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Flashcards in Urology II Deck (43):
1

Which of the following has been shown to increase the risk of prostate cancer?
(Please select 1 option)
Caucasian race
Exposure to cadmium
Family history of colon cancer
Low intake of animal fats
Occupational exposure to dust

Cadmium
Black ethnicity is associated with a higher risk of prostate cancer than Caucasian.

A family history of breast cancer increases the risk of prostate cancer as does a family history of prostate cancer.

An occupation in farming also seems to increase the risk of prostate cancer.

High intake of animal fats and low selenium intake as well as exposure to radiation and cadmium all increase the risk of prostate cancer.

2

A 56-year-old male who has presented with chest pain, has a PSA of 45 ng/ml (normal s management?
(Please select 1 option)
An elevated PSA is a definitive test for prostate cancer
High selenium intake is related to prostate cancer
Prostate cancer is more aggressive with increasing age
Prostate cancer is typically squamous call carcinoma
The most commonly used pathological grading system is the Gleason score

The most commonly used pathological grading system is the Gleason score CorrectCorrect
Prostate-specific antigen (PSA) may be elevated in

Prostatitis
Benign prostatic hyperplasia
Prostate cancer.
As a rule, prostate cancer is more aggressive in younger men.

Prostate cancer is an adenocarcinoma.

The Gleason score is recommended by the American College of Pathologists.

The most well differentiated tumours have a Gleason score of 2, and the most poorly differentiated a Gleason score of 10.

High intake of animal fats is related to prostate cancer as well as low intake of selenium.

3

A 56-year-old male presents with pain in the lower back.
The pain has a girdle-like distribution beginning in the lower back and radiating to the lower abdomen. He has not been on any drugs.
The patient is hypertensive but there are no other physical signs of note. Investigations reveal a normocytic normochromic anaemia, raised erythrocyte sedimentation rate and C reactive protein. Renal function is impaired. Ultrasound scanning reveals bilateral hydronephrosis.
Which of the following investigations is most likely to give you the diagnosis?
(Please select 1 option)
Computerised tomogram of abdomen
Intravenous urogram
Isotope renogram
Renal biopsy
Retrograde urogram

CT abdo

The patient has idiopathic retroperitoneal fibrosis (peri-aortitis).

This is a condition in which the ureters become embedded in dense fibrous tissue usually at the junction of the middle and lower thirds of the ureters. This results in unilateral or bilateral ureteric obstruction.

CT scanning will show a peri-aortic mass.

Histological confirmation is obtained by CT guided biopsy or laparotomy.

4

A 15-year-old boy presents with acute left testicular pain. He is not sexually active.
On examination the scrotum appears normal but he has a tender, swollen left testis. Right testis appears normal.
What is the most likely diagnosis?
(Please select 1 option)
Acute epididymitis
Mumps orchitis
Ruptured epididymal cyst
Testicular neoplasm
Testicular torsion

Testicular torsion This is the correct answerThis is the correct answer
The features of acute testicular pain suggest testicular torsion and should prompt surgical referral.

Torsion: acute pain and swelling of testis, with absent cremasteric reflex.

Epididimitis: acute pain and swelling. Rare before puberty, and commoner in sexually active.

5

A 23-year-old man with a teratoma of the testis attended for review following chemotherapy.
Which one of the following serum tumour markers is of most value in monitoring the clinical progression of his disease?
(Please select 1 option)
Alpha-fetoprotein
Carbohydrate antigen CA 15-3
Carbohydrate antigen CA 19-9
Carbohydrate antigen CA 125
Carcinoembryonic antigen

AFP
Alpha-fetoprotein (AFP), beta-hCG and PLAP (placental like isoenzyme of alkaline phosphatase) are the major tumour markers in use for the monitoring of testicular teratoma.

CA 125 is a tumour marker used for ovarian tumours.

CA 15-3 is a tumour marker for breast carcinoma, and CA 19-9 is used in pancreatic tumours.

Carcinoembryonic antigen (CEA) is a marker for colonic tumours.

6

Which one of the following is true of undescended testes?
(Please select 1 option)
25% of undescended testes descend in the first year of life
Is associated with a reduced risk of testicular malignancy
Is associated with normal fertility
Laparoscopy is indicated for impalpable testes
Surgery should be considered in the neonatal period

Laparoscopy is indicated for impalpable testes

Undescended testes affect 3% of full-term boys. However, the majority of these lie in the inguinal canal and approximately 75% of undescended testes descend into the scrotum during the first year of life.

