A chronic and debilitating disorder characterized by urinary frequency, urgency, nocturia, and suprapubic or pelvic pain
• Remains a diagnosis of exclusion after all other causes for the symptoms have been ruled out
• The term 'interstitial cystitis' is usually reserved for patients with typical cystoscopic features.
Presentation:
• Persistent or recurrent pain perceived in the urinary bladder region
• Suprapubic pain worsening with bladder filling
• Pain relieved by voiding but returns when the bladder fills again
• Urinary frequency and urgency
• In women the symptoms are often worse during menstruation. It presents similarly to symptoms of a urinary tract infection (urgency, frequency, dysuria, suprapubic pain).
This is why it is important to send midstream urine for urine cultures to rule out a UTI.
Investigations :
• Cystoscopy for the sole reason of excluding bladder malignancy
Management :
• First line - Bladder training. Analgesics such as NSAIDS.
• Second-line - Amitriptyline has anticholinergic effects. Oxybutynin & Gabapentin.
Q.9. A 77 year old man has a long term indwelling urinary catheter. A recent catheter urine sample was sent for culture and sensitivity and was found to have heavy growth of Escherichia coli. What is the most appropriate management?
Correct Answer : B
It is important to note that the stem has not provided symptoms of a urinary tract infection. There is no fever, dysuria, or pelvic discomfort. Although patients who have an indwelling urinary catheter are at increased risk of getting an infection there are no signs of any infection at the moment.
Changing the catheter would prevent an ascending infection.
A bladder washout is an incorrect answer. It is a technique used to flush out the bladder by introducing saline through your catheter and into your bladder. It is usually used when the catheter is not draining correctly.
Q.10. A 70 year old man with a history of prostatic cancer has severe acute back pain waking him up at night for the past 4 weeks. This pain radiates to his lower limbs and he has slight difficulty in walking. On examination, he is tender at the lumbar spine. What is the most appropriate investigation?
Correct Answer : A
This patient has neurological signs of metastatic spinal cord compression. An urgent MRI would be suitable in this case to look for cord compression caused by osteoporotic collapse of which urgent surgical decompression may be required.
Isotope bone scan would be appropriate to identify bone metastasis in prostate cancer as well but not as an emergency.
Q.11. A 32 year old woman presents with severe intermittent right sided abdominal pain radiating to the groin which has lasted for 3 hours. She is writhing in pain and vomited twice in the last hour. WBCs are 14 x 109/L and CRP is 83 mg/l. A urine HCG was negative. What is the most likely cause of her abdominal pain?
Correct Answer : B
The intermittent right-sided abdominal pain radiating to the groin indicates a stone at the lower ureter.
‘Ureteric / renal colic’ :
Severe, intermittent, stabbing pain radiating from loin to groin.
- Microscopic or, rarely, frank haematuria.
- Systemic symptoms such as nausea, vomiting, tachycardia, pyrexia.
- Loin or renal angle tenderness due to infection or inflammation.
- Iliac fossa tenderness if the calculus has passed into the distal ureter.
Investigations :
- Raised WBC and CRP suggest superadded infection
- Stones often visible on plain abdominal X-ray (KUB)
- Non-contrast spiral CT is the gold standard for locating stones and assessing evidence of complications.
- VU will locate stones and show any proximal obstruction.
- Renal ultrasound scan for hydronephrosis.
Q.12. A 42 year old woman has recently returned from working in the Middle East. She has episodes of loin pain, urinary frequency, dysuria and has passed a urinary stone in the past. She plans to return to the Middle East in a month’s time. What is the best advice to give to prevent recurrent stone formation?
Correct Answer : D
Dehydration is a risk factor for renal stones. Protein, calcium, and fibre consumption have no relevance to urinary stone formation.
Q.13. A 43 year old woman who has just undergone an abdominal hysterectomy and bilateral salpingo-oophorectomy 5 days ago has severe right flank pain and lower abdominal pain. She is seen to be nauseous and has been vomiting. She has a persistent ileus. On examination, her abdomen is distended and there are sluggish bowel sounds. She has a temperature is 38 C. Her blood results show: Haemoglobin 120 g/L White cell count 14 x 109/L CRP 48 Urea 9 mmol/L Creatinine 490 micromol/L. What is the most appropriate investigation?
Correct Answer : A
She is likely suffering from a ureteric injury that occurred during the surgery. As she is suffering from right flank pain, the ipsilateral kidney is likely prevented from draining into the bladder. Since a complete ligation is suspected, hydronephrosis would be seen on an intravenous urogram.
An intravenous urogram would also be an option if there is clinical suspicion of a urine leakage from a transected ureter. Fever and sepsis may present when the urine in the obstructed system becomes infected.
Postoperative ureteric injury may present in the first few days following surgery but it may also be delayed by weeks. It is one of the most serious complications during gynecological surgeries.
• Renal ultrasound : Is the best non-invasive method to visualize the kidney.
Q.14. A 15 year old boy was woken up from sleep with severe, sudden pain in the testis. There was no history of trauma. On examination, the testis is tender on palpation. He is afebrile. Analgesia has been given. What is the most appropriate next step in management?
Correct Answer : C
There is a possibility of testicular torsion in this question thus exploratory surgery would be the next course of action. Thus, a referral to a surgeon would be appropriate.
The key here is to explore the possibility of testicular torsion. The main differential is usually epididymo-orchitis in which the onset of pain is much more gradual. In a patient in whom the onset is dramatic and sudden, then torsion becomes the favorite.
Once torsion tops the list, treatment is surgery (for detorsion and orchidopexy). The sooner this happens, the greater the chance of the testis being saved.
Q.15. A 20 year olf woman 6 hours post-lower segment Caesarean section has not passed urine since her operation. She denies any urinary symptoms preoperatively. She appears unwell. She has a temperature of 37.5 C, a pulse of 110 beats/minute, a blood pressure of 94/60 mmHg and a respiratory rate of 23 breaths/minute. Her abdomen is distended with tenderness in the left flank and suprapubic region. Bowel sounds are not audible. What is the most likely postoperative complication?
Correct Answer : B
Ureteric injuries can occur during pelvic or abdominal surgery, e.g. hysterectomy, or colectomy. The ureter may be divided, ligated, or angulated by a suture;
a segment excised or damaged by diathermy.
• The injury may be suspected at the time of surgery, but the injury may not become apparent until some days or weeks post-operatively.
• The diagnosis is usually apparent in the first few days following surgery, but it may be delayed by weeks, months, or years
• It may present with flank pain or post-hysterectomy incontinence (a continuous leak of urine suggests a ureterovaginal fistula).
Q.16. A 33 year old man presents with bilateral flank pain. He is later diagnosed to have bilateral kidney stones. His medical history includes sarcoidosis. What is the most likely cause that attributed to the development of his urinary stones?
Correct Answer : A
Hypercalcaemia is seen commonly in sarcoidosis. It is due to the increased circulation of vitamin D produced by macrophages.
Renal stone risk factors :
There are certain risk factors or drugs that may precipitate renal stones that you need to know for an exam as these are the most commonly asked.
These are:
- Dehydration
- Hypercalcaemia
- Polycystic kidney disease
- Gout
- Loop diuretics.
Q.17. A 31 year old presents with sudden onset of flank pain, nausea and vomiting. He recently passed a 4 mm stone in his urine. Urine microscopy reveals microscopic haematuria. On ultrasuond, a 3 mm stone is found in the renal pelvis. What is the most appropriate management?
Correct Answer : D
The key question in kidney stones is: When to watch and wait and when not to?
There is no specific rule on how we treat renal stones. As a rule of thumb, the younger the patient, the larger the stone, and the more symptoms it is causing, the more inclined we are to recommend treatment.
• Stones < 0.5 cm. Just increase fluid intake. Likely to pass spontaneously.
• Stones 0.5 cm to 2 cm - Extracorporeal shock-wave lithotripsy (ESWL) or Ureteroscopy using dormia basket
• Stones > 2 cm Percutaneous nephrolithotomy.
Q.18. A 46 year old man presents to clinic with a scrotal swelling. The swelling is cystic and non-tender. It developed slowly and it lies above and behind the testis. What is the most appropriate diagnostic test?
Correct Answer : A
The most probable diagnosis here is an epididymal cyst. This is confirmed with an ultrasound.
Epididymal cyst :
• Derived from the collecting tubules of the epididymis and contains clear fluid. They develop slowly and lie within the scrotum. They are often multiple (multiloculated).
• Most common cause of scrotal swellings seen in primary care.
