Theme: Treatment options for renal/ureteric calculi

A Percutaneous nephrolithotomy
B Conservative management
C Insertion of a ureteric stent
D Extracorporeal shock-wave lithotripsy
E Nephrectomy
For each of the following case histories, select the most likely answer from the above list.
Each option may be used once, more than once, or not at all.

Scenario 1

Incorrect

A 32-year-old man has a 24-hour history of right ureteric colic. He is apyrexial and pain controlled with
simple analgesia, and imaging reveals a 3-mm distal right ureteric calculus with no hydronephrosis.

B Correct answer

More than 95% of ureteric calculi of 5 mm or less will pass through without intervention. Indications for
intervention in patients with ureteric calculi include: severe pain; sepsis (an obstructed infected system);
or a large calculus that is very unlikely to pass. Intervention is also indicated for patients with a single
kidney.

Scenario 2

Incorrect

A 72-year-old woman has a history of recurrent urinary tract infections (UTIs). Imaging demonstrates a
large staghorn calculus in her right kidney with a normal-looking left kidney. A renogram demonstrates
35% function on the right side.

B Your answer

A Correct answer

Large staghorn calculi are best treated with a percutaneous nephrolithotomy. This offers the best chance
of stone clearance in patients with large stone burdens. The recurrent UTIs are most likely to be due to the
large staghorn calculus.

Scenario 3

Incorrect

A 40-year-old woman has a 3-day history of left ureteric colic. She is pyrexial and tachycardic with an
increased white cell count. Imaging reveals a 9-mm mid-ureteric calculus on the left with severe left-
sided hydronephrosis.
C Correct answer

This patient clinically and radiologically has an obstructed infected system that requires intervention. In
the acute phase, the objective is to drain the kidney – the insertion of a ureteric stent would be an
appropriate course of action.

Scenario 4

Incorrect

A 58-year-old man has a history of recurrent UTIs. Imaging reveals a large left-sided staghorn calculus
with renographic evidence of a non-functioning left kidney and a normal right kidney.

E Correct answer

In a patient with a large stone burden and a non-functioning kidney, the most appropriate treatment option
is a nephrectomy. A non-functioning kidney is one demonstrated renographically to have a function of <
15%.

Theme: Renal masses

 
A Angiomyolipoma
B Wilms’ tumour
C Renal cell carcinoma
D Transitional cell carcinoma
E Xanthogranulomatous pyelonephritis
 

For each of the statements below select the most likely answer from the list above. Each
option may be used once, more than once or not at all.

Angiomyolipoma is four times more common in women, is seen in the 40s and is
associated with a family history of tuberous sclerosis. It is a haematoma containing
vasculature, smooth muscle and fat and is usually unilateral. Renal cell carcinomas
present with pain, haematuria and a mass. It may also present as a fever, pyrexia of
unknown origin (PUO), disordered coagulation and liver function and polycythaemia. A
left renal cell carcinoma invading the renal vein and inferior vena cava (IVC) will present
with a varicocele and symptoms of IVC obstruction. Workers in the rubber and dye
industry have an increased risk of transitional cell carcinoma and often undergo yearly
urine cytology screening.

Scenario 1
 Incorrect

A 40-year-old women with a history of epilepsy presents with right loin pain, but no haematuria. A
computerised tomography (CT) scan shows a large right renal mass of low attenuation with some
bleeding into it.

A Correct answer

Angiomyolipoma

Scenario 2

Incorrect

A 60-year-old man presents with left loin pain and haematuria. He has had unexplained pyrexia and his
coagulation screen is abnormal.

C Correct answer

Renal cell carcinoma

Scenario 3

Incorrect

A 60-year-old retired worker in the dye industry presents with loin pain and intermittent haematuria.
Intravenous urogram shows a filling defect in the bladder.

D Correct answer

Transitional cell carcinoma

Theme: Staging of bladder tumours

A T3aG2
B TisG3
C TisG1
D T3bG2
E T4G3
F T4G1
G TaG2 
For each of the cases below, chose the most appropriate staging from those above. Each
may be used once, more than once or not at all.

Scenario 1

Correct

Well-differentiated in situ carcinoma

C Correct answer

TisG1

Scenario 2

Incorrect

Moderately differentiated tumour invading the perivesical fat

C Your answer

D Correct answer

T3bG2

Scenario 3

Incorrect

Poorly differentiated tumour invading the pelvis

E Correct answer

T4G3

Theme: Renal calculi

 
A Percutaneous nephrolithotomy (PCNL)
B Extracorporeal shock wave lithotripsy (ESWL)
C Alkaline diuresis
D Nephrectomy
E Percutaneous nephrostomy
F Expectant therapy
 

For each of the following cases listed below, select the most likely single treatment from
the options listed above. Each option can be used once, more than once or not at all.

Scenario 1

Incorrect

A 30-year-old pregnant woman (26 weeks) presents with septicaemia and abdominal pain. Investigations
reveal an obstructed right kidney due to a 2 cm calculus. She is commenced on intravenous
antimicrobials.

E Correct answer

Percutaneous nephrostomy

The most appropriate treatment in this patient is to drain the kidney through a percutaneous nephrostomy
and administer antimicrobials.

Scenario 2

Incorrect

A 40-year-old man presents with a left-sided renal colic. Intravenous urogram (IVU) shows a 1 cm
calculus in the upper third of his ureter. There is no complete obstruction. His symptoms fail to resolve on
conservative management.

B Correct answer

Extracorporeal shock wave lithotripsy (ESWL)

ESWL is now used to treat 90% of calculi that do not pass spontaneously upto 2cm in proper place.

Scenario 3

Incorrect

A 20-year-old man presents with a renal colic secondary to a 1 cm cystine calculus.

C Correct answer
Alkaline diuresis

Cystine calculi dissolve in alkaline media. Other conservative measures include penicillamine and
methionine restriction.

Scenario 4

Incorrect

A 30-year-old man presents to the casualty department with a right-sided renal colic. An IVU shows a 4
mm calculus in the distal part of the ureter with no complete obstruction.

F Correct answer

Expectant therapy

Calculi up to 5 mm in diameter usually pass out spontaneously. Non-steroidal anti-inflammatory drugs

(NSAIDs) provide effective analgesia.

Scenario 5

Incorrect

A 40-year-old woman is found to have a staghorn calculus in a non-functioning kidney.

D Correct answer

Nephrectomy

Scenario 6

Incorrect

A 60-year-old man presents with frequent attacks of left-sided renal colic due to a 2.5 cm calculus in the
renal pelvis. He has a cardiac pacemaker and is known to have a 6 cm aortic aneurysm.

A Correct answer

Percutaneous nephrolithotomy (PCNL)

Cardiac pacemakers and abdominal aortic aneurysms are contraindications to ESWL.

Theme: Haematuria
 
A Acute prostatitis
B Anticoagulation therapy
C Benign prostatic hyperplasia
D Bladder cancer
E Cystitis
F Haemophilia
G Nephritis
H Polycystic kidney disease
I Prostatic adenocarcinoma
J Pyelonephritis
K Renal cell carcinoma
L Renal papillary necrosis
M Trauma
N Urethral caruncle
O Urethritis
P Urolithiasis
 

The following patients all present with haematuria. From the list above, select the most
likely diagnosis. The items may be used once, more than once, or not at all.

Haematuria may occur as a result of renal, ureteric, bladder, prostatic and urethral
causes. The following pathological processes are usually implicated: trauma, infection,
tumours, or stones. In addition, bleeding diatheses may manifest as haematuria. When
investigations fail to identify a cause, medical disorders of the kidney should be sought by
a nephrologist.

Scenario 1

Incorrect

A 32-year-old man attends The Emergency Department with frank haematuria. He describes a several
month history of bilateral loin pain, followed by the recent onset of frank haematuria. On examination, his
blood pressure is 165/100 mmHg and he is tender in both renal angles. Abdominal examination reveals
bilateral lumbar abdominal masses. Urinalysis: 3+ blood and protein. Urea & Electrolytes: Na+ 138
mmol/litre, K+ 5.6 mmol/litre, urea 13.6 mmol/litre, creatinine 195 µmol/litre.

H Correct answer

H – Polycystic kidney disease

Adult polycystic kidney disease is an autosomal dominant condition (the PKD gene is on chromosome 6)
that affects 1 in 1000 of the population, and accounts for approximately 10% of cases of chronic renal
failure. Polycystic changes are always bilateral and present from early childhood to old-age. Patients most
commonly present with bilateral loin pain, haematuria, hypertension, proteinuria, progressive renal failure
and bilateral abdominal masses. Cysts arise anywhere along the nephron, may reach 3–4 cm in diameter,
and so compress the surrounding parenchyma. Forty per cent of patients have associated liver cysts, and
10–30% have berry aneurysms. Intravenous urogram, ultrasound scan and computed tomography are
helpful. Management is aimed at controlling hypertension, treating infections, and monitoring for renal
failure. Surgery is only indicated for bleeding or intractable pain.

Scenario 2

Incorrect

A 56-year-old diabetic woman presents to The Emergency Department with severe colicky right loin pain
followed by the passage of blood-stained material per urethrum with subsequent resolution of the pain.
She currently takes non-steroidal antiinflammatory agents for chronic back pain. Urinalysis reveals
microscopic haematuria. A kidney and upper bladder X-ray demonstrates ring-shaped calcification, in the
distribution of both kidneys. An intravenous urogram film obtained at 5 min shows horns from the calices
and ring shadows. There are no other obvious filling defects.

L Correct answer

L – Renal papillary necrosis

Renal papillary necrosis affects the distal portion of the renal pyramid. It is seen in association with
analgesic abuse and diabetes mellitus, which provide clues in distinguishing it clinically from urolithiasis.
The condition is caused by infarction of renal pyramids as a result of co-existing arteriosclerosis or an
acute vasculitis. Clinical presentation may be related to symptoms of urinary tract infection, such as
recurrent fever, malaise, dysuria, flank pain, proteinuria, haematuria and leukocytosis. Passage of
sloughed papillae can cause renal colic, ureteric obstruction and, rarely, urinoma. Rarely, renal papillary
necrosis can present as acute oliguric renal failure. In the advanced stage, renal function may be impaired
and anaemia and uraemia may be noted. The patient may witness the passage of ‘tissue’ (sloughed
papillae), rather than ‘grit’ (calculi) in the urine, as in the case described. Early in the disease, renal size
and function are preserved. Function may deteriorate with eventual renal failure in the later stages of the
disease. Radiography may demonstrate a wavy renal outline with tracks of contrast, ring shadows as a
result of sloughing of papillae, and an egg-in-a-cup appearance characteristic of renal papillary necrosis.

Scenario 3

Incorrect

A 75-year-old woman is referred with painless microscopic haematuria. She has also noticed a bloody
discharge staining her underwear. On examination, there are no abdominal masses, inspection of the
perineum reveals a red mass at the urethral meatus. Intravenous urogram and cystoscopy are normal.