Undescended testes are associated with an increased risk of testicular malignancy which develops in 5% of intra-abdominal testes.

Overall, 80% of males with bilateral descended testes are fertile but only 30% of men with bilateral undescended testes have normal fertility.

Surgery should be performed at 12-18 months of age.

Boys with an undescended but palpable testis should undergo a routine orchidopexy.

Impalpable testes should be assessed with laparoscopy

7

A 28-year-old male presents with a small painless lump in his left testis. On examination the lump lies within the testes and does not transilluminate.

Neoplasm of the testes
Testicular tumours are the most common in males between the age of 20-40. In 80% of cases the patient notices a painless lump in one testis, or that one testis is larger than the other.

8

A 32-year-old male presents with pain in his left testis. On examination his left testicle is red tender and swollen. Prehn's sign is positive.

Acute epididymitis
Neoplasm of the testes
Testicular tumours are the most common in males between the age of 20-40. In 80% of cases the patient notices a painless lump in one testis, or that one testis is larger than the other.

9

A 25-year-old army officer presents with a discomfort of his left testicle. On examination his testicle feels like a bag of worms with a cough impulse.

Varicocele of the testes
A varicocele is a dilation of the pampiniform venous plexus and the internal spermatic vein.

10



A 14-year-old boy presents with severe pain in his right testicle. On examination the testis is tender and high in the scrotum. Prehn's sign is negative

Torsion of the testes
Torsion of the testes is a surgical emergency and typically presents with severe painful, swollen and tender testes. Prehn's sign distinguishes between bacterial epididymitis and testicular torsion. Scrotal elevation relieves pain in epididymitis but not torsion.

11

A 58-year-old gentleman presents with vomiting and anorexia of six days duration. He has had a right nephrectomy for chronic pyelonephritis two years ago and now suffers from recurrent left renal calculi. His urea is 27 mmol/l and creatinine 456 µmol/l.

Normal ranges are:
Urea 3-8 mmol/l
Creatinine 50-110 µmol/l
ESR 1-10 mm/hr

ARF
This patient has developed acute renal failure secondary to obstruction due to renal calculi (since he has got only one kidney). It is essential to exclude obstruction as the cause for acute renal failure particularly in patients with a solitary kidney. The obstruction needs to be relieved either surgically (neprostomy/ extracorporeal shock wave lithotripsy) or radiologically (percutaneous) depending on the level and type of calculi, and the patient's general health.

12

Normal ranges are:
Urea 3-8 mmol/l
Creatinine 50-110 µmol/l
ESR 1-10 mm/hr
38-year-old gentleman of Pakistani origin complains of increased urinary frequency, haematuria and evening pyrexia. His ESR is 98 mm/hr but routine urine culture is negative.

Renal tuberculosis
Renal tuberculosis usually occurs between the ages of 20 and 40, and is more common in men. Urinary frequency is often the earliest symptom. The urine shows sterile pyuria and urine culture is negative. Haematuria is present in 5% of cases. Constitutional symptoms such as weight loss and evening pyrexia are common. ESR may be raised. The patient may have other symptoms such as cough, haemoptysis suggestive of lung involvement or symptoms of intestinal tuberculosis.

13

Normal ranges are:
Urea 3-8 mmol/l
Creatinine 50-110 µmol/l
ESR 1-10 mm/hr
A 65-year-old man undergoes nephrostomy to relieve hydronephrosis of his left kidney. Four hours post-operatively he develops rigors, pyrexia and his blood pressure is 100/60 mmHg. Investigations show a urea of 28 mmol/l and a creatinine of 330 µmol/l.

Gram negative sepsis
This patient has developed Gram negative sepsis due to instrumentation of the renal tract. The common organisms include Escherichia coli, coliforms, and Bacteroides. Prophylaxis with an aminoglycoside such as gentamicin is usually recommended before surgery or instrumentation of the renal tract.

14

A 73-year-old man presents to the surgical outpatient clinic with a three month history of difficulty in passing urine. On further questioning, he states that he wakes up frequently at night to pass urine but has difficulty in voiding or in maintaining the stream.

After baseline investigations, he is referred to the urologists who make a diagnosis of carcinoma of the prostate. He does not have any local or regional metastasis. He undergoes a transurethral resection of prostate and makes an uneventful post-operative recovery.