• Painless
• Lie behind and above the testis
Diagnosis :
• Ultrasound
Management :
• Usually supportive but surgical removal may be attempted for larger or symptomatic cysts.
DIFFERENTIATING EPIDIDYMAL CYST AND HYDROCELE :
Another painless scrotal swelling commonly asked in exam is hydrocele. But in these questions, they usually state that it “transilluminates with light”.
The hydrocele is also usually anterior to and below the testicle. Both epididymal cysts and hydrocele transilluminates. So sometimes the only clue in the stem would be “the testis is palpable separately from the cyst (or swelling)” which indicates an epididymal cyst.
In hydrocele, the testis is palpable within the fluid-filled swelling.
Q.19. A 60 year old patient had a cystoscopy for painfless, gross haematuria and pathology revealed transitional cell carcinoma of the bladder. He has smoked a pack a day for the last 15 years and currently works in a coal factory. What is the greatest risk factor for transitional cell carcinoma in this patient?
Correct Answer : D
Whenever you see painless, gross hematuria in an elderly male, you should immediately be thinking of cancer.
Cancer of the bladder (transitional cell cancer) has a very close correlation with smoking and usually presents with painless visible haematuria.
Risk factors :
• Men are 2.5 times more likely to develop the disease than women
• Age increases risk, most commonly diagnosed in the eighth decade and rare below age 50.
• Smoking is the major cause of bladder cancer in the developed world.
• Occupational exposure to carcinogens, in particular aromatic hydrocarbons like aniline, is a recognized cause of bladder cancer.
• Other risk factors include industrial exposure to aromatic amines in dyes, paints, solvents, leather dust, inks, combustion products, rubber and textiles.
Q.20. A 15 year old boy presents with testicular pain for 3 days. The pain had a gradual onset. There is no history of trauma. On examination, his right hemiscrotum is tender, swollen and red. He has a temperature of 38.5 C. What is the most appropriate treatment?
Correct Answer : A
The history here is of epididymo-orchitis. The two major things you need to look out for when someone presents with testicular pain are epididymo-orchitis and testicular torsion.
Epididymo-orchitis would have a more gradual onset of symptoms like in this case.
His age here is quite misleading as a young boy below the age of 20, the first thought that usually comes to your mind is testicular torsion but as you go on reading, it becomes quite clear that this is epididymo-orchitis, especially with the gradual onset and the fever.
Antibiotics would be the best option here. Analgesia would be given too but more important management would be antibiotics.
Q.21. A 25 year old man collapsed during a football match and was brought in by the paramedics. There was no trauma during the football game and he was only found to be unconscious for less than a minute. On taking a history in the hospital, he says that he has been experiencin shortness of breath for the past two weeks. His only past medical history is surgery at the age of 4 years old for maldescended tested. A chest x-ray demonstrates multiple well circumscribed, round pulmonary masses. A computed tomography of his chest, abdomen and pelvis were requested. Which tumour marker is likely to be raised?
Correct Answer : D
Being born with unilateral or bilateral undescended testicles increases the risk of testicular cancer (particularly seminomas) by up to 10 times higher than that in the general population.
The most common type of testicular cancer occurring in undescended testes is seminoma (a type of germ cell tumour).
The management of an undescended testicle is usually a surgical orchiopexy, performed at 6 months of age.
The symptoms of shortness of breath experienced by the patient are secondary to metastases, presumably from testicular cancer. Whilst tumour markers such as beta-HCG, AFP and LDH are an indicator of disease activity and would be requested in a clinical setting, the question here specifically asks which of them is likely to be elevated.
As the likely diagnosis here is a seminoma, LDH is most likely to be elevated. In some seminomas, LDH may be the only tumour marker seen to be elevated.
Q.22. A 20 year old rugby player comes in with severe pain in his left scrotum after he was struck in the groin during the game. The left testes is placed higher than the right testes. The pain is not eased by elevation of the testes. What is the most appropriate next course of action?
Correct Answer : C
There is a possibility of testicular torsion in this question thus exploratory surgery would be the most appropriate next course of action.
The key here is to explore the possibility of testicular torsion. The main differential is usually epididymo-orchitis in which the onset of pain is much more gradual. In a patient in whom the onset is dramatic and sudden, then torsion becomes the favourite.
Once torsion tops the list, treatment is surgery (for detorsion and orchidopexy). The sooner this happens, the greater the chance of the testis being saved.
Q.23. A 79 year old man who is being treated with GnRH antagonist for a diagnosed prostate adenocarcinoma attends the clinic. What is the most appropriate follow-up investigation?
Correct Answer : B
Serum PSA is currently the best method of detecting localized prostatic cancer and monitoring response to treatment but it lacks specificity, as it is also increased in most patients with benign prostatic hyperplasia. The level of PSA over time would determine the next management of treatment.
Q.24. A 47 year old woman has had 3 urinary tract infections confirmed with urine culture in the past 8 months. She has been started on cefalexin for prophylaxis. A kidney ureter bladder X-ray has been performed and no renal stones were identified. Ultrasound of the kidneys and ureter shows no evidence of hydronephrosis or renal stones. Post voiding residual volume is minimal on a bladder ultrasound. What is the most appropriate investigation?
Correct Answer : D
Flexible cystoscopy would be the next investigation looking for possible causes of recurrent urinary tract infections.
Recurrent urinary tract infection in adults :
• Recurrent UTI is defined as more than 2 infections in 6 months or 3 within 12 months
• Most commonly caused by reinfection with the original bacterial isolate
• Escherichia coli is the most common organism in all patient groups
• There is often an underlying functional or anatomical problem and infection will often not resolve until this has been corrected.
Causes of recurrent UTIs :
- Incomplete bladder emptying
- Renal or bladder stones
- Indwelling catheter
- Chronic bacterial prostatitis
- Vesicovaginal or colovesical fistula
- Bacteria within an obstructed or atrophic infected kidney.
Presentation :
- Dysuria
- Frequency
- Urgency
- Suprapubic pain or discomfort
- Cloudy foul-smelling urine
Investigations :
• MSU microscopy and culture
• KUB X-ray to detect radio-opaque renal calculi
• Renal and bladder ultrasound -
Looking for renal stones
To determine the presence or absence of hydronephrosis.
To measure pre-void bladder volume and postvoid residual urine volume
• Flexible cystoscopy to identify abnormalities that may cause recurrent UTIs such as bladder stones, an underlying bladder cancer that is rare, urethral or bladder neck stricture, or fistula.
Management :
• Fix any underlying functional or anatomical abnormality if identified.
• Low-dose antibiotic prophylaxis. Usually trimethoprim, nitrofurantoin, or cephalexin.
• If there is residual urine present. Optimize bladder emptying by intermittent catheterization.
• Oestrogen replacement in post-menopausal women. Lack of oestrogen in post-menopausal women causes loss of vaginal lactobacilli and increased colonization by Escherichia coli.
Q.25. A 26 year old sexually active male presents with severe pain in the left scrotum lasting for 4 hours. He complains of a past history with similar episodes of pain over the past 2 years but has never sought treatment before. His scrotum is extremely tender and examination is impossible because of the pain. What is the best management for this patient?
Correct Answer : C
In this stem, mentioning that this young man is sexually active is aiming to distract you from the correct choice.
The history of severe pain with a history of similar episodes of severe pain is indicative of testicular torsion (this is likely due to the testis swelling and then spontaneously resolving). The fact that the examination is extremely painful is another hint toward testicular torsion as the diagnosis.
Q.26. A 78 year old man with a history of prostate adenocarcinoma has left loin pain. He says that he has been drinking fluid as usual but his urine output is decreased today. He feels extremely fatigued over the past 48 hours. On examination, there is no limb weakness or saddle paraesthesia. A rectal examination shows good anal tone. His blood results show: Haemoglobin 98 g/L Creatinine 230 micromol/L eGFR 50. What is the most appropriate investigation?
Correct Answer : D
Locally invasive disease of prostate cancers can present with obstructive uropathy. The obstruction of the left ureter in this case is causing his symptoms of loin pain and anuria.
An ultrasound of the kidney and ureters would be appropriate. If there were symptoms of metastatic spinal cord compression in this stem, an MRI would be more suitable.
However, since there are no neurological signs and symptoms of metastatic spinal cord compression included in this question, it is safe to pick ultrasound of the kidney, ureters, and bladder would be more appropriate.
