Urology 🚽

A 75 year old man has urinary symptoms of frequency and nocturia. He finds it difficult to start his urine flow. Once he starts, the flow stops halfway through and starts again. He often has the sensation of not being able to empty his bladder. His medical history includes having prostate cancer 11 years ago which was treated and went into remission. A digital rectal examination reveals an irregular, hard asymmetric prostate gland. What is the SINGLE most appropriate investigation to perform next?

A 39 year old coal miner was recently diagnosed with bladder cancer. He is a smoker and has a family history of bladder cancer. He also has been diagnosed with benign prostatic hyperplasia. Which SINGLE risk factor is likely to be associated with transitional cell carcinoma of the bladder?

An 18 year old rugby player comes with sudden onset pain in his left scrotum which started while playing. On examination, there is swelling and tenderness noted. The left testes is placed higher than the right testes. Urine examination is positive for nitrites and leukocytes. What is the SINGLE most appropriate management for this patient?

A 34 year old woman presents to the Emergency Department with sudden onset, severe colicky pain from her right loin radiating to her labia which started 10 hours ago. She has also noticed blood in her urine. The pain occurs in spasm with intervals of dull ache. The pain is accompanied by nausea. She complains of urinary frequency and dysuria. She has a temperature of 36.1°C, a blood pressure of 110/80 mmHg and a heart rate of 80 beats/minute. She is restless and unable to sit still. A urine HCG done in the department has come back as positive. What is the SINGLE most appropriate investigation to request?

A 19 year old man has pain in his scrotum for the past 12 hours. He complains of dysuria and increased frequency. His scrotum is tender, swollen and erythematous. He has a temperature of 36.7°C. A urinalysis was performed which shows 2+ leukocytes and 2+ nitrates. What is the SINGLE most likely diagnosis?

A 59 year old man presents to the Emergency Department with the inability to pass urine over the past 20 hours. He has found it increasingly difficult to urinate over the past week. He has been diagnosed with prostate cancer 3 months ago. He is experiencing suprapubic pain. His surgical history is unremarkable. Abdominal examination reveals a tender palpable bladder midway between the pubic symphysis and umbilicus. Urethral catheterization was performed but failed. What is the SINGLE most appropriate management?

A 15 year old boy presents with testicular pain for 3 days. The pain had a gradual onset. There is no history of trauma. On examination, his right hemi-scrotum is tender, swollen and red. He has a temperature of 38.5°C. He has just become sexually active. What is the SINGLE most appropriate management?

A 65 year old lady presents with the complaint of urinary incontinence to the GP surgery. She is distressed by her symptom, which has been going on for the past year and wishes to have something done to preserve her dignity. She claims that she does not have a burning sensation when she passes urine and has not noticed a change in colour or smell of urine. She only experiences an urgency to rush to the loo but wets herself before she gets there, and her bladder habits do not have any relation to coughing, sneezing or laughing. A urine dipstick test performed at the office is negative for nitrites and leukocytes. A midstream urine culture sent last week was negative. Which of the following is the most appropriate step in managing this patient?

A 61 year old woman complains of continuous leakage of a small amount of urine vaginally over the past few months. It is not worsened when she coughs but occurs throughout the day. She has had pelvic radiotherapy for cervical cancer 6 months ago. She has no neurological deficits. What is the SINGLE most likely diagnosis?

A 61 year old man, known smoker, comes to the hospital with complaints of painless frank haematuria. He also describes worsening urinary urgency and frequency. He has been worried about his loss of weight and reduced general activity. A digital rectal examination in the clinic reveals an enlarged smooth prostate with no nodules. Urine microscopy shows red cells but no white cells. What is the SINGLE most appropriate diagnostic test?

A 52 year old man presents to his general practitioner with the complaint of urinary trouble for the last year which had gotten worse during the preceding week. He describes hesitancy and dribbling of urine and has recently noticed blood in his urine. His past medical history includes recently diagnosed hypertension for which he was started on ramipril. He was also diagnosed with hyperlipidaemia last year for which he is an a statin. The patient swears compliance with all his medications and does not take any aver the counter medications. His blood pressure today is 160/90 mmHg. Blood tests were taken the following week and the results are as follows:

Haemoglobin 127 g/L (130-180 g/L)

Prostate-specific antigen 4.5 ng/mL (0-4 ng/mL)

Urea 8.2 mmol/L (20-7 mmol/L)

Creatinine 162 μmol/L (70-150 μmol/L)

Potassium 5.2 mmol/L (3.5-5 mmol/L)

Calcium (total) 2.2 mmol/L (2.2-2.6 mmol/L)

What is the SINGLE most appropriate action?