Assuming he remains symptom-free for the next five years, what is the most appropriate investigation to follow up this patient's condition?
From the options below choose the one that you think is the most appropriate answer:
(Please select 1 option)
Bone scan
Computerised topographic scan
Magnetic resonance imaging
Prostate specific antigen level
Transrectal ultrasonography

PSA

The prostate specific antigen (PSA) level will be the most appropriate investigation in this patient since it is an excellent marker in the follow up of patients with established prostate cancer.

PSA is an enzyme produced by the prostate. Its normal function is to liquefy gelatinous semen after ejaculation, thus allowing the spermatozoa more easily to navigate through the cervix. PSA levels less than 4 ng/mL are generally considered normal; however, an age-specific PSA reference range level is widely used.

Transrectal ultrasonography may be used in the diagnosis of carcinoma prostate but has no role in the follow up of the disease.

CT scan may be used for staging of the disease and not for prognostic purposes.

Bone scan is indicated in patients with suspected bone metastasis and again not used as a prognostic marker.

15

A 13-year-old boy presents with a three hour history of right testicular pain. Urinalysis does not reveal any abnormality. On clinical examination he is tender over the superior pole of the right testis and a black spot is visible through the scrotal skin.

Torted appendix testis
The appendix testis may undergo torsion and mimic the presentation of testicular torsion. It usually presents in boys under the age of 16 but can occur in adults. There is acute testicular pain, confined to the upper pole of the testis. There may be a black spot visible through the scrotal skin which suggests this diagnosis. Where there is any doubt the testicle should be explored, if a firm diagnosis can be made the patient can be treated with rest and analgesia and the pain will subside in five to seven days.

16

A 22-year-old man presents with a two day history of left testicular pain and swelling. Urinalysis reveals leucocytes, blood and nitrites. On examination he has a swollen erythematous scrotum, the testis is non-tender, the epididymis is swollen and exquisitely tender.

Epididymitis
Epididymitis usually occurs in young and middle aged men. There is often a history of lower urinary tract symptoms preceding the testicular pain, urinalysis may show pyuria / nitrites, the scrotal skin may be oedematous and red, there may be a secondary hydrocele and careful examination of the affected side may reveal tenderness confined to a swollen epididymis.

17

A 21-year-old man presents with a two hour history of severe right testicular pain and swelling. Urinalysis does not reveal any abnormality. On examination his scrotum is swollen and erythematous, his testis is high in the scrotum and exquisitely tender.

Testicular torsion
Testicular torsion most commonly affects adolescent males presenting with severe testicular pain. The overlying skin may be red and oedematous as in epididymitis. The testis is high in the scrotum and the testis and cord cannot be identified as separate structures. Immediate exploration is indicated in all acute presentations with testicular pain where torsion cannot confidently be excluded.

18

Which of the following is correct concerning undescended testes?
(Please select 1 option)
Are commonly associated with a direct inguinal hernia
Are located in the abdomen in 50% of cases
Detected at one year of age have a 50% chance of spontaneously completing their descent by 5 years
Surgically relocated in the scrotum before puberty have a reduced risk of subsequent malignancy compared with no surgical relocation
Which occupy an ectopic site are usually of a reduced prepubertal size

Surgically relocated in the scrotum before puberty have a reduced risk of subsequent malignancy compared with no surgical relocation

Failure to find one or both testes in the scrotum may indicate any variety of congenital or acquired conditions, for example, ectopic testes, maldescended testes, retractile or absent testes.

Maldescended or ectopic testes and true undescended testicles are differentiated from each other surgically.

The ectopic testis has completed its descent through the inguinal canal but ends up in a subcutaneous location. Spontaneous testicular descent does not occur after the age of 1 year. Complications include infertility in adulthood, associated hernias and torsion and tumour development in the affected testis.

The patient with cryptorchidism has a 20-40% chance of developing malignancy, and those most at risk are those untreated or those whose surgery was carried out during or after puberty.

19

Which of the following is the correct advice to a mother who is concerned because she cannot retract the prepuce of her two year old son?
(Please select 1 option)
Circumcision is indicated
He is likely to get recurrent balanitis
Regular retraction of the prepuce during bathing
This is a completely normal condition at this age
Urethral valves are well known association and further investigations are required

This is a completely normal condition at this age

This question relates to the natural history of the foreskin. The foreskin is still developing at birth and hence is often non-retractable up to the age of 3 years.

The process of separation is spontaneous and does not require manipulation.

By the age of 3 years 90% of boys will have a retractable foreskin. In a small proportion of boys this natural process of separation continues well into childhood.

