1/3 Question 1-3 of 78

Theme: Management of urinary tract calculi

A. Nephrectomy
B. Open ureteric exploration
C. Extra corporeal shock wave lithotripsy
D. Percutaneous nephrostomy
E. Pyeloplasty
F. Conservative management
G. Percutaneous nephrolithotomy

Please select the most appropriate management for the scenario given. Each option may be used once, more
than once or not at all.

1. A 23 year old male is admitted with left sided loin pain and fever. His investigations demonstrate a left
sided ureteric calculi that measures 0.7cm in diameter and associated hydronephrosis.

You answered Percutaneous nephrolithotomy

The correct answer is Percutaneous nephrostomy

Theme from January 2013 Exam

An obstructed, infected system is an indication for urgent decompression. This may be achieved by
ureteroscopy or nephrostomy. In addition to this the patient should also receive broad spectrum,
intravenous antibiotics.

2. A 23 year old man is admitted with left sided loin pain that radiates to his groin. His investigations
demonstrate a 1cm left sided ureteric calculus with no associated hydronephrosis.

Extra corporeal shock wave lithotripsy

Stones with a total volume of less than 2cm can be considered for lithotripsy. If it is impacted in the
upper ureter then some may consider a ureteroscopy.

3. A 30 year old male presents with left sided loin pain. His investigations demonstrate a large left sided
staghorn calculus that measures 2.3cm in diameter.

You answered Extra corporeal shock wave lithotripsy

The correct answer is Percutaneous nephrolithotomy

Large, proximal stones are generally best managed with a percutaneous nephrolithotomy. The use of
lithotripsy has low clearance rates. Where stones remain after the initial procedure a repeat
percutaneous nephrolithotomy is generally preferred over follow up lithotripsy.
Management of renal stones

Urolithiasis will affect up to 15% of the worldwide population. The development of sudden onset loin to groin
pain which is colicky in nature is a classic feature in the history. It is nearly always associated with haematuria
that is either micro or macroscopic.
Where the diagnosis is suspected the most sensitive and specific diagnostic test is helical, non contrast,
computerised tomographic (CT) scanning.

Management
Most renal stones measuring less than 5mm in maximum diameter will typically pass within 4 weeks of
symptom onset. More intensive and urgent treatment is indicated in the presence of ureteric obstruction, renal
developmental abnormality such as horseshoe kidney and previous renal transplant. Ureteric obstruction due to
stones together with infection is a surgical emergency and the system must be decompressed. Options include
nephrostomy tube placement, insertion of ureteric catheters and ureteric stent placement.
In the non emergency setting the preferred options for treatment of stone disease include extra corporeal shock
wave lithotripsy, percutaneous nephrolithotomy, ureteroscopy, open surgery remains an option for selected
cases. However, minimally invasive options are the most popular first line treatment.

Shock wave lithotripsy

A shock wave is generated external to the patient, internally cavitation bubbles and mechanical stress lead to
stone fragmentation. The passage of shock waves can result in the development of solid organ injury.
Fragmentation of larger stones may result in the development of ureteric obstruction. The procedure is
uncomfortable for patients and analgesia is required during the procedure and afterwards.

Ureteroscopy
A ureteroscope is passed retrograde through the ureter and into the renal pelvis. It is indicated in individuals
(e.g. pregnant females) where lithotripsy is contraindicated and in complex stone disease. In most cases a stent
is left in situ for 4 weeks after the procedure.

Percutaneous nephrolithotomy
In this procedure access is gained to the renal collecting system. Once access is achieved, intra corporeal
lithotripsy or stone fragmentation is performed and stone fragments removed.

Therapeutic selection
Disease Option
Stone burden of less than 2cm in aggregate Lithotripsy
Stone burden of less than 2cm in pregnant females Ureteroscopy
Complex renal calculi and staghorn calculi Percutaneous nephrolithotomy
Ureteric calculi less than 5mm Manage expectantly

3/3 Question 4-6 of 78

Theme: Testicular disorders

A. Antibiotics
B. Aspiration
C. Testicular exploration after 6 hours
D. Testicular exploration within 6 hours
E. Orchidectomy via inguinal approach
F. Orchidectomy via scrotal approach
G. No treatment needed
H. Ligation of patent processus vaginalis via inguinal approach
I. Jaboulay procedure via scrotal approach

For each scenario please select the most appropriate management. Each option may be used once, more than
once or not at all.

4. A parent brings her 4 year old child to the surgical clinic. She has noticed an intermittent swelling in
the right scrotum that is worse in the evening. On examination he has a soft fluctuant swelling in the
right scrotum that cannot be separated from the testis. It transilluminates when a pen torch is held
against it.

Ligation of patent processus vaginalis via inguinal approach

In children a hydrocele is most commonly due to a persistent processus vaginalis. The swelling is
intermittent and in most cases that are diagnosed in infancy the hydrocele resolves. Cases that persist
beyond two years of age are best managed surgically and the surgical approach is usually made via the
inguinal canal where the patent processus is identified and ligated.

5. A 20 year old complains of severe pain in the right scrotal area after jumping onto his moped. He has
noticed discomfort intermittently in this area over the past few months. Clinically the testis is tender.

Testicular exploration within 6 hours

Testicular torsion: Severe pain which can be spontaneous or precipitated by minor trauma. The patient
may have noticed pain previously. Surgical intervention is needed as soon as possible to prevent the
risk of loss of the testis.

6. A 44 year old man is referred to the clinic because of an swelling in the right scrotum. This is present
most of the time and he is otherwise well with no urinary symptoms. On examination he has a soft,
fluctuant swelling in the right scrotum that transilluminates easily. An ultrasound is performed that
confirms that the underlying testicle is structurally normal.

Jaboulay procedure via scrotal approach

Adult hydroceles are less commonly due to the persistence of embryonic remnants and therefore can
be managed via a scrotal approach. Both the Lords and Jaboulay procedures are reasonable options.

Scrotal swelling

Differential diagnosis
Inguinal hernia If inguinoscrotal swelling; cannot "get above it" on examination
 Cough impulse may be present
May be reducible
Testicular tumours Often discrete testicular nodule (may have associated hydrocele)
Symptoms of metastatic disease may be present
USS scrotum and serum AFP and β HCG required
Acute epididymo- Often history of dysuria and urethral discharge
orchitis Swelling may be tender and eased by elevating testis
Most cases due to Chlamydia
Infections with other gram negative organisms may be associated with underlying
structural abnormality
Epidiymal cysts Single or multiple cysts
May contain clear or opalescent fluid (spermatoceles)
Usually occur over 40 years of age
Painless
Lie above and behind testis
It is usually possible to "get above the lump" on examination
Hydrocele Non painful, soft fluctuant swelling
Often possible to "get above it" on examination
Usually contain clear fluid
Will often transilluminate
May be presenting feature of testicular cancer in young men
Testicular torsion Severe, sudden onset testicular pain
Risk factors include abnormal testicular lie
Typically affects adolescents and young males
On examination testis is tender and pain not eased by elevation
Urgent surgery is indicated, the contra lateral testis should also be fixed
Varicocele Varicosities of the pampiniform plexus
Typically occur on left (because testicular vein drains into renal vein)
May be presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicoceles may affect fertility

Management

• Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high
ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour.
• Torsion is commonest in young teenagers and the history in older children can be difficult to elicit.
Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular
fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch.
• Varicoceles are usually managed conservatively. If there are concerns about testicular function of
infertility then surgery or radiological management can be considered.
• Epididymal cysts can be excised using a scrotal approach
• Hydroceles are managed differently in children where the underlying pathology is a patent processus
vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In
adults a scrotal approach is preferred and the hydrocele sac excised or plicated.

1/3 Question 7-9 of 78

Theme: Urinary tract trauma

A. Urinary tract infection

B. Bladder outlet obstruction
C. Bulbar urethral rupture
D. Membranous urethral rupture
E. Bladder rupture
F. Bladder contusion

For the scenario given please select the most likely injury. Each option may be used once, more than once or not
at all.

7. A 56 year old man is involved in a road traffic accident. He is found to have a pelvic fracture. He
reports that he has some lower abdominal pain. He has peritonism in the lower abdomen. The nursing
staff report that he has not passed any urine. A CT scan shows evidence of free fluid.

Bladder rupture

A pelvic fracture and lower abdominal peritonism should raise suspicions of bladder rupture
(especially as this man cannot pass urine).

8. A 52 year old man falls off his bike. He is found to have a pelvic fracture. On examination he is found
to have perineal oedema and on PR the prostate is not palpable. A urine dipstick shows blood.

You answered Bulbar urethral rupture

The correct answer is Membranous urethral rupture

A pelvic fracture and highly displaced prostate should indicate a diagnosis of membranous urethral
rupture.

9. A 52 year old woman falls out of a tree while rescuing a cat. She has a pelvic fracture. She has
suprapubic tenderness and complains of dysuria. Her abdomen is soft and non tender. A urine dipstick
shows blood, nitrites and leucocytes.