N Correct answer

N – Urethral caruncle

A urethral caruncle is an inflammatory tumour, 1–1.5 cm in diameter, of the urethral meatus in women,
most frequently in the 6 o’clock position. They are very vascular and covered with transitional
epithelium. Although frequently asymptomatic, they may give rise to spotting and microscopic
haematuria. Oestrogen deficiency is implicated in the aetiology. The diagnosis is clinical, although failure
to respond to oestrogen therapy should prompt excisional biopsy to exclude a more sinister pathology.
Theme: Investigation of urinary tract disorders
A Antegrade ureteropyelography
B Computed tomography (CT)
C Computed tomography urography (CTU)
D Cystourethroscopy
E DMSA (dimercaptosuccinic acid) scan
F Intravenous ureterogram (IVU)
G Kidney, ureter and bladder (KUB) X-ray
H MAG 3 scan
I   Magnetic resonance imaging (MRI)
J Renal angiography
K Retrograde ureteropyelography
L Transrectal prostatic biopsy
M Transrectal ultrasound (TRUS)
N Ultrasound kidneys, ureters and bladder
O Urethrography and cystography
P Urodynamic studies

The above are all examples of investigations used in the diagnosis of urinary tract
disorders. Please pick the most appropriate investigation for the following clinical
presentations/descriptions. The items may be used once, more than once, or not at all.

Scenario 1

Incorrect

A 62-year-old man presents to The Emergency Department complaining of haematuria, gnawing right
loin pain and malaise. Abdominal examination does not reveal anything grossly abnormal. Urine cytology
and culture are normal. An ultrasound is performed urgently and shows a complex right renal cyst with a
calcified wall and a more solid central component. The patient tells you that he has had a prior allergic
reaction to an injected contrast that he had in his 50s for some form of abdominal investigation. How
should he be further investigated?

I Correct answer

I – Magnetic resonance imaging (MRI)

The standard primary investigation for haematuria and loin pain (with or without a mass) is an ultrasound,
which has already been undertaken for this patient. If a renal cyst demonstrates a solid intracystic element
or an irregular or calcified wall, as in this case, it is regarded as potentially malignant and requires further
imaging for staging. This is usually completed by computed tomography (CT) scanning of the chest and
abdomen, with intravenous contrast administration. In patients who have a prior history of reaction to
contrast, MRI is the chosen modality for staging assessment. In the staging of patients with renal
carcinoma MRI appears more accurate in delineating inferior vena cava or renal vein involvement,
compared with CT.

Scenario 2
 Incorrect

A 40-year-old woman who is an inpatient on the Urology Ward recently had a left-sided percutaneous
nephrostomy tube sited for pyonephrosis. This was performed as an emergency procedure on her
admission with sepsis and right loin pain, following an ultrasound KUB showing left-sided
hydronephrosis. Urea 15 mmol/litre; creatinine 205 µmol/litre. What further imaging should be
undertaken to assess the cause of her infected kidney?

K Your answer

C Correct answer

C – Computed tomography urography (CTU)

Although this woman has a nephrostomy tube sited and this could be used for antegrade contrast studies
of her urinary tract, she has raised urea and creatinine that could be exacerbated by contrast use. CTU has
the advantage in this scenario of allowing rapid visualisation of the renal tract without the need for
contrast injection. It has a high sensitivity for ureteric stones. If no renal tract stone is identified, CTU has
the advantage over intravenous urogram, and retrograde or antegrade ureteropyelography, in that it can
demonstrate other intra-abdominal pathologies that might be causing upper tract obstruction.

Scenario 3

Incorrect

A 50-year-old smoker presents to the urology outpatients after referral by his general practitioner for
painless haematuria. His prostate feels smooth and of normal size and he denies any lower urinary tract
symptoms. All relevant blood tests and urine samples have been taken and show nothing of significance
other than confirming haematuria. You need to arrange the next investigation.

F Correct answer

F – Intravenous ureterogram (IVU)

The gold standard first investigation (cystourethroscopy may often be required subsequently) for
investigating painless macroscopic haematuria is still IVU. Although many urology departments may
combine plain abdominal kidney, ureter and bladder X-ray with renal tract ultrasound it is important to
recognise that ultrasonography is less sensitive than IVU for detecting tumours of the upper tract, which
comprise 1–2% of all urothelial tumours.

Theme: Bladder outflow obstruction

A Benign prostatic hyperplasia (BPH)
B Bladder neck dyssynergia
C Bladder neck stone
D Bladder neck tumour
E Carcinoma of the prostate
F Clot retention
G Detrusor-external sphincter dyssynergia (DESD)
H Neuropathic bladder
I Pelvic mass/tumour
J Pelvic organ prolapse
K Previous bladder neck suspension surgery
L Urethral diverticulae
M Urethral dysfunction
N Urethral stone
O Urethral stricture

The pathologies above can all contribute to bladder outflow obstruction. For the following
scenarios please pick the most appropriate cause from the list. The items may be used
once, more than once, or not at all.

Scenario 1

Incorrect

A 52-year-old man presents to the urology outpatient department complaining of a progressively ‘poor
stream’ over the past few weeks. He tells you that he was recently an in-patient, having undergone
coronary artery bypass graft surgery, and that he required an in-dwelling catheter for 6 weeks after
suffering complications from the surgery post-operatively. Before this he had had no urinary symptoms at
all.

O Correct answer

O – Urethral stricture

This gentleman is likely to have developed a urethral stricture. Strictures can result from an inflammatory
process or trauma. Historically, gonorrhoea was a common cause of stricture, but nowadays they tend to
arise secondary to traumatic urethral instrumentation (eg long-term catheterisation, cystoscopy, or as a
result of large-bore resectoscope use in transurethral resection of the prostate). Prolonged urethral
catheterisation, such as in this case, can lead to stricture. This is particularly true in this scenario when,
following coronary bypass grafting, urethral ischaemia in a patient with cardiovascular disease may be an
exacerbating factor.

Scenario 2

Incorrect

A 73-year-old man finally presents to his general practitioner (GP) after an 18-month history of urinary
symptoms. He was previously too embarrassed to discuss his worsening hesitancy, postmicturition
dribbling and nocturia. You later see him in the outpatients on his GP’s referral. On examination his
abdomen is unremarkable and his prostate appears smoothly enlarged. Prostatespecific antigen 5.0 ng/ml.

A Correct answer

A – Benign prostatic hypertrophy (BPH)

The presenting symptoms and prostate-specific antigen (PSA) result in this clinical picture point to a
diagnosis of BPH. Lower urinary tract symptoms (LUTS) can vary between irritative storage symptoms
(frequency, urgency, nocturia) and voiding symptoms (hesitancy, poor flow, intermittent flow and post-
micturition dribbling). The PSA is within normal limits for age (age-specific value for 70+ can be up to
6.5 ng/ml), although in BPH, because of the increased prostatic volume, the level can be higher, making it
more difficult to rule out prostatic cancer. Management can initially be via drug therapy (a-blockers or 5a-
reductase inhibitors, eg Finasteride) but ultimately, if patients remain symptomatic, they will be offered a
transurethral resection of the prostate (TURP).

Scenario 3

Incorrect

A 58-year-old man presents to The Emergency Department complaining of severe suprapubic pain and an
inability to pass urine for the preceding 12 h. He tells you that he was recently discharged from hospital
following a transurethral resection of bladder tumour procedure.

F Correct answer

F – Clot retention

The cause of this man’s acute retention is clot within the bladder. His history of frank haematuria on a
background of surgery for transitional cell cancer resection (following transurethral resection of bladder
tumour) makes this the clear diagnosis. Immediate management will require the insertion of a rigid three-
way irrigating catheter (a normal flexible Foley catheter is likely to obstruct with clot after a short
period). This allows perfusion of the bladder with a normal saline irrigation fluid until the bleeding has
settled. More persistent bleeding may require repeat rigid cystoscopy and diathermy to the affected area.
Obviously a full set of bloods should be drawn and transfusion should be undertaken as necessary.

Scenario 4

Incorrect

A 35-year-old professional show jumper who had sustained a spinal cord injury after a fall from his horse
1 month prior, is seen in the urology outpatients. On leaving hospital after his initial injury he was
reluctant to have a long-term urinary catheter and it was agreed that he should try intermittent self-
catheterisation (ISC) under the supervision of the community continence nurse. He admits to you that he
has been a little unenthusiastic with the catheterisation in the past week (only emptying once or twice a
day) and had been experiencing some leaking in between attempts. On examination he has a distended
bladder. On siting a catheter, approximately 800 ml of clear urine drains rapidly. A voiding
cystourethrogram shows a voluminous bladder and every time the patient tries to pass urine a narrowing
is observed in the urethra between the prostatic and bulbar urethra. Urea 16 mmol/litre; creatinine 240
µmol/litre.

G Correct answer

G – Detrusor-external sphincter dyssynergia (DESD)

The higher centre for co-ordination of bladder with urethral function lies within the pons and is known as
the pontine micturition centre (PMC). The cell bodies of the parasympathetic motor fibres to the detrusor
muscle (S2–S4) and somatic motor fibres innervating the striated urethral sphincter (S2–S4) are located in
the sacral spinal cord. They receive descending impulses from the PMC, which is therefore responsible
for ensuring that co-ordinated contraction of the bladder and relaxation of the sphincter occur
simultaneously, allowing normal voiding. In DESD the PMC is disconnected from the sacral spinal cord
(classically by spinal cord injury) and patients lose the appropriate bladder–sphincter synchronisation. In
a reversal of normal function, when their bladder contracts it does so forcibly against a closed urethral
sphincter and hence these patients develop retention with very high bladder pressures leading to renal
back pressure and renal failure (note raised urea and creatinine). As the patient tries to pass urine the
voiding cystourethrogram shows the external sphincter (positioned between the prostatic and bulbar
urethra) continuing to contract when it should be relaxing.

Theme: Disorders of the prostate

 
A Acute prostatitis
B Benign prostatic hyperplasia
C Carcinoma of the prostate
D Chronic prostatitis
E Granulomatous prostatitis
F Prostatic abscess
G Prostatodynia

From the list above, select the most likely diagnosis for the following patients with
disorders of the prostate. The items may be used once, more than once, or not at all.

Scenario 1

Incorrect

A 72-year-old diabetic gentleman is referred for assessment of lower urinary tract symptoms. He reports
worsening frequency of micturition and nocturia. He has also noticed difficulties initiating micturition,
and terminal dribbling. Abdominal examination is normal, digital examination per rectum reveals a non-
tender, enlarged prostate gland. Urinalysis reveals microscopic haematuria. The following investigation
results are available: haemoglobin 13.4 g/dl, white cell count 5.4 x 109/litre, platelets 254 x 109/litre, Na+
132 mmol/litre, K+ 5.3 mmol/litre, urea 9.8 mmol/litre, creatinine 165 µmol/litre, prostate-specific antigen
4.2 ng/ml.