20

The right ureter lies in close relationship to which of the following?
(Please select 1 option)
Bifurcation of the aorta
Inferior mesenteric artery
Infundibulopelvic ligament
Median sacral artery
Parietal attachment of the sigmoid mesocolon

Infundibulopelvic ligament

At its origin the right ureter is usually covered by the descending part of the duodenum, and, in its course downward, lies to the right of the inferior vena cava, and is crossed by the right colic and ileocolic vessels.

Near the superior aperture of the pelvis it passes behind the lower part of the mesentery and the terminal part of the ileum. The left ureter is crossed by the left colic vessels, and near the superior aperture of the pelvis passes behind the sigmoid colon and its mesentery.

The ureter forms, as it lies in relation to the wall of the pelvis, the posterior boundary of a shallow depression named the ovarian fossa, in which the ovary is situated.

It then runs medialward and forward on the lateral aspect of the cervix uteri and upper part of the vagina to reach the fundus of the bladder.

In this part of its course it is accompanied for about 2.5 cm by the uterine artery, which then crosses in front of the ureter and ascends between the two layers of the broad ligament. The ureter is distant about 2 cm from the side of the cervix of the uterus.

The ureter is sometimes duplicated on one or both sides, and the two tubes may remain distinct as far as the fundus of the bladder. On rare occasions they open separately into the bladder cavity.

21

Which of the following is correct concerning the urinary bladder?
(Please select 1 option)
Has a venous plexus draining to the external iliac veins
Has an epithelium derived from the ectoderm
Is related superomedially to the levator ani muscle
Is separated from the symphysis pubis by a fold of peritoneum
Is situated in the abdomen of the young child

Is situated in the abdomen of the young child This is the correct answerThis is the correct answer
The bladder is derived from two sources, the cloaca and mesonephric ducts. The primitive cloaca is divided by the urorectal septum into the urogenital sinus and rectum.

The bladder largely develops from the vesicle part of the urogenital sinus.

The mesonephric ducts are drawn into the floor of the bladder as it expands, to form the trigone.

The epithelium is derived from the endoderm of the urogenital sinus, whereas the ureter and pelvis epithelium are derived from mesoderm.

Venous drain is to the internal iliac veins.

The vertex is directed forward towards the upper part of the symphysis pubis (fascial separation), and from it the middle umbilical ligament continues upward on the back of the anterior abdominal wall to the umbilicus.

The peritoneum is carried by it from the vertex of the bladder on to the abdominal wall to form the middle umbilical fold.

22

During the development of the urinary system, which of the following is true?
(Please select 1 option)
Fundus of the bladder is derived from the mesonephric ducts
Hilum of the metanephros faces posteriorly
Mesonephros completely disappears
Metanephros becomes functional at birth
Ureteric bud gives rise to the collecting tubules of the metanephros

Ureteric bud gives rise to the collecting tubules of the metanephros This is the correct answerThis is the correct answer
The kidneys, urinary tract and the majority of the reproductive organs arise in the intermediate mesoderm between the somites and the lateral plate.

The kidney goes through three stages of development that recapitulate evolution of the kidney:

pronephros
mesonephros
metanephros.
In the majority of vertebrates the pronephros becomes atrophic early in their embryonic life. The mesonephros becomes replaced by the metanephros.

In adult humans remnant mesonephric tissues are a source of cysts and tumors.

The metanpehros is responsible for the formation of the majority of the urogenital system and is functional well before birth.

23

Which of the following is true regarding undescended testis?
(Please select 1 option)
In the inguinal canal cannot undergo torsion
Is often associated with a hernia
Is present in 5% of the male population at 6 months of age
The risk of malignancy is not significantly increased
The testes and epididymis are usually not affected

Hernia

Failure to find one or both testes in the scrotum may indicate any variety of congenital or acquired conditions, for example:

Ectopic testes
Maldescended testes, and
Retractile or absent testes.
4.5% of males have an undescended testis at birth, falling to 0.8% by six months.

Maldescended or ectopic testes and true undescended testicles are differentiated from each other surgically.

The ectopic testis has completed its descent through the inguinal canal but ends up in a subcutaneous location. Spontaneous testicular descent does not occur after the age of one year.

Complications include infertility in adulthood, associated hernias and torsion and tumour development in the affected testis (if not operated on before 11 years).

The patient with cryptorchidism has a 20-40% chance of developing malignancy, and those most at risk are those untreated or those whose surgery was carried out during or after puberty.

