UROLOGY Flashcards
A 39 year old man notices a swelling in his left hemiscrotum. On examination he has a left sided varicocele. The ipsilateral testis is normal on palpation. What is the most appropriate course of action?
Scrotal exploration and ligation of the varicocele Abdominal ultrasound Scrotal ultrasound Left orchidectomy Discharge
A left sided varicocele is a recognised presenting sign of a renal tumour occluding the renal vein (into which the left testicular vein drains). An abdominal ultrasound should be undertaken to exclude this. Surgery for uncomplicated varicocele is usually unnecessary.
A 3 month old boy is brought to the clinic by his mother who has noticed a swelling in the right hemiscrotum. On examination, there is a firm mass affecting the right spermatic cord distally, the testis is felt separately from it. What is the most likely diagnosis?
Inguino scrotal hernia Rhabdomyosarcoma Leydig cell tumour Torsion of testicular hydatid Hydrocele
Rhabdomyosarcoma are paratesticular tumours with a bimodal distribution. Because the mass is felt separate to the testis, this is the more likely diagnosis.
5% of testicular tumors
Most often arises in distal portion of spermatic cord and may invade testis of surrounding tissues
60% occur in the first 2 decades of life
Bimodal age distribution - 3-4 months - 16 years
Arises from mesenchymal tissue - 90% embryonal variant (better prognosis) - 30% - 50% have metastasis (usually lymph node) at diagnosis
A 22 year old man presents with an aching pain and discomfort in his right testicle. He has felt systemically unwell for the preceding 48 hours. On examination, there is tenderness of the right testicle. He has an exaggerated cremasteric reflex. What is the correct course of action?
Scrotal exploration via a scrotal approach Testicular inspection via an inguinal approach Administration of antibiotics Fine needle aspiration cytology Reassure and discharge
Administration of antibiotics
This is likely to represent epididymo-orchitis, this is usually due to infection with gonorrhoea or chlamydia in this age group. In addition to treatment with antibiotics contact tracing and appropriate swabs should also be performed.
A 78 year old man has a long history of nocturia, urinary frequency and terminal dribbling. He was admitted with urinary retention and was catheterised. On removal of the catheter he has noticed some haematuria. What is the most likely cause?
Transitional cell carcinoma of the bladder Squamous cell carcinoma of the bladder Polycystic kidney disease Renal cell carcinoma Benign prostatic hyperplasia
The symptoms are typical for prostatic disease.
A 32 year old lady suffers from severe left sided abdominal pain, that radiates to her groin. As part of her evaluation the nurses identify microscopic haematuria on dipstick. What is the explanation?
Staghorn calculus Ureteric calculus Transitional cell carcinoma of the ureter Adenocarcinoma of the ureter Cystitis
Ureteric calculi will often present with loin pain radiating to the groin. It is usually severe. There may be macroscopic or microscopic haematuria. The absence of haematuria on dipstick testing should prompt investigations for alternative diagnoses. The best investigation is a non contrast CT scan. CT changes consistent with stone or recent stone passage include evidence of stone, perinephric stranding, ureteric oedema or hydronephrosis.
A 56 year old man presents with urinary symptoms and on investigation is found to have a 2cm nodule in the left lobe of the prostate. Imaging with whole body MRI and pelvic CT/MRI demonstrates a likely cancer with no distant disease and no nodal metastasis. What is the most appropriate course of action?
Robotic prostatectomy Open prostatectomy Transvesical prostatectomy Prostatic biopsy Radical pelvic radiotherapy
Prostate cancers are typically biopsied prior to treatment.
A 49 year old man presents with a single episode of haematuria. Investigations demonstrate adenocarcinoma of the prostate gland. Imaging shows T2 disease and no evidence of metastasis. What is the best treatment option?
Chemotherapy alone Radical prostatectomy Trasvesical prostatectomy TURP External beam radiotherapy
In a young patient with local disease only a radical prostatectomy is the best chance of cure. Radiotherapy may be given instead but has long term sequelae (and inferior survival outcomes). A transvesical prostatectomy is a largely historical operation performed for BPH before TURP was established.