B Correct answer

B – Benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is the commonest disease to affect middle-aged men. The aetiology
remains unknown, although some form of androgen imbalance appears important. The gland is enlarged
by nodules of variable size arising in the inner (peri-urethral) portion. Enlargement of the inner zone of
the gland tends to produce atrophy of the outer gland, which forms a pseudocapsule to the prostate.
Consequently, smooth enlargement of the gland is characteristic of BPH on digital examination.
Microscopically, these nodules are composed of proliferating glands and fibromuscular stroma. The
relative obstruction of urinary flow produces the classical ‘obstructive’ symptoms associated with BPH,
namely, hesitancy, poor flow and terminal dribbling. Such symptoms are relatively successfully addressed
by surgical ‘decompression’ (eg transurethral resection of the prostate). However, the bladder detrusor
compensates for increased outflow resistance with muscular hypertrophy and an increase in collagen,
resulting in trabeculation. Trabeculation is asymptomatic but the detrusor becomes increasingly irritable,
giving rise to ‘irritative’ symptoms of urinary frequency, nocturia and urgency. Such symptoms are not
usually addressed by surgery, and are best treated medically (eg anti-cholinergics). With progressive
obstruction, chronic retention of urine secondary to incomplete bladder emptying may precipitate
infections, and in the longterm may lead to chronic renal failure. Patients may experience acute retention
of urine. Management includes a-blockers, 5a-reductase inhibitors and, in resistant, cases transurethral or
transvesical resection of the prostate.

Scenario 2

Incorrect

A 34-year-old gentleman presents to The Emergency Department with acute retention of urine. He reports
worsening dysuria over the last few days, associated with rigors and night sweats. He is currently taking
triple immunosuppression therapy following heart and lung transplantation for cystic fibrosis. Vital
observations: temperature 38.9°C, pulse rate 125/min, blood pressure 90/46 mmHg, respiratory rate 16
breaths/min, SaO2 98%. Digital per rectal examination reveals a tender boggy prostate that is fluctuant.

F Correct answer

F – Prostatic abscess

Effective treatment of acute prostatitis with antibiotics has reduced the prevalence of prostatic abscesses.
However, they may be seen in patients with immunocompromise. The clinical picture is of systemic
sepsis as a result of abscess formation, and occasionally, outflow obstruction/retention of urine when the
collection is large, as in the case described. The initial treatment is with parenteral antibiotics.
Transurethral incision may be required to drain the abscess if medical treatment is ineffective.

Scenario 3

Incorrect
A 65-year-old gentleman presents with a history of abdominal distension and pain, and worsening
constipation. He has also suffered from weight loss. On direct questioning he also reports marked perineal
and lumbar pain. Urinalysis reveals microscopic haematuria. Urea & Electrolytes reveal evidence of renal
failure: Na+ 132 mmol/litre, K+ 5.9 mmol/litre, urea 20.6 mmol/litre, creatinine 256 µmol/litre.

C Correct answer

C – Carcinoma of the prostate

Carcinoma of the prostate is usually an adenocarcinoma of acinar form. Its aetiology remains unknown.
Most arise in the peripheral part of the gland, and so it is amenable to detection on rectal examination.
Presentation may be asymptomatic (incidental finding), with a palpable nodule on per rectum
examination, with LUTI’s (usually obstructive in nature), although given the peripheral location of
tumours there is usually considerable involvement of the gland by the time outflow obstruction develops.
Patients may also present with disseminated metastatic disease (bone and/or perineal pain), or locally
advanced disease, encircling the rectum and causing mechanical obstruction of the large intestine, as in
the clinical scenario presented.

Theme: Urinary incontinence

A Acute retention of urine
B Chronic retention of urine
C Detrusor overactivity
D Detrusor hypotonia
E Faecal impaction
F Fistulation
G Functional
H Urethral diverticulum
I Urethral sphincter incompetence
J Urethral stricture
K Urinary tract infection
L Uterovaginal prolapse

The following patients all present with urinary incontinence. From the list above, select
the most likely diagnosis. The items may be used once, more than once, or not at all.

For continence to exist, urethral pressure must exceed intravesical pressure at all times.
Urinary incontinence is defined by the International Continence Society as ‘the
involuntary loss of urine which is objectively demonstrable and a social or hygienic
problem’. It may be classified into urethral or extra-urethral conditions.
Urethral causes include

 urethral sphincter incompetence

 detrusor overactivity (uninhibited detrusor contractions)
  overflow incontinence (eg secondary to retention of urine/faecal
impaction/uterovaginal prolapse/drugs/urethral strictures/detrusor hypotonia etc)
 urinary tract infection
 urethral diverticulum
 functional (impaired cognition/intellectual function/immobility etc).

Extra-urethral causes include

 congenital abnormalities (eg ectopic ureter/bladder exstrophy)

 fistula formation (ureteric/vesical/vagina).

Scenario 1

Incorrect

A 68-year-old woman complains of worsening urinary incontinence. She reports loss of a trickle of urine
when coughing or during physical exertion. She denies urinary frequency and urgency. In the past she has
had four normal vaginal deliveries. Urine culture is normal. On examination, there is no evidence of
urinary retention clinically, vaginal examination excludes significant prolapse. There is objective loss of
urine on coughing.

I Correct answer

I – Urethral sphincter incompetence

This has recently, and more accurately, been re-defined as ‘urodynamic stress incontinence’.
Consequently, it is a ‘urodynamic diagnosis’. It is defined as the involuntary loss of urine when
intravesical pressure exceeds the maximum urethral closure pressure in the absence of detrusor
overactivity. It occurs as a result of incompetence of the urethral sphincter (hence its former name), which
can be the result of weakness in any component of the sphincter mechanism (supporting structures, eg
pubourethral and vesical ligaments), intrinsic sphincter mechanism, or extrinsic sphincter mechanism
(puborectalis). It is more common in women, because of their anatomically shorter and straighter urethra.
Presentation is commonly with incontinence provoked by ‘stresses’ that increase intraabdominal pressure
(eg coughing, sneezing, abdominal masses etc). In the first instance, treatment may be conservative
[physiotherapy/mechanical devices/pharmacological agents (oestrogens)] or surgical (suspension/sling
procedures/peri-urethral bulking agents).

Scenario 2

Incorrect

A 72-year-old man presents with symptoms of urinary incontinence. The loss is associated with marked
urinary urgency and is worse when the ‘weather is cold’. He has a 15-year history of bladder outflow
obstruction. He recently underwent transurethral resection of the prostate, which has been associated with
a deterioration of his continence.

C Correct answer
C – Detrusor overactivity

Detrusor overactivity (DO) refers to objective contraction (spontaneous or on provocation) during the
filling phase of cystometry, while the patient is attempting to inhibit micturition. It is, therefore, a
urodynamic (cystometrographic) diagnosis. The contractions precipitate urinary urgency, and may result
in leakage of urine (‘urge incontinence’). The pathophysiology of DO remains poorly understood, and so
it is termed idiopathic in the majority of cases. However, it may occur secondary to neuropathic lesions
(multiple sclerosis/spinal injury/cerebrovascular accidents/Parkinsonism) or bladder outflow obstruction
in men, as in the scenario presented. In the case of chronic obstruction, there is associated trabeculation
(muscular hypertrophy and an increase in collagen) and increasing bladder irritability. Management of
DO involves behavioural therapy (bladder drill), pharmacological manipulation (anti-cholinergic
agents/calcium-channel blockers/anti-diuretics/hormone replacement therapy), and in severe refractory
cases augmentation cystoplasty or more rarely urinary diversion.

Scenario 3

Incorrect

A 48-year-old woman complains of ‘constantly being wet – day and night’ following a radical
hysterectomy and radiotherapy for cervical cancer. Urinalysis and urodynamic investigations are normal.

F Correct answer

F – Fistulation

A history of constant, uncontrollable loss of urine in an otherwise mentally intact individual should alert
you to the presence of a fistula. Vesicovaginal, and less commonly urethrovaginal, fistulae usually occur
secondary to gynaecological surgery in the developed world. By contrast, obstetric injury is the most
common aetiology in the developing world. Assessment of such patients is clinical (examination under
anaesthesia with dye insertion) and radiological (micturating cystogram). Repair is surgical.

Theme: Scrotal swellings

A Acute epididymo-orchitis
B Acute haematocoele
C Chronic haematocoele
D Epididymal cyst
E Inguinal hernia
F Orchitis
G Primary hydrocoele
H Secondary hydrocoele
I Testicular seminoma
J Testicular teratoma
K Testicular torsion
L Tuberculous
M Varicocoele

The above are all potential causes of a swelling in the scrotum. For the ensuing clinical
scenarios please pick the most appropriate answer from the list. Each item may be used
once, more than once, or not at all.

Scenario 1

Incorrect

A 16-year-old presents to his general practitioner (GP) complaining of a vague, dragging sensation and
aching in the left scrotum. The GP examines him lying flat and cannot identify anything unremarkable
within either hemi-scrotum. On standing, however, there is a soft area of bulging swelling that appears in
the left upper scrotum.

M Correct answer

M – Varicocoele

This is a condition of varicosities of the pampiniform plexus of veins (ie varicose veins of the spermatic
cord) and is present in 15–25% of all men.They usually manifest first in adolescence and are more
common on the left. This is explained by the venous drainage of the left testicular vein into the left renal
vein at right angles (the right testicular vein drains obliquely into the inferior vena cava). Absent or
incompetent valves at this junction with the left renal vein lead to back pressure, and the formation of the
varicocoele. On examination with the patient standing the varicocoele is said to feel like a ‘bag of
worms’; it cannot be felt supine as the veins are empty. Usually varicocoeles are managed conservatively
(close-fitting underwear, reassurance, analgesia for testicular ache); however, troublesome varicosities
can be treated by radiological embolisation, or by surgical ligation of the testicular veins in the inguinal
canal.

Scenario 2

Incorrect

A 13-year-old boy presents to Casualty in the early hours of the morning complaining of unbearable pain
in his left scrotum. The onset was sudden, woke him from sleep and caused him to vomit.

K Correct answer

K – Testicular torsion

The classical age, history and clinical presentation in this scenario clearly points to testicular torsion. The
commonest age for torsion is between 10 and 15 years and the problem is very uncommon over the age of
25 years. The majority of torsions occur spontaneously, often in the early hours of the morning; however,
some follow minor trauma (eg blow to the scrotum during sport or while mounting a bicycle). In young
sexually active men it may be difficult to distinguish between an acute epididymo-orchitis and testicular
torsion. Surgical exploration is compulsory.

Scenario 3

Incorrect

A 47-year-old man presents to the urology outpatient clinic with a 3–4-year history of a slowly enlarging,
non-tender swelling in his right scrotum. On examination you note a multilocular 2-cm swelling located
at the upper, posterior pole of the right testis. It is fluctuant, transmits a fluid thrill and transilluminates.
The cord is easily palpated above the bulge.

D Correct answer

D – Epididymal cyst

Epididymal cysts are fluid-filled swellings connected to the epididymis and are thought to be derived
from the collecting tubules of the epididymis. Most occur in men over the age of 40 years who complain
of a slowly enlarging, non-tender bulge in the scrotum. Clinically they are as described in the scenario
above. The differential diagnosis is that of a hydrocoele, but the epididymal cyst can easily be
distinguished because of its position above and behind the superior pole of the testis. The fluid of a
hydrocoele surrounds the testis and usually makes the testis impalpable.