24

Which of the following is correct regarding the female urethra?
(Please select 1 option)
Corresponds developmentally to the prostatic urethra in the male
Has a muscular layer continuous with that of the bladder
Has an external sphincter supplied by the obturator nerve
Is embedded in the posterior wall of the vagina
Is lined throughout by transitional epithelium

Has a muscular layer continuous with that of the bladder

The female urethra is a narrow membranous canal, about 4 cm long, extending from the internal to the external urethral orifice.

It is placed behind the symphysis pubis, embedded in the anterior wall of the vagina, and its direction is obliquely downward and forward; it is slightly curved with the concavity directed forward.

Its lining is composed of stratified squamous epithelium, which becomes transitional near the bladder.

The urethra consists of three coats:

Muscular
Erectile, and
Mucous
The muscular layer is a continuation of that of the bladder.

Between the superior and inferior fascia of the urogenital diaphragm, the female urethra is surrounded by the sphincter urethrae.

Somatic innervation of the external urethral sphincter is supplied by the pudendal nerve.

The uro-genital sinus may be divided into three component parts. The first of these is the cranial portion which is continuous with the allantois and forms the bladder proper. The pelvic part of the sinus forms the prostatic urethra and epithelium as well as the membranous urethra and bulbo urethral glands in the male and the membranous urethra and part of the vagina in females.

25

Which of the following is not a recognised complication of circumcision?
(Please select 1 option)
Bleeding
Damage to the glans
Delayed healing
Orchitis
Pain

Orchitis

The post-operative complications following circumcision is estimated to be between 2-10%. The most common complication is pain, bleeding and infection. Damage to the glans may not become apparent until the child grows into adulthood and results from excessive skin removal or scarring.

26

A 9-month-old boy presents with an acute scrotal swelling.
What is the most likely diagnosis?
(Please select 1 option)
Acute idiopathic scrotal oedema
Epididymitis
Irreducible inguinal hernia
Orchitis
Torsion of the testicular appendage

Irreducible inguinal hernia

With any acute swollen scrotum the fear is of torsion of testis. This is uncommon in the neonate and is much commoner around puberty. Presentation is with a hard tender testis and spermatic cord -/+ a red scrotum.

Torsion of the appendage of testis has a peak incidence of between 4 and 8 years of age as does acute idiopathic scrotal oedema. In the former, there is a tender upper pole of testis with a blue spot on transillumination. In the latter the erythema extends beyond the scrotum and the testis is minimally tender.

Epididymitis is rare before puberty, and presents with a tender epididymus (urological investigations are needed, as it is associated with reflux of infected urine via the vas deferens).

Inguinal herniae that are irreducible have a peak incidence below 2 years of age. A firm immobile tender swelling is found in the scrotum, which becomes inflamed as the strangulation occurs. Occasionally, acute hydroceles can also present with a mobile blue transilluminating swelling at 1-3 years of age.

27

Which of the following investigations is useful in locating an ectopic testis?
(Please select 1 option)
Abdominal x ray
Chromosomes
Radionucleotide scan
Testosterone response to HCG
Ultrasound scan

Ultrasound scan This is the correct answerThis is the correct answer
If the testis is ectopic then it may be palpable outside the normal line of descent. However in obese boys ultrasound may be useful in identifying its location.

Radionucleotide scans and x rays should be avoided and hormonal testing may be useful in cases of bilateral impalpable testes to detect the presence of testicular tissue within the body.

Laparoscopy is the investigation of choice if the testes are impalpable to determine whether they are absent or intra-abdominal.

28

Which of the following statements is true regarding inguinal hernias in children?
(Please select 1 option)
50% of hernias are bilateral
Approximately 50% of patients will develop a contralateral hernia
Are less common in preterm infants
Girls are affected more often than boys
In infants under one year approximately 50% present with incarceration

In infants under one year approximately 50% present with incarceration This is the correct answerThis is the correct answer
Inguinal hernias are the commonest surgical condition of childhood. Approximately 2% of male infants will develop an inguinal hernia and 99% will be indirect.

The male:female ratio is 9:1.

Inguinal hernias are more common on the right and 10% are bilateral.

Prematurity is a significant risk factor.

The risk of incarceration is increased in infants and therefore a hernia presenting before one year of age requires urgent surgical assessment.

Approximately 20% will develop a contralateral hernia. The role of contralateral groin exploration at the time of a unilateral herniotomy is controversial.