A 38 year old man is investigated and found to have a left sided renal mass. Imaging demonstrates a 5cm renal tumour invading the left renal vein. There is no evidence of distant disease. What is the most appropriate course of action?
Renal biopsy Radical nephrectomy External beam radiotherapy Combined chemoradiotherapy Neoadjuvent chemotherapy
Renal tumours that are operable are nearly always managed surgically in the first instance. It is not common practice to biopsy prior to surgery. They are not usually radiosensitive.
A 52 year old man falls off his bike. He is found to have a pelvic fracture. On examination, he is found to have perineal oedema and on PR the prostate is not palpable. What is the most likely underlying problem?
Bulbar urethral rupture Bladder outflow obstruction Bladder rupture Bladder contusion Membranous urethral rupture
A pelvic fracture and highly displaced prostate should indicate a diagnosis of membranous urethral rupture
Why is a 73 year old lady receiving a course of intravesical BCG therapy?
Bladder tuberculosis Transitional cell carcinoma of the bladder Adenocarcinoma of the bladder Squamous cell carcinoma of the bladder Rhabdomyosarcoma of the bladder
Transitional cell carcinoma of the bladder may be treated with intravesical BCG therapy.
A 72 year old man presents with haematuria which is recurrent. On investigation, a retrograde pyelogram shows multiple ureteric filling defects and the renal pelvis is irregular. What is the most likely cause?
Squamous cell carcinoma of the renal pelvis Transitional cell carcinoma Adenocarcinoma of the kidney Retroperitoneal sarcoma Retroperitoneal fibrosis
TCC of the renal pelvis may seed down the ureter.
What is the most useful test for a 5 year old who has vesicoureteric reflux in whom there are concerns about the potential of renal scarring?
Intravenous urogram Renal CT scan DMSA scan Micturating cystourethrogram Retrograde ureterogram
Although MAG 3 renograms may provide some information relating to the structural integrity of the kidney, many still consider a DMSA scan to be the gold standard for the detection of renal scarring (which is the main concern in PUJ obstruction and infections).
DMSA = Dimercaptosuccinic acid
A 28 year old man presents with pain in the testis and scrotum. It began 10 hours previously and has worsened during that time. On examination, he is pyrexial, the testis is swollen and tender and there is an associated hydrocele. What is the most likely diagnosis?
Torsion of testicular hydatid Torsion of the testis Testicular seminoma Acute epididymo-orchitis Torsion of the spermatic cord
The onset is relatively slow for torsion and the presence of fever favors epididymo-orchitis.
A 20 year old male notices a mild painful swelling of his right scrotum. He also complains of abdominal pain. Clinically, the patient is found to have a swollen right testicle. Apart from a supraclavicular node, there is no obvious lymphadenopathy. What is the best course of action?
Orchidectomy via a scrotal approach Tru cut biopsy of the testis FNAC of the testis Orchidectomy via an inguinal approach Administration of antibiotics
The patient is likely to have a teratoma which has metastasized to the supraclavicular nodes. There is suspicion of spread to the para-aortic nodes due to the abdominal pain. He will need orchidectomy and combination chemotherapy. There is no role for orchidectomy via scrotal approach in malignancy.
An 83 year old man with a long standing staghorn calculus presents with recurrent haematuria and investigation shows a mass of the left renal pelvis. Of the lesions listed below, the diagnosis is:
Squamous cell carcinoma Adenocarcinoma Transitional cell carcinoma Sarcoma Transitional metaplasia
SCC of the kidney usually arises in an area of chronic inflammation such as a staghorn calculus. They are rare
A 75 year old lady reports urinary incontinence when coughing and sneezing. She has had 2 children with no complications. She has no significant past medical history and is on no medications. What is the most appropriate initial management?