Scenario 4

Incorrect

A 27-year-old man attends The Emergency Department complaining of bilateral testicular pain and
swelling. He gives a 5-day history of fever and malaise and tells you that he had some bilateral jaw
swelling and pain that appears to be settling now. On examination he has a temperature of 38.9°C; his
testes are swollen, tender to palpation and feel somewhat soft.

F Correct answer

F – Orchitis

This man’s history of fever, malaise and parotitis indicates infection with the mumps virus (a systemic
paramyxovirus). Orchitis occurs in up to 20% of post-pubertal men that contract the virus, commencing
4–6 days after the onset of the parotid gland swelling and lasting 7–10 days. Diagnosis is confirmed by
the rising titre of anti-mumps antibody. Treatment is supportive (bed rest, analgesia and scrotal support).
Mumps orchitis can be complicated by testicular atrophy. If the orchitis is bilateral fertility may be
impaired.
Theme: Hemiscrotal pain
A Acute epididymo-orchitis
B Chronic post-vasectomy pain
C Fournier’s gangrene
D Hydrocoele epidydimo-orchitis
E Inguinoscrotal hernia
F Orchitis appendage
G Referred pain
H Testicular injury
I Testicular torsion
J Testicular tumour
K Tuberculous
L Torsion of testicular appendage
M Varicocoele

The following patients all present with hemiscrotal pain. From the list above, select the
most likely diagnosis. The items may be used once, more than once, or not at all.

Scenario 1

Incorrect

A 9-year-old boy attends The Emergency Department with a sudden onset of severe pain in the left
hemiscrotum, which is associated with lower abdominal discomfort. There is no history of trauma. He is
in pain but afebrile. Examination of the external genitalia reveals normal position of both testicles, and no
erythema or increased temperature. The left testicle is exquisitely tender over a small area on the upper
pole, and there is marked thickening of the cord.

L Correct answer

L – Torsion of testicular appendage

There are four testicular appendages, which represent embryological remnants. These are the appendix
testis (hydatid of Morgagni); the paraepididymis (organ of Giraldes); vasa aberrantia; and the appendix
epididymis (pedunculated hydatid). The appendix testis undergoes torsion in 90% of cases. Torsion of an
appendage is more common in boys under the age of 11 years than torsion of the testis. Similarly, acute
epididymoorchitis is unusual in young boys, unless there is an anatomical abnormality. The onset of pain
is acute, and there is usually oedema of the cord. There may be an associated hydrocoele, making
palpation of the twisted appendage difficult. Treatment involves exploration (also allowing absolute
exclusion of testicular torsion) and removal of the appendage.

Scenario 2

Incorrect

A 58-year-old diabetic gentleman develops worsening scrotal pain following drainage of a peri-anal
abscess. He is unwell and has a temperature of 38.5°C. Examination of his external genitalia reveals a
painful, erythematous swollen right scrotum. The swelling also appears to be extending into the right
inguinal region, and to a lesser degree, the left scrotum.

C Correct answer

C – Fournier’s gangrene

This is necrotising subcutaneous infection of the scrotum. The initial description by Fournier was in
young healthy men, without obvious cause. Nowadays, the condition is most commonly seen in middle-
aged or elderly gentlemen; there are frequently contributory factors such as local perineal/peri-anal or
lower urinary tract surgery and immunocompromise (eg diabetes mellitus). Streptococci and Clostridium
perfringens are usually implicated, and infection results in vascular thrombosis, subcutaneous tissue
necrosis and eventually gangrene. The infection follows the same path as extravasation of urine,
spreading into the perineum and lower abdominal wall. Treatment involves aggressive broad-spectrum
antibiotic therapy, and emergency wide surgical excision of affected tissue.

Scenario 3

Incorrect

A 33-year-old man presents to The Emergency Department with a 7-day history of pain affecting the right
hemiscrotum. On direct questioning, he reports symptoms of dysuria preceding the onset of the pain.
There is no history of trauma. On examination, his temperature is 37.9°C, and his right scrotum appears
enlarged compared to the left. Palpation of scrotal contents reveals a tender thickening posterior to the
testis, which itself is relatively painless.

A Correct answer

A – Acute epididymo-orchitis

The aetiology of this infection varies with age. In young boys it is usually a bacterial infection associated
with a structural abnormality of the lower genitourinary system. In young men it is most commonly
sexually transmitted in origin, with Chlamydia and Neisseria gonorrhoeae commonly implicated. In older
men it usually relates to prostatism, chronic retention of urine and/or instrumentation of the lower urinary
tract. There is usually gradual onset of pain and swelling over several hours or days. There may be
associated lower urinary tract symptoms. A swollen, tender epididymis may be palpable, but it may also
fuse with the testis, forming a large inflammatory mass. A careful history and examination is crucial in
establishing the correct diagnosis, and differentiating the problem from torsion. There may be associated
bacteriuria. Treatment is with broadspectrum antibiotics, with the addition of doxycycline (to cover
Chlamydia) if an acquired cause is expected.
Theme: Renal masses
A Hydronephrosis
B Nephroblastoma (Wilm’s tumour)
C Peri-nephric abscess
D Polycystic disease
E Renal cell carcinoma
F Renal haematoma
G Solitary cysts
H Supernumerary kidney

From the list above, select the most likely diagnosis for the following patients who all
present with enlargement of the kidney on physical examination. The items may be used
once, more than once, or not at all.

Scenario 1

Incorrect

A 59-year-old man is found to have enlargement of his right kidney on physical examination. Past history
includes emergency repair of a ruptured abdominal aortic aneurysm 5 years ago. Urinalysis is normal, and
no malignant cells are seen on microscopy. His Urea & Electrolytes are normal.

A Correct answer

A – Hydronephrosis

Hydronephrosis refers to dilatation of the renal pelvis and calyces associated with progressive atrophy of
the kidney as a result of the obstruction of outflow of urine. Such obstruction may affect the upper urinary
tract (ie ureteric obstruction), potentially resulting in unilateral hydronephrosis, or the lower urinary tract
(bladder outflow obstruction etc), which usually results in bilateral hydronephrosis. Ureteric obstruction
may be the result of congenital pelviureteric junction obstruction, or intraluminal (stones/tumours) or
intramural (primary megaureter) pathology. It may occur secondary to extrinsic compression in the
retroperitoneum (eg malignant disease/inflammatory disease/aneurysms/retroperitoneal fibrosis etc).
Fibrosis around an aortic graft may result in ureteric obstruction, as in the case described. There may be
associated impairment of renal function, particularly if the obstruction is bilateral. Ultrasound scanning
will confirm that hydronephrosis is the cause of the renal enlargement. Treatment is directed towards the
cause of the obstruction.

Scenario 2

Incorrect

A 4-year-old boy is referred by his general practitioner with an enlarged left kidney. He is otherwise
asymptomatic and completely well. He is afebrile. Urinalysis reveals microscopic haematuria. Urine
cultures are negative.
B Correct answer

B – Nephroblastoma (Wilm’s tumour)

This tumour is the commonest intra-abdominal malignancy in children under the age of 10 years. It is
composed of primitive renal tubules, primitive renal blastoma-like mesenchyme, and fibroblast-like
spindled cells. The peak incidence is between 2 and 4 years but cases may present during adolescence or
even adulthood. The child is usually well, unlike in cases of neuroblastoma from which nephroblastoma
must be distinguished. The commonest presentation is with an abdominal mass. Haematuria, pain,
hypertension and intestinal obstruction may occur. Metastases occur to the liver. Treatment involves
surgical excision and aggressive chemotherapy and radiotherapy. Five-year survival is in the order of
90%.

Scenario 3

Incorrect

A 39-year-old woman is referred for assessment by an The Emergency Department Senior House Officer
who has identified a tender right renal mass. She tells you that she has been unwell for several days, when
she has been anorexic, suffering with night sweats and generalised malaise. Previously, she has noted
frequency of micturition. There is no history of trauma. She presented to The Emergency Department
with ureteric colic 5 days ago but was discharged because the pain appeared to settle. Urinalysis reveals
3+ of blood and protein.

C Correct answer

C – Peri-nephric abscess

Acute bacterial infections of the kidney form a spectrum ranging from relatively simple infection
resulting in acute cystitis/pyelonephritis through to peri-nephric abscess formation. It is often difficult to
clearly differentiate these on clinical grounds alone because they all present with localised symptoms of
infection affecting the urinary tract, coupled with a degree of systemic effects (malaise, rigors, pyrexia,
raised white count etc). Severe infection of the urinary tract may lead to pyonephrosis, particularly if the
outflow of the kidney is obstructed by the presence of stones, as alluded to in the case scenario presented.
Such a collection may discharge into the surrounding peri-renal tissue forming a peri-nephric abscess.
Radiology is essential in differentiating between the various forms of acute infection. Treatment involves
appropriate broad-spectrum antibiotics, and percutaneous or open drainage as required. An obstructed
infected kidney is an indication for emergency nephrostomy.
Theme: Tumours of the genitourinary tract
A Carcinoma of the penis
B Carcinoma of the urethra
C Cervical carcinoma
D Nephroblastoma (Wilm’s tumour)
E Ovarian carcinoma
F Prostatic carcinoma
G Renal cell carcinoma
H Squamous cell carcinoma of the bladder
I Testicular cancer
J Transitional cell carcinoma of the bladder
K Transitional cell carcinoma of the ureter
L Uterine carcinoma
M Vaginal carcinoma
N Vulval carcinoma

The following patients all present with genitourinary tract malignancies. From the list
above, select the most likely diagnosis. The items may be used once, more than once, or
not at all.

Scenario 1

Incorrect

A 54-year-old woman attends The Emergency Department with a 2-day history of frank haematuria. On
direct questioning, she reports a several month history of irritative lower urinary tract symptoms. Her
general practitioner has been treating her for recurrent urinary tract infections as urinalysis has repeatedly
revealed the presence of microscopic haematuria. However, urine cultures have all been negative. She has
noticed that the bleeding over the last few days only affects the end of her stream. She has smoked 40 per
day for the last 40 years.

J Correct answer

J – Transitional cell carcinoma of the bladder

Carcinoma of the bladder has a peak incidence in the seventh decade of life, and is three times more
common in men. Many epidemiological studies have also shown a clear association with cigarette
smoking. Ninety per cent of cancers are transitional cell carcinoma (TCC) in origin. Squamous cell
carcinoma occurs frequently where bilharzial infections of the bladder are prevalent, and secondary to
chronic infection with irritation (eg catheterised paraplegics/bladder stones). TCC demonstrate two
patterns of growth: papillary and infiltrating. Haematuria is the cardinal symptom and may occur towards
the end of micturition as a result of compression on the tumour as the bladder contracts to empty. Large
tumours may give rise to irritative symptoms, and so such symptoms must not be assumed to be
secondary to infection in older individuals, particularly if persistent or occurring in the absence of
microbiological evidence of infection, as in the case described.

Scenario 2
 Incorrect

A 64-year-old nulliparous woman presents with increasing abdominal distension and pain. Previously,
she was completely asymptomatic but more recently has also become increasingly short of breath. On
examination, there is evidence of a left pleural effusion and gross ascites.