Q.27. An 85 year old male was admitted to the hospital with a six month history of nocturia, hesitancy and dribbling. Over the past three months, he has lost more than 5 kilograms. He also complains about lower back pain during this period. A prostate specific antigen (PSA) test was performed and showed a value of 150 ng/mL (normal 0-4 ng/mL). The patient was subsequently referred for a transrectal ultrasound of the prostate and for a biopsy. On the fourth day after the biopsy procedure, the patient noticed cloudy urine with a pungent smell. He also complained of a burning feeling during urination accompanied by lower abdominal pain. What is the most likely organism that can cause these symptoms after a prostate biopsy?
Correct Answer : D
The scenario depicted here describes a common biopsy-related complication – an infection.
Escherichia coli is one of the most common causal organisms causing prostatitis after prostate biopsy. Pseudomonas aeruginosa most commonly affects immuno-compromised patients. There is nothing in the stem that gives a clue as to the immune status of this patient.
Q.28. A 47 year old man comes to the GP surgery with swelling on his left scrotum which disappears on lying down. The swelling was bluish in colour and felt like a “bag of worms”. He also complains of a dull ache along the left loin along with painless haematuria occasionally. What is the most likely diagnosis?
Correct Answer : C
The bluish swelling that feels like a bag of worms is a perfect description of varicocele. The most common secondary cause of left-sided varicocele is renal cell carcinoma.
Varicocele is common on the left side as the left testicular veins drain to the left renal vein, while the right testicular vein drains directly into the inferior vena cava.
It is very common to hear complaints of feeling heavy in the scrotal area. The blue appearance gives the clue that these are veins. The reason the mass is less obvious when lying supine is that gravity allows the drainage of the pampiniform plexus and thus the mass decompresses.
Q.29. A 64 year old man presents with the complaint of pain in his mid-thigh. He was diagnosed with prostate cancer a year ago and has since underwent a radical prostatectomy as treatment for his cancer. A few days ago, he began experiencing pain in his left mid-thigh region. He describes the pain as being dull and constant and complains of an inability to sleep at night due to the pain. The pain sometimes radiates to his back. He has taken an over-the-counter paracetamol for the pain, to no avail. He has no other complaints. Other than his prostate cancer history, he has no other significant medical history of note. A radioisotope bone scan reveals scattered and distant bony metastssis involving his left femur and left tibia. What is the best method for managing this patient’s pain?
Correct Answer : B
The best treatment for palliative cancer-induced bone pain is radiotherapy.
• Radiotherapy – First-line
• Bisphosphonates in conjunction with NSAIDs – second-line
Q.30. A 48 year old woman complains of continuous leakage of small amount of fluid vaginally continuously throughout since she had a laparoscopic hysterectomy for a uterine fibroid 5 days ago. The discharge is clear without any distinct odour. What is the most likely diagnosis?
Correct Answer : A
She has a vesicovaginal fistula which is a fistulous tract extending between the bladder and the vagina that allows the continuous involuntary discharge of urine into the vaginal vault.
In the developed world, gynaecological and uterine surgery is the most frequent cause of bladder lesions leading to the formation of a vesicovaginal fistula with hysterectomy carrying the highest risk for fistulae formation.
A 3 swab test could help identify a vesicovaginal fistula.
This involves 3 gauze swabs placed into the vagina that allows the continuous involuntary discharge of urine into the vaginal vault.
A 3-swab test could help identify a vesicovaginal fistula. This involves 3 gauze swabs placed into the vagina using a speculum. One at the top, one in the middle, and one at the bottom.
Blue dye is inserted into the bladder by passing through a catheter. The catheter is then removed and the patient is asked to walk around for an hour without urinating. After this, the swabs are taken out and evaluated for blue dye.
Q.31. A 30 year old man presents with dull pain and swelling in his left scrotum. He says that he feels a dragging pain that is particularly worse after playing sports or at the end of the day. This has been gradually worsening over the past few weeks. The sweling demonstrates a cough impulse. What is the most likely cause of the swelling?
Correct Answer : B
One feature of varicocele is that patients may complain of a dull ache at the scrotal area at the end of a day or following sports. Another key hint is the fact that the question says “left scrotum”.
Varicocele presents on the left more commonly due to the anatomy of how the left testicular vein is drained. Swellings from varicocele may also demonstrate cough impulses much like a hernia and they also tend to disappear when lying down.
The reason the mass is less obvious when lying supine is that gravity allows the drainage of the pampiniform plexus and thus the mass decompresses.
Q.32. A 16 year old boy complains of having a heavy feeling in the scrotal area. He is concerned by the appearance. On physical examination, a soft painless swelling in the left scrotum is noticed. The swelling appears like a ‘bag of worms’ and is less obvious when he is lying supine. What is the most appropriate investigation?
Correct Answer : D
The diagnosis here is varicocele.
It is very common to hear complains of feeling heavy in the scrotal area. The blue appearance gives the clue that these are veins. Another key hint is the fact that the question says “left scrotum”. Varicocele very commonly presents on the left.
The reason the mass is less obvious when lying supine is that gravity allows the drainage of the pampiniform plexus and thus the mass decompresses. Varicocele can be reliably diagnosed with ultrasound, which will show dilation of the vessels of the pampiniform plexus.
Q.33. A 38 year old man has severe loin pain with nausea and vomiting. Ultrasound shows right hydronephrosis. A non-enhanced computerised tomography scan reveals a 3.2 cm in diameter stone at the level of the minor calyx. What is the most appropriate management?
Correct Answer : A
Please see Q-17
Q.34. A 59 year old man attends the clinic with complaints of obstructive urinary symptoms for the past 3 months. A digital rectal examination reveals a smoothly enlarged prostate. The patient is anxious about the diagnosis of prostate cancer as his father had died from prostate cancer. A prostate specific antigen (PSA) is requested. What is the most appropriate advice to provide the patient in regards to the PSA test?
Correct Answer : B
Serum PSA increases immediately after ejaculation and if PSA is taken within 24 hours after ejaculation, it may lead to a false positive result. The PSA test is a good screening tool for prostate cancer, but remember it is not specific for prostate cancer.
This is because it can be found in many other conditions such as prostatitis, and urinary tract infections, or can be found high even from trauma from placing a catheter into the bladder.
It is also worth knowing that PSA can be found mildly elevated after a digital rectal examination however this mild elevation is usually not enough to make a significant difference clinically unless the serum PSA level is borderline.
Q.35. A 62 year old man has been waking up in the middle of the night to use the bathroom. He complains of having difficulty in initiating micturition and dribbling afterwards. A diagnosis of benign prostatic hyperplasia was made after a transrectal ultrasound guided biopsy was performed. He is due for a transurethral resection of the prostate (TURP) later this evening. What most likely electrolyte abnormality should be expected after the procedure?
Correct Answer : B
Transurethral resection of the prostate (TURP) is a treatment for benign prostatic hyperplasia. It involves the insertion of a resectoscope via the penile urethra.
The bladder and prostate are irrigated and prostatic tissues are removed using diathermy.
TURP syndrome is rare but can potentially be life-threatening and is characterized by hyponatremia.
It occurs when irrigation fluid enters the systemic circulation. It is caused by venous destruction and absorption of the irrigation fluid. The management usually involves fluid restriction to correct hyponatremia.
Q.36. A 34 year old man attends the GP surgery with a painless left testicular enlargement. He first noticed it 6 months ago. It has been gradually increasing in size. On examination, the left testicle is noted to be 3 times the size of the right testicle. A 4 mm firm, non-tender lump is felt within the body of the left testicle. There is no redness. What is the most likely diagnosis?
Correct Answer : C
It is important to note where the enlargement is located. One can mistakenly answer epididymal cyst or hydrocele if one does not read the stem properly. Note that the enlargement (sometimes lump or swelling) is of the testicle and not scrotum. If it was scrotal swelling, that you can think of hydrocele or epididymal cyst.
Q.37. A 15 year old boy complains of having a heavy feeling in the scrotal area. On physical examination, a soft painless swelling in the left scrotum is noticed. The swelling appears blue in colour and is less obvious when he is lying supine. He states that he has just become sexually active and fears that it is a sexually transmitted infection. What is the most appropriate management?
Correct Answer : C
The diagnosis here is varicocele.
Heaviness in the scrotal area is one of the major complaints for varicocele although the majority may be asymptomatic and found during subfertility investigations.
The blue appearance gives the clue that these are veins. Another key hint is the fact that the question says “left scrotum”. Varicocele very commonly presents on the left for anatomical reasons.