Trial of sacral neuromodulation Urodynamic studies Pelvic floor exercises for 3 months Bladder drill training for 6 weeks Administration of oxybutinin
A diagnosis of stress incontinence is obvious from the history, therefore there is no need for a bladder diary or urodynamic studies. Pelvic floor exercises would be the first line management.
Which of the following renal stone types is most radiodense on a plain x-ray?
Calcium phosphate Calcium oxalate Uric acid Struvite Cystine
Calcium phosphate stones are the most radiodense stones, calcium oxalate stones slightly less so. Uric acid stones are radiolucent (unless they have calcium contained within them).
A 32 year old male presents with a swollen right scrotum which has developed over 3 weeks after being kicked in the groin area. There is a non tense swelling of the right scrotum and the underlying testis cannot be easily palpated. A dipstick is positive for nitrates only. What is the most likely diagnosis?
Epididymo-orchitis Testicular torsion Torsion of testicular appendage Hydrocele Haematocele
This is a secondary hydrocele which occurs in patients aged 20-40 years. It develops over days/ weeks and there may not be a tense swelling. The underlying testis is NOT palpated therefore indicating a hydrocele. Causes include trauma, infection and tumour.
A 52 year old male with hypercalcaemia secondary to primary hyperparathyroidism presents with renal colic. USS demonstrates ureteric obstruction due to a stone. Multiple attempts at stone extraction are performed. However, the stone could not be removed. He is now septic with a pyrexia of 39.5 oc and he has been given antibiotics. What is the best course of action?
Cystoscopy and insertion of ureteric stent Laparotomy and ureteric exploration Insertion of nephrostomy Laparoscopic ureteric exploration Lithotripsy
The likely scenario is that this man has developed a calculus causing ureteric obstruction. The stagnant column of urine can become colonised and infected. An infected obstructed system is one of the few true urological emergencies. A nephrostomy is needed as the stone could not be removed.
A 56 year old man is involved in a road traffic accident. He is found to have a pelvic fracture. He reports that he has some lower abdominal pain. He has peritonism in the lower abdomen. The nursing staff report that he has not passed any urine. A CT scan shows evidence of free fluid. What is the most likely diagnosis?
Membranous urethral injury Bladder rupture Bladder contusion Bulbar urethral injury Urinary tract infection
A pelvic fracture and lower abdominal peritonism should raise suspicions of bladder rupture (especially as this man cannot pass urine).
A 58 year old man has an episode of painless frank haematuria whilst undergoing a 24 urine collection for investigation of hypertension. What is the most likely cause?
Renal adenocarcinoma Neuroblastoma Transitional cell carcinoma of the ureter Squamous cell carcinoma of the bladder Phaeochromocytoma
Renal adenocarcinoma
These tumours may often have paraneoplastic effects such as hypertension
A 34 year old woman from Chad presents with continuous dribbling incontinence after having her 2nd child. Apart from prolonged labour the woman denies any complications related to her pregnancies. She is normally fit and well. What is the most likely diagnosis?
Vesicovaginal fistula Stress urinary incontinence Overactive bladder syndrome Colovesical fistula Pudendal neuropathy
Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after prolonged labour and from an area with limited obstetric services.
A 23 year old woman is admitted with loin pain and a fever, she has noticed haematuria for the past week accompanied by dysuria, this was treated empirically with trimethoprim. What is the most likely cause?
Stone disease Cystitis Pyelonephritis Renal cancer Detrusor instability
This is most likely pyelonephritis and partially treated cystitis is a common cause.
A 75 year old man presents with locally advanced carcinoma of the prostate and vertebral body metastasis with impending spinal cord compression. Which of the following agents (if used in isolation) carries the greatest risk of worsening his symptoms in the short term?
Surgical orchidectomy Cyproterone acetate Luteinising hormone releasing hormone analogues Flutamide None of the above
LHRH analogues may cause flare of metastatic disease and anti androgens should be administered to counter this. Surgical orchidectomy reduces testosterone levels within 8 hours (but fails to reduce adrenal androgen release). Cyproterone and flutamide are androgen blockers that may be considered as add on therapy to reduce the risk of tumour flare when commencing treatment with LH RH analogues.