E Correct answer

E – Ovarian carcinoma

Ovarian carcinoma is responsible for the fourth highest number of cancer deaths in women in the UK.
Most of the cancers are of epithelial origin, and the peak incidence occurs in women aged 50–70 years.
The aetiology is unknown but genetic factors are increasingly recognised as being important (BRCA1). In
addition, ‘incessant ovulation’ appears important as nulliparity, early menarche and a late menopause are
frequently associated with its development, whereas use of the contraceptive pill, which inhibits
ovulation, affords protection. Most epithelial tumours are advanced at presentation, having spread beyond
the pelvis, because of the insidious nature of symptoms and signs. Consequently, the overall 5-year
survival rate is less than 25%. Presenting symptoms are frequently vague and non-specific. Abdominal
distension and pain (secondary to peritoneal seeding and ascites formation: stage III), weight loss,
anorexia, and occasionally a hard-irregular mass arising in the pelvis are the commonest symptoms.
Pleural effusion with positive cytology confirms distant spread of disease (stage IV). Surgery is the
mainstay of both diagnosis and treatment of ovarian cancer and involves debulking of tumour wherever
possible.

Scenario 3

Incorrect

56-year-old man attends The Emergency Department with frank haematuria and some vague abdominal
pain. On examination there is a swelling in the right loin.

G Correct answer

G – Renal cell carcinoma

Renal cell carcinoma arises from the cells of the proximal convoluted tubule. It commonly affects
individuals in their sixth or seventh decade, and is twice as common in men. It presents commonly with
one or more of the classic triad: haematuria, loin pain and palpable mass (all present in this case).
Theme: Scrotal swellings
 
A Encysted hydrocele of cord
B Epididymo-orchitis
C Hydrocele
D Inguinoscrotal hernia
E Testicular tumour
F Torsion of hydatid of Morgagni
G Varicocele
 

For each of the patients described below, select the most likely diagnosis from the list of
options above. Each option may be used once, more than once, or not at all.

A painless, long-standing swelling that transilluminates within the scrotum is most likely
to be a hydrocele. A hydrocele of the cord will be separate from the testis.
 
A varicocele is often referred to as the sensation of a ‘bag of worms’ in the scrotum. The
varicosities are more prominent when the patient is standing, and they disappear or
decrease in size when the patient lies down.
An indirect inguinal hernia is more likely to occur on the right, as the right testis
descends later. However, 98% of varicoceles occur on the left. The reasons for this are:
(1) the left testicular vein forms a greater angle with the left renal vein;
(2) the left renal vein is crossed and may be compressed by the pelvic colon;
(3) the left testicular vein is longer than the right ; and
(4) the terminal valve is frequently absent in the left testicular vein.
 

The history of onset of testicular tumour is varied, but is often associated with the onset
of sudden pain. One should always suspect a testicular tumour if an irregular testis is ever
felt, and an urgent ultrasound is required.

Scenario 1

Incorrect

A 42-year-old man presents with a left-sided scrotal swelling. You are unable to get above the swelling, it
is compressible, increases on standing, but does not have a positive cough impulse.

G Correct answer

G – Varicocele

Scenario 2

Incorrect
An 18-year-old man presents with a sudden onset of testicular pain. On examination you note a firm
irregular testis at the apex of the scrotum.

E Correct answer

E – Testicular tumour

Scenario 3

Incorrect

A 22-year-old patient presents with a scrotal swelling that you are unable to get above, it is compressible,
increases on standing and has a cough impulse present.

D Correct answer

D – Inguinoscrotal hernia

Scenario 4

Incorrect

A patient presents with a painless long-standing scrotal swelling which transilluminates. The swelling is
not separate from the testis.

C Correct answer

C – Hydrocele

Theme : Scrotal pain and swellings

A Epididymo-orchitis
B Hydrocele
C Inguinoscrotal hernia
D Mumps
E Testicular seminoma
F Testicular teratoma
G Testicular torsion
H Torsion hydatid of Morgagni
I Varicocele

For each of the following situations, select the most likely cause of scrotal pain from the
above list. Each option may be used once, more than once, or not at all.
 

Scenario 1

Incorrect

A 20-year-old man has a 24-hour history of severe left scrotal pain and swelling. There is frequency of
micturition and dysuria for the past few days. He has a temperature of 39 ºC. There are leukocytes in the
urine and the WBC is 15 x 109/l.

D Your answer

A Correct answer

A – Epididymo-orchitis

The history here is characteristic of an acute epididymo-orchitis. The preceding urinary symptoms and
raised WBC make the diagnosis most likely. The most common causative organisms are the Gram-
negative bacilli. Thus therapy is most appropriately directed towards these.

Scenario 2

Incorrect

A 30-year-old man gives a history of dull left-sided scrotal pain for several months. On examination both
testes are normal and you notice some veins on his scrotal skin. There is, however, a left hemiscrotal
swelling present on lying down and it is not possible to get above this.

G Your answer

C Correct answer

C – Inguinoscrotal hernia

The presence of veins on the scrotal skin here is a red herring. Varicoceles do not cause large swellings in
the hemiscrotum per se, but also disappear in the recumbent position. The inability to get above the
swelling is a clinical sign of an inguinoscrotal hernia.

Scenario 3

Incorrect

A 30-year-old man presents to his GP with swelling of his right–left hemiscrotum. He has noticed a dull
ache but feels otherwise well. The testis is slightly enlarged and feels irregular in shape. Blood tests show
raised  -HCG but normal  -fetoprotein.

E Correct answer
E – Testicular seminoma

Testicular cancer usually presents in the 20–40-year age group. It may be asymptomatic, but there is often
a history of incidental trauma – the reason for this is unknown. Seminomas most commonly occur in 30–
40-yearolds. In contrast, teratoma occurs in a younger age group (20–30 years). The  -fetoprotein
produced by yolk-sac elements is raised in teratomas but not in seminomas. Trophoblastic cells secrete 
-HCG and this may be present in either tumour.

Scenario 4

Incorrect

A 7-year-old boy presents with a swelling of his right–left hemiscrotum. He is in considerable discomfort
with a temperature of 37.5 ºC. On examination his pain is very well localised to the upper pole of the
testicle. A bluish hue can be seen through the scrotal skin.

H Correct answer

H – Torsion hydatid of Morgagni

The differential diagnosis here is that of testicular torsion and torsion of a

hydatid of Morgagni. The very localised tenderness and the presence of the bluish discoloration would
make the latter the more likely diagnosis.

Theme: Renal tract calculi

 
A Conservative management
B Extracorporeal shock wave lithotripsy (ESWL)
C Nephrectomy
D Percutaneous nephrolithotomy (PCNL)
E Percutaneous nephrostomy
F Ureteroscopy
 

For each of the patients below, select the most appropriate treatment from the above
list. Each option may be used once, more than once, or not at all.

Scenario 1
 Incorrect

A 24-year-old woman presents with intermittent right loin pain. A mid-stream urine specimen (MSU)
confirms microscopic haematuria. A plain radiograph shows a 1.2-cm calculus in the region of the right
kidney. An intravenous urogram (IVU) confirms that it lies within the renal pelvis but is not causing
obstruction.

B Correct answer

B – Extracorporeal shock wave lithotripsy (ESWL)

Stones measuring < 2 cm in diameter, that lie within the kidney, are usually treated with ESWL.
Percutaneous nephrolithotomy (PCNL) is used for a stone bulk > 2 cm (or > 1 cm in the lower pole
calyx). ESWL can be used afterwards to residual fragments (called Steinstrasse, which have the
appearance of a stone street in the ureter). Stones in the lower pole calyx have poor clearance rates and
thus PCNL is the preferred option.

Scenario 2

Correct

A 45-year-old woman presents with a history of recurrent urinary tract infections (UTIs) and chronic left
loin pain. An ultrasound shows a large echogenic mass in the left pelvicalyceal system. A plain kidney
and upper bladder (KUB) demonstrates a staghorn calculus. A dimercaptosuccinic acid (DMSA) scan
shows differential split function left : right, 9 : 91.

C Correct answer

C – Nephrectomy

A staghorn calculus in a functional kidney is treated with PCNL followed by ESWL to remove residual
fragments. However, in a patient with a 15% split function, the most appropriate treatment would be
nephrectomy if the split function is < 15%.

Scenario 3

Incorrect

A 31-year-old man presents with colicky left loin pain. He is tachycardic, flushed and has a temperature
of 38.5 °C. An IVU shows a 3-mm calculus in the mid-ureter.

E Correct answer

E – Percutaneous nephrostomy

Obstructed infected kidneys need immediate drainage by percutaneous nephrostomy (from above).
Insertion of a ureteric stent (from below) is useful for preventing a stone causing a PUJ obstruction, for
the prophylaxis of stones > 1 cm prior to more definitive treatment and to keep luminal patency after
accidental or planned ureteric opening.

Theme: Benign Prostatic Hyperplasia

 
A Doxazosin
B Prazosin
C Radical prostatectomy
D Retropubic (open) prostatectomy
E Trial without catheter
F Transurethral resection of the prostate (TURP)
G Urethral catheterisation

For each of the patients below, select the most appropriate treatment from the above
list. Each option may be used once, more than once, or not at all.

The morbidity in patients with very large prostates (> 100 g) is less if open retropubic
prostatectomy is performed rather than a transurethral resection of the prostate (TURP),
as this reduces operation time and avoids excessive fluid absorption during prolonged
surgery. Finasteride is a useful treatment in men with large (> 40 g) prostates. It also
reduces prostatic bleeding.
 
One must always warn a patient undergoing TURP of the risk of retrograde ejaculation
following the operation.

Scenario 1

Incorrect

A 71-year-old man presents with acute urinary retention. On catheterisation his residual volume was 800
ml. His creatinine concentration on admission was 350 mmol/l. Following management of a
postobstructive diuresis the creatinine concentration returned to 90 mmol/l. Digital rectal examination
suggests a large benign prostate. A transrectal ultrasound shows a prostate volume of 180 ml with no
hypoechoic areas.

D Correct answer

Scenario 2

Incorrect

A 56-year-old man presents with moderate lower urinary tract symptoms. He has persistent macroscopic
haematuria. A digital rectal examination shows a large benign-feeling prostate. MSU, cytology, an IVU
and flexible cystoscopy were negative for transitional cell carcinoma. He wishes to have another child in
the near future.

B Correct answer

Scenario 3

Incorrect

A 59-year-old man presents with vague abdominal pain. An ultrasound showed bilateral hydronephrosis
with a post-micturition residual volume of 1500 ml. His serum creatinine was normal.

G Correct answer

Theme: Testicular tumours

 
A Antiandrogen therapy
B Chemotherapy
C Close follow-up
D Radical orchidectomy
E Radiotherapy
F Retroperitoneal lymph node dissection
G Testicular biopsy
 

For each of the patients below, select the most appropriate subsequent treatment from
the above list. Each option may be used once, more than once, or not at all.

