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SU29.1-11 | Urinary System Surgery — Practice Quiz
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A 64-year-old man who has smoked for 40 years reports two episodes of passing visible red urine over the past month. He has no pain, fever, or dysuria, and the bleeding stopped on its own each time. Urine culture is sterile. Which statement best guides his evaluation?
Correct. Painless gross haematuria in an adult — especially an older smoker — is malignancy until proven otherwise. The standard work-up is upper-tract imaging (CT urogram) plus cystoscopy to inspect the bladder and urethra.
Painless gross haematuria = malignancy until proven otherwise. Evaluate the WHOLE tract: cystoscopy for bladder/urethra, CT urogram for kidneys/ureters.
Painless visible haematuria in an adult is a red-flag for urothelial or renal malignancy and is never observed. The full work-up is cystoscopy (lower tract) and CT urogram (upper tract); ultrasound alone misses small bladder and ureteric lesions.
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A newborn boy is found to have the urethral meatus opening on the ventral surface of the penile shaft, with a hooded dorsal foreskin. The parents ask the surgeon when circumcision can be performed. What is the most appropriate advice?
Correct. This is hypospadias. Circumcision is contraindicated because the foreskin is used as a tissue source during reconstructive urethroplasty, typically performed around 6–18 months of age.
Hypospadias: NEVER circumcise — the foreskin is required for urethroplasty. Repair around 6–18 months.
This is hypospadias (ventral meatus + hooded prepuce). Circumcision is contraindicated — the prepuce is needed as graft/flap tissue for urethral reconstruction. Repair is done in infancy.
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A 28-year-old woman presents with three days of dysuria, frequency and suprapubic discomfort. She is afebrile with no loin pain. Urine dipstick shows nitrites and leucocyte esterase. Which is the most appropriate initial management?
Correct. This is uncomplicated lower UTI (acute cystitis) in a young woman: dysuria, frequency, suprapubic pain, no systemic features. A short course of appropriate oral antibiotics is first-line.
Uncomplicated cystitis in a young non-pregnant woman: short oral antibiotic course. Reserve imaging for recurrent/complicated/atypical UTI.
The clinical picture is uncomplicated cystitis — afebrile, no loin pain, positive nitrites/leucocytes. A short oral antibiotic course is correct; imaging/cystoscopy is reserved for recurrent, complicated, or red-flag presentations.
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A 35-year-old man presents with severe colicky right loin pain radiating to the groin and microscopic haematuria. Which investigation is the gold standard for confirming a suspected ureteric calculus?
Correct. Non-contrast CT KUB is the gold-standard investigation for urinary calculi: it detects stones of virtually all compositions (including radiolucent uric-acid stones) and defines size and site.
NCCT KUB = gold standard for urinary calculi. Detects radiolucent uric-acid stones that plain films miss.
NCCT KUB is the gold standard for stones — it detects nearly all calculi including radiolucent uric-acid stones and gives size/location. Plain films miss radiolucent stones; IVU is now largely superseded.
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Which urinary stone type is the most common overall and is typically radiopaque on plain imaging?
Correct. Calcium oxalate is the commonest urinary stone and is radiopaque. Struvite stones form staghorn calculi in infected (urease-producing) urine; uric-acid stones are radiolucent.
Calcium oxalate = commonest, radiopaque. Uric acid = radiolucent. Struvite = infection/staghorn.
Calcium oxalate is the commonest stone and is radiopaque. Uric-acid stones are radiolucent; struvite stones associate with infection and staghorn calculi.
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A 58-year-old man presents with a flank mass, loin pain and haematuria, and is found to have hypercalcaemia and polycythaemia. Which malignancy best accounts for this combination?
Correct. The classic triad of flank mass, loin pain and haematuria, together with paraneoplastic effects (hypercalcaemia from PTHrP, polycythaemia from erythropoietin), is characteristic of renal cell carcinoma. Wilms tumour is the childhood renal malignancy.
RCC: triad of mass + loin pain + haematuria, plus paraneoplastic hypercalcaemia/polycythaemia. Wilms = childhood renal tumour.
Renal cell carcinoma causes the classic triad (mass, pain, haematuria) and paraneoplastic syndromes — hypercalcaemia (PTHrP) and polycythaemia (erythropoietin). Wilms tumour affects young children, not adults.
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A 67-year-old man with a long smoking history presents with painless visible haematuria. Cystoscopy shows a papillary bladder tumour. What is the most likely histological type?
Correct. Transitional cell (urothelial) carcinoma is by far the commonest bladder cancer, strongly linked to smoking and presenting with painless haematuria. Squamous cell carcinoma is associated with chronic irritation and schistosomiasis.
Bladder cancer: TCC commonest (smoking, painless haematuria). Schistosomiasis → squamous cell carcinoma.
Transitional cell (urothelial) carcinoma is the commonest bladder cancer and is smoking-related, presenting with painless haematuria. Squamous cell carcinoma is linked to schistosomiasis/chronic irritation.
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A 72-year-old man presents at night with sudden, painful inability to pass urine and a tender, palpable suprapubic swelling. What is the most appropriate immediate management?
Correct. Acute urinary retention is an emergency. The first priority is to relieve the obstructed bladder by immediate urethral catheterisation; if urethral access fails, a suprapubic catheter is used. Definitive treatment of the cause follows later.
Acute retention = emergency. Relieve the bladder first: urethral catheter (suprapubic if it fails). Treat the cause afterwards.
Acute retention demands immediate bladder drainage — pass a urethral catheter without delay (suprapubic if urethral catheterisation fails). TURP and other definitive measures come later.
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A 70-year-old man has a hard, irregular (nodular) prostate on digital rectal examination and a raised serum PSA. Which statement is correct regarding his evaluation?
Correct. A hard, irregular/nodular prostate plus raised PSA is suspicious for carcinoma and requires biopsy for diagnosis and Gleason grading. BPH typically gives a smooth, symmetrically enlarged gland. Prostate cancer characteristically metastasises to bone (osteoblastic lesions).
Prostate Ca: nodular hard DRE + raised PSA → biopsy + Gleason grade; osteoblastic bone mets. BPH: smooth symmetric gland (IPSS, TURP).
A nodular hard gland with raised PSA suggests prostate carcinoma → biopsy. BPH gives a smooth symmetric gland. PSA is organ-specific not cancer-specific (a normal PSA does not exclude cancer). Gleason = histological grade. Prostate cancer favours bone metastases.
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A 45-year-old man with a history of urethral trauma now has a poor, narrow urinary stream and recurrent UTIs. A urethral stricture is suspected. Which investigation best defines the site and length of the stricture?
Correct. The retrograde urethrogram is the key investigation for urethral stricture — it outlines the urethral lumen and defines the site and length of the stricture, guiding management.
Urethral stricture: RGU defines site and length and guides management.
Retrograde urethrogram (RGU) is the investigation of choice for urethral stricture: it shows the site and length of the narrowing. CT KUB and DMSA assess the upper tract, not the urethra.
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