The reason the mass is less obvious when lying supine is that gravity allows the drainage of the pampiniform plexus and thus the mass decompresses. There are no features of an STI in this stem.
Reassurance is all that is needed as this boy is not experiencing any pain from the dilated pampiniform plexus.
Q.38. A 77 year old eldery man has symptoms of poor and intermittent urinary flow. It takes him a few minutes to generate a pressure high enough to start the urine flow. In the last few months, he has been seen to be increasingly fatigued. He also complains of feeling thirsty most of the day. He has a blood pressure of 150/90 mmHg. On digital rectal examination , his prostate is firm, smooth wtihout nodules, and enlarged to about two finger breadths. His blood results show: Haemoglobin 129 g/L Prostate-specific antigen (PSA) 4.5 ng/mL Urea 11 mmol/L Creatinine 290 micromol/L Serum calcium 2.1 mmol/L. What is the most likely diagnosis?
Correct Answer : B
A PSA level of 4.5 in a 77-year-old man is considered an intermediate elevation that could be seen in multiple conditions including benign prostatic hyperplasia, old age, acute prostatitis, and prostate cancer. There is no specific guidance on considering prostate cancer using age-specific cut-off values but this is a good guide, especially in the exam.
Q.39. A 79 year old African-Caribbean man comes in complaining of difficulty in passing urine. He has a weak stream, and says that he is unable to completely empty his bladder. 3 months ago he suffered from a urinary tract infection. He also complains of back pain and suprapubic pain. He has lost significant weight and looks cachexic. What is the most likely diagnosis?
Correct Answer : D
Urinary tract infections can occur with the local disease of prostate cancer. The back pain and suprapubic pain could be either from bone metastasis from enlarged lymph nodes compressing the ureter or from enlarged prostate cancer causing an obstructive urine flow.
Q.40. A 79 year old African American male complains of thirst and fatigue. He has symptoms of frequency, urgency and terminal dribbling. He has lost 8 kg over the last 3 months. Laboratory findings show a calcium of 3.0 mmol/L and haemoglobin of 90 g/L. What is the most likely underlying diagnosis?
Correct Answer : D
Frequency, urgency, and terminal dribbling are features of prostate cancer. Black men are at greatest risk for prostate cancer. Weight loss and anaemia are also a feature of prostate cancer
The most frequent sites of metastasis for prostate carcinoma are bone and lymph nodes of the obturator fossae, internal, external, and common iliac arteries, and presacral regions. Metastasis in the bones could explain the high serum calcium which in turn results in the symptoms of thirst.
Q.41. A 25 year old man has a painful right testis, lower abdominal pain, vomiting and nausea. The testis is swollen, hot, and extremely tender. The onset of pain was dramatic and sudden. He complains of some pain on passing urine. What is the most appropriate next course of action?
Correct Answer : D
There is a possibility of testicular torsion in this question thus exploratory surgery would be the most appropriate next course of action.
The key here is to explore the possibility of testicular torsion. The main differential is usually epididymo-orchitis in which the onset of pain is much more gradual. In a patient in whom the onset is dramatic and sudden, then torsion becomes the favorite.
Whilst urinary symptoms are also more common in epididymo-orchitis, they may overlap as part of the general extreme lower abdominal pain seen in torsion. Once torsion tops the list, treatment is surgery (for detorsion and orchidopexy). The sooner this happens, the greater the chance of the testis being saved.
Q.42. A 75 year olf man has urinary symptoms of hesitancy, frequency and nocturia. A digital rectal examination reveals a large, irregular, hard asymmetric prostate gland. What is the most appropriate investigation that will help with the diagnosis?
Correct Answer : A
A large, irregular, hard asymmetric prostate gland is indicative of prostate cancer. Serum PSA is currently the best method of detecting localised prostatic cancer and monitoring response to treatment but it lacks specificity, as it is also increased in most patients with benign prostatic hyperplasia.
Q.43. A 44 year old man presents with a scrotal swelling. The swelling is cystic and is non-tender. It is located in the upper pole of the posterior part of the testes. What is most likely diagnosis?
Correct Answer : A
Please see Q-18
Q.44. A 77 year old African-Caribbean man comes in complaining of difficulty in passing urine. He has a weak stream, and says that he is unable to completely empty his bladder. He also has lower back pain and has lost 10 kg in the last 3 months. An ultrasound shows bilateral hydronephrosis. His blood results show the following: Haemoglobin 105 g/L CRP 25. What is the most likely diagnosis?
Correct Answer : C
An elderly patient of 77 years with obstructive symptoms of the lower urinary tract and bilateral hydronephrosis points toward prostate cancer or benign prostatic hyperplasia.
Given that there is weight loss and back pain, one should consider prostatic cancer as a more likely answer. Metastatic diseases can result in anaemia and also raised inflammatory markers.
Q.45. A 25 year old woman presents with urinary frequency, suprapubic pain and dysuria. She has a temperature of 38.5 C. Nitrites and leucocytes are positive on a dipstick. What is the most likely diagnosis?
Correct Answer : A
Cystitis presents with frequency, dysuria, urgency, haematuria, suprapubic pain. Signs of fever and nitrates and leukocytes points towards a urinary tract infection.
Q.46. A 61 year old man, known smoker, comes to the hospital with complaints of painless frank haematuria. He has been worried about his loss of weight and reduced general activity. Urine microscopy shows red cells but no white cells. What is the most diagnostic test?
Correct Answer : C
The two most important risk factors for transitional cell carcinoma of the bladder are:
1. Exposure to aromatic hydrocarbons, e.g. workers in the petrochemical, industrial dye, rubber industries, chimney sweeps.
2. Here they give a history of smoking with loss of weight.
The absence of white cells implies a non-infectious cause of the painless frank haematuria. In the elderly, one must always have transitional cell carcinoma of the bladder as part of a differential diagnosis when a patient presents with painless haematuria.
Cystoscopy is the most common diagnostic test.
Q.47. A 39 year old coal miner was recently diagnosed with bladder cancer. He is a smoker and has a family history of bladder cancer. He also has been diagnosed with benign prostatic hyperplasia. Which risk factor is likely to be associated with transitional cell carcinoma of the bladder?
Correct Answer : D
Please see Q-46
Q.48. A 13 year old boy develops acute pain in his right testicle while playing football. Examination reveals a very tender mass in the right scrotum with reddening of scrotal skin. Lifting the testis causes more pain. What is the most likely diagnosis?
Correct Answer : C
Acute swelling of the scrotum in a boy indicates torsion of the testis until proven otherwise. The history of pain developing during sports is very classical of testicular torsion.
“Pain worsening on the elevation of testis” are key phrases commonly used in the stems that shout out testicular torsion as the answer.
Q.49. A 57 year old chronic smoker reports three instances in the past 2 weeks when she has had painless, gross, total haematuria. Intravenous urograms (IVU) was done and was reported as normal. In the last month, she has been treated for irritative voiding symptoms, but has not been febrile, and urinary cultures have been negative. She complains of a long-standing urinary incontinence that is made worse when coughin. A urine dispstick done in clinic shows microscopic haematuria. What is the most appropriate next step?
Correct Answer : B
The most feared diagnosis here is transitional cell carcinoma of the bladder. This needs to be addressed first before the urinary incontinence, especially given the haematuria and smoking history.
Q.50. A 67 year old man has a diagnosis of benign prostatic hyperplasia undergoes transurethral resection of the prostate (TURP). What is the most likely electrolyte abnormality should be expected after the procedure?
Correct Answer : D
Please see Q-35
Q.51. An 18 year old rugby player comes with sudden onset pain in his left scrotum which started while playing. On examination, there is swelling and tenderness noted. The left testis is placed higher than the right testis. Urine examination is positive for nitrites and leukocytes. What is the most appropriate management for this patient?
Correct Answer : B
This question has both features of testicular torsion and also epididymo-orchitis.
TESTICULAR TORSION :
• Below 20 years old
• Pain started while playing (possible trauma)
• Sudden onset
EPIDIDYMO-ORCHITIS :
• Leukocytes and nitrates positive
Since there are more points given towards testicular torsion, urgent exploratory surgery for reduction of the testis is the answer.
Q.52. A 65 year old man presents with frank haematuria. He is afebrile and has no other urinary symptoms. There was no history of trauma and he has no relevant medical history. He looks well. Urinary cultures are negative. What is the most appropriate investigation that would lead to a diagnosis?
Correct Answer : C
Painless haematuria at this age group must be treated as malignancy of the urinary tract until proven otherwise.
