Download Question 1 : SC

Case 1273: Urology MCQs - 3
Authors and Affiliations
Hannah Pham
School of Medicine
University of Adelaide
A/Professor Peter Devitt
Head, Professorial Surgical Unit
Royal Adelaide Hospital
Adelaide, South AustraliaThese multiple choice questions are suitable for students approaching their
end-of-year examinations. In general, the content and the standard of the questions focus on the
knowledge and understanding of the subject material that would be expected of a general practitioner
without any expert knowledge of the Discipline. Some of the questions perhaps go to a slightly higher
standard.
Case Overview
Learning Objectives
The graduating student should be familiar with the topics presented in this small quiz.
Question 1 : SC
Question Information:
A 20-year-old man presents with testicular pain. This has been ongoing since a groin injury during a
soccer match two days ago. The pain has not abated with regular analgesia and ice packs applied to
the groin. On examination, the left testis is swollen, tender on palpation, with a palpably thickened cord.
There is no overlying erythema of the skin. The testis does not transilluminate.
Question:
Which one of the following is the most likely diagnosis?
Choice 1: Hydrocele Score : 0
Choice Feedback:
Incorrect.
Choice 2: Haematoma Score : 1
Choice Feedback:
Correct. This is the most likely explanation for the pain - particular if the patient had a direct blow to his
scrotum. The other condition to be considered and excluded is torsion of the testis. In a small proportion
of cases, torsion can be precipitated by sport or injury - but this is very uncommon. Patients with torsion
usually have pain of such severity that they seek prompt medical help.
Choice 3: Testicular torsion Score : 0
Choice Feedback:
Incorrect.
Choice 4: Epididymitis Score : 0
Choice Feedback:
Incorrect.
Choice 5: Testicular cancer Score : 0
Choice Feedback:
Incorrect.
Question 2 : SC
Question Information:
A 20-year-old man presents with testicular pain. This has been ongoing since a groin injury during a
soccer match two days ago. The pain has not abated with regular analgesia and ice packs applied to
the groin. On examination, the left testis is swollen, tender on palpation, with a palpably thickened cord.
There is no overlying erythema of the skin. The testis does not transilluminate.
Question:
Which one of the following is the next most appropriate investigation?
Choice 1: Radionuclide studies Score : 0
Choice Feedback:
Incorrect.
Choice 2: Ultrasound Score : 1
Choice Feedback:
Correct. Torsion needs to be excluded. If the pain had been of short duration and the scrotum difficult to
examine, the most appropriate next step would be surgical exploration. However, in this case the length
and nature of the history is rather against torsion and more in favour of trauma. Ultrasound can serve
two purposes. First, it can define the anatomy of the region and in particular, look for any evidence of
haematoma formation and the integrity of the various structures with the scrotum. Trauma may lead to
haemorrhage within the testis itself or bleeding within the tunica vaginalis. If epididymitis or torsion are
serious contenders in the list of differential diagnoses, then doppler ultrasonography will be helpful in
looking at the vascularity - increased in epididymitis and decreased in torsion.
Choice 3: Surgical exploration Score : 0
Choice Feedback:
Incorrect.
Choice 4: Testicular biopsy Score : 0
Choice Feedback:
Incorrect.
Choice 5: Urinalysis Score : 0
Choice Feedback:
Incorrect.
Question 3 : SC
Question Information:
A 20-year-old man presents with testicular pain. This has been ongoing since a groin injury during a
soccer match two days ago. The pain has not abated with regular analgesia and ice packs applied to
the groin. On examination, the left testis is swollen, tender on palpation, with a palpably thickened cord.
There is no overlying erythema of the skin. The testis does not transilluminate. An ultrasound
examination shows a small quantity (<10ml) of blood within the tunica vaginalis and a 1 cm tear in the
tunica albuginae.
Question:
Which one of the following is the most appropriate management approach?
