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