You answered Bladder contusion

The correct answer is Urinary tract infection

There is no indication of a more sinister diagnosis here. The patient's abdomen is normal and she is
able to pass urine. Her dipstick confirms an infection. Also in women urethral injury is rare.
Similar theme questions in September 2009 and April
2010

Lower genitourinary tract trauma

• Most bladder injuries occur due to blunt trauma

 • 85% associated with pelvic fractures
• Easily overlooked during assessment in trauma
• Up to 10% of male pelvic fractures are associated with urethral or bladder injuries

Types of injury

Urethral injury • Mainly in males

• Blood at the meatus (50% cases)
• There are 2 types:

i.Bulbar rupture
- most common
- straddle type injury e.g. bicycles
- triad signs: urinary retention, perineal haematoma, blood at the meatus
ii. Membranous rupture
- can be extra or intraperitoneal
- commonly due to pelvic fracture
- Penile or perineal oedema/ hematoma
- PR: prostate displaced upwards (beware co-existing retroperitoneal
haematomas as they may make examination difficult)

- Investigation: ascending urethrogram

- Management: suprapubic catheter (surgical placement, not percutaneously)
External genitalia injuries (i.e., • Secondary to injuries caused by penetration, blunt trauma,
the penis and the scrotum) continence- or sexual pleasure-enhancing devices, and mutilation

Bladder injury • rupture is intra or extraperitoneal

• presents with haematuria or suprapubic pain
• history of pelvic fracture and inability to void: always suspect
bladder or urethral injury
• inability to retrieve all fluid used to irrigate the bladder through a
Foley catheter indicates bladder injury
• investigation- IVU or cystogram
• management: laparotomy if intraperitoneal, conservative if
extraperitoneal

Question 10 of 78
Which of the following renal stone types is most radiodense on a plain x-ray?

A. Calcium phosphate

B. Calcium oxalate

C. Uric acid

D. Struvite

E. Cystine
Calcium phosphate stones are the most radiodense stones, calcium oxalate stones slightly less so. Uric acid
stones are radiolucent (unless they have calcium contained within them).

Renal stones

Type of Features Percentage of all

stones calculi
Calcium Hypercalciuria is a major risk factor (various causes) 85%
oxalate Hyperoxaluria may also increase risk
Hypocitraturia increases risk because citrate forms complexes with calcium
making it more soluble
Stones are radio-opaque (though less than calcium phosphate stones)
Hyperuricosuria may cause uric acid stones to which calcium oxalate binds
Cystine Inherited recessive disorder of transmembrane cystine transport leading to 1%
decreased absorption of cystine from intestine and renal tubule
Multiple stones may form
Relatively radiodense because they contain sulphur
Uric acid Uric acid is a product of purine metabolism 5-10%
May precipitate when urinary pH low
May be caused by diseases with extensive tissue breakdown e.g. malignancy
More common in children with inborn errors of metabolism
Radiolucent
Calcium May occur in renal tubular acidosis, high urinary pH increases 10%
phosphate supersaturation of urine with calcium and phosphate
Renal tubular acidosis types 1 and 3 increase risk of stone formation (types 2
and 4 do not)
Radio-opaque stones (composition similar to bone)
Struvite Stones formed from magnesium, ammonium and phosphate 2-20%
Occur as a result of urease producing bacteria (and are thus associated with
chronic infections)
Under the alkaline conditions produced, the crystals can precipitate
Slightly radio-opaque

Effect of urinary pH on stone formation

Urine pH will show individual variation (from pH 5-7). Post prandially the pH falls as purine metabolism will
produce uric acid. Then the urine becomes more alkaline (alkaline tide). When the stone is not available for
analysis the pH of urine may help to determine which stone was present.

Stone type Urine acidity Mean urine pH

Calcium phosphate Normal- alkaline >5.5
Calcium oxalate Variable 6
Uric acid Acid 5.5
Struvate Alkaline >7.2
Cystine Normal 6.5

0/3 Question 11-13 of 78

Theme: Scrotal swellings

A. Haematocele
B. Epididymal cyst
C. Hydrocele
D. Testicular torsion
E. Orchitis
F. Epididymo-orchitis

For each case please select the most likely underlying diagnosis from the list. Each option may be used once,
more than once or not at all.

11. A 32 year old male presents with a swollen right scrotum which has developed over 3 weeks after
being kicked in the groin area. There is a non tense swelling of the right scrotum and the underlying
testis cannot be easily palpated. A dipstick is positive for nitrates only.

You answered Haematocele

The correct answer is Hydrocele

This is a secondary hydrocele which occurs in patients aged 20-40 years. It develops rapidly and there
may not be a tense swelling. The underlying testis is NOT palpated therefore indicating a hydrocele.
Causes include trauma, infection and tumour.

12. A 40 year old male presents with a non painful, bilateral scrotal swellings over 3 years. The testis is
felt separately and the swelling transilluminates.

You answered Hydrocele

The correct answer is Epididymal cyst

The testis is palpated therefore this differentiates it from a hydrocele

13. A 32 year old male presents with a swollen, painful right scrotum after being kicked in the groin area
1 hour ago. There is a painful swelling of the right scrotum and the underlying testis cannot be easily
palpated.

You answered Testicular torsion

The correct answer is Haematocele

Acute haematocele: tense, tender and non transilluminating mass post trauma. A chronic haematoma
causes a blood clot to surround the testis. The blood clot hardens and contracts causing a hard mass
which may be indistinguishable from a tumour. Therefore the testis will need surgical exploration.
Scrotal swelling

Differential diagnosis
Inguinal hernia If inguinoscrotal swelling; cannot "get above it" on examination
Cough impulse may be present
May be reducible
Testicular tumours Often discrete testicular nodule (may have associated hydrocele)
Symptoms of metastatic disease may be present
USS scrotum and serum AFP and β HCG required
Acute epididymo- Often history of dysuria and urethral discharge
orchitis Swelling may be tender and eased by elevating testis
Most cases due to Chlamydia
Infections with other gram negative organisms may be associated with underlying
structural abnormality
Epidiymal cysts Single or multiple cysts
May contain clear or opalescent fluid (spermatoceles)
Usually occur over 40 years of age
Painless
Lie above and behind testis
It is usually possible to "get above the lump" on examination
Hydrocele Non painful, soft fluctuant swelling
Often possible to "get above it" on examination
Usually contain clear fluid
Will often transilluminate
May be presenting feature of testicular cancer in young men
Testicular torsion Severe, sudden onset testicular pain
Risk factors include abnormal testicular lie
Typically affects adolescents and young males
On examination testis is tender and pain not eased by elevation
Urgent surgery is indicated, the contra lateral testis should also be fixed
Varicocele Varicosities of the pampiniform plexus
Typically occur on left (because testicular vein drains into renal vein)
May be presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicoceles may affect fertility

Management

• Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high
ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour.
• Torsion is commonest in young teenagers and the history in older children can be difficult to elicit.
Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular
fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch.
• Varicoceles are usually managed conservatively. If there are concerns about testicular function of
infertility then surgery or radiological management can be considered.
• Epididymal cysts can be excised using a scrotal approach
• Hydroceles are managed differently in children where the underlying pathology is a patent processus
vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In
adults a scrotal approach is preferred and the hydrocele sac excised or plicated.
1/3 Question 14-16 of 78
Theme: Management of testicular disorders

A. Antibiotics
B. Aspiration
C. Testicular exploration after 6 hours
D. Testicular exploration within 6 hours
E. Orchidectomy via inguinal approach
F. Orchidectomy via scrotal approach
G. No treatment needed

Please select the most appropriate management for the scenario given. Each option may be used once, more
than once or not at all.

14. A 20 year old male notices a mild painful swelling of his right scrotum. He also complains of
abdominal pain. Clinically the patient is found to have a swollen right testicle. Apart from a
supraclavicular node, there is no obvious lymphadenopathy.

Orchidectomy via inguinal approach

The patient is likely to have a teratoma which has metastasized to the supraclavicular nodes. There is
suspicion of spread to the para-aortic nodes due to the abdominal pain. He will need orchidectomy
and combination chemotherapy. There is no role for orchidectomy via scrotal approach in
malignancy.

15. A 40 year old male presents with a non painful, bilateral scrotal swellings over 3 years. The testis is
felt separately and the swelling transilluminates.

You answered Aspiration

The correct answer is No treatment needed

This is an epididymal cyst, the testis is palpated therefore this differentiates it from a hydrocele.

16. A 32 year old male presents with a swollen, painful right scrotum after being kicked in the groin area.
There is a painful swelling of the right scrotum and the underlying testis cannot be easily palpated.

You answered Testicular exploration after 6 hours

The correct answer is Testicular exploration within 6 hours

Acute haematocele: tense, tender and non transilluminating mass. The testis will need surgical
exploration to evacuate the blood and repair any damage.

Question 17 of 78
A 75 year old man presents with locally advanced carcinoma of the prostate and vertebral body metastasis and
impending spinal cord compression. Which of the following agents (if used in isolation) carries the greatest risk
of worsening his symptoms in the short term?

A. Surgical orchidectomy

B. Cyproterone acetate

C. Luetenising hormone releasing hormone analogues

D. Flutamide

E. None of the above

LHRH analogues may cause flare of metastatic disease and anti androgens should be administered to counter
this. Surgical orchidectomy reduces testosterone levels within 8 hours (but fails to reduce adrenal androgen
release). Cyproterone and flutamide are androgen blockers that may be considered as add on therapy to reduce
the risk of tumour flare when commencing treatment with LH RH analogues.

Prostate Cancer

Prostate Cancer
This is a common condition and up to 30,000 men are diagnosed with the condition each year. Up to 9,000 will
die in in the UK from the condition per year.

Diagnosis
Early prostate cancers have few symptoms.
Metastatic disease may present as bone pain.
Locally advanced disease may present as pelvic pain or with urinary symptoms.
Prostate specific antigen measurement
Digital rectal examination
Trans rectal USS (+/- biopsy)
MRI/ CT and bone scan for staging.

PSA Test
The normal upper limit for PSA is 4ng/ml. However, in this group will lie patients with benign disease and
some with localised prostate cancer. False positives may be due to prostatitis, UTI, BPH, vigorous DRE.
The percentage of free: total PSA may help to distinguish benign disease from cancer. Values of <20% are
suggestive of cancer and biopsy is advised.