A 20 year old women 6 hours post-lower segment Caesarean section has not passed urine since her operation. She denies any urinary symptoms preoperatively. She appears unwell. She has a temperature of 37°SC, a pulse of 110 beats/minute, a blood pressure of 94/60 mmHg and a respiratory rate of 23 breaths/minute. Her abdomen is distended with tenderness in the left flank and suprapubic region. Bowel sounds are not audible. What is the SINGLE most likely postoperative complication?

A 20 year old man comes to the GP clinic hours after being kicked in the scrotum during a football match. The pain has subsided and there is minimal tenderness on his right scrotum with no swelling. What is the SINGLE most appropriate action?

A 58 year old man has renal colic for the past 12 hours. In the last two years, he has presented with three episodes of acute onset of pain in his right knee. What is the SINGLE most likely cause of his renal colic?

A 62 year old man attends the Emergency Department with difficulty passing urine for the past 24 hours. He feels the urge to urinate but is unable to do so. He has suprapubic pain. He has a history of lower urinary symptoms including a weak stream, intermittent flow, dribbling and the need to strain to urinate. His pain is relief following a urinary catheter insertion which drained 750 ml of urine. On per rectal examination, his prostate is enlarged symmetrically with the median sulcus felt. His prostate specific antigen (PSA) and renal function is within normal levels. What is the SINGLE most appropriate action?

A 34 year old woman has ongoing right upper quadrant pain which is worse after eating. An ultrasound scan was requested due to her pain. It is reported as having a renal cyst measuring 2 cm at the superior pole of the right kidney. It is round and has a distinct outline with sharp, thin posterior walls. There are no echoes within the cyst. There is no evidence of calcification or septation. What is the SINGLE most appropriate action in regard to the renal cyst?

A 45 year old man is seen in the Emergency Department with severe right flank pain for the past 3 days. His urine output has been reduced over the past 2 days. He has a temperature of 37.9°C and a heart rate of 103 beats/minute. He was started on pain relief, intravenous antibiotics and intravenous fluids. A CTKUB reveals an 11 mm stone at his right distal ureter with the presence of hydronephrosis. His blood test shows the following results:

Haemoglobin 148 g/L (130-180)

White cell count 18 x 10^9/L (4-11)

Platelets 350 x 10^9/L (150-400)

Sodium 144 mmol/L (135-145)

Potassium 3.8 mmol/L (3.5-5)

Urea 21 mmol/L (2.0-7)

Creatinine 240 μmol/L (70-150)

eGFR 49 mL/min

CRP 315 mg/L (<10)

What is the SINGLE most appropriate management?

A 72 year old man brought to the emergency department with onset of paraplegia following a trivial fall. He was treated for prostatic malignancy in the past. What is the SINGLE most likely diagnosis?

A 79 year old man who is being treated with GnRH antagonist for a diagnosed prostate adenocarcinoma attends the clinic. What is the SINGLE most appropriate follow up investigation?

A 52 year old man has swelling of his right scrotum. He first noticed the swelling 2 months ago and it has increased in size. The swelling is painless. On examination, there is a 6 cm non-tender cystic swelling of the right scrotum which transilluminates. The right testis is impalpable. What is the SINGLE most appropriate investigation?

A 26 year old sexually active male presents with severe pain in the left scrotum lasting for 4 hours. He complains of a past history with similar episodes of pain over the past few weeks but has never sought treatment before. His scrotum is extremely tender and examination is impossible because of the pain. What is the SINGLE best management for this patient?

A 70 year old man with a history of prostatic cancer has severe acute back pain waking him up at night for the past 4 weeks. This pain radiates to his lower limbs and he has slight difficulty in walking. On examination, he is tender at the lumbar spine. What is the SINGLE most appropriate investigation?

A 20 year old rugby player comes in with severe pain in his left scrotum after he was struck in the groin during the game. The left testicle is placed higher than the right testicle. The pain is not eased by the elevation of the testes. What is the SINGLE most appropriate next course of action?

