UROLOGY
Questions&Answers
Q-1
A 58 year old man has renal colic for the past 12 hours. In the last two
years, he has presented with three episodes of acute onset of pain in his
right knee. What is the SINGLE most likely cause of his renal colic?
A. Systemic lupus erythematosus associated glomerulopnephritis
B. Hypercalcaemia
C. Hyperuricaemia
D. Chlamydia trachomatis
E. Hyperoxaluria
ANSWER:
Hyperuricaemia
EXPLANATION:
Hyperuricaemia is the only one of the choices that has links to both a gouty
arthritis and formation of renal stones which causes renal colic.
Q-2
An 85 year old war veteran complains of loss of appetite and says that he
has lost weight over the past few months. He says that he has passed
some blood in his urine however, there was no pain. He finds it difficult to
empty his bladder completely and complains of having to urinate more
often than usual. He also states that he has worsening pelvic pain over the
past 3 months. A recent report shows that PSA is 9.5 ng/ml. What is the
SINGLE most likely reason for his symptoms?
A. Benign prostatic hyperplasia
B. Renal cell carcinoma
C. Bladder stones
D. Prostate cancer
E. Urinary tract infection
ANSWER:
Prostate cancer
EXPLANATION:
These are the features of prostate cancer. The raised PSA would be a reason to
investigate further for prostate cancer.
,The pelvic pain could be a sign of bone metastasis or it could be obstructive
symptoms due to prostate cancer.
PROSTATE CARCINOMA
Risk factors
• Increasing age is the most important risk factor
• Men of black African-Caribbean family origin
• First-degree relative with prostate cancer
Presentation
• Lower urinary tract symptoms (LUTS) do not particularly raise suspicion of
prostate cancer because LUTS are common in older men and are rarely the
presenting symptom of prostate cancer. However, locally advanced prostate
cancer may cause obstructive LUTS
Local disease:
• Raised PSA on screening
• Weak stream, hesitancy, sensation of incomplete emptying, urinary
frequency, urgency, urge incontinence
• Urinary tract infection
Locally invasive disease:
• Haematuria, dysuria, incontinence
• Haematospermia
• Perineal and suprapubic pain
• Obstruction of ureters, causing loin pain, anuria, symptoms of acute kidney
injury or chronic kidney disease
Metastatic disease:
• Bone pain or sciatica
• Paraplegia secondary to spinal cord compression
• Lymph node enlargement
• Lethargy (anaemia, uraemia)
• Weight loss
Q-3
An 81 year old Afro-Caribbean man presents with pain in his lower back
and hip. He complains of waking up in the middle of the night to go to the
washroom and often he wets himself before reaching the toilet. He also
has to urinate much more frequent than in the past and has terminal
dribbling. What is the SINGLE most likely underlying diagnosis?
A. Benign prostatic hyperplasia
B. Prostatitis
C. Bladder carcinoma
D. Prostate carcinoma
E. Urinary tract infection
ANSWER:
Prostate carcinoma
,EXPLANATION:
His age, ethnicity and urgency points towards a prostatic pathology. Metastasis
to the bones could explain the pain in his back and hips.
Frequency, urgency and terminal dribbling are features of prostate cancer. Black
men are at greatest risk for prostate cancer.
The most frequent sites of metastasis for prostate carcinoma are bone and lymph
nodes of the obturator fossae, internal, external and common iliac arteries, and
presacral regions.
Q-4
A 14 year old boy presents with a 3 hour history of severe left testicular
pain. He has no urinary symptoms and is otherwise well. On examination,
the right testis looks normal but the left hemiscrotum is swollen and
acutely tender. The pain is not eased by elevation of the testes. What is the
SINGLE most appropriate initial step?
A. Mid stream urine
B. Ultrasound scan of the testes
C. Urethral swab
D. Exploratory surgery
E. Computed tomography scan of the testes
ANSWER:
Exploratory surgery
EXPLANATION:
This boy is having a testicular torsion.
Testicular torsion
Key features of testicular torsion include:
• Severe, sudden onset testicular pain
• Typically affects adolescents and young males
• On examination testis is tender and pain not eased by elevation. Remember:
In testicular torsion, lifting the testis up over the symphysis increases pain,
whereas in epididymitis this usually relieves pain.
• Urgent surgery is indicated
Management:
• Urgent exploratory surgery is needed to prevent ischaemia of the testicle
Colour Doppler USS (reduced arterial blood flow in the testicular artery) and
radionuclide scanning (decreased radioisotope uptake) can be used to diagnose
testicular torsion, but in many hospitals, these tests are not readily available and
the diagnosis is based on symptoms and signs. Scrotal exploration should be
undertaken as a matter of urgency. Delay in relieving the twisted testis results in
permanent ischaemic damage to the testis, causing atrophy.