Pathology

• 95% adenocarcinoma
• In situ malignancy is sometimes found in areas adjacent to cancer. Multiple biopsies needed to call true
in situ disease.
• Often multifocal- 70% lie in the peripheral zone.
• Graded using the Gleason grading system, two grades awarded 1 for most dominant grade (on scale of
1-5) and 2 for second most dominant grade (scale 1-5). The two added together give the Gleason score.
Where 2 is best prognosis and 10 the worst.
• Lymphatic spread occurs first to the obturator nodes and local extra prostatic spread to the seminal
 vesicles is associated with distant disease.

Treatment

• Watch and wait- Elderly, multiple co-morbidities, low Gleason score

• Radiotherapy (External)- Both potentially curative and palliative therapy possible. Similar survival
figures to surgery. However, radiation proctitis and rectal malignancy are late problems. Brachytherapy
is a modification allowing internal radiotherapy.
• Surgery- Radical prostatectomy. Surgical removal of the prostate is the standard treatment for localised
disease. The robot is being used increasingly for this procedure. As well as the prostate the obturator
nodes are also removed to complement the staging process. Erectile dysfunction is a common side
effect.
• Hormonal therapy- Testosterone stimulates prostate tissue and prostatic cancers usually show some
degree of testosterone dependence. 95% of testosterone is derived from the testis and bilateral
orchidectomy may be used for this reason. Pharmacological alternatives include LHRH analogues and
anti androgens (which may be given in combination).

Question 18 of 78
A 42 year old man undergoes a vasectomy at the surgical clinic. He is reviewed at the request of his general
practitioner. On examination he has a small rounded nodule adjacent to the vas. What is the most likely
underlying diagnosis?

A. Haematoma

B. Sperm granuloma

C. Varicocele

D. Hydrocele

E. Epididymal cyst

Sperm granulomas are a common sequelae of vasectomy and are smooth round lumps adherant to the vas. They
may be safely left alone.

Vasectomy

Vasectomy is a commonly performed technique for achieving permanent sterilisation. It has a failure rate of 1 in
2000 and is conveniently performed under local anaesthesia.
Reversal success rates are approximately 55% if performed within 10 years of the procedure. For the purposes
of counseling the procedure should be deemed permanent.

Procedure
Small bilateral incisions and formal dissection of the vas is the standard technique. A technique involving the
use of haemostats for skin puncture is used in the "no scalpel"
technique. It is not necessary to routinely send the vas for histology.

Controversies
Be wary of performing the procedure in childless, single men under age 30.

Risks
Following the procedure between 12 and 52% of men reported chronic scrotal pain. Of which 5.2% sought help.
Haematomas and sperm granulomas may also occur.

Follow up
Viable sperm may persist following surgery. Clearance should not be granted until a negative sperm sample is
available. This is usually taken after 12-16 weeks post procedure (and preferably after 24 ejaculates).
Recanalisation may occur in 0.04% of cases.In a small minority of men, non-motile sperm persist after
vasectomy. In such cases, "special clearance" to stop contraception may be given when less than 10,000 non-
motile sperm/mL are found in a fresh specimen examined at least 7 months after vasectomy.
The risks of STI's are unchanged.

2/3 Question 19-21 of 78

Theme: Haematuria

A. Retroperitoneal liposarcoma
B. Transitional cell carcinoma
C. Retroperitoneal fibrosis
D. Renal squamous cell carcinoma
E. Renal adenocarcinoma
F. Nephroblastoma

Please select the most likely cause of haematuria for the scenarios given. Each option may be used once, more
than once or not at all.

19. A 28 year old man presents with hypertension and haematuria. Haematological investigations show
polycythaemia but otherwise no abnormality. CT scanning shows a left renal mass.

Renal adenocarcinoma

Renal adenocarcinoma is the most common variant and is associated with polycythaemia.

20. A 68 year of man presents with recurrent episodes of left sided ureteric colic and haematuria.
Investigations show some dilatation of the renal pelvis but the outline is irregular.

You answered Retroperitoneal liposarcoma

The correct answer is Transitional cell carcinoma

These arise from urothelium and necessitate a nephroureterectomy.

21. A 4 year old boy presents with haematuria and on examination is found to have a right sided renal
mass.
 Nephroblastoma

Wilms tumours (nephroblastoma) usually present in the first 4 years of life and may cause lung
metastases.

Haematuria

Causes of haematuria

Trauma • Injury to renal tract

• Renal trauma commonly due to blunt injury (others penetrating injuries)
• Ureter trauma rare: iatrogenic
• Bladder trauma: due to RTA or pelvic fractures

Infection • Remember TB

Malignancy • Renal cell carcinoma (remember paraneoplastic syndromes): painful or painless

• Urothelial malignancies: 90% are transitional cell carcinoma, can occur
anywhere along the urinary tract. Painless haematuria.
• Squamous cell carcinoma and adenocarcinoma: rare bladder tumours
• Prostate cancer
• Penile cancers: SCC

Renal disease • Glomerulonephritis

Stones • Microscopic haematuria common

Structural • Benign prostatic hyperplasia (BPH) causes haematuria due to hypervascularity

abnormalities of the prostate gland
• Cystic renal lesions e.g. polycystic kidney disease
• Vascular malformations
• Renal vein thrombosis due to renal cell carcinoma

Coagulopathy • Causes bleeding of underlying lesions

Drugs • Cause tubular necrosis or interstitial nephritis: aminoglycosides, chemotherapy

• Interstitial nephritis: penicillin, sulphonamides, and NSAIDs
• Anticoagulants

Benign • Exercise

Gynaecological • Endometriosis: flank pain, dysuria, and haematuria that is cyclical

Iatrogenic • Catheterisation
 • Radiotherapy; cystitis, severe haemorrhage, bladder necrosis

Pseudohaematuria

Question 22 of 78
A 22 year old man is involved in a road traffic accident. He is found to have a pelvic fracture. While on the
ward the nursing staff report that he is complaining of lower abdominal pain. On examination you find a
distended tender bladder. What is the diagnosis?

A. Bladder rupture

B. Ureter injury

C. Urethral injury

D. Clot retention

E. Prostate rupture

Theme from 2009 Exam

Pelvic fractures may cause laceration of the urethra. Urinary retention, blood at the urethral meatus and a high
riding prostate on digital rectal examination are the typical features.

1/3 Question 23-25 of 78

Theme: Haematuria

A. Benign prostatic hyperplasia

B. Ureteric calculus
C. Pyelonephritis
D. Prostatitis
E. Cystitis
F. Prostate cancer

Please select the most likely source of haematuria for the scenarios given. Each option may be used once, more
than once or not at all.

23. A 67 year old man presents with recurrent episodes of haematuria, typically at the end of the urinary
stream, he has been suffering from occasional fevers and has noticed pus on the urethral meatus on
occasion. On examination the prostate has no discernable masses but is tender.

Prostatitis
 This is most likely prostatitis and the bleeding at the end of micturition suggests a distal problem.
Treatment is usually with prolonged courses of antibiotics.

24. A 23 year old girl is admitted with loin pain and a fever, she has noticed haematuria for the past week
accompanied by dysuria, this was treated empirically with trimethoprim.

You answered Cystitis

The correct answer is Pyelonephritis

This is most likely pyelonephritis and partially treated cystitis is a common cause.

25. A 56 year old man is admitted with severe loin to groin pain associated with haematuria. He was well
until 1 week ago when he was unwell with diarrhoea and vomiting.

You answered Pyelonephritis

The correct answer is Ureteric calculus

Ureteric stones may develop in a background of dehydration.

Question 26 of 78
Which of the following would be most consistent with a histologically aggressive form of prostate cancer?

A. FIGO stage 1 disease

B. FIGO stage IV disease

C. EuroQOL score of 5

D. Gleason score of 2

E. Gleason score of 10

Prostate cancer is histologically graded using the Gleason score (see below). A score of 10 is consistent with a
histologically aggressive form of the disease. The FIGO staging system is used to stage gynaecological
malignancy. The EuroQOL score is a quality of life measurement tool.

Question 27 of 78
A 13 month old boy is brought to the paediatric clinic by his mother who is concerned that his testis are not
palpable. On examination his testis are not palpable either in the scrotum or inguinal region and cannot be
visualised on ultrasound either. What is the most appropriate next stage in management?

A. Laparoscopy
 B. Re-assess at 5 years of age

C. Re-assess at 13 years of age

D. Administration of testosterone

E. Administration of cyproterone acetate

Impalpable testes are an indication for laparoscopy. Ultrasound is a relatively unhelpful tool in evaluating
cryptorchid patients and most experienced paediatric surgeons would not use it pre-operatively. They may be
associated with an intra-abdominal location. Whilst it is reasonable to defer orchidopexy for retractile testis
completely absent testes should be investigated further.

Cryptorchidism

A congenital undescended testis is one that has failed to reach the bottom of the scrotum by 3 months of age. At
birth up to 5% of boys will have an undescended testis, post natal descent occurs in most and by 3 months the
incidence of cryptorchidism falls to 1-2%. In the vast majority of cases the cause of the maldescent is unknown.
A proportion may be associated with other congenital defects including:

Patent processus vaginalis

Abnormal epididymis
Cerebral palsy
Mental retardation
Wilms tumour
Abdominal wall defects (e.g. gastroschisis, prune belly syndrome)

Differential diagnosis
These include retractile testes and, in the case of absent bilateral testes the possibility of intersex conditions. A
retractile testis can be brought into the scrotum by the clinician and when released remains in the scrotum. If the
examining clinician notes the testis to return rapidly into the inguinal canal when released then surgery is
probably indicated.