The present treatment of stage I seminoma is radical orchidectomy and prophylactic

radiotherapy to the retroperitoneal nodes, although trials are under way comparing
adjuvant radiotherapy with carboplatin (adjuvant chemotherapy). More advanced
seminomas should be treated with chemotherapy also. Intratubular germ cell neoplasia
inevitably develops into cancer; therefore, a prophylactic radiotherapy dose of 20 Gy is
given to the remaining testis after sperm banking has been offered. The treatment of
residual nodes following chemotherapy and normalisation of tumour markers is
retroperitoneal lymph node dissection.
 

Teratomas are much less radiosensitive and should be treated by orchidectomy and
platinum-based combination chemotherapy.

Scenario 1
 Incorrect

A 34-year-old man presents with a hard, irregular swelling of his right testis. Alpha-fetoprotein and â-
hCG are normal. An ultrasound shows a heterogeneous mass in the upper pole of the right testis.
Investigations reveal no lymphadenopathy. A radical orchidectomy confirms a testicular seminoma which
is completely excised.

D Your answer

E Correct answer

E – Radiotherapy

Scenario 2

Incorrect

A 22-year-old man presents with a hard, irregular swelling of his right testis. Ultrasound suggests a right
testicular tumour and a left testis containing hypoechoic areas and microcalcification. A right radical
orchidectomy and a left testicular biopsy are performed. Histology shows the right testicular seminoma is
completely excised. A widespread, low-grade, intratubular, germ cell neoplasia is found on the left.

A Your answer

E Correct answer

E – Radiotherapy

Scenario 3

Correct

A 24-year-old man underwent an orchidectomy for a nonseminatous, germ cell tumour. A post-operative
CT scan shows a 7-cm mass of retroperitoneal lymphadenopathy. After a course of chemotherapy the
tumour markers normalise and CT scanning shows shrinkage of the nodal mass to 3.5 cm.

F Correct answer

F – Retroperitoneal lymph node dissection

Theme: Transitional cell carcinoma
A Cystoscopy
B Intravesical BCG
C Intravesical mitomycin
D Methotrexate, doxorubicin, cyclophosphamide (M-VAC) chemotherapy
E Nephrectomy
F Nephroureterectomy
G Radical cystectomy
H Transurethral resection of bladder tumour

For each of the patients below, select the most appropriate treatment from the above
list. Each option may be used once, more than once, or not at all.

The treatment (in most cases) of a bladder tumour is a transurethral resection (TURBT) of
the polypoid part of the tumour and a biopsy to stage muscle invasion. If it is found to be
stage T2–T4a, one should perform cystectomy ± radiotherapy, plus chemotherapy if
preferred.

The standard treatment of a transitional-cell carcinoma in either the kidney or ureter is a

nephroureterectomy, as these tumours are often multifocal and surveillance of a ureteric
stump is difficult. A cystectomy is contraindicated if enlarged pelvic lymph nodes are
detected preoperatively.

Scenario 1

Incorrect

A 64-year-old man presents with haematuria. An IVU shows normal upper tracts with a filling defect in
the bladder. Flexible cystoscopy confirms a tumour.

H Correct answer

H – Transurethral resection of bladder tumour

Scenario 2

Incorrect

A 58-year-old woman with a history of superficial bladder cancer is found to have an irregular filling
defect in the right renal pelvis. CT confirms a solid mass.

F Correct answer

F – Nephroureterectomy

Scenario 3
 Incorrect

A fit 55-year-old man presents with haematuria. Investigations reveal a bladder tumour. Transurethral
resection of bladder tumour (TURBT) shows a muscle-invasive bladder cancer (stage T2) and EUA
confirms the bladder is mobile. CT scanning shows three 2–3-cm pelvic lymph nodes.

D Correct answer

D – M-VAC chemotherapy

Theme: Imaging
 
A Cystogram
B DMSA scan
C DTPA scan
D IVU H Ultrasound
E Plain KUB
F Retrograde ureterogram
G Spiral CT scan
 

For each of the patients below, select the most appropriate treatment from the above
list. Each option may be used once, more than once, or not at all.

Scenario 1

Incorrect

A 34-year-old obese man presents with a sudden onset of colicky right loin pain radiating to his groin. He
has microscopic haematuria. He has a history of severe anaphylaxis with intravenous contrast. An
ultrasound scan is unhelpful because of obesity.

G Correct answer

G – Spiral CT scan

A non-contrast spiral CT with thin cuts will detect ‘all’ calculi. This imaging modality may be used when
an IVU or ultrasound are contraindicated or impractical.

Scenario 2
 Incorrect

A 45-year-old woman has a right staghorn calculus on plain KUB. An IVU shows this kidney fails to
excrete contrast. An ultrasound scan shows the kidney has a thin parenchyma without evidence of
hydronephrosis.

B Correct answer

B – DMSA scan

Staghorn calculi require DMSA imaging to ascertain the split function of the kidneys, as DMSA is
secreted by the kidney.

Scenario 3

Incorrect

A 22-year-old woman presents with a history of left loin pain shortly after drinking alcohol. An
ultrasound scan shows hydronephrosis with a normal calibre ureter. An IVU shows a narrowing at the
pelviureteric junction.

C Correct answer

C – DTPA scan

DTPA scans are used to show which kidney is obstructed, as it is filtered by the glomerulus. MAG-3 is
filtered and secreted, and is now the most commonly used isotope in imaging departments. PUJ
obstruction has a trimodal distribution: antenatal, teenagers (when they start drinking alcohol) and the
elderly. A diuresis in a patient with a PUJ obstruction worsens the pain and should arouse suspicion of
this condition.

Theme: Scrotal swellings

 
A Acute epididymo-orchitis
B Chylocele
C Haematocele
D Lymph varix
E Papillary cystoadenoma
F Primary hydrocele
G Strangulated inguinal hernia
H Teratoma of testis
I Torsion of testis
J Varicocele
 

For each of the following statements, select the most likely cause of scrotal pain from the
above list. Each option may be used once, more than once, or not at all.

Scenario 1

Incorrect

A 25-year-old presents with a painless, scrotal swelling of 8 months’ duration which he attributes to an
injury while playing football. On examination, the swelling over the testis is uniform, firm and smooth.
There is loss of testicular sensation.

H Correct answer

H – Teratoma of testis

Ninety per cent of testicular neoplasms are germ cell in origin and the majority are malignant. Teratomas
(seen in the 20–30-years age group) and seminomas (seen in the 30–40-years age group) are the
commonest tumours. Others include: Sertoli cell tumours (causing feminising symptoms such as
gynaecomastia) and Leydig cell tumours (causing sexual precocity). Approximately 10% of malignancies
are found in undescended testes, even after orchidopexy. Most men present with a painless swelling,
although 10% may present with an acutely painful testis. The usual presentation is a sensation of
heaviness in the testis and the groin. A history of trauma is usually given in history. Testicular sensation
is lost early. A small hydrocele may be present and the spermatic cord may be thickened from malignant
infiltration. Trans-scrotal biopsies should never be performed and the initial management is
orchidectomy.

Scenario 2

Incorrect

A 7-year-old presents with a sudden onset of severe pain in his right groin and lower abdomen associated
with vomiting. On examination, a thickened and tender spermatic cord is palpable above the testis.

I Correct answer

I – Torsion of testis

Testicular torsion is common in children. Symptoms include sudden agonising pain in the groin and lower
abdomen associated with vomiting. Torsion of the fully descended testis may be difficult to diagnose. A
high-lying testis with thickening of the tender twisted cord is observed. Elevation of the testis worsens the
pain (in contrast to epididymo-orchitis where elevation relieves the pain). However, these clinical signs
are relatively non-specific and surgical exploration is mandatory if the diagnosis is suspected.

Scenario 3
 Incorrect

A 42-year-old tall, thin man of Asian origin presents with an aching pain and a left-sided scrotal swelling
of 18 months duration. On examination, the scrotum on the left side hangs lower, cough impulse is
present and the left testis is smaller than the right. The swelling disappears on lying down.

J Correct answer

J – Varicocele

A varicocele is the varicose dilatation of the veins draining the testis. It is common in tropical countries
and usually seen in tall, thin men with a pendulous scrotum. Varicocele is generally asymptomatic but at
times may cause a vague and dragging discomfort. The scrotum on the affected side hangs lower than the
other side. The cough impulse may be present (hence a differential for an inguino-scrotal hernia). When
the patient stands the varicocele feels like a ‘bag of worms’. On lying down, the swelling disappears as
the veins empty. In long-standing cases, the affected testis is smaller because of atrophy. Varicoceles are
associated with infertility. The sudden appearance of a varicocele in a middle-aged man should always
raise the suspicion of retroperitoneal disease.

Scenario 4

Incorrect

A 37-year-old presents with a right-sided scrotal swelling. On examination, the testis is not palpable and
there is dullness on percussion. It is possible to get above the swelling.

F Correct answer

F – Primary hydrocele

Primary hydrocele is mostly seen in the middle aged. The common presenting complaint is a scrotal
swelling. On examination, a cough impulse is absent, the swelling is dull to percussion and it is clinically
possible to ‘get above’ it (thus distinguishing it from an inguino-scrotal hernia). The fluid of the
hydrocele surrounds the body of the testis, making the testis impalpable. A hydrocele is fluctuant and
trans-illuminates.

Theme: Renal presentations

 
A Acute renal failure
B Acute tubular necrosis
C Focal segmental glomerulosclerosis
D Gram-negative sepsis
E Membranous glomerulonephritis
F Renal abscess
G Renal calculi
H Renal papillary necrosis
I Renal tubular acidosis
J Renal tubular injury
 

For each of the following statements, select the most likely cause for the renal disease
from the above list. Each option may be used once, more than once, or not at all.

Scenario 1

Correct

A 32-year-old man presents to the Emergency Department with sudden excruciating right-sided
abdominal pain of 4 hours duration. The pain is radiating from the right side of his ribs towards the groin.
Urinalysis reveals red blood cells.

G Correct answer

G – Renal calculi

Patients with renal calculi present with sudden severe flank or abdominal pain which may radiate to the
scrotum or labia and/or into the ipsilateral costovertebral angle. The patient is restless and inconsolable
(unlike in acute appendicitis and perforated viscera where he or she lies still). Urinalysis usually shows
red blood cells. White blood cells may be seen if there is an associated infection. The development of
calculi may be the result of altered metabolism and excretion of calcium, uric acid, cystine or oxalate. The
calculi usually consist of the above elements either on their own or in combination. Investigations for
suspected renal calculi include: plain radiography kidneys and upper bladder (KUB), IVU, ultrasound or a
CT urogram (CTU). Calcium oxalate calculi make up about 90% of the stones. Since they are radio-
opaque, they are visible in plain radiographs. Uric acid stones are virtually radiolucent.

Scenario 2

Incorrect

A 61-year-old presents with vomiting and anorexia of 4 days duration. He has had a left nephrectomy for
chronic pyelonephritis 3 years ago and now suffers from recurrent right renal calculi. His urea is 24 and
creatinine is 461.

