Clinical SBAs
Clinical Urology: (25 questions)

Questions

• 1
  A 15-year old boy presents with a 8-hour history of vomiting, abdominal pain and a painful right testicle, that lies high and transversely. The consultant on call suspects infarction. What procedure should he be consented for?
  Difficulty: Easy     Topic: Painful testicle 2
  a

  Bilaterally orchidopexy

  b

  Bilateral orchidectomy

  c

  Unilateral orchidectomy and bilateral orchidopexy

  d

  Unilateral orchidopexy

  e

  Unilateral orchidectomy
  Explanation: It is highly likely that this boy has testicular torsion, where the testicle has rotated and begins to infarct due to vessel occlusion. Definitive diagnosis is only made during surgery but the patient must be consented for removal of the affected testis if it is no longer viable (unilateral orchidectomy). After an 8 hour history it is likely that there is significant ischaemic damage to the testis, which makes removal more likely. If it is viable then it is fixed in place (orchidopexy) but the unaffected testis is also fixed in place, therefore this may be bilateral. Therefore consent for unilateral orchidectomy and bilateral orchidopexy allows all surgical options.
• 2
  A 62-year old woman undergoes a clam ileo-cystoplasty. What condition is she most likely to have suffered from?
  Difficulty: Hard     Topic: Clam ileo-cystoplasty
  a

  Bladder carcinoma

  b

  Stress incontinence

  c

  Urge incontinence

  d

  Overflow incontinence

  e

  Haemorrhagic cystitis
  Explanation: In clam ileo-cystoplasty, the bladder is bisected and sewn into the ileum. It is reserved for the most severe cases of urge incontinence and is not a common treatment. Bladder carcinoma may undergo cystoscopic resection or cystectomy. Stress incontinence is treated with pelvic floor exercises or copulosuspension if severe. Overflow incontinence may require intermittent self-catheterisation if due to neuropathy. Haemorrhagic cystitis is a complication of cyclophosphamide, giving thiol-mensa helps reduce this side-effect.
• 3
  Which of the following statements about testicular cancer is correct?
  Difficulty: Easy     Topic: Testicular cancer
  a

  Seminomas are more common than teratomas

  b

  AFP is raised in seminomas

  c

  Orchidectomy is performed via a scrotal incision

  d

  Teratomas are most common at 30-45yrs

  e

  Radiotherapy is used to treat cerebral metastases
  Explanation: The 2 main types of testicular cancer are seminomas, the most common, and teratomas. Teratomas are more frequent at 20-30yrs and seminomas at 30-45yrs. Alpha-feto protein and beta-human chorionic gonadotrophin are both raised in teratomas but only B-HCG is raised in seminomas. Orchidectomy is done via a groin incision to reduce risk of seeding during surgery. Radiotherapy doesn't form part of management and metastases are treated with chemotherapy (often cisplatin) with a very high response rate.
• 4
  A 71-year old man is diagnosed with prostate cancer. It is high grade and there is no spread outside the prostate capsule. What is the most appropriate management?
  Difficulty: Medium     Topic: Treatment of prostate cancer
  a

  Active surveillance

  b

  Radical prostatectomy

  c

  Bilateral orchidectomy

  d

  Goserelin

  e

  Radio-labelled strontium
  Explanation: If prostate cancer is localised then it potentially curable. Many carcinomas are indolent and will not progress or cause significant morbidity. This is partly predicted using Gleason grade. If low grade, active surveillance with clinical examination and PSA may be appropriate. If high grade then the tumour is more likely to progress and radical treatment is indicated, which can be surgical excision (open or laparoscopic) or radical radiotherapy (external beam or brachytherapy). If there has been spread beyond the capsule then neoadjuvant goserelin is used, with radical radiotherapy and adjuvant hormone treatment. Disseminated disease is treated with hormone therapy with radiotherapy or strontium for painful bony metastases.
• 5
  A 62-year old woman with T4 bladder carcinoma develops pneumaturia and recurrent urinary tract infections. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Pneumaturia
  a

  Occlusion of the bladder neck

  b

  Bladder perforation

  c

  Vaginal-vesicular fistula

  d

  Colo-vesicular fistula

  e

  Urolithiasis
  Explanation: This woman has developed a fistula between her colon and bladder due to tumoural infiltration. This causes air in the urine (pneumaturia) and recurrent infection with colonic organisms. Vaginal-vesicular fistulas may cause pneumaturia but would also cause passage of urine par vagina. Bladder neck occlusion would cause obstruction and urine retention. Bladder perforation would present with abdominal pain and chemical peritonitis. Urolithiasis (bladder stone) causes pain and intermittent obstruction.
• 6
  A 63-year old man presents with abdominal pain and intermittent haematuria without clots. A mass is palpable in the left flank, which can be balloted. Which of the following is not a risk factor for this condition?
  Difficulty: Medium     Topic: Abdominal pain and haemturia
  a