Exam has very limited variations on questions regarding frank haematuria. The usual case is if you see frank haematuria that is asymptomatic, you should be thinking of bladder cancers.
Do not substitute urinary biomarkers for cystoscopy to investigate suspected bladder cancer or for follow-up after treatment for bladder cancer, except in the context of a clinical research study.
Q.53. A 49 year old man presents with sudden onset, severe colicky pain from his right flank radiating to his groin associated with nausea and vomiting. He subsequently develops rigors and a tender abdomen. His urinalysis reveals a trace of blood. What is the most appropriate investigation to request?
Correct Answer : A
This is a typical presentation of a ureteric calculus. The pain is severe and associated with nausea and vomiting. Urinalysis or microscopy would reveal blood.
Non-enhanced CT scanning is the imaging modality of choice and has replaced intravenous pyelogram (IVP). It is a very accurate method of diagnosing renal and ureteric stones with up to 99% of them being visible.
Q.54. A 32-year-old man presented with painless hematuria. He is hypertensive but the rest of the exam is unremarkable. What is the most likely diagnosis?
Correct Answer : A
Autosomal dominant polycystic kidney disease is a multisystemic and progressive disorder characterized by cyst formation and enlargement in the kidney and other organs (eg, liver, pancreas, spleen).
Up to 50% of patients with ADPKD require renal replacement therapy by 60 years of age. In younger cysts may be smaller to palpate. Renal ultrasound is used to diagnose the condition.
Q.55. In chronic renal failure, main cause of Vit D deficiency is the failure of which of the following?
Correct Answer : D
1 alpha hydroxylation of Vit D.
There are 3 steps in synthesizing vitamin D.
i) Cholecalciferol in the skin from 7-dehydrocholesterol under the action of ultraviolet light.
ii) Hydroxylation in the liver of cholecalciferol to 25-hydroxycholecalciferol.
iii) Hydroxylation in the kidneysof 25-hydroxycholecalciferol to calcitriol.
Q.56. A 35-year-old man presented with hematuria, abdominal swelling and has a BP of 190/140. What is the most diagnostic investigation?
Correct Answer : B
The diagnosis is ADPKD.
Autosomal dominant polycystic kidney disease (ADPKD) is a genetic disorder characterized by the growth of numerous cysts in the kidneys.
It is the most common inherited disorder of the kidneys.
Symptoms usually develop between the ages of 30 and 40, but they can begin earlier, even in childhood.
Haematuria, abdominal swelling, and raised BP are the most common findings.
USG diagnostic criteria are: Unilateral or bilateral cysts.
Q.57. A 15-year-old male has bilateral ankle edema. His BP is 110/70 mmHg and urinalysis shows protein++++. What is the most likely diagnosis?
Correct Answer : D
Minimal change glomerulonephritis.
Points in favour of minimal change glomerulonephritis are :
i) Age 15
ii) Ankle oedema
iii) Normotension
iv) Heavy proteinuria
The treatment of choice is a steroid (Prednisolone).
In case of failure of steroid or frequent relapse, Cyclophosphamide should be given.
Q.58. 15-year-old boy has a soft painless swelling in the left scrotum, blue in color and can be compressed. What is the most appropriate next step?
Correct Answer : D
This is varicocele. If asymptomatic nothing needs to be done.
Q.59. A 15-year-old boy presents with generalized edema. His urinalysis reveals protein +++, eGFR 110. What is the most likely diagnosis?
Correct Answer : C
Minimal change disease.
Points in favour of:
i) Age 15 yrs
ii) Generalized oedema
iii) Protein in urine +++
vi) Normal eGFR of 110 (Normal range- 90 to 120 mL/min).
Q.60. A man presents with scrotal swelling, the swelling is cystic and is non-tender. It is located in the upper pole of the posterior part of the testis. What is the most likely diagnosis?
Correct Answer : A
Epididymal cyst.
The location of upper pole of the posterior part of testis is the common site for epididymal pathology.
Q.61. 46-year-old man, known case of chronic GN presents to OPD. He feels well. BP 140/90mmHg. Urine dipstick: protein ++, blood ++ and serum creatinine 106 ?mol/L. Which medication can prevent the progression of this disease?
Correct Answer : A
Renal impairment is delayed by ACEI.
Q.62. A 2-year-old patient presents with colicky pain which radiates from loin to groin. He complains of similar episodes in the past. Investigation has been done and 7mm stone was found in the ureter. What is the most appropriate management?
Correct Answer : D
Given its minimally invasive features, extracorporeal shock wave lithotripsy (ESWL) has become a primary mode of treatment for pediatric patients with reno ureteral stones.
Q.63. A 34-year-old African-caribbean man with a history of sarcoidosis has presented with bilateral kidney stones. What is the most likely cause for this patient’s stones?
Correct Answer : A
Hypercalcemia in sarcoidosis is due to the uncontrolled synthesis of 1,25-dihydroxyvitamin D3 by macrophages. 1,25-dihydroxyvitamin D3 leads to an increased absorption of calcium in the intestine and an increased resorption of calcium in the bone.
Q.64. A 15-year-old boy presents with testicular pain for 2 days. There is no history of trauma. Examination: temp=38.5C, right hemi-scrotum tenderness. What is the most appropriate management?
Correct Answer : A
Give antibiotics.
This is a case of epididymoorchitis. Testicular pain with fever without a history of trauma points towards the diagnosis of epididymoorchitis.
Q.65. A 58-year-old lady presented with urinary incontinence. She looks anxious for her condition. Urine culture is sterile. Her urodynamic study is normal. What is the next step?
Correct Answer : D
Diagnosis is stress incontinence. Stress incontinence is usually the result of the weakening of or damage to the muscles used to prevent urination, such as the pelvic floor muscles and the urethral sphincter. Pelvic floor exercise improves the symptoms.
Q.66. A 44-year-old man presents with periorbital and pedal edema. 24 hours urine shows 8 g of protein/day and serum cholesterol 7 mmol/L. Renal biopsy results are awaited. What would be the most likely diagnosis?
Correct Answer : C
This is nephrotic syndrome. It is characterized by proteinuria more than 3gm/24 hours, low albumin, edema, and high cholesterol.
The most common causes of nephrotic syndrome in adults are membranous glomerulonephropathy and FSGS (Focal segmental glomerulosclerosis).
Q.67. A 47-year-old man comes to the GP with a swelling in his left groin which disappears on lying down. The swelling was bluish in color and felt like a bag of worms. He also complains of a mass in the left loin along with hematuria occasionally. What could be the possible diagnosis?
Correct Answer : A
Left-sided RCC (renal cell carcinoma).
The most common secondary cause of left-sided varicocele is RCC. Newly diagnosed varicocele over the age of 40 years are very much suggestive of RCC. Varicocele is common on the left side as left testicular veins drain to the left renal vein, while the right testicular vein drains directly into IVC.
Q.68. A man has a BP of 160/90 mmHg, proteinuria ++. KUB US shows kidneys are equally reduced in size with smooth borders and normal pelvic calyceal system. What is the cause of hypertension in the patient?
Correct Answer : C
Renal artery stenosis is the narrowing of the renal arteries, most often caused by atherosclerosis or fibromuscular dysplasia. This narrowing of the renal artery can impede blood flow to the kidneys, resulting in renovascular hypertension – a secondary type of high blood pressure.
Q.69. A 40-year-old male with pre-existing glomerulonephritis having proteinuria and hematuria suddenly deteriorates and presents with oliguria and serum K+ 7.8 mmol/L, urea 13 mmol/L, Creat 342 ?mol/L, GFR 19 mL/hour. What would be the best management?
Correct Answer : B
Next or most appropriate is E.
10ml of 10% calcium gluconate; but the best or definitive treatment is hemodialysis.
Q.70. A 22-year-old sexually active male came with 2 days history of fever with pain in scrotal area. Examination: scrotal skin is red and tender. What is the most appropriate diagnosis?
Correct Answer : D
Epididymo-orchitis.
In epididymal-orchitis there should be fever, the elevation of testes reduces pain (positive Prehn sign), and In torsion testis lies at a higher level. In torsion urinalysis negative but in epididymo-orchitis it is positive. Epididymo-orchitis usually occurs in sexually active men.
Q.71. A 32-year-old woman has severe right sided abdominal pain radiating into the groin which has lasted for 3 hours. She is writhering in pain. She has no abdominal signs. What is the most likely cause of her abdominal pain?
Correct Answer : D
Ureteric colic.