A 42 year old man underwent a vasectomy at the surgical clinic. He is reviewed at the request of his general practitioner. On examination he has a small rounded nodule adjacent to the vas. What is the most likely underlying diagnosis?
Haematoma Sperm granuloma Varicocele Hydrocele Epididymal cyst
Sperm granulomas are a common sequelae of vasectomy and are smooth round lumps adherant to the vas. They may be safely left alone
A 15 year old boy develops sudden onset of pain in the left hemiscrotum. He has no other urinary symptoms. On examination, the superior pole of the testis is tender and the cremasteric reflex is particularly marked. What is the most likely underlying diagnosis?
Epididymo-orchitis Torsion of the testis Torsion of a testicular hydatid Viral orchitis Testicular malignancy
Torsion of a testicular hydatid
The cremasteric reflex is usually preserved when the torsion affects the appendage only.
A 32 year old male presents with a swollen, painful right scrotum after being kicked in the groin area. There is a painful swelling of the right scrotum and the underlying testis cannot be easily palpated. What is the best course of action?
Inguinal orchidectomy Scrotal orchidectomy Scrotal exploration Testicular USS Testicular aspiration
Acute haematocele: tense, tender and non transilluminating mass. The testis will need surgical exploration to evacuate the blood and repair any damage.
A 33 year old man presents with a painless lump in his left testis. USS and blood tests are suspicious for teratoma. What is the most appropriate next step?
Orchidectomy via an inguinal approach Orchidectomy via a scrotal approach Fine needle aspiration cytology of the lesion Core biopsy of the lesion Incisional biopsy of the lesion
Oncological orchidectomy is routinely performed via an inguinal approach to avoid contamination of another lymphatic field.
Do not biopsy suspected testicular cancer
A 23 year old man presents with severe loin to groin pain. Imaging demonstrates a 2mm left sided calculus in the distal ureter, renal function is normal. What is the most appropriate course of action?
Arrange for ureteroscopy and stone extraction Arrange for open ureterotomy and stone extraction Arrange for a percutaneous nephrolithotomy Arrange for extracorporeal shock wave lithotripsy Arrange to review the patient in 2 weeks with a KUB x-ray
Arrange to review the patient in 2 weeks with a KUB x-ray
Rate of stone passage Stone size Chances of stone passage 1mm 85% 2-4mm 75% 5-7mm 60%
A 67 year old man presents with recurrent episodes of haematuria, typically at the end of the urinary stream, he has been suffering from occasional fevers and has noticed pus on the urethral meatus on occasion. On examination the prostate has no discernable masses but is tender. What is the most likely cause?
Prostatitis Cystitis BPH Prostate cancer Nephritis
This is most likely prostatitis and the bleeding at the end of micturition suggests a distal problem. Treatment is usually with prolonged courses of antibiotics.
A 22 year old man is involved in a road traffic accident. He is found to have a pelvic fracture. While on the ward the nursing staff report that he is complaining of lower abdominal pain. On examination, you find a distended tender bladder. What is the most likely diagnosis?
Bladder rupture Ureter injury Urethral injury Clot retention Prostate rupture
Pelvic fractures may cause laceration of the urethra. Urinary retention, blood at the urethral meatus and a high riding prostate on digital rectal examination are the typical features.
A 44 year old man is referred to the clinic because of a swelling and discomfort in the right scrotum. This is present most of the time and he is otherwise well with no urinary symptoms. On examination, he has a soft, fluctuant swelling in the right scrotum that transilluminates easily. An ultrasound is performed that confirms that the underlying testicle is structurally normal. What is the best course of action?
Ligation of patent processus vaginalis via inguinal approach Ligation of patent processus vaginalis via a scrotal approach Jaboulay procedure via scrotal approach Lords procedure via inguinal approach Aspiration and injection of sclerosant
Adult hydroceles are less commonly due to the persistence of embryonic remnants and therefore can be managed via a scrotal approach. Both the Lords and Jaboulay procedures are reasonable options. However, only a scrotal approach should be adopted.