  Von Hippel Lindau (VHL) syndrome

  b

  Smoking

  c

  Polycystic kidney disease

  d

  Aromatic amine exposure

  e

  Dialysis
  Explanation: This man has renal cell carcinoma (RCC) and has presented with the classic triad of: abdominal pain, flank mass and haematuria. Aromatic amine exposure (e.g. dyes, rubber) is a risk factor for transitional cell carcinoma (most commonly bladder) but not for RCC. VHL syndrome has an inherited mutation that increases risk of: RCC, phaeochromocytoma and haemangiomas. Risk of RCC is increased 2x by smoking. PCKD and dialysis increase the risk of RCC development.
• 7
  A 42-year old man presents with fever, rigors and severe right loin pain. Ultrasound scan shows right sided pelvi-calyceal dilatation above a blockage. What is the most appropriate initial management?
  Difficulty: Medium     Topic: Fever, rigors and loin pain
  a

  Percutaneous nephrostomy

  b

  Extracorporeal shock-wave lithotripsy (ESWL)

  c

  Ureteroscopic retrieval

  d

  Serial X-rays and supportive treatment

  e

  Serial CT scans and supportive treatment
  Explanation: This man has pyonephrosis, build-up of pus within the kidney, most likely due to a stone obstructing the pelvi-ureteric junction. Presentation of hydronephrosis with sepsis is assumed to be pyonephrosis and the pus must be relieved via percutaneous nephrostomy. Depending on the size of the stone, ESWL may be appropriate. Ureteroscopic retrieval can only be used for stones in the lower part of the ureter. Serial X-rays or CT scans may be used for small stones not causing obstruction.
• 8
  A 88-year old man presents with difficulty passing urine. He finds it takes longer for him to empty, the stream is weaker and he has to go three times per night. Which of the following statements about this condition is incorrect?
  Difficulty: Medium     Topic: Difficulty passing urine
  a

  Incontinence is a question on the IPSS

  b

  Reducing caffeine intake can help

  c

  Retrograde ejaculation is a common complication of surgical treatment

  d

  Finasteride takes 3-6 months to work

  e

  Tamsulosin works within 1-2 weeks
  Explanation: This man has benign prostatic hypertrophy with bladder outlet obstruction plus nocturia. The International Prostate Symptom Score (IPSS) should be done on all men with suspected BPH. There are questions about 7 symptoms, but incontinence does not feature. It is helpful to reduce caffeine intake, especially in the evening. Retrograde ejaculation occurs in up to 90% post-TURP. Finasteride reduces prostate size so takes months to work. Tamsulosin relaxes smooth muscle therefore works quickly.
• 9
  A 62-year old man presents with back pain and weight loss. Abdominal ultrasound shows moderate bilateral hydronephrosis. CT abdomen shows a poorly defined mass on the posterior abdominal wall. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Back pain, weight loss and hydronephrosis
  a

  Colorectal carcinoma

  b

  Retroperitoneal sarcoma

  c

  Transitional cell carcinoma

  d

  Retroperitoneal fibrosis

  e

  Prostatic carcinoma
  Explanation: Retroperitoneal fibrosis is an idiopathic condition with inflammation of the aortic adventitia. A fibrotic mass develops and causes bilateral ureter obstruction. Other symptoms: vague back pain, weight loss and pyrexia so malignancy must be excluded, which may require biopsy to differentiate diagnoses. CRC causes change in bowel habit or anaemia. Sarcomas are very rare and occur in children. TCC cause intermittent haematuria and are unilateral. Prostatic carcinoma would be very advanced to cause bilateral obstruction, with urinary symptoms.
• 10
  A 72-year old diabetic man presents acutely unwell with pyrexia and perineal pain. A small wound is visible near the base of his penis with surround spreading erythema and oedema. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Perineal pain and pyrexia
  a