Reasons for correction of cryptorchidism

• Reduce risk of infertility

• Allows the testes to be examined for testicular cancer
• Avoid testicular torsion
• Cosmetic appearance

Males with undescended testis are 40 times as likely to develop testicular cancer (seminoma) as males without
undescended testis
The location of the undescended testis affects the relative risk of testicular cancer (50% intra-abdominal testes)

Treatment

• Orchidopexy at 6- 18 months of age. The operation usually consists of inguinal exploration, mobilisation
of the testis and implantation into a dartos pouch.
• Intra-abdominal testis should be evaluated laparoscopically and mobilised. Whether this is a single stage
or two stage procedure depends upon the exact location.
 • After the age of 2 years in untreated individuals the Sertoli cells will degrade and those presenting late in
teenage years may be better served by orchidectomy than to try and salvage a non functioning testis with
an increased risk of malignancy.

Question 28 of 78
A 34-year-old man from Zimbabwe is admitted with abdominal pain to the Emergency Department. An
abdominal x-ray reveals urinary bladder calcification. What is the most likely cause?

A. Schistosoma mansoni

B. Sarcoidosis

C. Leishmaniasis

D. Tuberculosis

E. Schistosoma haematobium
Schistosoma haematobium causes
haematuria

Schistosomiasis is the most common cause of bladder calcification worldwide

Schistosomiasis

Schistosomiasis, or bilharzia, is a parasitic flatworm infection. The following types of schistosomiasis are
recognised:

• Schistosoma mansoni and Schistosoma intercalatum: intestinal schistosomiasis

• Schistosoma haematobium: urinary schistosomiasis

Schistosoma haematobium
This typically presents as a 'swimmer's itch' in patients who have recently returned from Africa. Schistosoma
haematobium is a risk factor for squamous cell bladder cancer

Features

• Frequency
• Haematuria
• Bladder calcification

Management

• Single oral dose of praziquantel

3/3 Question 29-31 of 78

Theme: Testicular disorders

A. Testicular tumour
B. Torsion of the spermatic cord
C. Acute infective epididymo-orchitis
D. Non infective epididymo- orchitis
E. Torsion of testicular appendage
F. Hydrocele
G. Haematocele

Please select the most likely cause for the testicular disorder described. Each option may be used once, more
than once or not at all.

29. An 28 year old man presents with pain in the testis and scrotum. It began 10 hours previously and has
worsened during that time. On examination he is pyrexial, the testis is swollen and tender and there is
an associated hydrocele.

Acute infective epididymo-orchitis

The onset is relatively slow for torsion and the presence of fever favors epididymo-orchitis.

30. A 15 year old boy develops sudden onset of pain in the left hemiscrotum. He has no other urinary
symptoms. On examination the superior pole of the testis is tender and the cremasteric reflex is
particularly marked.

Torsion of testicular appendage

The cremasteric reflex is usually preserved when the torsion affects the appendage only.

31. A 14 year old boy develops sudden onset severe pain in the left testicle radiating to the left groin. He
is distressed and vomits. On examination the testis is very tender and the cremasteric reflex is absent.

Torsion of the spermatic cord

The cremasteric reflex is usually absent in torsion.

Similar theme question in September 2011 exam

Testicular disorders

Testicular cancer
Testicular cancer is the most common malignancy in men aged 20-30 years. Around 95% of cases of testicular
cancer are germ-cell tumours. Germ cell tumours may essentially be divided into:

Tumour type Key features Tumour markers Pathology

Seminoma • Commonest subtype • AFP usually normal Sheet like lobular patterns
(50%) • HCG elevated in of cells with substantial
• Average age at 10% seminomas fibrous component.
diagnosis = 40 • Lactate Fibrous septa contain
• Even advanced dehydrogenase; lymphocytic inclusions
disease associated elevated in 10-20% and granulomas may be
with 5 year survival of seminomas (but also seen.
73% in many other
conditions)
Non seminomatous germ cell • Younger age at • AFP elevated in up Heterogenous texture
tumours (42%) presentation =20-30 years to 70% of cases with occasional ectopic
• Advanced disease carries • HCG elevated in up tissue such as hair
• Teratoma worse prognosis (48% at 5 to 40% of cases
• Yolk sac tumour years) • Other markers
• Choriocarcinoma • Retroperitoneal lymph rarely helpful
• Mixed germ cell node dissection may be
tumours (10%) needed for residual disease
after chemotherapy

Image demonstrating a classical seminoma, these tumours are typically more uniform than teratomas
 Image sourced from Wikipedia

Risk factors for testicular cancer

• Cryptorchidism
• Infertility
• Family history
• Klinefelter's syndrome
• Mumps orchitis

Features

• A painless lump is the most common presenting symptom

• Pain may also be present in a minority of men
• Other possible features include hydrocele, gynaecomastia
Diagnosis

• Ultrasound is first-line
• CT scanning of the chest/ abdomen and pelvis is used for staging
• Tumour markers (see above) should be measured

Management

• Orchidectomy (Inguinal approach)

• Chemotherapy and radiotherapy may be given depending on staging
• Abdominal lesions >1cm following chemotherapy may require retroperitoneal lymph node dissection.

Prognosis is generally excellent

• 5 year survival for seminomas is around 95% if Stage I

• 5 year survival for teratomas is around 85% if Stage I

Benign disease

Epididymo-orchitis
Acute epididymitis is an acute inflammation of the epididymis, often involving the testis and usually caused by
bacterial infection.

• Infection spreads from the urethra or bladder. In men <35 years, gonorrhoea or chlamydia are the usual
infections.
• Amiodarone is a recognised non infective cause of epididymitis, which resolves on stopping the drug.
• Tenderness is usually confined to the epididymis, which may facilitate differentiating it from torsion
where pain usually affects the entire testis.

Testicular torsion

• Twist of the spermatic cord resulting in testicular ischaemia and necrosis.

• Most common in males aged between 10 and 30 (peak incidence 13-15 years)
• Pain is usually severe and of sudden onset.
• Cremasteric reflex is lost and elevation of the testis does not ease the pain.
• Treatment is with surgical exploration. If a torted testis is identified then both testis should be fixed as
the condition of bell clapper testis is often bilateral.

Question 32 of 78
Which of the following statements is false in relation to renal adenocarcinoma?

A. They account for over 75% cases of renal tumours

B. Renal biopsy should be performed in all cases considered for radical nephrectomy
 C. They typically spread via the haematogenous route

D. Patients with completely resected T2 disease should not receive adjuvant chemotherapy

E. Partial nephrectomy gives equivalent oncological outcomes in patients with T1 disease

Routine chemotherapy is not effective in patients with renal adenocarcinoma and should not be used following
R0 resections.

Routine renal biopsy should not be performed in cases for nephrectomy. Most cases of malignancy can be
accurately classified on imaging.

Renal tumours

Renal cell carcinoma

Renal cell carcinoma is an adenocarcinoma of the renal cortex and is believed to arise from the proximal
convoluted tubule. They are usually solid lesions, up to 20% may be multifocal, 20% may be calcified and 20%
may have either a cystic component or be wholly cystic. They are often circumscribed by a pseudocapsule of
compressed normal renal tissue. Spread may occur either by direct extension into the adrenal gland, renal vein
or surrounding fascia. More distant disease usually occurs via the haematogenous route to lung, bone or brain.
Renal cell carcinoma comprise up to 85% of all renal malignancies. Males are more commonly affected than
females and sporadic tumours typically affect patients in their sixth decade.
Patients may present with a variety of symptoms including; haematuria (50%), loin pain (40%), mass (30%) and
up to 25% may have symptoms of metastasis.Less than 10% have the classic triad of haematuria, pain and mass.

Investigation
Many cases will present as haematuria and be discovered during diagnostic work up. Benign renal tumours are
rare, so renal masses should be investigated with multislice CT scanning. Some units will add and arterial and
venous phase to the scan to demonstrate vascularity and evidence of caval ingrowth.

CT scanning of the chest and abdomen to detect distant disease should also be undertaken.

Routine bone scanning is not indicated in the absence of symptoms.

Biopsy should not be performed when a nephrectomy is planned but is mandatory before any ablative therapies
are undertaken.

Assessment of the functioning of the contra lateral kidney.

Management
T1 lesions may be managed by partial nephrectomy and this gives equivalent oncological results to total radical
nephrectomy. Partial nephrectomy may also be performed when there is inadequate reserve in the remaining
kidney.

For T2 lesions and above a radical nephrectomy is standard practice and this may be performed via a
laparoscopic or open approach. Preoperative embolisation is not indicated nor is resection of uninvolved adrenal
glands. During surgery early venous control is mandatory to avoid shedding of tumour cells into the circulation.

Patients with completely resected disease do not benefit from adjuvant therapy with either chemotherapy or
biological agents. These should not be administered outside the setting of clinical trials.
Patients with transitional cell cancer will require a nephroureterectomy with disconnection of the ureter at the
bladder.

3/3 Question 33-35 of 78

Theme: Haematuria

A. Benign prostatic hyperplasia

B. Transitional cell carcinoma of the bladder
C. Renal cell carcinoma
D. Ureteric calculus
E. Staghorn calculus
F. Uncomplicated urinary tract infection
G. Adenocarcinoma of the bladder

Please select the most likely cause of haematuria from the scenarios given. Each option may be used once, more
than once or not at all.

33. A 58 year old man has an episode of painless frank haematuria whilst undergoing a 24 urine
collection for investigation of hypertension.