Which of the following would be most consistent with a histologically aggressive form of prostate cancer?
FIGO stage 1 disease FIGO stage IV disease EuroQOL score of 5 Gleason score of 2 Gleason score of 10
Prostate cancer is histologically graded using the Gleason score (see below). A score of 10 is consistent with a histologically aggressive form of the disease. The FIGO staging system is used to stage gynaecological malignancy. The EuroQOL score is a quality of life measurement tool.
A 13 month old boy is brought to the paediatric clinic by his mother who is concerned that his testis are not palpable. On examination his testis are not palpable either in the scrotum or inguinal region and cannot be visualised on ultrasound either. What is the most appropriate next stage in management?
Laparoscopy Re-assess at 5 years of age Re-assess at 13 years of age Administration of testosterone Administration of cyproterone acetate
Impalpable testes are an indication for laparoscopy. Ultrasound is a relatively unhelpful tool in evaluating cryptorchid patients and most experienced paediatric surgeons would not use it pre-operatively. They may be associated with an intra-abdominal location. Whilst it is reasonable to defer orchidopexy for retractile testis completely absent testes should be investigated further
A 40 year old male presents with a non painful, bilateral scrotal swellings over 3 years. The swellings are smooth and adherent to the testicular surface. What is the most likely diagnosis?
Epididymal cyst Testicular torsion Haematocele Epididymo-orchitis Hydrocele
Epididymal cyst
The testis is palpated therefore this differentiates it from a hydrocele.
A 34-year-old man from Zimbabwe is admitted with abdominal pain to the Emergency Department. An abdominal x-ray reveals urinary bladder calcification. What is the most likely cause?
Schistosoma mansoni Sarcoidosis Leishmaniasis Tuberculosis Schistosoma haematobium
Schistosomiasis is the most common cause of bladder calcification worldwide. Schistosoma mansoni typically resided in the colon from where it is excreted.
Schistosoma haematobium causes haematuria
A 43 year old female has undergone a renal transplant 12 months previously. Over the past few weeks there have been concerns about deteriorating renal function. What is the most useful investigation?
MAG 3 renogram DMSA scan Intravenous KUB urogram Renal CT scan Micturating cystourethrohram
Because it is excreted by renal tubular cells a MAG 3 renogram provides excellent imaging of renal function and is often used in investigating failing transplants.
A 24 year old man presents with a persistent and unwanted erection that has been present for the previous 6 hours. On examination the penis is rigid and tender. Aspiration of blood from the corpus cavernosa shows dark blood. Which of the following is the most appropriate initial management?
Discharge the patient home and review in 12 hours Admit the patient to hospital and review in 12 hours Aspirate further blood from the corpus cavernosa in an attempt to decompress Use a trucut needle to induce an arteriovenous shunt Administer intracavernosal adrenaline 1 in 500 concentration
Low flow priapism is a urological emergency. Aspiration of bright red blood is more reassuring and may indicate high flow priapism that may be actively monitored. Low flow priapism should be decompressed with aspiration of blood from the corpus cavernosum.
A 68 year old man has a TCC of the bladder. He has a right hydronephrosis detected on ultrasound and deteriorating renal function. A DMSA scan shows a non functioning left kidney. At cystoscopy the ureteric orifice cannot be readily accessed. What is the best course of action?
Insertion of antegrade ureteric stent Insertion of retrograde ureteric stent Cystectomy and ileal conduit Radiotherapy Instillation of intravesical BCG
A TCC occluding the ureteric orifice will obscure its identification during surgery, so that passage of a retrograde stent is difficult. Therefore passage of a stent from the renal pelvis is preferable.
A 16 year old boy presents with renal colic. His parents both have a similar history of the condition. His urine tests positive for blood. A KUB style x-ray shows a relatively radiodense stone in the region of the mid ureter. What is the most likely composition of the stone?