Abdominal pain radiating to groin indicates stone at lower ureter.
i) Pain from upper ureteral stones tends to radiate to the flank and lumbar areas.
ii) Midureteral calculi cause pain that radiates anteriorly and caudally. This midureteral pain in particular can easily mimic appendicitis on the right or acute diverticulitis on the left.
iii) Distal ureteral stones cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female.
Q.72. A 39-year-old coal miner who smokes, drinks and has a family history of bladder cancer is suffering from BPH. Which is the most important risk factor for his bladder carcinoma?
Correct Answer : B
Risk factors of bladder cancer:
i) Smoking
ii) Exposure to chemicals used in the dye industry
iii) Whites are more likely to develop bladder cancer
iv) Risk increases with age
v) More common in men
vi) Chronic bladder irritation and infections (urinary infections, kidney, and bladder stones, bladder catheter left in place a long time.)
vii) Personal history of bladder or other urothelial cancer
viii) Family history
ix) Chemotherapy or radiotherapy
x) Pioglitazone for more than one year and certain herbs
xi) Arsenic in drinking water
xii) Low fluid consumption.
Q.73. A 39-year-old man with acute renal failure presents with palpitations. His ECG shows tall tented T waves and wide QRS complex. What is the next best step?
Correct Answer : B
The ECG changes are suggestive of Hyperkalemia.
At a potassium level of >5.5 mEq/L occurs tall tented T waves and at a potassium level >7 mEq/L occurs wide QRS complex with bizarre QRS morphology. Though patient needs dialysis, “NEXT” best treatment is calcium chloride as it will stabilize the heart from potassium induced arrhythmias while we prepare the patient for dialysis.
Q.74. An old lady had UTI and was treated with antibiotics. She then developed diarrhea. What is the most likely treatment?
Correct Answer : D
Pseudomembranous colitis is treated with metronidazole or vancomycin.
Q.75. A 32-year-old woman of 38 weeks gestation complains of feeling unwell with fever, rigors and abdominal pains. The pain was initially located in the abdomen and was associated with urinary frequency and dysuria. The pain has now become more generalized specifically radiating to the right loin. She says that she has felt occasional uterine tightening. CTG is reassuring. What's the most likely diagnosis?
Correct Answer : B
Fever, rigor, abdominal pain associated with frequency, dysuria, and radiation to the right loin suggest right-sided pyelonephritis.
Q.76. A 10-year-old girl presents with pallor and features of renal failure. She has hematuria as well as proteinuria. The serum urea and creatinine are elevated. These symptoms started after an episode of bloody diarrhea 4 days ago. What is the most probable diagnosis?
Correct Answer : B
Most cases of hemolytic uremic syndrome develop in children after two to 14 days of diarrhea often bloody, due to infection with a certain strain of E. coli.
Features may be :
i) abdominal pain,
ii) pale skin,
iii) hematuria and proteinuria,
iv) features of renal failure like nausea/ vomiting, swelling of face, hand, feet, or entire body, etc.
v) elevated urea and creatinine etc.
Q.77. A 25-year-old woman presents with urinary frequency, dysuria and fever. Urine microscopy shows 20-50 RBC and 10-20 WBC in each field. What is the most probable diagnosis?
Correct Answer : D
Hematuria and significant WBC in urine (>10 per HPF) makes cystitis the most likely diagnosis.
Q.78. A 29-year-old lady admitted with history of repeated UTI now developed hematuria with loin pain. What is the most probable diagnosis?
Correct Answer : A
In a patient having hematuria and loin pain with a history of repeated UTI suggests acute pyelonephritis.
Q.79. An 18-year-old man presents to his GP with thirst and polyuria. Some 6 months ago he had a significant head injury as the result of a RTA. He is referred to the local endocrine clinic. Which of the following results would be the most useful in confirming the diagnosis of diabetes insipidus after a water deprivation test (without additional desmopressin)?
Correct Answer : D
Plasma osmolality of 335 mosmol/kg and urine osmolality of 200 mosmol/kg.
In DI, plasma osmolality will be high due to excess fluid loss with urine and urine osmolality will be low due to polyuria.
Hence E. is the best option here (normal plasma osmolality 275-295 mosmol/kg and normal urine osmolality are 300-900 mosmol/kg.
Q.80. A 10-year-old boy presents with generalized swelling. This has been present for 4 days and included swollen ankles and puffiness of the face. It started a few days after he had a mild cold with runny nose. His only PMH (past medical history) was eczema. Urine analysis: hematuria, proteinuria 10 g/24 hours, creatinine 60?mol/l and albumin=15 g/l. What is the most likely diagnosis?
Correct Answer : A
10 yr old boy, history of URTI and hematuria points towards the diagnosis of IgA nephropathy. It may be present with proteinuria and generalized swelling. The important differentiating point from rapidly progressive GN is duration.
IgA nephropathy <10 days (usually 4/5 days history of infection but in rapidly progressive GN history of infection for >10 days.
Q.81. A 42-year-old woman with a past medical history of severe headache treated in the emergency department presents with signs and symptoms of renal failure. She has been seen by her GP for hypertension and abdominal pain with outpatient investigations pending. Which investigation is most likely to lead to a diagnosis?
Correct Answer : A
Hypertension, abdominal pain, and features of renal failure indicate the diagnosis of ADPKD for which the diagnosis is best made by US KUB.
Q.82. A 50-year-old newly diagnosed with hypertension complains of urinary frequency and dysuria. The urinalysis reveals presence of white cells and protein. Choose the most appropriate treatment?
Correct Answer : D
Symptoms (urinary frequency and dysuria) along with white cells and protein in urine suggest UTI. Treatment is with trimethoprim.
Q.83. A 44-year-old lady who has PCKD is concerned because her 38 years old brother has just died of an intracranial insult. She knows he was not hypertensive. What was the most likely cause of her brother’s death?
Correct Answer : B
Cerebral aneurysms are recognized association of PCKD which may lead to subarachnoid hemorrhage.
Q.84. An 80-year-old man has a permanent catheter. Catheter specimen urine found lots of ecoli. What is the most appropriate management as he wants to attend his daughter’s wedding next week?
Correct Answer : A
Change the catheter
Q.85. A 35-year-old man with painless left testicular enlargement for the past 6 months which is increasing in size and 3 times larger than the right side. There is no tenderness or redness. What is the most likely diagnosis?
Correct Answer : B
Hydrocele
Q.86. A 60-year-old man presents with severe colicky pain from his right flank radiating to his groin. His urinalysis reveals trace blood cells. What is the most discrimatory investigation?
Correct Answer : A
Features are of ureteric colic. X-ray KUB may miss radiolucent stones so the US abdomen is the discriminatory investigation.
Q.87. A patient had passed a 4 mm stone in his urine. He has a 3 mm stone in the renal pelvis found on US. What is the management?
Correct Answer : B
•Stones less than 5 mm in diameter pass spontaneously in up to 80% of people.
• Stones between 5 mm and 10 mm in diameter pass spontaneously in about 50% of people.
• Stones larger than 1 cm in diameter usually require intervention (urgent intervention is required if complete obstruction or infection is present).
• Two-thirds of stones that pass spontaneously will do so within four weeks of onset of symptoms.
Q.88. A 52-year-old man, known diabetic presents to emergency department with sudden onset of pain in the left loin and hematuria. Investigations: 8 mm stone in left lower ureter. Nifedipine with steroids was prescribed as initial treatment with supportive therapy. He returned complaining of worsening pain, vomiting with passing of 2 stones. Renal function tests indicate impending ARF (acute renal failure). How will you manage this patient?
Correct Answer : D
Percutaneous nephrostomy, or nephropyelostomy, is an interventional procedure that is used mainly in the decompression of the renal collecting system. Percutaneous nephrostomy catheter placement has been the primary option for the temporary drainage of an obstructed collecting system. Here impending ARF indicates obstructive uropathy.
Q.89. A 2-year-old boy presented with gradual swelling of feet and poor feeding. He has gained weight and has dark urine. What is the most appropriate investigation?
Correct Answer : B
A case of nephritic syndrome. So the single most appropriate investigation from the given options is 24-hour urinary protein.
Q.90. A 45-year-old known hypertensive man presents with hematuria, proteinuria and edema. What is the definitive diagnostic test for him?
Correct Answer : B
In nephritic syndrome glomerulus is affected. So renal biopsy is the definitive diagnostic test.
Q.91. A 47-year-old man presents with proteinuria +, BP 160/95 mmHg, small kidneys that have smooth renal pelvis. What is the most probable diagnosis?