Renal cell carcinoma

These tumours may often have paraneoplastic effects such as hypertension.

34. A 73 year old lady has an episode of haematuria whilst receiving a course of intravesical BCG
therapy.

Transitional cell carcinoma of the bladder

Transitional cell carcinoma of the bladder may be treated with intravesical BCG therapy.

35. A 32 year old lady suffers from severe left sided abdominal pain, that radiates to her groin. As part of
her evaluation the nurses identify microscopic haematuria on dipstick.

Ureteric calculus

Ureteric calculi will often present with loin pain radiating to the groin. It is usually severe. There may
be macroscopic or microscopic haematuria. The absence of haematuria on dipstick testing should
prompt investigations for alternative diagnoses. The best investigation is a non contrast CT scan. CT
changes consistent with stone or recent stone passage include evidence of stone, perinephric
stranding, ureteric oedema or hydronephrosis.

Question 36 of 78
A 24 year old man presents with a persistent and unwanted erection that has been present for the previous 6
hours. On examination the penis is rigid and tender. Aspiration of blood from the corpus cavernosa shows dark
blood. Which of the following is the most appropriate initial management?

A. Discharge the patient home and review in 12 hours

B. Admit the patient to hospital and review in 12 hours

C. Aspirate further blood from the corpus cavernosa in an attempt to

decompress

D. Use a trucut needle to induce an arteriovenous shunt

E. Administer intracavernosal adrenaline 1 in 500 concentration

Low flow priaprism is a urological emergency. Aspiration of bright red blood is more reassuring and may
indicate high flow priaprism that may be actively monitored. Low flow priaprism should be decompressed with
aspiration of blood from the corpus caveronsum.

Penile erection

Physiology of erection
Autonomic • Sympathetic nerves originate from T11-L2 and parasympathetic nerves from S2-4 join to
form pelvic plexus.
• Parasympathetic discharge causes erection, sympathetic discharge causes ejaculation and
detumescence.

Somatic Supplied by dorsal penile and pudendal nerves. Efferent signals are relayed from Onufs nucleus
nerves (S2-4) to innervate ischiocavernosus and bulbocavernosus muscles.

Autonomic discharge to the penis will trigger the veno-occlusive mechanism which triggers the flow of arterial
blood into the penile sinusoidal spaces. As the inflow increases the increased volume in this space will
secondarily lead to compression of the subtunical venous plexus with reduced venous return. During the
detumesence phase the arteriolar constriction will reduce arterial inflow and thereby allow venous return to
normalise.

Priapism
Prolonged unwanted erection, in the absence of sexual desire, lasting more than 4 hours.

Classification of priaprism
Low flow priaprism Due to veno-occlusion (high intracavernosal pressures).

• Most common type

• Often painful
• Often low cavernosal flow
• If present for >4 hours requires emergency treatment

High flow priaprism Due to unregulated arterial blood flow.

• Usually presents as semi rigid painless erection

Recurrent priaprism Typically seen in sickle cell disease, most commonly of high flow type.

Causes

• Intracavernosal drug therapies (e.g. for erectile dysfunction>

• Blood disorders such as leukaemia and sickle cell disease
• Neurogenic disorders such as spinal cord transection
• Trauma to penis resulting in arterio-venous malformations

Tests

• Exclude sickle cell/ leukaemia

• Consider blood sampling from cavernosa to determine whether high or low flow (low flow is often
hypoxic)

Management

• Ice packs/ cold showers

• If due to low flow then blood may be aspirated from copora or try intracavernosal alpha adrenergic
agonists.
• Delayed therapy of low flow priaprism may result in erectile dysfunction.

0/3 Question 37-39 of 78

Theme: Management of urinary obstruction

A. Discharge
B. Start oxybutynin
C. Intravenous antibiotics
D. Urethral catheter
E. Emergency nephrostomy
F. Antegrade ureteric stent
G. Retrograde ureteric stent

What is the best management for the scenario given? Each option may be used once, more than once or not at
all.

37. A 68 year old man has a TCC of the bladder. He has a right hydronephrosis detected on ultrasound
and deteriorating renal function. A DMSA scan shows a non functioning left kidney.

You answered Emergency nephrostomy

The correct answer is Antegrade ureteric stent

A TCC occluding the ureteric orifice will obscure its identification during surgery, so that passage of
a retrograde stent is difficult. Therefore passage of a stent from the renal pelvis is preferable.
 38. A 52 year old male with hypercalcaemia secondary to primary hyperparathyroidism presents with
renal colic. Multiple attempts at stone extraction are performed. However, the stone could not be
removed. He is now septic with a pyrexia of 39.5 oc.

You answered Intravenous antibiotics

The correct answer is Emergency nephrostomy

The likely scenario is that this man has developed a calculus causing ureteric obstruction. The
stagnant column of urine can become colonised and infected. An infected obstructed system is one of
the few true urological emergencies. A nephrostomy is needed as the stone could not be removed.

39. A 56 year old man is admitted with acute retention of urine. He has had a recent urinary tract
infection. An USS shows bilateral hydronephrosis.

You answered Emergency nephrostomy

The correct answer is Urethral catheter

Establishing bladder drainage will often correct the situation. These patients often have a significant
diuresis with associated electrolyte disturbance.

Hydronephrosis

Causes of hydronephrosis

Unilateral: PACT

• Pelvic-ureteric obstruction (congenital or acquired)

• Aberrant renal vessels
• Calculi
• Tumours of renal pelvis

Bilateral: SUPER

• Stenosis of the urethra

• Urethral valve
• Prostatic enlargement
• Extensive bladder tumour
• Retro-peritoneal fibrosis

Investigation

• USS- identifies presence of hydronephrosis and can assess the kidneys

 • IVU- assess the position of the obstruction
• Antegrade or retrograde pyelography- allows treatment
• if suspect renal colic: CT scan (majority of stones are detected this way)

Management

• Remove the obstruction and drainage of urine

• Acute upper urinary tract obstruction: Nephrostomy tube
• Chronic upper urinary tract obstruction: Ureteric stent or a pyeloplasty

Question 40 of 78
A 45 year old Accountant is involved in a road traffic accident. He complains of pain in his groin. On
examination his BP is 110/60mmHg, HR 80 bpm and saturations are 99%. He has tenderness in his groin area
and there is blood at the entrance of his urethral meatus. A subsequent pelvic x-ray shows a pelvic fracture.
What is the next best managment step?

A. Urgent urethral catheterisation

B. Conservative management

C. Urgent suprapubic catheterisation

D. Retrograde urethrogram

E. Cystoscopy

Males with pelvic fracture and blood at the urethral meatus must not have a urethral catheter placed until a
retrograde urethrogram can rule out urethral disruption. The correct management will therefore be a suprapubic
catheter insertion pending more definitive urethral imaging.

2/3 Question 41-43 of 78

Theme: Haematuria

A. Transitional cell carcinoma of the bladder

B. Squamous cell carcinoma of the bladder
C. Renal cell carcinoma
D. Polycystic kidney disease
E. Wilms tumour
F. Neuroblastoma
G. Benign prostatic hyperplasia

Please select the most likely cause of haematuria for the scenarios given. Each option may be used once, more
than once or not at all.
 41. A 40 year old women is being investigated for haematuria. She was living with her sister who has just
died from a sub arachnoid haemorrhage. The haematuria is painless and she has mild renal
impairment.

Polycystic kidney disease

This is likely to be polycystic kidney disease as she has renal failure and family history of sub
arachnoid haemorrhage.

42. A 75 year old lady is investigated for episodes of painless haematuria. Apart from COPD from long
term smoking she is otherwise well. She has no other urinary symptoms.

You answered Renal cell carcinoma

The correct answer is Transitional cell carcinoma of the bladder

TCC commonly presents with painless haematuria that may be detected during testing carried out for
other reasons.

43. A 78 year old man has a long history of nocturia, urinary frequency and terminal dribbling. He was
admitted with urinary retention and was catheterised. On removal of the catheter he has noticed some
haematuria.

Benign prostatic hyperplasia

The symptoms are typical for prostatic disease.

Question 44 of 78
A 65 year old man presents with significant lower urinary tract symptoms and is diagnosed as having benign
prostatic hyperplasia. Which of the following drug treatments will produce the slowest clinical response?

A. Tamsulosin

B. Alfuzosin

C. Doxazosin

D. Finasteride

E. Terazosin
5 alpha reductase inhibitors have a more favorable side effect profile than α blockers.

Alpha blockers have a faster onset of action (but lower reduction of complications from BPH) than 5 α
reductase inhibitors.

Benign Prostatic Hyperplasia

Benign prostatic hyperplasia occurs via an increase in the epithelial and stromal cell numbers in the peri-
urethral zone of the prostate. BPH is very common and 90% of men aged over 80 will have at least microscopic
evidence of benign prostatic hyperplasia. The causes of BPH are still not well understood, but the importance of
androgens remains appreciated even if the exact role by which they induce BPH is elusive.

Presentation
The vast majority of men will present with lower urinary tract symptoms. These will typically be:

• Poor flow
• Nocturia
• Hesitancy
• Incomplete and double voiding
• Terminal dribbling
• Urgency
• Incontinence

Investigation

• Digital rectal examination to assess prostatic size and morphology.

• Urine dipstick for infections and haematuria.
• Uroflowmetry (a flow rate of >15ml/second helps to exclude BOO)
• Bladder pressure studies may help identify detrusor failure and whilst may not form part of first line
investigations should be included in those with atypical symptoms and prior to redo surgery.
• Bladder scanning to demonstrate residual volumes. USS if high pressure chronic retention.