  Dry gangrene

  b

  Fournier gangrene

  c

  Gas gangrene

  d

  Meleney gangrene

  e

  Venous gangrene
  Explanation: This man has Fournier's gangrene, a rapidly spreading infection the subcutaneous tissues characterised by infection with both aerobic and anaerobic organisms. It is more common in diabetics and usually occurs following trauma or surgery. It requires triple antibiotic therapy, catheterisation and surgical debridement. Gas gangrene is usually abdominal wound complicated by Clostridium perfringens infection. Dry gangrene describes aseptic irreversible tissue necrosis, which is often vascular. Meleney gangrene is a necrotizing post-operative ulcer. Venous gangrene is a rare complication of DVT, featuring proximally spreading lower limb tissue necrosis.
• 11
  A man presents with a hard testicular swelling that cannot be separated from the testicle. Which of the following is least likely?
  Difficulty: Easy     Topic: Testicular swelling
  a

  Haematocele

  b

  T. pallidum infection

  c

  Mycobacterium infection

  d

  Seminoma

  e

  Spermatocele
  Explanation: Spermatoceles are a form of epididymal cyst that contains milky-fluid. They can be separated from the testis (lying posterior) and are cystic. Haematoceles occur post-trauma where the clot surrounds the testis. Treponema pallidum infection causes syphilis, where a granuloma in the testicle causes painless hard enlarging. TB granuloma may give the same appearance. Seminoma are the most common form of testicular tumour.
• 12
  Which of the following statements about hydroceles is true?
  Difficulty: Easy     Topic: Hydroceles
  a

  It is a collection of fluid in the tunica albuginea

  b

  Primary hydroceles are less common than secondary

  c

  The testis is usually palpable

  d

  Aspiration is the definitive treatment

  e

  Primary hydroceles are in continuity with the peritoneal cavity
  Explanation: A hydrocele is a collection of fluid inside the tunica vaginalis. Primary hydroceles are due to a patent processus vaginalis, which connects the scrotum to the peritoneal cavity through the inguinal canal. They are the most common type, present in younger men and are large. Secondary hydroceles are due to inflammation, infection or malignancy. The testis is usually not palpable, especially if the hydrocele is large. Aspiration may give some relief but surgery is usually required to prevent recurrence.
• 13
  Which of the following is not a recognised feature of a renal cell carcinoma (RCC) ?
  Difficulty: Easy     Topic: Renal cell carcinoma
  a

  Polycythaemia

  b

  Right sided varicocele

  c

  Hypercalcaemia

  d

  Fever

  e

  Thrombosis
  Explanation: The left gonadal vein drains into the left renal vein and a left side RCC invading the renal vein may disrupt left testicle venous drainage, which results in a varicocele. The right testicular vein drains into the IVC therefore this does not occur. EPO production causes polycythaemia. Parathyroid hormone-related protein production causes hypercalcaemia. RCC is a known cause of pyrexia. Thrombosis occurs due to polycythaemia and malignant hyperviscosity.
• 14
  A 78-year old man presents with immobility, diffuse abdominal pain, bilateral leg pain and anuria. He has a history of angina and bronchial carcinoma. Catheter drains 600ml. A digital rectal examination is normal. Which investigation is most likely to give the diagnosis?
  Difficulty: Medium     Topic: Immobility and anuria
  a

  PSA measurement

  b

  MRI spine

  c

  Intravenous ureterogram (IVU)

  d

  XR spine

  e

  CT chest, abdomen and pelvis
  Explanation: This man has spinal cord compression. He has immobility, bilateral sciatica and acute urinary retention. Anal tone is normal until late therefore its presence does not exclude spinal cord compression. The history of malignancy suggests bone metastases as a cause. MRI spine is the investigation of choice for suspected cord compression. PSA will be raised due to acute retention so should not be measured. IVU will probably be normal. XR has low sensitivity in spinal cord compression because it may demonstrate vertebral lesions but cannot visualise the cord therefore MRI is superior. CT may suggest cord lesions however is poorer for imaging soft tissue that MRI. CT has a role in diagnosing cervical spine fractures that cannot be seen on X-ray but is not first-line if malignant cord compression is suspected.
• 15
  A 21-year old man presents with an acutely painful and swollen testicle. What is the least likely cause?
  Difficulty: Easy     Topic: Painful swollen testicle 1
  a

  E. coli

  b

  Chlamydia

  c

  Mumps

  d

  Idiopathic scrotal oedema

  e

  Testicular torsion
  Explanation: Idiopathic scrotal oedema is a benign condition that occurs in young boys, not adults. The scrotum is red and swollen but not painful, unlike torsion. E. coli and Chlamydia are the most common causes of acute epididymo-orchitis; Chlamydia being the most common infectious cause in young men. Mumps is a viral cause of orchitis, it may also cause bilateral parotiditis and pancreatitis. Torsion presents with as above plus an absent cremasteric reflex.
• 16
  A 16-year boy with sickle-cell disease presents with intermittent severe left flank pain and passing clots of blood in his urine. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Severe flank pain
  a