29

Which of the following statements is correct regarding testicular torsion?
(Please select 1 option)
Always presents with abdominal pain and vomiting and few testicular symptoms
Occurs frequently in neonates
Requires contralateral orchidopexy if a torsion is confirmed
Requires scanning with Doppler ultrasound or isotope scanning
Viability is reduced if surgery is delayed by more than 24 hours

Requires contralateral orchidopexy if a torsion is confirmed

The commonest causes of the 'acute scrotum' in childhood are testicular torsion, torsion of an appendix testis and idiopathic scrotal oedema.

Testicular torsion can occur at any age with a peak incidence between 14 and 20 years. It usually presents with severe testicular pain but this may be absent and the testis should be examined in all boys with abdominal symptoms.

If torsion is clinically suspected then radiological investigations have little to offer. None are diagnostic and may delay surgery. Testicular viability is reduced with increasing time from the onset of symptoms.

Following reduction of a torsion, 3-point fixation with an non-absorbable suture should be performed. The contralateral testis should also be fixed.

30

On physical examination, the right testis of an 18-month-old boy is not in the scrotum.
Which of the following is true?
(Please select 1 option)
An inguinal hernia is unlikely to occur with testicular maldescent
If the right testis is palpable, no surgical procedure would be required
Orchidopexy should be performed when the patient is about six years old
The maldescended right testis is often palpable in the groin
The most likely cause is an ectopic testis

The maldescended right testis is often palpable in the groin

By 18 months the testicles should have descended. If they are not in the scrotum it is important to determine whether they are undescended, retractile and ectopic or absent.

The maldescended testicle is often palpable in the groin and is often associated with indirect inguinal hernias.

Orchidopexy needs to be carried out in the second year of life to minimise the risk of complications. Depending on the location of the testicle, surgery may or may not be required.

If the testicle is considered to be retractile the patient needs to be monitored, and if maldescended, orchidopexy is required.

31

A 6-month-old boy develops a small right scrotal swelling.
Which of the following is true?
(Please select 1 option)
An important cause for inguinal hernia in children is muscle weakness
An operation is required for an inguinal hernia
Hydrocele is more common on the right side, whereas inguinal hernia is more common on the left
Swelling due to a hydrocele should always be surgically corrected
The operation for an inguinal hernia in children is inguinal herniorrhaphy

An operation is required for an inguinal hernia

A hydrocele is an accumulation of fluid in the tunica vaginalis. Small hydroceles tend to disappear spontaneously by the age of 1 year. Larger ones may need surgical correction.

When the amount of fluid varies there is communication with the peritoneal cavity and these hydroceles need to be treated as indirect inguinal hernias. The treatment for inguinal hernias is called a herniotomy. This is the excision of the hernial sac.

A herniorrhaphy is carried out in addition to herniotomy in older patients and involves the repair of the posterior weak muscle wall.

In adults muscle weakness is an important cause for the development of hernias, however in children they form during embryology.

Testes descend into the scrotum during the seventh month of gestation. They are preceded by processus vaginalis - an outpouching of peritoneum. This obliterates before birth, and failure to do so results in inguinal hernia, hydrocele of the cord or hydrocele.

32

Bladder irrigation with glycine solution following transurethral resection of the prostate (TURP) may lead to which of the following?
(Please select 1 option)
Cerebral oedema
Hypernatraemia
Hypotension and bradycardia
Increased osmolality of the plasma
Increased total body sodium

Cerebral oedema

Bladder irrigation with glycine can result in acute hyponatraemia, the so called TURP syndrome, which may precipitate cerebral oedema, and in turn result in relative hypotension with a bradycardia.

33

Which of the following is true regarding benign prostatic hyperplasia (BPH)?
(Please select 1 option)
Can be treated with 5-alpha-reductase-inhibitors
Causes a normal serum PSA
Incidence is increased in males castrated before puberty
Mainly affects the peripheral zone
Symptoms improve with oxybutynin

Can be treated with 5-alpha-reductase-inhibitor

BPH mainly affects the inner transitional zone. The outer peripheral zone is usually compressed and feels smooth to digital rectal examination.

Any palpable nodule or irregularity should raise the possibility of malignancy. BPH seems to be an androgen-driven disease.

Castration prior to puberty seems to prevent the disease.

Alpha-blockers cause relaxation of smooth muscles and improve symptoms, whereas anticholinergic drugs could worsen symptoms and precipitate acute urinary retention.

34

Painless haematuria is a characteristic feature of which of the following?
(Please select 1 option)
Acute glomerulonephritis
Endometriosis
Interstitial cystitis
Schistosoma haematobium infection
Squamous cell carcinoma of the bladder

Schistosoma haematobium infection

Painless haematuria is typical of bladder transitional cell carcinoma, not squamous cell carcinoma.