Management

• Lifestyle changes such as stopping smoking and altering fluid intake may help those with mild
symptoms.
• Medical therapy includes alpha blockers and 5 α reductase inhibitors. The former work quickly on
receptor zones located at the bladder neck. Cardiovascular side effects are well documented. The latter
work on testosterone metabolising enzymes. Although they have a slower onset of action, the 5 α
reductase inhibitors may prevent acute urinary retention.
• Surgical therapy includes transurethral resection of the prostate and is the treatment of choice in those
with severe symptoms and those who fail to respond to medical therapy. More tailored bladder neck
incision procedures may be considered in those with small prostates. Retrograde ejaculation may occur
following surgery. The change in the type of irrigation solutions used has helped to minimise the TURP
syndrome of electrolyte disturbances.

1/3 Question 45-47 of 78

Theme: Testicular disorders

A. Haematocele
B. Epididymal cyst
C. Hydrocele
D. Testicular torsion
E. Orchitis
F. Epididymo-orchitis

Please select the most likely diagnosis for the scenario given. Each option may be used once, more than once or
not at all.

45. A 20 year old complains of severe pain and swelling of the scrotum after a cystoscopy. He had
mumps as a child. The testis is tender. The urine dipstick is positive for leucocytes.

You answered Orchitis

The correct answer is Epididymo-orchitis

Epididymo-orchitis: acute pain and swelling after urological intervention. To differentiate from
testicular torsion there is usually pyrexia and positive urine dipstick.

46. A 20 year old complains of severe pain in the right scrotal area after jumping onto his moped. He has
also noticed discomfort in this area over the past few months. On examination there is a swollen,
painful testis that is drawn up into the groin.

You answered Epididymo-orchitis

The correct answer is Testicular torsion

Testicular torsion: Severe pain which can be spontaneous or precipitated by minor trauma. There is
usually severe pain and the patient will often not tolerate the testis being touched. Urgent scrotal
exploration is indicated. It is associated with a high investment of the the tunica vaginalis with
horizontal testicular lie, or when the epididymis and testis are separated by a mesorchium, in which
case the twist occurs at that point.

47. An 8 year old presents with scrotal swelling. He has just recovered from an acute viral illness with
swelling of the parotid glands. On examination both testes are tender and slightly swollen.

Orchitis

Orchitis may be associated with mumps viral infections.

48-50 0 / 3
0/3 Question 48-50 of 78
Theme: Renal imaging

A. Non contrast abdominal CT scan

B. DMSA scan
C. PET/CT scan
D. MAG 3 Renogram
E. Renal ultrasound scan
F. DTPA Scan
G. Micturating cystourethrogram
H. Intra venous urography

Please select the most appropriate imaging modality for the scenario descrived. Each agent may be used once,
more than once or not at all.

48. A 43 year old female has undergone a renal transplant 12 months previously. Over the past few weeks
there have been concerns about deteriorating renal function.

You answered DMSA scan

The correct answer is MAG 3 Renogram

Theme from 2010 Exam

Similar theme September 2012 Exam
Because it is excreted by renal tubular cells a MAG 3 renogram provides excellent imaging of renal
function and is often used in investigating failing transplants.

49. A 5 year old boy presents with recurrent urinary tract infections and left sided loin pain. On investigation
he is found to have a left sided PUJ obstruction, there are concerns that he may have developed renal
scarring.

You answered Non contrast abdominal CT scan

The correct answer is DMSA scan

Although MAG 3 renograms may provide some information relating to the structural integrity of the
kidney, many still consider a DMSA scan to be the gold standard for the detection of renal scarring
(which is the main concern in PUJ obstruction and infections).

50. A 17 year old man is referred to the urology clinic. As a child he was diagnosed as having a right sided
PUJ obstruction. However, he was lost to follow up. Over the past 7 months he has been complaining of
recurrent episodes of right loin pain. A CT scan shows considerable renal scarring.

You answered DTPA Scan

The correct answer is MAG 3 Renogram

In patients with long standing PUJ obstruction and renal scarring the main diagnostic question is whether
the individual has sufficient renal function to consider a pyeloplasty or whether a primary nephrectomy is
preferable. Since the CT has demonstrated scarring there is no use in obtaining a DMSA scan. Of the
investigations listed both a DTPA and MAG 3 renogram will allow assessment of renal function.
However, MAG 3 is superior in the assessment of renal function in damaged kidneys (as it is subjected to
tubular secretion).

Functional renal imaging

DMSA scan
Dimercaptosuccinic acid (DMSA) scintigraphy
DMSA localises to the renal cortex with little accumulation in the renal papilla and medulla. It is useful for the
identification of cortical defects and ectopic or abhorrent kidneys. It does not provide useful information on the
ureter of collecting system.

Diethylene-triamine-penta-acetic acid (DTPA)

This is primarily a glomerular filtration agent. It is most useful for the assessment of renal function. Because it
is filtered at the level of the glomerulus it provides useful information about the GFR. Image quality may be
degraded in patients with chronic renal impairment and derangement of GFR.

MAG 3 renogram
Mercaptoacetyle triglycine is an is extensively protein bound and is primarily secreted by tubular cells rather
than filtered at the glomerulus. This makes it the agent of choice for imaging the kidneys of patients with
existing renal impairment (where GFR is impaired).

Micturating cystourethrogram (MCUG scan)

This scan provides information relating to bladder reflux and is obtained by filling the bladder with contrast
media (via a catheter) and asking the child to void. Images are taken during this phase and the degree of reflux
can be calculated

Intra venous urography

This examination is conducted by the administration of intravenous iodinated contrast media. The agent is
filtered by the kidneys and excreted and may provide evidence of renal stones or other structural lesions. A
rough approximation of renal function may be obtained using the technique. But it is not primarily a technique
to be used for this purpose. With the advent of widespread non contrast CT scan protocols for the detection of
urinary tract calculi it is now rarely used.

PET/CT
This may be used to evaluate structurally indeterminate lesions in the staging of malignancy.

Question 51 of 78
A 35-year-old female is admitted to hospital with hypovolaemic shock. CT abdomen reveals a haemorrhagic
lesion in the right kidney. Following surgery and biopsy this is shown to be an angiomyolipomata. What is the
most likely underlying diagnosis?

A. Neurofibromatosis

B. Budd-Chiari syndrome

C. Hereditary haemorrhagic telangiectasia

D. Von Hippel-Lindau syndrome

E. Tuberous sclerosis
Tuberous sclerosis

Tuberous sclerosis (TS) is a genetic condition of autosomal dominant inheritance. Like neurofibromatosis, the
majority of features seen in TS are neuro-cutaneous

Cutaneous features

• depigmented 'ash-leaf' spots which fluoresce under UV light

• roughened patches of skin over lumbar spine (Shagreen patches)
• adenoma sebaceum: butterfly distribution over nose
• fibromata beneath nails (subungual fibromata)
• café-au-lait spots* may be seen

Neurological features

• developmental delay
• epilepsy (infantile spasms or partial)
• intellectual impairment

Also

• retinal hamartomas: dense white areas on retina (phakomata)

• rhabdomyomas of the heart
• gliomatous changes can occur in the brain lesions
• polycystic kidneys, renal angiomyolipomata

*these of course are more commonly associated with neurofibromatosis. However a 1998 study of 106 children
with TS found café-au-lait spots in 28% of patients

Question 52 of 78
A 22 year old man is participating in vigorous intercourse and suddenly feels a snap and his penis becomes
swollen and painful. The admitting surgeon suspects a penile fracture. Which of the following is the most
appropriate initial management?

A. MRI scan of the penis

B. Immediate surgical exploration

C. CT scan of the penis

D. USS of the penis

E. Cystogram
Suspected penile fractures should be surgically explored and the injury repaired.

Penile fracture

Penile fractures are a rare type of urological trauma that may be encountered. The injury is usually in the
proximal part of the penile shaft and may involve the ureter. A classically history of a snapping sensation
followed by immediate pain is usually given by the patient (usually during vigourous intercourse). On
examination there is usually a tense haematoma and blood may be seen at the meatus if the urethra is injured.
When there is a a strong suspiscion of the diagnosis the correct management is surgical and a circumferential
incision made immediately inferior to the glans. The skin and superficial tissues are stripped back and the penile
shaft inspected. Injuries are usually sutured and the urethra repaired over a catheter.

53
Question 53 of 78
Which of the following does not cause red urine?

A. Rifampicin

B. Phosphaturia

C. Beetroot

D. Rhubarb

E. Blackberries

Phosphaturia causes cloudy urine.

Question 54 of 78
From the list below, which drug is known to cause haemorrhagic cystitis?

A. Rifampicin

B. Methotrexate

C. Dexamethasone

D. Leflunomide

E. Cyclophosphamide

Cyclophosphamide is metabolised into a toxic metabolite acrolein. The effects may be attenuated by
administration of large volumes of intravenous fluids and mesna (which neutralises the metabolite). The
condition may be managed initially by bladder catheterisation and irrigation.
3/3 Question 55-57 of 78
Theme: Haematuria

A. Squamous cell carcinoma of the renal pelvis

B. Renal adenocarcinoma
C. Nephroblastoma
D. Retroperitoneal fibrosis
E. Transitional cell carcinoma of the renal pelvis
F. Retroperitoneal sarcoma

Please select the most likely lesion for the scenario given. Each option may be used once, more than once or not
at all.

55. A 72 year old man presents with haematuria which is recurrent. On investigation a retrograde
pyelogram shows multiple ureteric filling defects and the renal pelvis is irregular.

Transitional cell carcinoma of the renal pelvis

TCC of the renal pelvis may seed down the ureter.