  Transitional cell carcinoma

  b

  Renal cell carcinoma

  c

  Interstitial nephritis

  d

  Acute tubular necrosis

  e

  Papillary necrosis
  Explanation: Sickle cell disease causes intermittent renal infarction, which results in papillary necrosis. The papillas slough into the pelvis and cause renal colic and haematuria with clots. This can also be caused by analgesic nephropathy. TCC causes painless haematuria. RCC haematuria does not contain clots and would be associated with a mass; at 16yrs RCC would be due to Von Hippel Lindau syndrome. Interstitial cystitis causes dysuria. Acute tubular necrosis causes painless acute renal failure.
• 17
  A 45-year old Egyptian lady presents with intermittent haematuria and dysuria. Abdominal X-ray is normal. Squamous change is noted on cystoscopic biopsy. What is the most likely cause?
  Difficulty: Medium     Topic: Intermittent haematuria and dysuria
  a

  Cyclophosphamide side-effect

  b

  Interstitial cystitis

  c

  A parasitic infection

  d

  Transitional cell carcinoma

  e

  Vesicular calculus
  Explanation: The woman has schistosomiasis, a parasite that lives in water and is at high prevalence in Egypt. It can cause cystitis with haematuria, but urine culture will be negative. Cystoscopy is required to exclude malignancy. Schistosomiasis also induces squamous metaplasia, which can lead to squamous cell carcinoma of the bladder, none of the other options cause this. Cyclophosphamide causes haemorrhagic cystitis. Interstitial cystitis occurs from drugs or radiotherapy. Urolithiasis cause pain and intermittent urinary retention.
• 18
  Which of the following is associated with chronic retention and overflow incontinence?
  Difficulty: Medium     Topic: Urine retention
  a

  Diabetes

  b

  Multiple sclerosis

  c

  Spinal cord injury at T3

  d

  Ischaemic stroke

  e

  Haemorrhagic stroke
  Explanation: The effects of manifestation of neuropathic bladder is determined by the level of the lesion. Peripheral lesions (e.g. diabetes) cause lower-motor neurone type effects with an atonic, weak bladder. It fills with low resistance until intra-vesicular pressure exceeds sphincter pressure, causing overflow incontinence. Central lesions ('B-E') cause an upper-motor neurone type bladder with increased tonic activity. The bladder empties at low volume with high force, a form of urge incontinence.
• 19
  Which of the following is not a cause of urinary retention?
  Difficulty: Medium     Topic: Urine retention
  a

  Morphine

  b

  Ipratropium

  c

  Imipramine

  d

  Pilocarpine

  e

  Haloperidol
  Explanation: The most common drug causes of urinary retention are those with anti-cholinergic properties. Pilocarpine is a muscarinic-agonist therefore will precipitate urgency, not retention. Opiates have anti-cholinergic side-effects as well as: nausea, drowsiness, respiratory depression, hallucinations and myoclonus. Ipratropium is a muscarinic antagonist. Imipramine is a TCA, which are anti-cholinergic and cause lethal seizures plus arrhythmias is overdose. Haloperidol is a typical neuroleptic, which causes anti-muscarinic side-effects as well as hypotension, drowsiness and extra-pyramidal side-effects.
• 20
  A 84-year old man presents to A&E with confusion. A mass is felt in the lower abdomen that is dull to percussion and it is not possible to get below it. Electrolytes are normal. What is the most appropriate immediate management?
  Difficulty: Medium     Topic: Confusion and lower abdominal mass
  a

  Insert a Foley catheter and give 5% dextrose

  b

  Insert a Foley catheter and give 0.9% saline IVI

  c

  Insert a Foley catheter and fluid restrict to 1.5L/day

  d

  Insert a 3-way catheter and give 0.9% saline IVI

  e

  Insert a 3-way catheter and give 5% dextrose
  Explanation: This man has acute urinary retention, a common cause of delirium in the elderly. He needs the obstruction removed with a catheter and there is no need to use a 3-way initially as there has been no history of haematuria. Following relief of an obstruction there is an electrolyte-wasting diuresis so. It is reasonable to begin a saline infusion even though his electrolytes are normal. 5% dextrose causes hyponatraemia and fluid restriction causes dehydration.
• 21
  An 81-year old man with a history of painless, intermittent haematuria goes into acute retention. Which investigation is most likely to give the diagnosis?
  Difficulty: Easy     Topic: Intermittent haematuria and retention
  a