A 34 year old man is seen in the Emergency Department with severe right flank pain for the past 4 days. His urine output has been reduced over the past 2 days. He has a body mass index of 41 kg/m2. He has a temperature of 37.3°C and a heart rate of 93 beats/minute. He has been given adequate pain relief. A CTKUB reveals a 14 mm stone at his right proximal ureter with the presence of hydronephrosis. His blood test shows the following results:

Haemoglobin 138 g/L (130-180)

White cell count 10 x 10^9/L (4-11)

Platelets 362 x 10^9/L (150-400)

Sadium 136 mmol/L (135-145)

Potassium 3.9 mmol/L (3.5-5)

Urea 24 mmol/L (2.0-7)

Creatinine 290 μmol/L (70-150)

eGFR 40 mL/min

CRP 16 mg/L (<10)

What is the SINGLE most appropriate management?

A 17 year old boy attends the A&E with sudden onset pain in his left testicular pain which started 6 hours ago when he was sleeping. The pain radiates to the groin. On examination, there is mild swelling of the left scrotum and tenderness when palpating the left testicle. His temperature is 38.9°C. What is the SINGLE most appropriate management for this patient?

A 23 year old man presents to the Emergency Department with severe pain in the left scrotum lasting for 3 hours. His scrotum is extremely tender and examination reveals his left testicle is significantly higher than the right. There is also swelling on the posterior aspect of the testicles. He is sexually active and does not use any protection. There is no history of trauma. What is the SINGLE most appropriate management?

A 47 year old woman has had 3 urinary tract infections confirmed with urine culture in the past 8 months. She has been started on cefalexin for prophylaxis. A kidney ureter bladder X-ray has been performed and no renal stones were identified. Ultrasound of the kidneys and ureter show no evidence of hydronephrosis or renal stones. Post voiding residual volume is minimal on a bladder ultrasound. What is the SINGLE most appropriate investigation?

A 53 year old African man attends the GP surgery with difficulty voiding. He has a sensation of not emptying his bladder completely after urination. He has a weak stream and often has to strain to begin urination. He has also found it difficult to postpone urination and would need to urinate quickly. He has no history of hypertension. His last recorded blood pressure is 110/80 mmHg. On digital rectal examination, he has a smooth enlarged prostate. There are no nodules and the median sulcus can be defined. What is the SINGLE most appropriate management?

A 61 year old man attends the urology clinic after being referred from the GP for persistent non-visible haematuria. His last urine dipstick shows +1 blood. His urine was sent to the laboratory but there was no evidence of bacterial growth. He does not complain of abdominal or back pain. His blood results show the following:

Haemoglobin 131 g/L (130-180)

White cell count 10 x 10^9/L (4-11)

Platelets 280 x 10^9/L (150-400)

Creatinine 140 μmol/L (70-150)

eGFR >90 mL/min

A CT scan has been performed which did not show any pathology. What additional investigation would be appropriate to request in his appointment?

A 43 year old woman who has just undergone an abdominal hysterectomy and bilateral salpingo-oophorectomy 5 days ago has severe right flank pain and lower abdominal pain. She is seen to be nauseous and has been vomiting. She has a persistent ileus. On examination, her abdomen is distended and there are sluggish bowel sounds. She has a temperature of 38°C. Her blood results show:

Haemoglobin 120 g/L (130-180)

White cell count 14 x 109/L (4-11)

Platelets 350 x 109/L (150-400)

Urea 9 mmol/L (20-7)

Creatinine 490 μmol/L (70-150)

CRP 48 mg/L (<10)

What is the SINGLE most appropriate investigation?

A 63 year old man presents with difficulty in holding his urine to the urology clinic. He wakes up three times a night to urinate. He has intermittent urine flow and dribbling on almost every occasion. His urine stream is very weak. He started on tamsulosin 6 months ago and he has been compliant with his medications. He has a recent PSA result of 4.5 nanogram/mL (normal age-specific PSA values are below 4.0 nanogram/mL). A digital examination reveals a large, symmetrical, soft prostate. His blood pressure is 130/80 mmHg. What is the SINGLE most appropriate medication to add on?