56. An 83 year old man with a long standing staghorn calculus presents with recurrent haematuria and
investigation shows a mass of the left renal pelvis.

Squamous cell carcinoma of the renal pelvis

SCC of the kidney usually arises in an area of chronic inflammation such as a staghorn calculus.

57. A 28 year old man presents to his GP with haematuria and on examination is noted to have a
varicocele. He was noted to have renal colic 8 weeks ago which was secondary to hypercalcaemia.

Renal adenocarcinoma

Renal adenocarcinoma on the left side may invade the gonadal vein and produce varicocele. They
also have paraneoplastic phenomena such as hypercalcaemia.

1/3 Question 58-60 of 78

Theme: Urinary incontinence

A. Bladder diary for 3 days

B. Urodynamic studies
C. Bladder drill training for 6 weeks
D. Pelvic floor exercises 3 months
E. Oxybutynin
F. IV urography
G. Urinary dye studies
H. None of the above

Choose the best management option for each clinical scenario. Each option may be used once, more than once
or not at all.

58. A 34 year old woman from Africa presents with continuous dribbling incontinence after having her
2nd child. Apart from prolonged labour the woman denies any complications related to her
pregnancies. She is normally fit and well.

You answered Pelvic floor exercises 3 months

The correct answer is Urinary dye studies

Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after
prolonged labour and from a country with poor obstetric services. A dye stains the urine and hence
identifies the presence of a fistula.

59. A 56 year woman reports incontinence. She has had a difficult recent hysterectomy and has had 2
previous children with no complications. She is fit and well.

You answered Urinary dye studies

The correct answer is IV urography

Ureter damage should be suspected in patients with incontinence after pelvic surgery. Ideally ureter
damage should be identified intra operatively, however post operatively IVU is the best test to review
the ureter.

60. A 56 year old lady reports incontinence mainly when walking the dog. A bladder diary is
inconclusive.

Urodynamic studies

Urodynamic studies are indicated when there is diagnostic uncertainty or plans for surgery.

Urinary incontinence

Urinary incontinence

Involuntary passage of urine. Most cases are female (80%). It has a prevalence of 11% in those aged greater
than 65 years. The commonest variants include:

• Stress urinary incontinence (50%)

• Urge incontinence (15%)
• Mixed (35%)
Males
Males may also suffer from incontinence although it is a much rarer condition in men. A number of anatomical
factors contribute to this. Males have 2 powerful sphincters; one at the bladder neck and the other in the urethra.
Damage to the bladder neck mechanism is a factor in causing retrograde ejaculation following prostatectomy.
The short segment of urethra passing through the urogenital diaphragm consists of striated muscle fibres (the
external urethral sphincter) and smooth muscle capable of more sustained contraction. It is the latter mechanism
that maintains continence following prostatectomy.

Females
The sphincter complex at the level of bladder neck is poorly developed in females. As a result the external
sphincter complex is functionally more important, its composition being similar to that of males. Innervation is
via the pudendal nerve and the neuropathy that may accompany obstetric events may compromise this and lead
to stress urinary incontinence.

Innervation
Somatic innervation to the bladder is via the pudendal, hypogastric and pelvic nerves. Autonomic nerves travel
in these nerve fibres too. Bladder filling leads to detrusor relaxation (sympathetic) coupled with sphincter
contraction. The parasympathetic system causes detrusor contraction and sphincter relaxation. Overall control
of micturition is centrally mediated via centres in the Pons.

Stress urinary incontinence

• 50% of cases, especially in females.

• Damage (often obstetric) to the supporting structures surrounding the bladder may lead to urethral
hypermobility.
• Other cases due to sphincter dysfunction, usually from neurological disorders (e.g. Pudendal neuropathy,
multiple sclerosis).

Urethral mobility:
Pressure not transmitted appropriately to the urethra resulting in involuntary passage of urine during episodes of
raised intra-abdominal pressure.

Sphincter dysfunction:
Sphincter fails to adapt to compress urethra resulting in involuntary passage of urine. When the sphincter
completely fails there is often to continuous passage of urine.

Urge incontinence
In these patients there is sense of urgency followed by incontinence. The detrusor muscle in these patients is
unstable and urodynamic investigation will demonstrate overactivity of the detrusor muscle at inappropriate
times (e.g. Bladder filling). Urgency may be seen in patients with overt neurological disorders and those
without. The pathophysiology is not well understood but poor central and peripheral co-ordination of the events
surrounding bladder filling are the main processes.

Assessment
Careful history and examination including vaginal examination for cystocele.
Bladder diary for at least 3 days
Consider flow cystometry if unclear symptomatology or surgery considered and diagnosis is unclear.
Exclusion of other organic disease (e.g. Stones, UTI, Cancer)
Management
Conservative measures should be tried first; Stress urinary incontinence or mixed symptoms should undergo 3
months of pelvic floor exercise. Over active bladder should have 6 weeks of bladder retraining.
Drug therapy for women with overactive bladder should be offered with oxybutynin if conservative measures
fail.
In women with detrusor instability who fail non operative therapy a trial of sacral neuromodulation may be
considered, with conversion to permanent implant if good response. Augmentation cystoplasty is an alternative
but will involve long term intermittent self catheterisation.
In women with stress urinary incontinence a urethral sling type procedure may be undertaken. Where cystocele
is present in association with incontinence it should be repaired particularly if it lies at the introitus.

NICE guidelines

• Initial assessment urinary incontinence should be classified as stress/urge/mixed.

• At least 3/7 bladder diary if unable to classify easily.
• Start conservative treatment before urodynamic studies if a diagnosis is obvious from the history
• Urodynamic studies if plans for surgery.
• Stress incontinence: Pelvic floor exercises 3/12, if fails consider surgery.
• Urge incontinence: Bladder training >6/52, if fails for oxybutynin (antimuscarinic drugs) then sacral
nerve stimulation.
• Pelvic floor exercises offered to all women in their 1st pregnancy.

Question 61 of 78
A 72 year old man presents with lower urinary tract symptoms. On digital rectal examination benign prostatic
hyperplasia is diagnosed. Which of the following treatments is associated with a reduction in the risk of urinary
retention?

A. Alfuzosin

B. Finasteride

C. Prazosin

D. Tamsulosin

E. Terazosin

5 alpha reductase inhibitors reduce the risk of urinary retention.

In the PLESS study, data show a reduction in the risk of urinary retention although the absolute risk reduction
was small.

Question 62 of 78
A 22 year old man is involved in a road traffic accident. He is found to have a pelvic fracture. While on the
ward the nursing staff report that he is complaining of lower abdominal pain. On examination you find a
distended tender bladder. What is the best management?

A. 10 Ch foley urethral catheter

 B. Suprapubic catheter

C. 16 Ch foley urethral catheter

D. 18 Ch coude tip urethral catheter

E. Pain relief and review in 1 hour

This patient has possible urethral injury based on the history. Urethral catheterisation is contraindicated in this
situation.

Question 63 of 78
Which of the following procedures represents the optimal operative procedure for testicular cancer?

A. Lords procedure

B. Orchidectomy via a scrotal approach

C. Orchidectomy via inguinal approach

D. Orchidectomy via a combined inguino-scrotal approach

E. None of the above

Testicular tumours metastasise to Para aortic nodes and thus an inguinal rather than scrotal approach should be
used. There are two main operations that are termed Lords procedure; one is for fissure in ano and the other is a
procedure for hydrocele.

3/3 Question 64-66 of 78

Theme: Management of testicular disorders

A. Fine needle aspiration cytology

B. Tru Cut biopsy
C. Orchidectomy via inguinal approach
D. Orchidectomy via scrotal approach
E. Administration of antibiotics
F. Exploration of scrotum via scrotal approach
G. Reassure and discharge

Please select the most appropriate management option for the scenario given. Each option may be used once,
more than once or not at all.

64. A 22 year old man presents with an aching pain and discomfort in his right testicle. He has felt
 systemically unwell for the preceding 48 hours. On examination there is tenderness of the right
testicle. He has an exaggerated cremasteric reflex.

Administration of antibiotics

This is likely to represent epididymo-orchitis, this is usually due to infection with gonorrhoea or
chlamydia in this age group. In addition to treatment with antibiotics contact tracing and appropriate
swabs should also be performed.

65. A 25 year old man presents with aching and discomfort of his right testicle. He has felt generally
unwell and lethargic over the past few weeks. On examination there is a small nodule palpable in the
testis, on ultrasound this is hypoechoic, systematic examination demonstrates supraclavicular
lymphadenopathy.

Orchidectomy via inguinal approach

Hypoechoic masses within the testicle in the context are most likely to represent malignancy. He
should have a staging CT scan, thereafter an orchidectomy should be performed via an inguinal
approach. Percutaneous biopsy has no role in the management of testicular malignancy.

66. A 15 year old boy is woken from sleep by a severe pain in his left testicle. He was previously fit and
well. On examination he has a tender left testicle with an absent cremasteric reflex.

Exploration of scrotum via scrotal approach

This is likely to represent torsion, surgical exploration is warranted.

2/3 Question 67-69 of 78

Theme: Haematuria

A. Interstitial nephritis
B. Membranous glomerulonephritis
C. Endometriosis
D. Placenta percreta
E. Adult polycystic kidney disease
F. Renal vein thrombosis
G. Urinary tract infection

Please select the most likely cause for haematuria for the scenario described. Each option may be used once,
more than once or not at all.

67. A 22 year female who is 24 weeks pregnant presents with frank haematuria. She is sexually active.
She has had a previous pregnancy resulting in caesarean section.