Calcium phosphate stone Uric acid stone Struvite stone Cystine stone Calcium oxalate stone
Cystine stones are associated with an inherited metabolic disorder.
A 55 year old man has multiple stones within the renal pelvis, including one measuring 25mm in diameter. What is the most appropriate course of action?
Arrange a nephrectomy Arrange a percutaneous nephrolithotomy Arrange for lithotripsy Conservative management Arrange for ureteroscopy and stone extraction
The intervention of choice for renal pelvis stones greater than 20mm is PCNL. This stone is highly unlikely to pass spontaneously and ureteroscopy for a stone of this size would be extremely time-consuming.
A parent brings her 4 year old child to the surgical clinic. She has noticed an intermittent swelling in the right scrotum that is worse in the evening. On examination he has a soft fluctuant swelling in the right scrotum that cannot be separated from the testis. It transilluminates when a pen torch is held against it. What is the best course of action?
Ligation of patent processus vaginalis via inguinal approach Ligation of patent processus vaginalis via a scrotal approach Jaboulay procedure via scrotal approach Lords procedure via scrotal approach Aspiration
In children, a hydrocele is most commonly due to a persistent processus vaginalis. The swelling is intermittent and in most cases that are diagnosed in infancy the hydrocele resolves. Cases that persist beyond two years of age are best managed surgically and the surgical approach is usually made via the inguinal canal where the patent processus is identified and ligated.
A 65 year old man presents with significant lower urinary tract symptoms and is diagnosed as having benign prostatic hyperplasia. Which of the following drug treatments will produce the slowest clinical response?
Tamsulosin Alfuzosin Doxazosin Finasteride Terazosin
Finasteride
Alpha blockers have a faster onset of action (but lower reduction of complications from BPH) than 5 α reductase inhibitors.
5 alpha reductase inhibitors have a more favorable side effect profile than α blockers
Which of the following treatments is not utilized in the treatment of overactive bladder syndrome?
Sacral neuromodulation Botulinum toxin injections Bladder drill Oxybutinin Colposuspension
Overactive bladder syndrome is very common and first line management includes the use of anticholinergics and bladder drill whereby voiding is deferred. Refractory cases can be treated with SNS or botulinum toxin injections. A Burch Colposuspension is used to treat stress urinary incontinence.
A 43 year old lady with episodes of recurrent urinary tract sepsis presents with a staghorn calculus of the left kidney. Her urinary pH is 7.8. A KUB x-ray shows a faint outline of the calculus. What is the most likely stone composition?
Struvite Calcium phosphate Calcium oxalate Uric acid Cystine
Chronic infection with urease producing enzymes can produce an alkaline urine with formation of struvite stone.
A 35-year-old female is admitted to hospital with hypovolaemic shock. CT abdomen reveals a haemorrhagic lesion in the right kidney. Following surgery and biopsy this is shown to be an angiomyolipomata. What is the most likely underlying diagnosis?
Neurofibromatosis Budd-Chiari syndrome Hereditary haemorrhagic telangiectasia Von Hippel-Lindau syndrome Tuberous sclerosis
Tuberous sclerosis (TS) is a genetic condition of autosomal dominant inheritance
Like neurofibromatosis, the majority of features seen in TS are neuro-cutaneous
Also
retinal hamartomas: dense white areas on retina (phakomata)
rhabdomyomas of the heart
gliomatous changes can occur in the brain lesions
polycystic kidneys, renal angiomyolipomata
A 22 year old man is participating in vigorous intercourse and suddenly feels a snap and his penis becomes swollen and painful. The admitting surgeon suspects a penile fracture. Which of the following is the most appropriate initial management?
MRI scan of the penis Immediate surgical exploration CT scan of the penis USS of the penis Cystogram
Suspected penile fractures should be surgically explored and the injury repaired
Which of the following does not cause red urine?
Rifampicin Phosphaturia Beetroot Rhubarb Blackberries
Phosphaturia causes cloudy urine.