This is a very high yield question and in most cases if you suspect testicular
torsion the answer would be exploratory surgery (or urgent surgery).
, REMEMBER: if clinical suspicion is high, surgical intervention should not be
delayed for the sake of further investigation!
Q-5
A 22 year old sexually active male comes into the hospital with a 2 day
history of fever with increasing pain in the scrotal area. He also describes
painful micturition. There is no history of trauma. On examination, the
scrotal skin is red and tender. He has a temperature of 37.8 C. What is the
SINGLE most likely diagnosis?
A. Testicular torsion
B. Torsion of a pedunculated cyst of Morgagni
C. Haematocele
D. Epididymo-orchitis
E. Spermatocele
ANSWER:
Epididymo-orchitis
EXPLANATION:
The history here is of epididymo-orchitis. The two major things you need to look
out for when someone presents with testicular/scrotal pain is epididymo-orchitis
and testicular torsion. Epididymo-orchitis would have a more gradual onset of
symptoms like in this case. It is quite clear that this is actually epididymo-orchitis
especially with the gradual onset and the fever.
Remember, dysuria is also a symptom of acute epididymo-orchitis although not
very frequently seen.
Epididymo-orchitis
Epididymo-orchitis describes an infection of the epididymis with or without an
infection of the testes resulting in pain and swelling. It is most commonly caused
by local spread of infections from the genital tract (such as Chlamydia
trachomatis and Neisseria gonorrhoeae) where there is a retrograde spread from
the prostatic urethra and seminal vesicles.
The most important differential diagnosis is testicular torsion. This needs to be
excluded urgently to prevent ischaemia of the testicle. Epididymo-orchitis has
similar presenting symptoms as testicular torsion. Tenderness is usually localized
to the epididymis (absence of testicular tenderness may help to distinguish
epididymo-orchitis from testicular torsion, but in many cases, it is difficult to
distinguish between the two).
Another feature that can help distinguish epididymo-orchitis from testicular
torsion is that the tenderness may be relieved by elevating the scrotum (positive
Prehn’s sign) in epididymo-orchitis. Whereas this same action would exacerbate
pain or show no relief in pain if one had a testicular torsion (negative Prehn’s
sign)
Features
• unilateral testicular pain and swelling
Questions&Answers
Q-1
A 58 year old man has renal colic for the past 12 hours. In the last two
years, he has presented with three episodes of acute onset of pain in his
right knee. What is the SINGLE most likely cause of his renal colic?
A. Systemic lupus erythematosus associated glomerulopnephritis
B. Hypercalcaemia
C. Hyperuricaemia
D. Chlamydia trachomatis
E. Hyperoxaluria
ANSWER:
Hyperuricaemia
EXPLANATION:
Hyperuricaemia is the only one of the choices that has links to both a gouty
arthritis and formation of renal stones which causes renal colic.
Q-2
An 85 year old war veteran complains of loss of appetite and says that he
has lost weight over the past few months. He says that he has passed
some blood in his urine however, there was no pain. He finds it difficult to
empty his bladder completely and complains of having to urinate more
often than usual. He also states that he has worsening pelvic pain over the
past 3 months. A recent report shows that PSA is 9.5 ng/ml. What is the
SINGLE most likely reason for his symptoms?
A. Benign prostatic hyperplasia
B. Renal cell carcinoma
C. Bladder stones
D. Prostate cancer
E. Urinary tract infection
ANSWER:
Prostate cancer
EXPLANATION:
These are the features of prostate cancer. The raised PSA would be a reason to
investigate further for prostate cancer.
,The pelvic pain could be a sign of bone metastasis or it could be obstructive
symptoms due to prostate cancer.
PROSTATE CARCINOMA
Risk factors
• Increasing age is the most important risk factor
• Men of black African-Caribbean family origin
• First-degree relative with prostate cancer
Presentation
• Lower urinary tract symptoms (LUTS) do not particularly raise suspicion of
prostate cancer because LUTS are common in older men and are rarely the
presenting symptom of prostate cancer. However, locally advanced prostate
cancer may cause obstructive LUTS
Local disease:
• Raised PSA on screening
• Weak stream, hesitancy, sensation of incomplete emptying, urinary
frequency, urgency, urge incontinence
• Urinary tract infection
Locally invasive disease:
• Haematuria, dysuria, incontinence
• Haematospermia
• Perineal and suprapubic pain
• Obstruction of ureters, causing loin pain, anuria, symptoms of acute kidney
injury or chronic kidney disease
Metastatic disease:
• Bone pain or sciatica
• Paraplegia secondary to spinal cord compression
• Lymph node enlargement
• Lethargy (anaemia, uraemia)
• Weight loss
Q-3
An 81 year old Afro-Caribbean man presents with pain in his lower back
and hip. He complains of waking up in the middle of the night to go to the
washroom and often he wets himself before reaching the toilet. He also
has to urinate much more frequent than in the past and has terminal
dribbling. What is the SINGLE most likely underlying diagnosis?