Placenta percreta
 Pregnancy and frank haematuria, especially if there is a history of placenta previa or prior caesarean
section, should indicate this diagnosis. There is invasive placental implantation into the myometrium,
which can rarely extend into the bladder causing severe bleeding.

68. A 22 year old woman presents with macroscopic haematuria. She is sexually active. She is known to
have renal calculi and had a berry aneurysm clipped.

Adult polycystic kidney disease

APKD is associated with liver cysts (70%), berry aneurysms (25%) and pancreatic cysts (10%).
Patients may have a renal mass, hypertension, renal calculi and macroscopic haematuria.

69. A 45 year woman presents with haematuria. She has a temperature of 38 oC and is found to have a Hb
17. Her urine dipstick shows nitrates and 3+ blood. Blood and urine cultures are negative.

You answered Interstitial nephritis

The correct answer is Renal vein thrombosis

Renal vein thrombosis is a common feature of renal cell carcinoma as it invades the renal vein. Other
features include PUO, left varicocele and paraneoplastic endocrine effects due to erythropoietin
factor, renin, ACTH and PTH like substance.

Question 70 of 78
A 55 year old man presents with an episode of frank haematuria and on investigation is found to have a T2
transitional cell carcinoma of the bladder. Hist staging investigations are negative for metastatic disease. What
is the most appropriate treatment?

A. Radical cystectomy

B. Palliative radiotherapy

C. Intravesical BCG

D. Intravesical mitomycin C

E. Intravesical cisplatin

T2 lesions in a young fit patient are best managed surgically. Up to 25 % patients may develop perioperative
complications. However, palliative treatments and intravesical chemotherapy (which does NOT include
cisplatin) are not used curatively in this situation.

Bladder cancer

Bladder cancer is the second most common urological cancer. It most commonly affects males aged between 50
and 80 years of age. Those who are current, or previous (within 20 years), smokers have a 2-5 fold increased
risk of the disease. Occupational exposure to hydrocarbons such as phenylalanine increases the risk. Although
rare in the UK, chronic bladder inflammation arising from Schistosomiasis infection remains a common cause
of squamous cell carcinomas, in those countries where the disease is endemic.

Benign tumours
Benign tumours of the bladder including inverted urothelial papilloma and nephrogenic adenoma are
uncommon.

Bladder malignancies

• Transitional cell carcinoma (>90% of cases)

• Squamous cell carcinoma ( 1-7% -except in regions affected by schistosomiasis)
• Adenocarcinoma (2%)

Transitional cell carcinomas may arise as solitary lesions, or may be multifocal, owing to the effect of "field
change" within the urothelium. Up to 70% of TCC's will have a papillary growth pattern. These tumours are
usually superficial in location and accordingly have a better prognosis. The remaining tumours show either
mixed papillary and solid growth or pure solid growths. These tumours are typically more prone to local
invasion and may be of higher grade, the prognosis is therefore worse. Those with T3 disease or worse have a
30% (or higher) risk of regional or distant lymph node metastasis.

TNM Staging
Stage Description
T0 No evidence of tumour
Ta Non invasive papillary carcinoma
T1 Tumour invades sub epithelial connective tissue
T2a Inner half of detrusor invaded
T2b Outer half of detrusor invaded
T3 Tumour extends to perivesical fat
T4a Invasion of uterus, prostate or bowel
T4b Invasion of other abdominal organs
N0 No nodal disease
N1 Single lymph node metastasis (up to 2cm)
N2 Single node >2cm or multiple nodes up to 5cm
N3 Nodes over 5cm
M1 Distant disease

Presentation
Most patients (85%) will present with painless, macroscopic haematuria. In those patients with incidental
microscopic haematuria, up to 10% of females aged over 50 will be found to have a malignancy (once infection
excluded).

Staging
Most will undergo a cystoscopy and biopsies or TURBT, this provides histological diagnosis and information
relating to depth of invasion. Locoregional spread is best determined using pelvic MRI and distant disease CT
scanning. Nodes of uncertain significance may be investigated using PET CT.
Treatment
Those with superficial lesions may be managed using TURBT in isolation. Those with recurrences or higher
grade/ risk on histology may be offered intravesical chemotherapy. Those with T2 disease are usually offered
either surgery (radical cystectomy and ileal conduit) or radical radiotherapy.

Prognosis
T1 90%
T2 60%
T3 35%
T4a 10-25%
Any T, N1-N2 30%

1/3 Question 71-73 of 78

Theme: Urinary incontinence

A. Bladder diary for 3 days

B. Urodynamic studies
C. Bladder drill training for 6 weeks
D. Pelvic floor exercises for 3 months
E. Oxybutynin
F. IV urography
G. Dyes studies including phenazopyridine
H. None of the above

Choose the best management option for each clinical scenario. Each option may be used once, more than once
or not at all.

71. A 75 year old lady reports urinary incontinence when coughing and sneezing. She has had 2 children
with no complications. She has no significant past medical history and is on no medications. What is
the most appropriate initial management?

You answered Urodynamic studies

The correct answer is Pelvic floor exercises for 3 months

A diagnosis of stress incontinence is obvious from the history, therefore there is no need for a bladder
diary or urodynamic studies.
Pelvic floor exercises would be the first line management.

72. A 26 year old pregnant woman having her 1st child and has never had problems with incontinence.

Pelvic floor exercises for 3 months

Pregnant women should receive instructions as to how to perform pelvic floor exercises during
 pregnancy as this may help to decrease subsequent risk of stress urinary incontinence.

73. A 67 year old lady reports urinary incontinence. She describes the sensation of needing to pass urine
immediately. She has had 2 children and is on no medications. What is the most appropriate initial
management?

You answered Dyes studies including phenazopyridine

The correct answer is Bladder diary for 3 days

The patient appears to be describing urge incontinence. A bladder diary is needed to establish the
baseline frequency of micturition and amounts of urine passed. Then bladder training can be initiated
to increase the volume of urine passed at reduced frequencies.

Question 74 of 78
A 47-year-old woman presents with loin pain and haematuria. Urine dipstick demonstrates:

Blood ++++
Nitrites POS
Leucocytes +++
Protein ++

Urine culture shows a Proteus infection. An x-ray demonstrates a stag-horn calculus in the left renal pelvis.
What is the most likely composition of the renal stone?

A. Xanthine

B. Calcium oxalate

C. Struvite

D. Cystine

E. Urate
Stag-horn calculi are composed of struvite and form in alkaline urine (ammonia producing bacteria therefore
predispose)

Renal stones on x-ray

• cystine stones: semi-opaque

• urate + xanthine stones: radio-lucent

Renal stones: imaging

The table below summarises the appearance of different types of renal stone on x-ray

Type Frequency Radiograph appearance

Calcium oxalate 40% Opaque
Mixed calcium oxalate/phosphate stones 25% Opaque
Triple phosphate stones* 10% Opaque
Calcium phosphate 10% Opaque
Urate stones 5-10% Radio-lucent
Cystine stones 1% Semi-opaque, 'ground-glass' appearance
Xanthine stones <1% Radio-lucent

*stag-horn calculi involve the renal pelvis and extend into at least 2 calyces. They develop in alkaline urine and
are composed of struvite (ammonium magnesium phosphate, triple phosphate). Ureaplasma urealyticum and
Proteus infections predispose to their formation

Question 75 of 78
A 35-year-old homosexual man is referred to the colorectal clinic with rectal pain and tenesmus. On
examination you note painful inguinal lymphadenopathy and a solitary painless penile ulcer. What is the most
likely diagnosis?

A. Herpes simplex infection

B. HIV infection

C. Granuloma inguinale

D. Chancroid

E. Lymphogranuloma venereum
Genital ulcers

• painful: herpes >> chancroid

• painless: syphilis > lymphogranuloma venereum + granuloma inguinale

Lymphogranuloma venereum usually involves three stages:

• 1 - small painless pustule which later forms an ulcer

• 2 - painful inguinal lymphadenopathy
• 3 - proctocolitis

2/3 Question 76-78 of 78

Theme: Management of prostatic disease

A. Commence alpha blocker

B. Commence 5 alpha reductase inhibitor
C. Transurethral resection of the prostate
D. Commence LnRH analogue
E. Radical prostatectomy
F. Transvesical prostatectomy
G. Unilateral orchidectomy
H. Watch and wait
I. Radical radiotherapy

For the prostatic disorders described please select the most appropriate management option. Each option may be
used once, more than once or not at all.

76. A 49 year old man presents with a single episode of haematuria. Investigations demonstrate
adenocarcinoma of the prostate gland. Imaging shows T2 disease and no evidence of metastasis.

Radical prostatectomy

In a young patient with local disease only a radical prostatectomy is the best chance of cure.
Radiotherapy may be given instead but has long term sequelae. A transvesical prostatectomy is a
largely historical operation performed for BPH before TURP was established.

77. A 72 year old man is admitted with acute urinary retention. On examination he has a small but
palpable bladder. Digital rectal examination identifies a benign feeling enlarged prostate gland. He
has been treated with finasteride for the past 9 months.

Transurethral resection of the prostate

Medical therapy has failed and although an alpha blocker may help his symptoms he would fare
better with a TURP.

78. A 73 year old man presents with haematuria. Investigations demonstrate a localised prostatic disease.
He suffers from mild COPD but otherwise has no major co-morbidities. His staging investigations
show no evidence of metastatic disease

You answered Watch and wait

The correct answer is Radical radiotherapy

Localised disease with minor medical co-morbidities would attract a recommendation for radical
radiotherapy. The long term follow up data does show complications related to radical radiotherapy
and those with more advanced co-morbidities should probably be managed medically.