Correct Answer : A
In chr. Pyelonephritis US will demonstrate renal scarring and urinalysis will demonstrate pyuria which are absent here. In unilateral renal artery stenosis, there will be considerable differences in kidney size from one another which is not found here. Here likely diagnosis is GN.
Q.92. A 27-year-old man presents with abdominal pain. He says his urine is dark. Examinations: BP 160/105mmHg. What is the most appropriate investigation?
Correct Answer : A
Abdominal pain, Dark urine (hematuria), and hypertension suggest ADPKD. The sensitivity of ultrasonography for ADPKD1 is 99% for at-risk patients older than 20 years.
Q.93. A 23-year-old man presents with severe pain in the right flank radiating to his groin. He is rolling about on the floor. An IVU confirms a stone in the ureter which is 8mm in size. Which treatment modality will be most effective?
Correct Answer : B
Though for 8 mm stone we can use medical expulsive therapy but for this patient with agonizing pain “most effective” therapy is ESWL.
Q.94. A 30-year-old man presents to hospital complaining that his urine has been very dark recently, resembling coffee at worst. He has been under the weather 2 weeks back and had taken a few days off work with a sore throat and coryzal symptoms. Urine dipstick in hospital returns highly positive for blood and protein. He is admitted for supportive management and is scheduled for a renal biopsy, which shows mesangial proliferation with a positive immune-flurescence pattern. What is the most probable diagnosis?
Correct Answer : D
Nephritic picture, H/O sore throat 2 weeks before the presentation and biopsy reports are suggestive of post-streptococcal glomerulonephritis.
Q.95. A 24-year-old male who is sexually active with other males with history of discharge per urethra. Diagnosis of chlamydia has been made. What is the possible complication if left untreated?
Correct Answer : C
Epididymo-orchitis
Q.96. A 74-year-old lady who has had a stroke in the past has an indwelling catheter for 10 months. She presents with bluish-purple discoloration of the catheter bag. What is the most likely explanation for this?
Correct Answer : D
Bacterial colonization of the urinary tract. Purple Urine Bag Syndrome.
Q.97. A 26-year-old passed a 4 mm stone in his urine. On US (ultrasonography) a 3 mm stone is found in the renal pelvis. What is the most appropriate management?
Correct Answer : D
Increased fluid intake is advised.
Q.98. A 26-year-old man presents with painless hematuria. He has no other complaints and on examination no other abnormality is found. What is the most appropriate initial investigation to get to a diagnosis?
Correct Answer : C
Abdominal US to exclude polycystic disease.
Q.99. A 34-year-old primigravida who is in her 16 weeks of GA comes for routine antenatal check-up. Her BP is 160/100 mmHg. She has a history of repeated childhood UTI. What is the most likely cause of her high BP?
Correct Answer : B
35% of childhood UTI (urinary tract infection) is associated with VUR (vesico ureteric reflux) and many of them develop renal scarring and chronic pyelonephritis causing hypertension.
Q.100. A 40-year-old woman who has recently returned from working in the middle east complains of thirst, episode of loin pain, urinary frequency, dysuria and has passed a urinary stone. All investigations are normal. She plans to return to the Middle East in a month’s time. What is the best advice to prevent recurrent stone formation?
Correct Answer : C
Risk factors for renal stones include being overweight, certain foods, some medications, and not drinking enough fluids.
Q.101. A 32-year-old man develops hematuria 2 weeks after a sore throat. What is the diagnosis?
Correct Answer : A
Hematuria 2 weeks after sore throat indicates post infection nephritis while hematuria after a few days of sore throat indicates IgA nephropathy.
Q.102. An elder man who has anorexia, prostate symptoms and hypertension. There are small kidneys on ultrasound. What is the diagnosis?
Correct Answer : A
Small kidneys suggest chronic renal failure and uremia here is the cause of anorexia. As an elder he may have associated prostate symptoms from concomitant BPH.
Q.103. A 2-year-old girl has frequency, urgency and burning micturition. She has some supra pubic tenderness. Which one of the following is the most appropriate initial investigation?
Correct Answer : B
The features are consistent with lower UTI for which clean catch of urine for C&S should be done.
Q.104. A young boy presented to the OPD 12 weeks after renal transplantation with fever and pain in lower abdomen. Renal functions were deranged. Renal biopsy showed immune cell infiltrate and tubular damage. What is the most probable diagnosis?
Correct Answer : C
Acute rejection usually occurs in the first few months after transplant but may occur up to a year after transplant. A rise of creatinine, fever, and graft pain may be seen in acute graft rejection. Biopsy showing immune cell infiltrate and tubular damage is suggestive of acute graft rejection.
Q.105. A 40-year-old man complains of severe colicky loin pain that radiates to his scrotum. He is noted to have microscopic hematuria. No masses are palpated. What is the most likely cause?
Correct Answer : D
In ureteric stone there is radiation of pain from loin to groin or scrotum. There also occurs hematuria.
Q.106. A 60-year-old man complains of tiredness, lethargy and itching that is severe after a hot bath. He also has nocturia, polyuria and nausea and vomiting. Examinations: pallor, pigmentation and generalized edema. What is the most likely diagnosis?
Correct Answer : D
Tiredness, lethargy, itching, nausea, and vomiting are common features of uremia. Increased urea excretion in chronic renal failure causes polyuria and nocturia.
Pallor is due to anemia of renal failure. Increased pigmentation in CRF patients is due to an increase in melanin in the basal layer and superficial dermis due to a failure of the kidneys to excrete B melanocyte stimulating hormone.
Oedema is also a common feature of renal failure.
Q.107. A 30-year-old man complains of vague pain in the loin with BP 140/90 mmHg. He is found to have proteinuria and hematuria. What is the investigation to confirm the diagnosis?
Correct Answer : A
The likely diagnosis is ADPKD for which the US is diagnostic investigation.
Q.108. A patient with renal failure has serum K+ 7.5, raised creatinine and broad complex tachycardia. What is the most appropriate management?
Correct Answer : A
Calcium gluconate doesn’t shift K+ to cell or reduce potassium level but it prevents arrhythmogenic action of raised K+ till definitive measure is taken.
Q.109. An elderly lady presents with confusion. She is apyrexial but complains of dysuria for 2 days duration. What is the definitive diagnostic investigation?
Correct Answer : B
Dysurea is suggestive of UTI. UTI also can lead to confusion. Urine nitrates if positive are diagnostic of UTI.
Q.110. A 24-year-old man presents with painless hematuria. No other complaint and no abnormality is found on physical exam. What is the most appropriate initial investigation which is helpful to get a diagnosis?
Correct Answer : D
Painless hematuria in a young male without any other findings on history or examination often suggests Polycystic Kidney Disease.
Q.111. An 84-year-old woman with Alzheimer's dementia has recently become incontinent and more confused than usual. What is the most likely diagnosis?
Correct Answer : D
In UTI there may be incontinence of urine and confusion particulary in elderly.
Q.112. A 34-year-old man had a 4 mm ureteric stone which he passed in urine. This time he presents with 3 cm stone in the right kidney. What is the most appropriate treatment?
Correct Answer : D
Stones < 5mm: pass spontaneously, Increase fluid intake.
Stones 5mm-1cm /pain not resolving: medical expulsive therapy---> Nifedipine or Tamsulosin (and/or prednisolone).
Stones 1cm-2cm: ESWL or Ureteroscopy using dormia basket.
Stones > 2cm/large/multiple/complex: Percutaneous nephrolithotomy.
Q.113. A 60-year-old woman has increasing frequency and urgency leading to occasional incontinence for 3 months. Abdominal and renal examination is normal. What is the most appropriate initial investigation?
Correct Answer : D
Use of urodynamic studies: To know the causes of incontinence, frequency, urgency, problems starting a urine stream, problems emptying the bladder completely, UTI, etc.
Q.114. An 8-year-old boy has symptoms of right sided abdominal pain. He has had symptoms of UTI in the past. Abdominal ultrasound shows right-sided hydronephrosis and excretory isotope scan confirms PUJ obstruction. What is the most appropriate management?
Correct Answer : C
Pyeloplasty +/- percutaneous nephrostomy.
As there is obstruction of pelvi-ureteric junction it lead to hydronephrosis and it may need to relieve acute pressure by percutaneous nephrostomy. For cure we have to go through the procedure of pyeloplasty.
Q.115. A 55-year-old man has leg swelling. He has heavy proteinuria and his serum creatinine concentration is 185mmol/L. What is the most appropriate investigation?