  Urodynamics

  b

  CT abdomen

  c

  IVU

  d

  Cystoscopy

  e

  Trans-rectal ultrasound and biops
  Explanation: Painless intermittent haematuria in an elderly patient is most likely due to transitional cell carcinoma of the bladder. Acute retention is usually from clot retention but can be due to tumour prolapse. Cystoscopy is the gold standard for symptomatic tumours but may not diagnose carcinoma in situ presenting with voiding irritability. These may be diagnosed using urine cytology, which is sensitive for high-grade tumours. Urodynamics diagnoses bladder outlet obstruction. CT abdomen demonstrates renal masses. IVU shows defects in the ureters. TRUS with biopsy is used to diagnose prostate cancer.
• 22
  A woman who initially presented with haematuria has gone into acute retention. What is the most appropriate catheter to use?
  Difficulty: Easy     Topic: Retention following haematuria
  a

  Foley 12F

  b

  3-way catheter

  c

  Coudé catheter

  d

  Teeman catheter

  e

  Silastic catheter
  Explanation: Acute retention following haematuria is most likely to be due to clot retention where the bladder neck becomes obstructed with a large clot. This requires a 20F (large) 3-way catheter to be inserted to allow irrigation as well as drainage. 12F catheters are small and are used for intermittent self-catheterisation. Coudé catheters have an angled tip and Teeman catheters are tapered; both help with prostatic obstruction. Silastic catheters are less irritant and are used long-term.
• 23
  A 78-year old man presents with dysuria, perineal pain and frank haematuria. Digital rectal exam is extremely painful. What is the most appropriate management?
  Difficulty: Hard     Topic: Pain and frank haematuria
  a

  Oral trimethoprim for 10 days

  b

  Oral levofloxacin for 10 days

  c

  Oral levofloxacin for 4 weeks

  d

  IV levofloxacin for 2 weeks

  e

  Cefuroxime IV for 7days, then oral for 7days
  Explanation: Painful haematuria with a tender prostate on PR suggests prostatitis, which is most commonly caused by E. coli. Initial treatment is with oral levofloxacin for 4 weeks. Trimethoprim is 1st line for uncomplicated UTIs, other options are nitrofurantoin and cefalexin. 2nd line is ciprofloxacin or co-amoxiclav. 'B' and 'D' are not commonly used treatments. 'E' is the treatment of pyelonephritis, which presents with loin pain, rigors, fever and pyuria.
• 24
  Which of the following does not predispose to recurrent pyelonephritis?
  Difficulty: Hard     Topic: Recurrent pyelonephritis
  a

  Pelviureteric junction (PUJ) obstruction

  b

  Duplex ureters

  c

  Horseshoe kidney

  d

  Medullary sponge kidney

  e

  Vesicoureteric junction (VUJ) reflux
  Explanation: Most malformations do increase risk of recurrent infection which damage and chronic scarring but congenital PUJ obstruction does not. A narrowing prevents flow of urine, which results in hydronephrosis and pain. In duplex ureters there are 2 ureters for each kidney. If the kidneys fail to separate they are joined anterior to the aorta as a horseshoe kidney. Medullary sponge kidney is due to dilatation of the collecting ducts and predisposes to nephrocalcinosis. Incompetent valves at the VUJ causes reflux and stasis of residual urine that leads to cystitis and pyelonephritis.
• 25
  A 43-year old man who has recently moved to the UK from south-east Asia presents with dysuria. USS shows no tract abnormalities, MSU is negative but urinary WCC is elevated. What is the next most appropriate investigation?
  Difficulty: Medium     Topic: Sterile pyuria
  a

  CT abdomen

  b

  Cystoscopy

  c

  3x early morning urine samples

  d

  Digital rectal examination

  e

  Intravenous urogram
  Explanation: This man has renal TB, which is one of the causes of sterile pyuria (also: poorly treated UTI, interstitial nephritis and stones). Conventional urine culture does not demonstrate TB and 3x early morning samples is the investigation most likely to secure the diagnosis. CT is used if renal cell carcinoma is suspected. Cystoscopy demonstrates bladder mucosal lesions. Rectal exam suggests prostatic pathology. IVU is used if a tract abnormality is suspected but testing for TB should come first.