A 73 year old man presents with haematuria. Investigations demonstrate a localised, high risk, prostatic cancer. His co-morbidities include COPD and ischaemic heart disease. His staging investigations show no evidence of metastatic disease. What is the best course of action?
Transvesical prostatectomy Radical prostatectomy External beam radiotherapy Chemotherapy alone Chemical orchidectomy
External beam radiotherapy
The co-morbidities of this patient make a surgical approach a less favorable option. Radical radiotherapy offers a more favorable alternative.
From the list below, which drug is known to cause haemorrhagic cystitis?
Rifampicin Methotrexate Dexamethasone Leflunomide Cyclophosphamide
Cyclophosphamide is metabolised into a toxic metabolite acrolein. The effects may be attenuated by administration of large volumes of intravenous fluids and mesna (which neutralises the metabolite). The condition may be managed initially by bladder catheterisation and irrigation.
A 73 year old lady is undergoing chemotherapy for treatment of acute leukaemia. She develops symptoms of renal colic. Her urine tests positive for blood. A KUB x-ray shows no evidence of stones. If a stone were present, what type could it be?
Calcium oxalate stone Calcium phosphate stone Cystine stone Struvite Uric acid stone
Chemotherapy and cell death can increase uric acid levels. In this acute setting the uric acid stones are unlikely to be coated with calcium and will therefore be radiolucent.
Which of the following statements is false in relation to renal adenocarcinoma?
They account for over 75% cases of renal tumours Renal biopsy should be performed in all cases considered for radical nephrectomy They typically spread via the haematogenous route Patients with completely resected T2 disease should not receive adjuvant chemotherapy Partial nephrectomy gives equivalent oncological outcomes in patients with T1 disease
Routine renal biopsy should not be performed in cases for nephrectomy. Most cases of malignancy can be accurately classified on imaging.
A 17 year old man is referred to the urology clinic. As a child he was diagnosed as having a right sided PUJ obstruction. However, he was lost to follow up. Over the past 7 months he has been complaining of recurrent episodes of right loin pain. A CT scan shows considerable renal scarring. What is the most useful investigation?
DMSA scan MAG 3 renogram CT scan of the kidney CT KUB Renal USS
In patients with long standing PUJ obstruction and renal scarring the main diagnostic question is whether the individual has sufficient renal function to consider a pyeloplasty or whether a primary nephrectomy is preferable. Since the CT has demonstrated scarring there is no use in obtaining a DMSA scan. Of the investigations listed both a DMSA and MAG 3 renogram will allow assessment of renal function. However, MAG 3 is superior in the assessment of renal function in damaged kidneys (as it is subjected to tubular secretion).
A 72 year old man presents with lower urinary tract symptoms. On digital rectal examination, benign prostatic hyperplasia is suspected. Which of the following treatments is associated with a reduction in the risk of urinary retention?
Alfuzosin Finasteride Prazosin Tamsulosin Terazosin
5 alpha reductase inhibitors reduce the risk of urinary retention.
In the PLESS study, data show a reduction in the risk of urinary retention although the absolute risk reduction was small.
A 22 year old man is involved in a road traffic accident. He is found to have a pelvic fracture. While on the ward the nursing staff report that he is complaining of lower abdominal pain. On examination, you find a distended tender bladder. What is the best management?
10 Ch foley urethral catheter Suprapubic catheter 16 Ch foley urethral catheter 18 Ch coude tip urethral catheter Pain relief and review in 1 hour
This patient has possible urethral injury based on the history. Urethral catheterisation is contraindicated in this situation.
Which of the following procedures represents the optimal operative procedure for testicular cancer?
Lords procedure Orchidectomy via a scrotal approach Orchidectomy via inguinal approach Orchidectomy via a combined inguino-scrotal approach None of the above
Testicular tumours metastasise to Para aortic nodes and thus an inguinal rather than scrotal approach should be used. There are two main operations that are termed Lords procedure; one is for fissure in ano and the other is a procedure for hydrocele.
A 56 year old lady reports incontinence mainly when walking the dog. A bladder diary is inconclusive. What is the most appropriate investigation?