Choice 1: Empirical antibiotics Score : 0
Choice Feedback:
Incorrect.
Choice 2: Surgical exploration Score : 1
Choice Feedback:
Correct. Without a tear in the outer component of the testis (the tunica albuginae), it might have been
quite appropriate to recommend bed rest, a scrotal support and ice packs, but with a rupture to the
testis, surgical exploration is appropriate. The aim of surgery is to excise any devitalised tissue, contain
any bleeding and to repair the tunica albuginae. Without decompression, the viability of the testis is in
jeopardy.
Choice 3: Conservative management Score : 0
Choice Feedback:
Incorrect.
Choice 4: Insertion of indwelling catheter Score : 0
Choice Feedback:
Incorrect.
Choice 5: Aspiration Score : 0
Choice Feedback:
Incorrect.
Question 4 : SC
Question Information:
A 30-year-old man presents to his general practitioner with a four week history of a scrotal swelling. He
first noticed the swelling after a game of soccer when he thought he might have been injured in that
area after a rough tackle. The left side of the scrotum and contents are normal and on the right side
there is a firm 6 cm diameter non-tender swelling which does not transilluminate.
Question:
Which one of the following is the most appropriate next investigation?
Choice 1: Scrotal ultrasound Score : 1
Choice Feedback:
Correct. The most important diagnosis to exclude is some form of testicular malignancy. Whilst it may
come as a surprise to many, men are not as conscientious as women when it comes to selfexamination and large testicular swellings can go unnoticed. It may take something like an apparent
blow to that region (as in a contact sport) that brings the swelling to the owner's notice. In other words,
this type of presentation is an all-too-frequent mode of presentation of testicular cancer. Only when the
ultrasound has been performed and a diagnosis of malignancy made more definite, should tumour
markers and staging (CT) be performed.
Choice 2: CT chest/abdomen/pelvis Score : 0
Choice Feedback:
Incorrect.
Choice 3: Tumour markers Score : 0
Choice Feedback:
Incorrect.
Choice 4: Testicular biopsy Score : 0
Choice Feedback:
Incorrect.
Choice 5: Surgical exploration Score : 0
Choice Feedback:
Incorrect.
Question 5 : SC
Question Information:
A 30-year-old man presents to his general practitioner with a four week history of a scrotal swelling. He
first noticed the swelling after a game of soccer when he thought he might have been injured in that
area after a rough tackle. The left side of the scrotum and contents are normal and on the right side
there is a firm 6 cm diameter non-tender swelling which does not transilluminate.
Question:
Which lymph node group is most commonly affected in pathological processes arising from a testis?
Choice 1: Superficial inguinal Score : 0
Choice Feedback:
Incorrect.
Choice 2: Deep inguinal Score : 0
Choice Feedback:
Incorrect.
Choice 3: Femoral Score : 0
Choice Feedback:
Incorrect.
Choice 4: Para-aortic Score : 1
Choice Feedback:
Correct. The testis have an intra-abdominal origin and their blood supply is the testicular arteries, which
branch off the aorta, immediately below the renal arteries. Likewise, the lymphatic vessels follow these
arteries, travel up the spermatic cord and drain into nodes along the aorta.
Choice 5: Exetrnal iliac Score : 0
Choice Feedback:
Incorrect.
Question 6 : SC
Question Information:
A 30-year-old man presents to his general practitioner with a four week history of a scrotal swelling. He
first noticed the swelling after a game of soccer when he thought he might have been injured in that
area after a rough tackle. The left side of the scrotum and contents are normal and on the right side
there is a firm 6 cm diameter non-tender swelling which does not transilluminate. The ultrasound shows
a 3 cm hyper echoic, well circumscribed heterogenous mass in the lower pole of the left testis. His
blood tests return the following results:
Beta
HCG positive
Alpha
LDH
fetoprotein positive
negative
Question:
Which one of the following is the most likely cause for this man†™s testicular swelling?