E Your answer

A Correct answer

A – Acute renal failure

The aetiology of acute renal failure could be classified into pre-renal (decreased renal perfusion due to
haemorrhage, dehydration, burns, sepsis, etc), renal (nephrotoxic drugs, such as NSAIDs and
angiotensinconverting enzyme inhibitors (ACE inhibitors)) and post-renal (ureteric and lower urinary
tract obstruction) causes. This patient has developed acute renal failure secondary to obstruction because
of renal calculi (only one kidney is present). It is essential to exclude obstruction as the cause for acute
renal failure, particularly in patients with a solitary kidney. Obstruction needs to be relieved either
surgically (nephrostomy / extracorporeal shock wave lithotripsy) or radiologically (percutaneous)
depending on the level and type of calculus and the patient’s general health.

Scenario 3

Incorrect

A 46-year-old patient with AIDS is noted to have proteinuria, hypoalbuminaemia and generalised oedema
1 week after a renal transplant. Renal biopsy reveals IgM deposits in the glomerulus.

A Your answer

C Correct answer

C – Focal segmental glomerulosclerosis

Focal segmental glomerulosclerosis is a recognised complication of renal transplantation. It has a higher

incidence in intravenous drug abusers and in patients with HIV infection or AIDS. The condition presents
with proteinuria, hypoalbuminaemia, oedema and hypercholesterolaemia. Biopsy of the kidney reveals
focal glomerular deposits of IgM. More than 50% of the patients progress to chronic renal failure.

Scenario 4

Incorrect

A 67-year-old man undergoes nephrostomy to relieve hydronephrosis of his right kidney. Four hours
post-operatively, he develops rigors and pyrexia and his blood pressure is 100/60 mmHg.

D Correct answer

D – Gram-negative sepsis

This patient has developed Gram-negative sepsis as a result of instrumentation of the renal tract. The
common organisms include Escherichia coli and bacteroides. Prophylaxis with an antibiotic such as
gentamicin is usually recommended before surgery or instrumentation of the renal tract. Immediate
management of Gram-negative sepsis entails antibiotics, oxygen and intravenous fluids.
Theme: Renal tract pathologies
 
A Adenocarcinoma of the kidney
B Adenoma of the renal cortex
C Angioma of the renal artery
D Angiomyolipoma
E Nephroblastoma
F Neuroblastoma
G Papillary transitional cell tumour of the renal pelvis
H Renal tuberculosis
I Squamous cell carcinoma of the renal pelvis
J Transitional cell carcinoma of the bladder
K Transitional cell tumour of the ureter
 

For each of the following statements, select the most likely cause for renal tract disease
from the above list. Each option may be used once, more than once, or not at all.

Scenario 1

Incorrect

A 55-year-old smoker presents with a dragging discomfort in his left loin. He also gives a history of
haematuria with occasional clot colic. On examination, a mass is felt over the left loin and he has a left-
sided varicocele.

A Correct answer

A – Adenocarcinoma of the kidney

Adenocarcinoma of the kidney (hypernephroma; Grawitz’s tumour) affects more males than females (2 :
1) and is more prevalent in patients over 40 years of age. Risk factors include smoking, genetic factors, a
high intake of fat, oil and milk, and exposure to toxins, such as lead, cadmium, asbestos and petroleum
products. Clinical features include: a dragging discomfort in the loin and a triad of haematuria (with
occasional clot colic), flank pain (in 35–40%) and palpable abdominal mass (in 25–45%). In men, a
rapidly developing varicocele (most often on the left) is a characteristic sign. This is because the left
testicular vein drains into the left renal vein, whereas the right testicular vein drains directly into the
inferior vena cava. The patient may also manifest symptoms of hypertension, erythrocytosis and
hypercalcaemia.

Scenario 2

Incorrect

A 20-month-old baby boy is brought to the paediatric surgical clinic by his mother who gives a history of
failure to thrive, fever and occasional blood in the nappy. On examination, a soft mass that does not cross
the midline is palpable on the right side of the abdomen.
E Correct answer

E – Nephroblastoma

Nephroblastoma (Wilms’ tumour) is a malignant mixed tumour seen in infancy. The tumours are usually
solitary, soft, lobulated and are tan or grey in colour. The infant may present with pyrexia, haematuria
(blood in the nappy), failure to thrive, and a non-tender abdominal (flank) mass. This mass does not cross
the midline which distinguishes it from neuroblastoma (which usually crosses the midline), and is more
nodular and irregular. Investigations include: blood count, biochemical profile, ultrasound scan (to
confirm the mass and to also to view the other kidney), intravenous urogram (to give anatomical detail
and an indication of renal function) and renogram. It is usually treated by total nephrectomy or partial
nephrectomy (in children with bilateral disease) followed by radiotherapy.

Scenario 3

Incorrect

A 35-year-old man of Asian origin presents with evening rise of temperature, weight loss, increased
urinary frequency and painful micturition. Urine investigation reveals a sterile pyuria.

H Correct answer

H – Renal tuberculosis

Renal tuberculosis commonly occurs in the 20–40-years age group; it is more common in males than
females (2 : 1) and the right kidney is affected more than the left. The symptoms are an increase in the
urinary frequency (both during the day and night), painful micturition, renal pain and haematuria.
Constitutional symptoms are weight loss and a slight evening rise in temperature. Chemotherapy
(pyrazinamide, isoniazid, rifampicin) forms the basis of management of genitourinary tuberculosis. The
antituberculous drugs have high urinary excretion rates.

Scenario 4

Incorrect

A 67-year-old smoker presents with a 5-month history of painless haematuria, increased frequency of
micturition and loss of weight. He worked in the dye industry before his retirement.

J Correct answer

J – Transitional cell carcinoma of the bladder

Transitional cell carcinoma of the bladder usually occurs over the age of 50 and is more common in men.
The aetiology of this condition includes cigarette smoking (more than 20 cigarettes/day has 2–6 times risk
of developing bladder cancer), working in the aniline dye and rubber industry (because of excretion of 
-naphthyl-amine in the urine), schistosomiasis infestation of the bladder and long-term catheterisation in
paraplegic patients. Patients may present with painless haematuria, dysuria, frequency and urgency of
micturition. Investigations include urine microscopy and culture (to rule out any infection) and
cystoscopy. Endoscopic resection of the mass followed by a 4–6 week course of radiotherapy to the
bladder and the pelvic side walls is useful in treating most tumours. Combination regimens of cisplatin,
methotrexate and vinblastine (and adriamycin in some cases) are useful in the treatment of metastatic
disease.

Theme: Initial treatment for patients with lower urinary tract symptoms

A    Transurethral resection of the prostate

B    5-reductase inhibitor
C    Anticholinergic
D    Urethral catheter
E    Alpha-blocker

For each of the following situations, select the most likely answer from the above list.
Each option may be used once, more than once, or not at all.

Scenario 1

Incorrect

A 70-year-old man presents with nocturia, a good urine flow, frequency, urgency, and on direct
questioning an episode of urge incontinence.

C Correct answer

This man presents with a history of filling (irritative) symptoms suggestive of an overactive bladder.
Present guidelines from the International Continence Society suggest initial treatment with an
anticholinergic agent, if this is unsuccessful then urodynamic studies should be performed.

Scenario 2

Incorrect

A 60-year-old, commercial airline pilot presents with a poor urine flow and hesitancy. This man has an
obstructed-looking flow rate trace and is keen to avoid surgery.

B Correct answer

This man presents with obstructive symptoms and is keen to avoid surgery. Typically, a patient with
symptoms such as these would be offered an alpha-blocker. However, such a drug would be
contraindicated for a pilot because of the recognised side-effect of postural hypotension. An alternative is
a 5-reductase inhibitor, although patients should be informed that it may take several months before they
notice any effect of the drug.

Scenario 3

Incorrect

A 94-year-old man presents with a poor urine flow, hesitancy and a feeling of incomplete bladder
emptying, with bilateral moderate hydronephrosis on ultrasound and a residual volume of 2 litres. His
creatinine is elevated at 200 mol/l.

D Correct answer

This patient presents in chronic retention of urine with bilateral hydronephrosis and renal impairment. In
the first instance this patient requires catheterisation, following which his options include either a long-
term catheter or a TURP.

Scenario 4

Incorrect

A 74-year-old man presents with a poor urine flow, hesitancy and an ultrasound demonstrating a small
bladder calculus.

A Correct answer

The patient has symptoms suggestive of bladder outflow obstruction. The presence of a bladder calculus,
formed most commonly as a result of outflow obstruction due to an enlarged prostate gland, is an
indication for a TURP.

Theme: Testicular swellings

A    Maldescended testis

B    Epididymo-orchitis
C    Testicular torsion
D    Spermatocele
E    Hydrocele
F    Varicocele
G    Teratoma of the testis
For each of the following situations, select the most likely answer from the above list.
Each option may be used once, more than once or not at all.

Scenario 1

Incorrect

A 21-year-old man presents with non-tender swelling in the scrotum and a mass in the neck.

G Correct answer

Testicular tumours can cause supraclavicular lymphadenopathy.

Scenario 2

Incorrect

A 30-year-old man with bilateral peri-mandibular swelling presents with painful testes.

B Correct answer

Epididymo-orchitis may occur secondary to mumps, though is usually a complication of a urinary tract
infection (UTI), prostatitis or urethritis. It may also be associated with hydrocele or urinary tract
tuberculosis.

Scenario 3

Incorrect

An 83-year-old man with a mass in the left flank presents with swelling and discomfort in the left testis,
which does not resolve on lying down.

F Correct answer

Varicocele (varicosity of the pampiniform plexus) occurs more frequently on the left side, due to
testicular vein drainage. The patient is elderly with a renal mass, most likely he has a renal carcinoma
causing renal vein obstruction and secondary varicocele.
Theme: Testicular swellings

A    Teratoma
B    Seminoma
C    Leydig-cell tumour
D    Sertoli-cell tumour

For each of the following situations, select the most likely answer from the above list.
Each option may be used once, more than once or not at all.

Scenario 1

Incorrect

A 22-year-old man presents with a painless swelling in his right testis.

A Correct answer

This is the commonest testicular tumour in this age group.

Scenario 2

Incorrect

A 25-year-old man presents with a painless swelling in his right testis and -fetoprotein (AFP) is raised.

A Correct answer

This is the commonest tumour in this age group and AFP is raised in 70% of these tumours.

Theme: Renal physiology

A    Distal tubule

B    Proximal convoluted tubule
C    Descending limb of loop of Henle
D    Ascending limb of loop of Henle
E    Collecting ducts
For each of the scenarios given choose the most appropriate site of action. Each option
may be used once, more than once, or not at all.

Sodium moves by co-transport or exchange from the tubular lumen into the tubular epithelial
cells down its concentration gradient; it is actively pumped from these cells into the
interstitial space. Sodium is mostly absorbed in the proximal convoluted tubule (70%). Glucose
reabsorption occurs in association with sodium in the early portion of the proximal convoluted
tubule. Facultative potassium control is in the distal convoluted tubule Na +/K+ ATPase pump,
which is regulated by aldosterone. The descending loop of Henle is permeable to water.

Scenario 1

Incorrect

Site of facultative potassium control.

A Correct answer

Scenario 2

Incorrect

Main site of glucose re-absorption.