A 44 year old man has swelling of his right scrotum. He first noticed the swelling 18 months ago and it has increased in size. The swelling is painless. On examination, there is a 4 cm non-tender cystic swelling of the right scrotum which transilluminates. The swelling encapsulates the testicle and is found mostly anterior and lateral of the testicle. The right testicle is palpated on the superior margin of the swelling. He has no history of trauma to the testicles. What is the SINGLE most appropriate diagnosis?

A 15 year old boy complains of having a heavy feeling in the scrotal area. On physical examination, a soft painless swelling in the left scrotum is noticed. The swelling appears blue in colour and is less obvious when he is lying supine. He states that he has just become sexually active and fears that it is a sexually transmitted infection. What is the SINGLE most appropriate management?

A 49 year old man presents with sudden onset, severe colicky pain from his right flank radiating to his groin associated with nausea and vomiting. He subsequently develops rigors and a tender abdomen. His urinalysis reveals a trace of blood. What is the SINGLE most appropriate investigation to request?

A 29 year old man attends the urology clinic with painless left testicular enlargement. He first noticed it 6 weeks ago. It has been gradually increasing in size. There is no history of trauma. On examination, the left testicle is noted to be 2 times the size of the right testicle. An 8 mm firm, non-tender lump is felt within the body of the left testicle. There is no redness. There is no scrotal discolouration. What is the SINGLE most appropriate action?

A 59 year old man attends the clinic with complains of obstructive urinary symptoms for the past 3 months. A digital rectal examination reveals a smoothly enlarged prostate. The patient is anxious about the diagnosis of prostate cancer as his father had died from prostate cancer. A prostate specific antigen (PSA) is requested. What is the SINGLE most appropriate advice to provide the patient in regards to the PSA test?

A 31 year old man attends the GP surgery with a painless lump in his scrotum. He first noticed it 2 weeks ago. He describes a dragging sensation in his scrotum. On examination, the dragging sensation does not improve on lying down flat. A palpable mass can be palpated in the scrotum in the body of the testis. It is felt as slightly larger than a pea size nodule. What is the SINGLE most appropriate action?

A 54 year old man attends the urology clinic with symptoms of intermittent frank haematuria over the past 3 weeks. He does not complain of pain. He has no fever and does not complain of dysuria. His blood results show the following:

Haemoglobin 138 g/L (130-180)

White cell count 8 x 10^9/L (4-11)

Platelets 250 x 10^9/L (150-400)

Creatinine 120 μmol/L (70-150)

eGFR >90 mL/min

He was booked for a cystoscopy. What additional investigation would be appropriate to request in his appointment?

A 28 year old woman presents to the GP surgery. She complains of having to urinate more often than usual and had unintentionally wet herself before she could reach the toilet. Her symptoms began 2 days ago, and her medical history includes a urinary tract infection 2 years ago, which responded well to antibiotics. She recalls her mother and sister having occasional urinary tract infections. She is sexually active with a new partner, having ended her previous relationship 2 weeks ago. Which of the following is the SINGLE best initial investigation to establish a diagnosis?

A 79 year old Afro-Caribbean man presents with pain in his lower back and hip. He complains of waking up in the middle of the night to go to the washroom and often he wets himself before reaching the toilet. He also has to urinate much more frequent than in the past and has terminal dribbling. He has lost significant weight in the past month and feels very lethargic. What is the SINGLE most likely underlying diagnosis?

A 35 year old woman presents to the GP surgery with painful micturation over the past 3 days. She also complains of increased urinary frequency during this time period. She denies any fever, haematuria, suprapubic pain or flank pain. She has had a history of pyelonephritis requiring admission to the hospital 2 years ago. She has a temperature of 37.3°C, a blood pressure of 120/80 mmHg and a heart rate of 85 beats/minute. Her urinalysis shows nitrates 1+. Examination of her lower abdomen and flanks are unremarkable. What is the SINGLE most appropriate investigation to request?

A 28 year old man presents with sudden onset right groin pain and scrotal pain which radiates from his right loin. The pain started 10 hours ago and has gradually worsened. The pain is associated with vomiting. He has pain when he urinates. He is sexually active. He denies any fever or urethral discharge. His urinalysis shows blood 3+. What is the SINGLE most appropriate investigation to request?