Schistosomiasis is a tropical disease caused by a worm. It typically presents with frequency and painless haematuria.

35

An otherwise healthy woman of 30 has a second attack of renal colic in two years and passes a stone.
Blood urea is normal.
Which one of the following investigations is indicated?
(Please select 1 option)
Culture of the urine
Renal biopsy
Serum amino-acid chromatography
Serum phosphate concentration
x Ray of the hands

Urine culture

Further investigation of young patients with a second episode of renal colic is recommended.

Clearly urine culture is an important investigation to exclude concurrent infection, and infection associated with stone formation.

x Ray of hands is really not required, nor is renal biopsy.

A urinary amino-acid chromatography and plasma calcium are also important, and assessment for cystinuria/renal tubular acidosis is also required.

36

Which of the following is true regarding priapism?
(Please select 1 option)
A peak systolic velocity of 1 m/s in the cavernosal arteries is normal
Has an association with diabetes mellitus in most cases
Poorly oxygenated blood within the corpora cavernosa is indicative of low flow (veno-occlusive) priapism
Results more commonly from high flow form rather than the veno-occlusive form
The treatment of choice for arterial priapism is intracavernous administration of alpha-adrenergic agonists

Poorly oxygenated blood within the corpora cavernosa is indicative of low flow (veno-occlusive) priapism

The peak systolic velocity in the cavernosal arteries is normally less than 0.4 m/s. A higher flow in the presence of priapism is indicative of high-flow (arterial) priapism.

Priapism is primary or idiopathic in 60% of cases.

Twenty per cent of secondary priapism cases are haematologic in origin, for example:

Sickle cell disease
Leukaemia, and
Heparin therapy.
Other causes are:

Neurogenic
Traumatic, and
Infectious.
On the basis of aetiology, priapism can be broadly divided into low flow (veno-occlusive) and high flow (arterial) varieties.

The former involves a physiologic or mechanical obstruction to venous drainage of the penis which causes a build-up of viscous, poorly oxygenated blood within the corpora cavernosa. The origin of priapism in these cases may be secondary to multiple areas of sludging and thrombosis.

The major causes of veno-occlusive priapism are:

Complication of sickle cell disease
Haematopoietic malignancy, and
A hypercoagulable state.
Arterial (high-flow) priapism is a physiologically distinct entity which is markedly less common than the veno-occlusive form. Arterial priapism results from unregulated inflow of arterial blood into the lacunar spaces of the corpora cavernosa from a lacerated cavernous artery, bypassing regulatory function of helicine arterioles.

Aetiology of increased arterial inflow may be:

Secondary to arteriovenous fistula
Frank arterial laceration with extravasation, and
A pseudoaneurysm.
Although most cases of high flow priapism are secondary to blunt or penetrating trauma to the perineum or penis, a large majority of cases - especially in adults - may be idiopathic, without history of pertinent trauma or findings of anatomic abnormalities.

Arterial priapism may be treated with arterial ligation or percutaneous embolisation. Other therapeutic modalities, such as sustained perineal compression and ice packs, or intracavernous administration of alpha-adrenergic agonists have proven to be less effective.

37

Which of the following is true of prostate specific antigen?

Proteolytic enzyme

PSA is a serine proteinase, a proteinolytic enzyme that is produced by the epithelial cells of the prostate and is involved in the liquefaction of the seminal fluid.

Small concentrations may be found in the blood and these may occur due to absorption across the prostate and urethral epithelium particularly following ejaculation. Hence the recommendation is to avoid measuring PSA for two days after ejaculation.

It does not appear to have any detrimental effect when released into the blood.

Levels can rise following manipulation but evidence would indicate that there is no or just a small rise after rectal examination. However, levels may rise after more direct manipulation such as catheterisation or cystoscopy.

38

Which of the following is true concerning transitional cell cancer (TCC) of the urinary bladder?
(Please select 1 option)
Causing ureteric obstruction is usually non-invasive
Following complete resection requires no surveillance
Is most common in non-smokers
Occupational history may be of relevance
Rarely presents with haematuria

Occupational history may be of relevance

Haematuria is the commonest presenting feature in TCC and TCC is found in approximately 20% of patients presenting with frank haematuria.

It is strongly associated with cigarette smoking and occupational exposure to certain chemicals (for example, â-napthalamine) greatly increases the risk of TCC.