B Correct answer

Scenario 3

Incorrect

Main site of sodium re-absorption.

B Correct answer

Scenario 4

Incorrect

Generation of hyperosmolality of renal medullary interstitium.

C Correct answer
Theme: Abdominal pain

A    Renal adenocarcinoma

B    Ureteric colic
C    Pelviureteric obstruction
D    Aortic aneurysm

For each of the scenarios given choose the most likely diagnosis. Each option may be used
once, more than once, or not at all.

The presentation of the patient in case 1 is classically that of renal carcinoma; however, this
triad of symptoms and signs occurs in only 30% of cases. Any male patient aged over 55 years
who presents with loin pain should be suspected of having a leaking abdominal aortic
aneurysm (AAA) till proven otherwise, because AAAs are more common in this age group than
urinary stones.

Scenario 1

Correct

A 55-year-old man presents with haematuria, loin pain and a loin mass. He has lost weight recently.

A Correct answer

Scenario 2

Incorrect

A 22-year-old patient gets loin pain mainly in the morning after drinking four cups of coffee.

B Your answer

C Correct answer

Scenario 3

Correct

A 70-year-old patient presents with loin pain, with pulse 120/min and BP 80/60.

D Correct answer
THEME: URINE PLASMA (U/P) OSMOLARITY RATIO

A    High urine Na+ and high U/P ratio

B    High urine Na+ and low U/P ratio
C    Low urine Na+ and high U/P ratio
D    Low urine Na+ and low U/P ratio
E    Normal U/P + high creatinine clearance
F    Normal U/P + low creatinine clearance

For each of the cases described below, select the single most appropriate option from
those listed above. Each option may be used once, more than once, or not at all.

In pre-renal failure, the urine sodium is low and the U/P osmolarity ratio is high. In renal
failure due to intrinsic disease or damage, the urine sodium is high as there is a failure of
absorption and thus the U/P ratio is low.

Scenario 1

Incorrect

Acute cortical necrosis.

B Correct answer

Scenario 2

Incorrect

Water depletion.

C Correct answer

Scenario 3

Incorrect

Partial ureteric obstruction.

F Correct answer

Scenario 4
 Incorrect

Hypovolaemia due to bleeding.

C Correct answer

THEME: SITES OF DRUG ACTION IN THE KIDNEY

A    Distal convoluted tubule

B    Proximal convoluted tubule
C    Ascending loop of Henle
D    Descending loop of Henle
E    Collecting ducts

For each of the drugs listed below, select the single most appropriate site of action from
the options listed above. Each option may be used once, more than once, or not at all.

Scenario 1

Incorrect

Frusemide.

C Correct answer

Frusemide is a loop diuretic and inhibits the sodium potassium chloride co-transport in the thick
ascending limb of Henle’s loop. It causes potassium loss in addition to sodium loss. Increased elimination
of salt or water decreases cardiac preload and reduces oedema.

Scenario 2

Incorrect

Amiloride.

A Correct answer

Amiloride is a non-competitive antagonist of aldosterone in the distal convoluted tubule. Its effect on the
sodium transport at this site is responsible for its therapeutic action. It is commonly used in combination
with frusemide because of its potassium-sparing action.

Scenario 3

Incorrect
ADH- Anti Diuretic Hormone.

E Correct answer

ADH acts on the collecting ducts making them more permeable to water. Consequently water leaves the
collecting ducts passively down its osmotic gradient from tubular fluid into the highly concentrated
papillary interstitium. This process results in the formation of a small volume of highly concentrated
urine.

Scenario 4

Incorrect

Aldosterone.

A Correct answer

Aldosterone is the main mineralocorticoid secreted by the adrenal cortex. It has approximately 1000 times
more activity than hydrocortisone as a mineralocorticoid. Aldosterone acts on the distal convoluted tubule
binding intracellularly to the mineralocorticoid receptor which controls sodium-potassium exchange. The
effect of aldosterone is to increase sodium and cause urinary loss of potassium and hydrogen ions.

Theme: Urology - loin pain

A    Urinary calculi

B    Pyelonephritis
C    Leaking aortic aneurysm
D    Pancreatitis
E    urinary bladder obstruction
F    Pelvi-ureteric junction obstruction
G    Renal cell carcinoma

For each of the patients described below, select the most likely diagnosis from the list of
options above. Each option may be used once, more than once or not at all. You may
believe that more than one diagnosis is possible but you should choose the ONE most
likely diagnosis.

Scenario 1

Incorrect

A 25-year-old female presents to her general practitioner with a 6-month history of recurrent left loin
pain. She says that the pain is worse in the morning. She consumes 3–4 cups of coffee before work.
F Correct answer

Loin pain in a young female patient, with the pain worsening after drinking 3–4 cups of coffee, is most
likely to be due to pelvic ureteric obstruction. Symptoms of ureteric obstruction in adults usually occur
after a fluid overload.

Scenario 2

Incorrect

A 22-year-old man presents to the emergency department with left loin pain, pyrexia and tachycardia.

B Correct answer

One would suspect pyelonephritis in a young male patient with loin pain, pyrexia and tachycardia.

Scenario 3

Incorrect

An 18-year-old man presents to the emergency department with pain in the right iliac fossa and
microscopic haematuria.

A Correct answer

An 18-year-old man with right iliac fossa pain and microscopic haematuria is most likely to have a
urinary calculus until proven otherwise.

Scenario 4

Incorrect

A 55-year-old lady, with previous history of bilateral reflux, presents to the emergency department with
dysuria, fever and feeling generally unwell.

B Correct answer

The diagnosis would most likely be a pyelonephritis in view of the bilateral reflux, dysuria, malaise and
fever.

Scenario 5

Incorrect

A 75-year-old man presents to the emergency department with hypotension, tachycardia and acute onset
of loin pain, with the pain radiating to the back.
C Correct answer

A 75-year-old man with hypotension, tachycardia and acute onset of loin/back pain would make one
suspect a diagnosis of leaking or ruptured abdominal aortic aneurysm.

Scenario 6

Incorrect

A 53-year-old man presents to the surgical outpatient clinic with a right-sided loin mass, haematuria and
loin pain.

G Correct answer

A 53-year-old man with a loin mass, pain and haematuria would point towards a diagnosis of renal cell
carcinoma.

THEME: Scrotal swellings

A    Epidydimal cyst

B    Hydrocele
C    Varicocele
D    Scrotal haematoma
E    Testicular tumour

For each of the following clinical scenarios select the most likely answer from the list
above. Each option may be used once, more than once or not at all.

Scenario 1

Incorrect

A young man presents to the clinic with a ‘dragging sensation’ in his scrotum. On palpation the scrotum
feels like a ‘bag of worms’.

C Correct answer

A varicocele is a varicosity of the pampiniform plexus. The left side is more commonly affected than the
right. There is a rare association with carcinoma of the left kidney.

Scenario 2
 Incorrect

A patient has a vasectomy. He presents a day later with bruising and swelling of his scrotum.

D Correct answer

Scrotal haematoma is a complication of operations on the testis, cord or scrotal structures. It can also
occur after trauma. Treatment is analgesia and scrotal support.

Scenario 3

Incorrect

An elderly man presents with a large painless scrotum. The scrotum transilluminates.

B Correct answer

A hydrocele occurs when fluid collects in the tunica vaginalis. Testicular tumours can present as
hydroceles, so ultrasound of the scrotum is recommended. They can be repaired surgically with
Jaboulay’s procedure – the sac is incised longitudinally, everted and approximated behind the cord.

Scenario 4

Incorrect

A young man presents with a painless hard lump in his testicle.

E Correct answer

Testicular tumours are the most common malignancy in young men. They are associated with maldescent
of the testicle. The most common types are seminomas, followed by non-seminomatous germ cell
tumours. Primary treatment is orchidectomy.

Scenario 5

Incorrect

On routine examination, a patient is noted to have a swelling above and behind his testicle.

A Correct answer

Epididymal cysts are generally painless, but patients sometimes complain of discomfort. They can be
confirmed by ultrasound. No treatment is necessary.
Theme: Urine output

A    Acute tubular necrosis

B    Acute urine retention
C    Blocked catheter
D    Dehydration
E    Ureteric obstruction
F    Chronic renal failure

Match the most appropriate option from the list above to each clinical situation described
below. Each option may be used once only, more than once or not at all.

Acute tubular necrosis is a common cause of acute renal failure in hospital, and in the
post-AAA repair patient, especially in an emergency scenario, this is usually due to
systemic hypotension (e.g. due to haemorrhage).
In the surgical patient with low urinary output always ensure there is not an obstruction.
This may be a blocked catheter or, if the patient is not catheterised, acute retention.
Acute retention is common in elderly men. Also check hydration.
The minimum urine output acceptable is 0.5 ml/kg/h, but ideally it should be 1–2 ml/kg/h.

Scenario 1

Incorrect

Post-operative emergency AAA repair in the intensive care unit. The patient is haemodynamically stable
with good peripheralcirculation, but his urine output is fluctuating between 1 and 5ml/h.

A Correct answer

Scenario 2

Incorrect

A woman who underwent an open cholecystectomy 24 h ago drops her urine output to 15 ml in 4 h. She
is hypotensive.

D Correct answer

Scenario 3
 Incorrect

A 68-year-old man who underwent a bilateral inguinal hernia repair has had no urine output in 36 h. He is
not catheterised.

B Correct answer

Scenario 4

Incorrect

A catheterised patient who is in the high-dependency unit with acute pancreatitis had a previously good
urine output. He is well hydrated. He has now been anuric for the last 2 h.

C Correct answer

Theme: Prostate cancer

A    Thermotherapy
B    Local radical therapy (surgery or radiotherapy)
C    Immunotherapy
D    Palliative radiotherapy
E    Phytotoxic chemotherapy
F    Tamoxifen therapy
G    Transurethral prostatectomy (TURp)
H    Watchful waiting
I    Androgen deprivation therapy

For each of the patients described below, select the single most likely intervention from
the options listed above. Each option may be used once, more than once or not at all.

Treatment of prostate cancer: TURP if there is obstruction. If there is no obstruction

treatment remains controversial. Hormonal therapy, orchidectomy to slow down tumour
growth. Cyproterone acetate, stilboestroel and local radiotherapy are alternatives.
Analgesia and radiotherapy to painful metastasis.

Scenario 1

Incorrect
An 89-year-old frail man presents with acute urinary retention. There is well-differentiated prostatic
adenocarcinoma in 3 out of 50 chips from the prostatectomy specimen.

H Correct answer

Scenario 2

Incorrect

A 72-year-old man presents with back pain and is found to have carcinoma of the prostate with a positive
bone scan, liver metastasis and prostate specific antigen of 450 ng/ml.

D Correct answer

Scenario 3

Incorrect

A 65-year-old man with known prostatic adenocarcinoma for which he had undergone a bilateral
orchidectomy presents with a wedge fracture of the third lumbar vertebra.

B Correct answer

Scenario 4

Incorrect

A 48-year-old man whose father died of prostate cancer presents with voiding dysfunction and prostate
specific antigen of 5 ng/ml. He is found to have localised prostate cancer.

G Correct answer