A 71 year old man is referred to the urology clinic by his GP with the complaints of intermittent haematuria for the two weeks. He does not think much of it when it happens because it is painless however, his wife has convinced him to seek help. He also complains of hesitancy and difficulty in emptying out his bladder completely. He has an increased frequency of micturition over the past month. When asked directly, he also admits to a constant, dull and aching lower back and pelvic pain. Blood test done by the GP reveals the following:

Haemoglobin 124 g/L (130-180 g/L)

Prostate-specific antigen 12 ng/mL (Age-specific threshold < 6.5 ng/mL)

Urea 9.3 mmol/L (2.0-7 mmol/L)

Creatinine 169 μmol/L (70-150 μmol/L)

What is the SINGLE most likely diagnosis in this patient?

A 15 year old boy was woken up from sleep with severe, sudden pain in the testis. He is brought into the Emergency Department by his mother with unbearable pain. There was no history of trauma. He has had a similar pain a few days ago on his left scrotum but it went away after two hours. He admits to having a sexual relationship with one of his classmates recently. On examination, the left testicle is tender on palpation and there is mild warmth and redness of the overlying area. He is afebrile. Analgesia has been given but the pain still persists. What is the SINGLE most appropriate next step in management?

A 33 year old man has a sudden onset of spasmodic pain from his left loin that radiates to his left groin and testicle. The pain started 5 hours ago. He is unable to sit still because of the pain. He feels nauseous. He has a history of renal stones in the past, otherwise, his medical history is unremarkable. A urine dipstick shows blood 2+. What is the SINGLE most appropriate management?

A 64 year old man attends the urology clinic with six episodes of frank haematuria over the past 4 weeks. He does not have pain with these episodes. He has no fever and does not complain of dysuria. A prostate examination reveals an enlarged, smooth prostate. His blood results show the following:

Haemoglobin 138 g/L (130-180)

White cell count 8 x 109/L (4-11)

Platelets 250 x 109/L (150-400)

Creatinine 130 μmol/L (70-150)

eGFR >90 mL/min

Prostate-specific antigen (PSA) 2.9 ng/mL (0-4)

What additional investigation would be appropriate to request in his appointment?

A 65 year old man attends the urology clinic after being referred by the GP for persistent non-visible haematuria. His last urine dipstick shows +1 blood without any nitrates and leukocytes. He initially suffered from a urinary tract infection a month ago but his symptoms of dysuria resolved; however, his urine dipstick has persistently shown +1 blood. His blood results show the following:

Haemoglobin 141 g/L (130-180)

White cell count 9 x 10^9/L (4-11)

Platelets 289 x 10^9/L (150-400)

Creatinine 150 μmol/L (70-150)

eGFR >90 mL/min

What additional investigation would be appropriate to request during his appointment?

A 25 year old woman presents with urinary frequency, suprapubic pain and dysuria. She has a temperature of 38.5°C. Nitrites and leucocytes are positive on a dipstick. What is the SINGLE most likely diagnosis?

A 77 year old elderly man has symptoms of poor and intermittent urinary flow. It takes him a few minutes to generate a pressure high enough to start the urine flow. In the last few months, he has been seen to be increasingly fatigue. He also complains of feeling thirsty most of the day. He has a blood pressure of 150/90 mmHg. On digital rectal examination, his prostate is firm, smooth without nodules, and enlarged to about two finger breadths. His blood results show:

Haemoglobin 129 g/L

Prostate-specific antigen (PSA) 4.5 ng/mL

Urea 11 mmol/L

Creatinine 290 μmol/L

Serum calcium 2.1 mmol/L

What is the SINGLE most likely diagnosis?

A 60 year old patient had a cystoscopy for painless, gross hematuria and pathology revealed transitional cell carcinoma of the bladder. He has smoked a pack a day for the last 15 years and currently works in a coal factory. What is the SINGLE greatest risk factor for transitional cell carcinoma in this patient?

A 67 year old man who has a diagnosis of benign prostatic hyperplasia undergoes a transurethral resection of the prostate (TURP) under general anaesthetic. The procedure time was 55 minutes and there were no immediate complications noted. Following the procedure, he becomes confused and agitated. What is SINGLE most likely electrolyte abnormality causing his symptoms?