Choice 1: Germ cell tumour Score : 0
Choice Feedback:
Incorrect.
Choice 2: Seminoma Score : 0
Choice Feedback:
Incorrect.
Choice 3: Choriocarcinoma Score : 0
Choice Feedback:
Incorrect.
Choice 4: Nongerminomatous cell tumour Score : 1
Choice Feedback:
Correct. The ultrasonographic description fits for a nongerminomatous germ cell tumour and the tumour
marker profile suggests the presence of two or more germ cell types.
Choice 5: Sex cord tumour Score : 0
Choice Feedback:
Incorrect.
Question 7 : SC
Question Information:
A 50-year-old man presents to the Emergency Department with a three hour history of severe left-sided
colicky abdominal pain. He has never had this pain before. There is a history of alcohol abuse, gout,
and hypercholesterolaemia. On examination, his pulse rate is 90/min, blood pressure 120/70mmHg,
respiratory rate 19/min, and his temperature is 38.3C. He is tender in the left flank. A non-contrast CT
scan demonstrates left-sided hydronephrosis with an obstructing 7mm stone at the proximal ureteric
junction. Urinalysis is positive for leucocytes and nitrates.
Question:
Which one of the following analgesic regimens is most appropriate?
Choice 1: Intravenous morphine Score : 0
Choice Feedback:
Incorrect.
Choice 2: Indomethacin suppository Score : 1
Choice Feedback:
Correct. In most cases of abdominal pain due to intermittent ureteric obstruction the symptoms can be
managed quite adequately with one of the non-steroidal anti-inflammatory drugs such as indomethacin.
This should be the first-line approach and if inadequate, stronger, codeine-containing agents can be
added. Failure of these regimens to control pain may lead to admission and parenteral analgesia. This
particular patient has evidence of sepsis and will require admission, intravenous antibiotics and
decompression of his obstructed left renal tract.
Choice 3: Oral paracetamol Score : 0
Choice Feedback:
Incorrect.
Choice 4: Fentanyl patch Score : 0
Choice Feedback:
Incorrect.
Choice 5: Intravenous ketorolac Score : 0
Choice Feedback:
Incorrect.
Question 8 : SC
Question Information:
A 25-year-old man presents to the Emergency Department with a first episode of severe right-sided
colicky abdominal pain associated with vomiting. He is otherwise well and takes no regular medications.
On examination, his pulse rate is 90/min, blood pressure 120/70mmHg, respiratory rate 20/min, and
temperature is 36.4C. There is some tenderness on palpation to the right flank. A non-contrast CT scan
shows a non-obstructing 3mm stone at the pelvi-ureteric junction and a 5mm distal ureteric stone.
Question:
Which one of the following is the most appropriate initial treatment?
Choice 1: Ureteroscopy and stent insertion Score : 0
Choice Feedback:
Incorrect.
Choice 2: Percutaneous nephrostomy Score : 0
Choice Feedback:
Incorrect.
Choice 3: Intravenous antibiotics Score : 0
Choice Feedback:
Incorrect.
Choice 4: Medical expulsion therapy Score : 1
Choice Feedback:
Correct. This patient is relatively well, can be managed on an out-patient basis and will almost certainly
pass his ureteric stones without the need for any intervention.
Choice 5: Extracorporeal shockwave lithotripsy Score : 0
Choice Feedback:
Incorrect.
Question 9 : SC
Question Information:
A 56-year-old man presents after an episode of renal colic which has resolved spontaneously and he
now feels well. A non-contrast CT shows a 8 mm stone in the upper right ureter. There is mild
hydronephrosis. Escherichia coli is cultured from the urine.
Question:
Which one of the following is the most appropriate management?
Choice 1: Medical expulsion therapy Score : 0
Choice Feedback:
Incorrect.