Correct Answer : C
At this age the most common cause of nephrotic syndrome is focal glomerulosclerosis and then membranous glomerulonephritis for both of which renal biopsy is needed to establish the diagnosis.
Q.116. A 75-year-old man has had a frequency of micturition, poor urinary stream and some incontinence for 2 years. His serum creatinine concentration is 350umol/L. What is the most appropriate investigation?
Correct Answer : D
Features of prostatism are suggestive of prostate pathology and from the given options most appropriate is D.
Diagnosis is BPH and US will show obstructive uropathy like dilatation of ureter and calyx or hydronephrosis.
Q.117. A 65-year-old woman has urinary frequency, weight loss, hematuria and blood clots. An abdominal ultrasound is inconclusive. What is the most appropriate investigation?
Correct Answer : D
Features of bladder cancer supported by age, weight loss, and hematuria. In bladder cancer there are UTI-like symptoms such as frequency, dysuria, etc.
Q.118. A 65-year-old man presents with painless hematuria, IVU is normal, prostate is mildly enlarged with mild frequency. What is the most appropriate next step?
Correct Answer : B
Painless hematuria in an elderly (here 65 years old man) indicates carcinoma bladder for which flexible cystoscopy is done. Here BEP is not advanced to cause hemorrhage.
There is a mild enlargement of the prostate and mild symptoms of prostatism and hemorrhage are unlikely at this initial stage of BEP which makes Bladder cancer a likely cause of painless hematuria.
It is also less likely to be prostate cancer as symptoms of prostatism are mild (indicates disease is not advanced). Moreover bleeding in cancer prostate is less common.
Q.119. A 79-year-old anorexic male complains of thirst and fatigue. He has symptoms of frequency, urgency and terminal dribbling. His urea and creatinine levels are high. His serum calcium is 2.9 and he is anemic. His BP is 165/95 mmHg. What is the most probable diagnosis?
Correct Answer : B
Features go in favour of prostatic carcinomas like frequency, urgency, and terminal dribbling are features of prostatism;
Age, anorexia and anemia are constitutional features of carcinoma prostate.
Renal failure from ureteral obstruction in carcinoma prostate is a common presentation. Thirst is a feature of hypercalcemia.
Prostate biopsy is the confirmatory diagnosis and others like PSA are suggestive.
Q.120. An 80-year-old man presented with pain in his lower back and hip. He also complains of waking up in the night to go to the washroom and has urgency as well as dribbling. What is the most likely diagnosis?
Correct Answer : D
Prostate carcinoma :
Age, nocturia, urgency, and dribbling point towards prostate pathology. The pain in the lower back and hip points toward probable bony metastases from prostate cancer.
Blood test for PSA
Prostate biopsy - if initial biopsy is negative, to decide repeat biopsy
MRI
Q.121. A 75-year-old alcoholic presents with a mass up to umbilicus, urinary dribbling, incontinence, and clothes smelling of ammonia. What is the next step in management?
Correct Answer : A
Alcoholism can cause urinary retention but it is a less a common cause of retention.
Q.122. A 64-year-old man has been waking up in the middle of the night to go to the bathroom. He also had difficulty in initiating micturition and complains of dribbling. A diagnosis of BPH was made after a transrectal US guided biopsy and the patient was prepared for a TURP. What electrolyte abnormality is highly likely due to this surgery?
Correct Answer : D
Absorption of fluid used for bladder irrigation to flush out blood clots and IV fluids all may lead to hypervolemia and dilutional hyponatremia.
Q.123. A 65-year-old man presented with frank hematuria. He has no other urinary symptoms. What is the most appropriate next step that will lead to the diagnosis?
Correct Answer : C
Probable diagnosis is bladder cancer. Points in favour, Age 65, asymptomatic haematuria.
Q.124. A patient after transurethral prostatic biopsy. What electrolyte imbalance can he develop?
Correct Answer : B
Use of fluid for bladder irrigation may lead to dilutional hyponatremia.
Q.125. A 75-year-old man with adenocarcinoma of the prostate which has spread outside the capsule of the gland has ARF (acute renal failure). What is the most appropriate next investigation?
Correct Answer : D
Extension beyond capsule may obstruct ureters, causing loin pain, anuria, symptoms of acute kidney injury or chronic kidney disease (here ARF).
Q.126. A 75-year-old war veteran complains of loss of appetite and says he has lost weight over the past few months. He says that he has passed some blood in his urine, however, he had no pain. A recent report shows that PSA >5.5ng/ml. How will you manage this patient?
Correct Answer : A
Radical prostatectomy.
Though PSA is a bit higher than normal it is not confirmatory of carcinoma!
But loss of appetite and weight loss are highly suggestive of cancer in this 75-year-old man.
Q.127. A 75-year-old man comes in complaining of difficulty in passing urine, poor stream and dribbling at the end of voiding and anorexia. US shows bilateral hydronephrosis. What is the cause of these findings?
Correct Answer : D
Elderly patient of 75yrs with obstructive symptoms of the lower urinary tract, bilateral hydronephrosis all can occur in BPH or ca prostate. Anorexia is the clincher here. It is a feature of carcinoma rather than BPH.
Q.128. A young boy has acute scrotal pain for a few hours. Exam: one testis is very painful to touch. He had this kind of pain before but it was mild and resolved itself within 30mins. What would you do next?
Correct Answer : A
As sudden onset of severe pain likely diagnosis is torsion of testis. Infection takes a more prolonged course. The next step is urgent exploration.
Q.129. A young man presents with sudden, severe pain and swelling in the scrotum. Exam: one testis seems higher than the other. What is the most probable diagnosis?
Correct Answer : D
Sudden severe pain, scrotal swelling, and higher position of the affected testis are diagnostic of testicular torsion. You may get further support from examining the cremesteric reflex which is absent in testicular torsion.
Q.130. A 65-year-old man complains of hematuria, frequency, hesistancy and nocturia. He reports that on certain occasions he finds it difficult to control the urge to pass urine. Urine microscopy confirms the presence of blood but no other features. What is the most probable diagnosis?
Correct Answer : A
There are no constitutional features of carcinoma. Bleeding is more common in BPH and occurs in a minority of cases and is much less common in prostatic carcinoma. Features given are of prostatism only which favours the diagnosis of BPH.
Q.131. A 79-year-old man who is being treated with GnRH antagonist for proven adenocarcinoma of the prostate attends a follow up session. What is the most appropriate investigation?
Correct Answer : B
Serum PSA is used to assess the progress of treatment.
If a man’s PSA level rises after prostate cancer treatment, his doctor will consider a number of factors before recommending further treatment.
Additional treatment based on a single PSA test is not recommended. Instead, a rising trend in PSA level over time in combination with other findings, such as an abnormal result on imaging tests, may lead a man’s doctor to recommend further treatment.
Q.132. A 61-year-old man, known smoker, comes to the hospital with complaints of painless hematuria, urgency and dysuria. He has been worried about his loss of weight and reduced general activity. Which investigation would be diagnostic of his condition?
Correct Answer : B
Painless hematuria in elderly men is due to Ca of the bladder usually and in bladder cancer there are UTI-like symptoms like urgency and dysuria. Also, constitutional symptoms like weight loss and reduced general activity are features of carinoma.
Q.133. A 32-year-old man presents with 3 days of scrotal pain. Examination: thickening of the left testis and it is hot to touch. What is the most appropriate management?
Correct Answer : C
Scrotal pain of 3 days with thickening of testis which is hot to touch suggests epididymoorchitis, which is treated with antibiotics.
Q.134. A man presented with carcinoma of the bladder and has been working in factories. He wants to know what dye has caused it. What is the most likely cause?
Correct Answer : A
Aniline dye is a well-known cause of bladder cancer.
Q.135. A 25-year-old man attended in urological OPD has single testis. He was investigated and other testis was located in the abdomen. What is the best management plan for this patient?
Correct Answer : B
Ectopic testis is prone to develop testicular cancer and therefore it should be surgically removed.
Q.136. A 75-year-old man has urinary symptoms of hesitancy, frequency and nocturia. Rectal examination: large hard prostate. What is the most appropriate investigation?
Correct Answer : D
Urinary symptoms and hard prostate on PR suggests prostatic cancer for which PSA should be done.
Q.137. A 70-year-old man presents with a fluctuant swelling of the scrotum which feels like worms when he is standing but regresses when he lies down. What is the most probable diagnosis?
Correct Answer : A
Fluctuant swelling of the scrotum which feels like worms are suggestive of varicocele.
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