A 13 year old boy develops acute pain in his right testicle while playing football. Examination reveals a very tender mass in the right scratum with reddening of scrotal skin. Lifting the testis causes more pain. What is the SINGLE most likely diagnosis?

A 62 year old white British man had a cystoscopy for painless, gross haematuria, and the pathology revealed transitional cell carcinoma of the bladder. He has smoked a pack a day for the past 20 years. He drinks an average of 10 units of alcohol a week. What is the SINGLE greatest risk factor for transitional cell carcinoma in this patient?

A 25 year old man presents to the GP surgery with a painful right testis, lower abdominal pain, vomiting and nausea. The testis is swollen, hot, and extremely tender. The onset of pain was dramatic and sudden. The pain started 4 hours ago. He complains of some pain on passing urine. What is the SINGLE most appropriate next course of action?

A 33 year old man presents with sudden onset, severe colicky pain from his right loin associated with nausea and vomiting. The pain started 12 hours ago. He denies any fever. His urinalysis shows blood 3+. He flew from Spain to the UK a day ago. What is the SINGLE most appropriate investigation to request?

A 51 year old man was treated with nitrofurantoin for ongoing dysuria and visible haematuria at the GP clinic 2 weeks ago. The urine culture at that time showed evidence of Escherichia coli which was sensitive to nitrofurantoin. He attends the GP clinic again as he still has visible haematuria although his symptoms of dysuria have resolved. He does not have any pain or fever. He is a non-smoker. His abdomen is soft and no mass can be felt. A urinalysis reveals 3+ blood, trace leukocytes and trace of nitrates. What is the most appropriate action?

A 79 year old African-Caribbean man comes in complaining of difficulty in passing urine. He has a weak stream, and says that he is unable to completely empty his bladder. 3 months ago he suffered from a urinary tract infection. He also complains of back pain and suprapubic pain. He has lost significant weight and looks cachexic. What is the SINGLE most likely diagnosis?

A 22 year old sexually active male comes into the hospital with a 2 day history of fever with increasing pain in the scrotal area. He also describes painful micturation. There is no history of trauma. On examination, the scrotal skin is red and tender. He has a temperature of 37.8°C. What is the SINGLE most likely diagnosis?

A 56 year old man has a lower backache and pain on urination for the past week. He also has increased urinary frequency over the past few days. On examination, he has suprapubic tenderness. There is a tender prostate on rectal examination. He has a temperature of 37.8°C. A midstream urine sample is sent to the lab for culture and sensitivity testing. What is the SINGLE most appropriate medication, if any, to prescribe?

A 74 year old lady who has had a stroke in the past has an indwelling catheter for 10 months. She presents with bluish-purple discolouration of the catheter bag. What is the SINGLE most likely explanation for this?

A 78 year old man with a history of prostate adenocarcinoma has left loin pain. He says that he has been drinking fluid as usual but his urine output is decreased today. He feels extremely fatigue over the past 48 hours. On examination, there is no limb weakness or saddle paresthesia. A rectal examination shows good anal tone.

His blood results show:

Haemoglobin 98 g/L

Creatinine 230 μmol/L

eGFR 50

What is the SINGLE most appropriate investigation?

A 71 year old man had a stroke two months ago. The stroke, unfortunately, affected his detrusor muscle which left him unable to voluntarily urinate. As a result, he has had an indwelling urinary catheter ever since. Today, the patient presents with the complaint of purplish coloured urine in his urine bag. He has no discomfort, pain or fever and the urine in the bag is not cloudy. A urinalysis demonstrated the following:

Protein 1+

Red blood cells 1+

Nitrites negative

What is the SINGLE best investigation for this patient?

A 32 year old woman presents with severe intermittent right sided abdominal pain radiating to the grain which has lasted for 3 hours. She is writhing in pain and vomited twice in the last hour. Her blood results show the following:

White cell count 14 x 10^9/L (4-11)

CRP 83 mg/L (<10)

A urine HCG was negative. What is the SINGLE most likely cause of her abdominal pain?

A 41 year old man presents with sudden onset, severe colicky pain from his right flank radiating to his groin associated with nausea. He is writhing in agony and restless. The pain radiates to his scrotum. He had flown back from Spain a day ago. His urinalysis reveals 2+ blood. What is the SINGLE most appropriate investigation to request?