Choice 2: Ureteric stent Score : 1
Choice Feedback:
Correct. The patient has an obstructed and infected collecting system. He needs some form of active
intervention to prevent any septicaemia. Medical expulsion therapy will be ineffective and the other
forms of active intervention will risk making the patient septic.
Choice 3: Percutaneous nephrolithotomy Score : 0
Choice Feedback:
Incorrect.
Choice 4: Extracorporeal lithotripsy Score : 0
Choice Feedback:
Incorrect.
Choice 5: Ureteroscopy and laser ablation Score : 0
Choice Feedback:
Incorrect.
Question 10 : SC
Question Information:
A 71-year-old man is referral for a urological assessment, based on a three month history of worsening
symptoms of poor stream, frequency and nocturia. His bladder is not palpable and on digital rectal
examination there is a hard, irregular enlargement of the right lobe of the prostate. A serum PSA two
weeks ago was 20 ng/ml (0-4) and this is repeated and has not changed.
Question:
Which one of the following is the most appropriate next investigation.
Choice 1: Transrectal prostate biopsy under ultrasound guidance Score : 0
Choice Feedback:
Incorrect. This his associated with a 3 - 5% rate of urosepsis and is now being replaced by
transperineal biopsy - which has urosepsis rate of 0.1%. The infecting organisms after TRUS are often
multi resistant gram negatives, whereas any infection that occurs after transperineal biopsy tend to be
gram positives and more easy to treat.
Choice 2: Transperineal biopsy of the prostate Score : 0
Choice Feedback:
Incorrect. Whilst this approach is now replacing the more traditional transrectal ultrasound-guided
biopsy (TRUS), MRI now has a substantial role to play in the initial assessment. There is a urosepsis
rate of 0.1% with the transperineal approach, compared with a rate of 3 - 5% with TRUS. The infecting
organisms after TRUS are often multi resistant gram negatives, whereas any infection that occurs after
transperineal biopsy tend to be gram positives and more easy to treat.
Choice 3: MRI Score : 1
Choice Feedback:
Correct. In recent years there have to two major changes regarding prostate cancer detection.
First, there has been a big improvement in radiologists' accuracy of reporting lesions suspicious of
being cancer on MRI prior to biopsy. A structured reporting system called PI-RADS (prostate imaging
reporting and data system) has been developed which allows more consistent reporting of how
suspicious lesions are. A PI-RADS score is assigned for each lesion between 1-5 where 1 represents
very low risk of being prostate cancer and 5 is very high risk of prostate cancer. Generally, all lesions
with a PI-RADS score of 3-5 would be biopsied and a PI-RADS score of 1-2 would be observed. MRI is
being arranged before biopsy most of the time, and the only thing holding it back from being universal is
government funding. MRI is not a rebatable study, so patients have to pay $350 in SA and up to $1000
in Vic/NSW. If a suspicious lesion is seen, then it is targeted with biopsy, in addition to doing a template
biopsy of the prostate.
Secondly, there has been a trend to perform prostate biopsy through the perineum rather than the
rectum. This has significantly decreased the rate of urosepsis (TRUS 3-5% and often is multi resistant
gram negatives, and transperineal biopsy 0.1% and are gram positives and not resistant). Transperineal
biopsy also allows better access to the anterior prostate, which is difficult to get to via transrectal route.
The main drawback is the ultrasound equipment and stepper (for needle guidance) required are
expensive, and a general anaesthetic is required and it takes 40 mins (compared to 10 mins for
transrectal).
Choice 4: PSMA-PET scan (prostate specific membrane antigen) Score : 0
Choice Feedback:
Incorrect. This investigation is used to detect metastatic disease, particularly small volume disease in
lymph glands or bones that are too small to be detected on CT or WBBS.
Choice 5: Whole body bone scan Score : 0
Choice Feedback:
Incorrect.
Synopsis
Recommended learning outcomes from this set of Urology MCQs include:
1. Testicular torsion
2. Testicular cancer
3. Renal colic