A. Benign prostatic hyperplasia
B. Prostatitis
C. Bladder carcinoma
D. Prostate carcinoma
E. Urinary tract infection
ANSWER:
Prostate carcinoma
,EXPLANATION:
His age, ethnicity and urgency points towards a prostatic pathology. Metastasis
to the bones could explain the pain in his back and hips.
Frequency, urgency and terminal dribbling are features of prostate cancer. Black
men are at greatest risk for prostate cancer.
The most frequent sites of metastasis for prostate carcinoma are bone and lymph
nodes of the obturator fossae, internal, external and common iliac arteries, and
presacral regions.
Q-4
A 14 year old boy presents with a 3 hour history of severe left testicular
pain. He has no urinary symptoms and is otherwise well. On examination,
the right testis looks normal but the left hemiscrotum is swollen and
acutely tender. The pain is not eased by elevation of the testes. What is the
SINGLE most appropriate initial step?
A. Mid stream urine
B. Ultrasound scan of the testes
C. Urethral swab
D. Exploratory surgery
E. Computed tomography scan of the testes
ANSWER:
Exploratory surgery
EXPLANATION:
This boy is having a testicular torsion.
Testicular torsion
Key features of testicular torsion include:
• Severe, sudden onset testicular pain
• Typically affects adolescents and young males
• On examination testis is tender and pain not eased by elevation. Remember:
In testicular torsion, lifting the testis up over the symphysis increases pain,
whereas in epididymitis this usually relieves pain.
• Urgent surgery is indicated
Management:
• Urgent exploratory surgery is needed to prevent ischaemia of the testicle
Colour Doppler USS (reduced arterial blood flow in the testicular artery) and
radionuclide scanning (decreased radioisotope uptake) can be used to diagnose
testicular torsion, but in many hospitals, these tests are not readily available and
the diagnosis is based on symptoms and signs. Scrotal exploration should be
undertaken as a matter of urgency. Delay in relieving the twisted testis results in
permanent ischaemic damage to the testis, causing atrophy.
This is a very high yield question and in most cases if you suspect testicular
torsion the answer would be exploratory surgery (or urgent surgery).
, REMEMBER: if clinical suspicion is high, surgical intervention should not be
delayed for the sake of further investigation!
Q-5
A 22 year old sexually active male comes into the hospital with a 2 day
history of fever with increasing pain in the scrotal area. He also describes
painful micturition. There is no history of trauma. On examination, the
scrotal skin is red and tender. He has a temperature of 37.8 C. What is the
SINGLE most likely diagnosis?
A. Testicular torsion
B. Torsion of a pedunculated cyst of Morgagni
C. Haematocele
D. Epididymo-orchitis
E. Spermatocele
ANSWER:
Epididymo-orchitis
EXPLANATION:
The history here is of epididymo-orchitis. The two major things you need to look
out for when someone presents with testicular/scrotal pain is epididymo-orchitis
and testicular torsion. Epididymo-orchitis would have a more gradual onset of
symptoms like in this case. It is quite clear that this is actually epididymo-orchitis
especially with the gradual onset and the fever.
Remember, dysuria is also a symptom of acute epididymo-orchitis although not
very frequently seen.
Epididymo-orchitis
Epididymo-orchitis describes an infection of the epididymis with or without an
infection of the testes resulting in pain and swelling. It is most commonly caused
by local spread of infections from the genital tract (such as Chlamydia
trachomatis and Neisseria gonorrhoeae) where there is a retrograde spread from
the prostatic urethra and seminal vesicles.
The most important differential diagnosis is testicular torsion. This needs to be
excluded urgently to prevent ischaemia of the testicle. Epididymo-orchitis has
similar presenting symptoms as testicular torsion. Tenderness is usually localized
to the epididymis (absence of testicular tenderness may help to distinguish
epididymo-orchitis from testicular torsion, but in many cases, it is difficult to
distinguish between the two).
Another feature that can help distinguish epididymo-orchitis from testicular
torsion is that the tenderness may be relieved by elevating the scrotum (positive
Prehn’s sign) in epididymo-orchitis. Whereas this same action would exacerbate
pain or show no relief in pain if one had a testicular torsion (negative Prehn’s
sign)
Features
• unilateral testicular pain and swelling