A 46 year old man presents to the clinic with a scrotal swelling. The swelling is cystic and is non-tender. It developed slowly and it lies above and behind the testis. What is the SINGLE most appropriate diagnostic test?

An 85 year old war veteran complains of loss of appetite and says that he has lost weight over the past few months. He says that he has passed some blood in his urine, however, there was no pain. He finds it difficult to empty his bladder completely and complains of having to urinate more often than usual. He also states that he has worsening pelvic pain over the past 3 months. A recent report shows that PSA is 9.5ng/ml. What is the SINGLE most likely reason for his symptoms?

A 47 year old man comes to the GP surgery with swelling on his left scrotum which disappears on lying down. The swelling was bluish in colour and felt like a “bag of worms”. He also complains of a dull ache along the left loin along with painless haematuria occasionally. What is the SINGLE most likely diagnosis?

A 38 year old man has severe loin pain with nausea and vomiting. The onset of symptoms began several hours ago. A non-enhanced computerised tomography scan reveals a 3.2 cm in diameter stone at the level of the minor calyx. What is the SINGLE most appropriate management?

A 35 year old man collapsed during a football match and was brought in by the paramedics. There was no trauma during the football game and he was only found to be unconscious for less than a minute. On taking a history in the hospital, he says that he has been experiencing shortness of breath for the past two weeks. His only past medical history is surgery at the age of 4 years old for maldescended testes. A chest x-ray demonstrates multiple well-circumscribed, round pulmonary masses. It was later discovered through histology that he has a seminoma. Which tumour marker is most likely to be raised?

A 64 year old man attends the Emergency Department with supraprapubic pain and difficulty passing urine for the past 48 hours. He has a 2-month history of a weak stream, intermittent flow and dribbling. He finds it difficult to start the flow of urine. On examination, his bladder is palpated. A bladder scan shows 1.5 litres of fluid. His pain was immediately relieved following insertion of a urinary catheter. His prostate was seen to be enlarged symmetrically and soft. His blood results show the following:

Haemoglobin 135 g/L (130-180)

White cell count 9 x 109/L (4-11)

Platelets 350 x 109/L (150-400)

Serum urea 6 mmol/L (2.0-7)

Serum creatinine 145 μmol/L (70-150)

eGFR >90 mL/min

What is the SINGLE most appropriate action?

A 31 year old taxi driver presents to the Emergency Department with sudden onset of left-sided flank pain radiation to the abdomen. He has been vomiting multiple times earlier in the day. He describes it as severe, continuous and colicky in nature. He is opening his bowels normally. On examination, there is tenderness of the left flank. He has a temperature of 36.6°C, heart rate of 67 beats/minute, blood pressure of 118/78 mmHg, respiratory rate of 17 breaths/minute and an oxygen saturation of 97%. He has been given adequate pain relief. His blood test shows the following results:

Haemoglobin 145 g/L (130-180)

White cell count 11.8 x 10^9/L (4-11)

Platelets 265 x 10^9/L (150-400)

Sadium 139 mmol/L (135-145)

Potassium 4.6 mmol/L (3.5-5)

Urea 10 mmol/L (2.0-7)

Creatinine 230 μmol/L (70-150)

eGFR 55 mL/min

CRP 30 mg/L (<10)

A CTKUB reveals a 6 mm distal ureteric calculus causing mild left hydroureteronephrosis. The right kidney is decompressed with no further urinary tract calculi identified. What is the SINGLE most appropriate urgent action?

A 65 year old man attends the GP surgery with complaints of painful urination, fever and right flank pain. His symptoms started 2 days ago and has been worsening. His temperature is 38°C, heart rate is 80 beats/minute and respiratory rate is 22 breaths/minute. His medical history includes a prostate cancer 12 years ago of which he was treated with brachytherapy. What is the SINGLE most appropriate investigation?

A 54 year old man attends the GP surgery with a history of trying to achieve a firm erection. He has a medical history of type 2 diabetes and hypertension. He takes regular enalapril as part of the management of his hypertension. He has no history of traumatic injuries. He is a non-smoker. He denies any issues with his relationship with his wife. He has been married to her for the past 20 years. He fails to have morning erections as well. His last HbA1c is 52 mmol/mol. His blood pressure is 135/90 mmHg. A digital rectal examination is unremarkable. There are no deformities of the penis. Further blood tests reveal a normal testosterone level. What is the SINGLE most appropriate management?