Intravenous urography Urodynamic studies Flexible cystoscopy Micturating cystourethrogram Rigid cystoscopy
Urodynamic studies are indicated when there is diagnostic uncertainty or plans for surgery.
A 55 year old man presents with an episode of frank haematuria and on investigation is found to have a T2 transitional cell carcinoma of the bladder. His staging investigations are negative for metastatic disease. What is the most appropriate treatment?
Radical cystectomy Palliative radiotherapy Intravesical BCG Intravesical mitomycin C Intravesical cisplatin
T2 lesions in a young fit patient are best managed surgically. Up to 25 % patients may develop perioperative complications. However, palliative treatments and intravesical chemotherapy (which does NOT include cisplatin) are not used curatively in this situation.
A 56 year old man is admitted with severe loin to groin pain associated with haematuria. He was well until 1 week ago when he was unwell with diarrhoea and vomiting. What is the most likely cause?
Ureteric calculus Renal cancer Pyelonephritis Prostatitis Prostate cancer
Ureteric stones may develop in a background of dehydration.
A 73 year old man has previously undergone a prostatectomy to treat prostate cancer. On review, his PSA has risen to 55 and he has developed pain in his lower back. Imaging shows osteosclerotic lesions in L4 and L3. What is the best treatment strategy?
Posterior spinal fusion Vertebral body reconstruction Bisphosphonates and radiotherapy Androgen suppression, bisphosphonates and radiotherapy Radiotherapy alone
In men with metastatic bone lesions from prostate cancer, the best outcomes are achieved with androgen suppression. Radiotherapy can also produced marked palliation. A 2010 Cochrane review has clearly demonstrated added benefit, in terms of symptom control, from the addition of a bisphosphonate.
A 25 year old man is admitted with left sided loin pain that radiates to his groin. His investigations demonstrate a 9mm left sided calculus within the proximal ureter. His renal function is normal. What is the most appropriate course of action?
Arrange a percutaneous nephrolithotomy Arrange extra corporeal shock wave lithotripsy Review the patient in 4 weeks with KUB x-ray on arrival Arrange for ureteroscopy and stent insertion Arrange for open ureteric stone extraction
For ureteric stones with a maximum diameter of less than 10mm the first-line treatment is extracorporeal shock wave lithotripsy (ESWL). If ESWL fails or if the stone is impacted in the upper ureter then ureteroscopy can be performed.
A 56 year old man is admitted with acute retention of urine. He has had a recent urinary tract infection. An USS shows bilateral hydronephrosis. What is the best course of action?
Antegrade ureteric stents Retrograde ureteric stents Urethral catheter Bilateral nephrostomy Suprapubic catheter
Establishing bladder drainage will often correct the situation. These patients often have a significant diuresis with associated electrolyte disturbance. The urethral route should be tried first.
A 32 year old male presents with a swollen, painful right scrotum after being kicked in the groin area 1 hour ago. There is a painful swelling of the right scrotum and the underlying testis cannot be easily palpated. What is the most likely explanation?
Hydrocele Haematocele Epididymo-orchitis Orchitis Epididymal cyst
Acute haematocele: tense, tender and non transilluminating mass post trauma. A chronic haematoma causes a blood clot to surround the testis. The blood clot hardens and contracts causing a hard mass which may be indistinguishable from a tumour. Therefore the testis will need surgical exploration.
A 47-year-old woman presents with loin pain and haematuria. Urine dipstick demonstrates:
Blood ++++
Nitrites POS
Leucocytes +++
Protein ++
Urine culture shows a Proteus infection. An x-ray demonstrates a stag-horn calculus in the left renal pelvis. What is the most likely composition of the renal stone?
Xanthine Calcium oxalate Struvite Cystine Urate
Stag-horn calculi are composed of struvite and form in alkaline urine (ammonia producing bacteria therefore predispose)
Renal stones on x-ray
cystine stones: semi-opaque
urate + xanthine stones: radio-lucent