Ureteric obstruction, when present, is usually in the presence of an invasive TCC.

TCC recurs frequently and in a proportion of patients will progress.

Cystoscopic surveillance is carried out on all patients following a diagnosis of TCC.

39

Medical indications for circumcision in children include which of the following?
(Please select 1 option)
Ambiguous genitalia
Cryptorchidism
Hypospadias
Non-retractile foreskin in a 5-year-old child
Recurrent balanitis

Recurrent balanitis This is the correct answerThis is the correct answer
Circumcision is contraindicated in hypospadiasis since the tissue of the foreskin may be required for urethral reconstruction.

Circumcision should be considered in the setting of recurrent urinary tract infections and particularly balanitis.

The foreskin would not necessarily be retractable at aged 5.

40

Which of the following is true regarding adenocarcinoma of the kidney?
(Please select 1 option)
Can lead to polycythaemia
Have an abdominal mass palpable in about 90% of cases
Is more common in infants and young children
Pain is usually the presenting symptom
Present with a right varicocele

Can lead to polycythaemia

Adenocarcinoma (hypernephroma), arising from renal tubular cells, is the most common neoplasm of the kidney (75%).

It is more prevalent in patients over 40 years of age and affects more males than females (2:1).

Haematuria with occasional clot colic is the usual presenting symptom. A dragging discomfort in the loin is felt in a significant proportion of the patients. An abdominal mass is palpable in only about 25-45% of the cases.

In men, a rapidly developing varicocele (most often on the left) is a rare but impressive sign. This is because the left testicular vein drains into the left renal vein, whilst the right testicular vein drains directly into the inferior vena cava.

Polycythaemia occurs in about 4% of cases as a result of erythropoietin production by tumour cells.

The other symptoms (features) or presentations include

Pyrexia
Hypertension
Hypercalcaemia and
Nephrotic syndrome.

41

Which of the following is correct in hypospadias?
(Please select 1 option)
A chordee is usually present
Circumcision should be performed to minimise the risk of urinary tract infection
Surgery should be undertaken around puberty when penile growth is complete
The defect occurs on the dorsum of the penis in 65% of cases
The incidence is approximately 0.3% of male infants

The incidence is approximately 0.3% of male infants This is the correct answerThis is the correct answer
Hypospadias, which is a defect in the ventral aspect occurs in three in 1000 births.

Epispadius is a defect in the dorsal aspect of the penis and this is much rarer occurring in one in 30,000 births. (Therefore the majority have hypospadias - ventral aspect).

It may occur on its own but is associated with exstrophy of the bladder (when the bladder mucosa is exposed to the outside).

The abnormalities associated with abnormal opening of the urethral meatus include:

A hooded prepuce (foreskin formed completely only on the dorsum)
Chordee: ventral curvature, present only in the worst cases. The incidence is 0.3% of males and surgery is usually undertaken before the age of 2 in order to create a terminal urethral meatus and a straight erection.
The foreskin is essential for surgical correction and should always be preserved.

42

Which one of the following is a recognised risk factor for the development of renal calculi?
(Please select 1 option)
Escherichia coli infection
Hyperoxaluria
Pseudohypoparathyroidism
Pseudomonas infection
Rickets

Hyperoxaluria

Pre-disposing causes for renal calculi include:

Urinary tract infection (especially Proteus)
Structural urinary tract abnormalities
Metabolic problems
Idiopathic hypercalciuria
Hyperuricosuria
Hyperoxaluria
Hypercystinuria.
Infected stones tend to be composed of magnesium ammonium phosphate and calcium phosphate.

Nephrocalcinosis can be a complication of furosemide therapy in the neonate.

Presentation is usually with haematuria, loin or abdominal pain, urinary tract infection or passage of a stone.

43

A 2-year-old child presents with a palpable abdominal mass.
Which one of the following renal pathology need not be considered?
(Please select 1 option)
Autosomal dominant polycystic kidney disease
Autosomal recessive polycystic disease
Nephroblastoma
Tuberous sclerosis
Wilm's tumour

AD PCKD

It is essential that all abdominal masses are promptly investigated using an ultrasound scan.

Causes of palpable kidneys include:

• Unilateral:

Multicystic kidneys
Compensatory hypertrophy
Obstructive hydronephrosis
Wilm's tumour
Renal vein thrombosis.
• Bilateral:

Autosomal recessive polycystic disease
Autosomal dominant polycystic disease (presents in adulthood)
Tuberous sclerosis
Renal vein thrombosis.