A 30 year old man presents with dull pain and swelling in his left scrotum. He says that he feels a dragging pain that is particularly worse after playing sports or at the end of the day. This has been gradually worsening over the past few weeks. The swelling demonstrates a cough impulse. What is the SINGLE most likely cause of the swelling?

A 57 year old chronic smaker reports three instances in the past 2 weeks when she has had painless, gross, total haematuria. Intravenous urograms (IVU) was done and was reported as normal. In the last month, she has been treated for irritative voiding symptoms, but has not been febrile, and urinary cultures have been negative. She complains of a long-standing urinary incontinence that is made worse when coughing. A urine dipstick done in clinic shows microscopic haematuria. What is the SINGLE most appropriate next step?

A 33 year old man presents with bilateral flank pain. He is later diagnosed to have bilateral kidney stones. His medical history includes sarcoidosis. What is the SINGLE most likely cause that attributed to the development of his urinary stones?

An 85 year old male was admitted to the hospital with a six month history of nocturia, hesitancy and dribbling. Over the past three months, he has lost more than five kilograms. He also complains about lower back pain during this period. A prostate specific antigen (PSA) test was performed and showed a value of 150 ng/mL (normal 0-4 ng/mL). The patient was subsequently referred for a transrectal ultrasound of the prostate and for a biopsy. On the fourth day after the biopsy procedure, the patient noticed cloudy urine with a pungent smell. He also complained of a burning feeling during urination accompanied by lower abdomen pain. What is the SINGLE most likely organism that can cause these symptoms after a prostate biopsy?

A 33 year old man has severe colicky pain on his right flank. The pain started 12 hours ago. The pain is so severe that he is rolling in bed trying to find a comfortable position. He is vomiting. A urinalysis shows 2+ blood. What is the most appropriate instigation?

A 14 year old boy presents with a 3 hour history of severe left testicular pain. He has no urinary symptoms and is otherwise well. On examination, the right testes looks normal but the left hemiscrotum is swollen and acutely tender. The pain is not eased by elevation of the testes. What is the SINGLE most appropriate initial step?

A 61 year old man complains of blood seen in his urine intermittently over the past week. He has been feeling fatigued and has significant weight loss over the past 3 months. He is a non-smoker. On examination, he has a mildly enlarged prostate. There are abnormal palpable masses on abdominal examination. His blood results show the following:Prostate-specific antigen (PSA) 21 ng/mL (0-4)

What is the SINGLE most likely diagnosis?

A 48 year old woman complains of continuous leakage of small amount of fluid vaginally continuously throughout since she had a laparoscopic hysterectomy for a uterine fibroid 5 days ago. The discharge is clear without any distinct odour. What is the SINGLE most likely diagnosis?

A 63 year old man attends the GP surgery with complaints of nocturia, the sensation of incomplete emptying of his bladder and having to strain to begin urination. He also describes terminal dribbling of his urine. He has to urinate frequently during the day and night. His prostate-specific antigen (PSA) level is normal. What is the SINGLE most appropriate management?

A 42 year old woman has recently returned from working in the Middle East. She has episodes of loin pain, urinary frequency, dysuria and has passed a urinary stone in the past. She plans to return to the Middle East in a month’s time. What is the SINGLE best advice to give to prevent recurrent stone formation?

A 48 year old man attends the GP surgery with a one-day history of frank haematuria. He has a history of unexplained right-sided back pain which has been worsening over the past 2 months. He denies any weight loss. He is a non-smoker. He has a temperature of 36.7°C, heart rate of 70 beats/minute, blood pressure of 130/80 mmHg, and a respiratory rate of 15 breaths/minute. There are no abnormal palpable masses on examination. His urinalysis shows 3+ blood. What is the SINGLE most likely diagnosis?

A 72 year old woman presents to the GP surgery with complaints of urinary urgency and urinary frequency over the past 4 days. She has the constant urge to urinate but only micturates small amounts of urine every time. She also feels the need to urinate more often than usual during the night. She takes oxybutynin for her urge incontinence. She is usually fit and healthy. Abdominal examination is unremarkable. Which of the following is the most appropriate step in managing this patient?

A 65 year old man presents with frank haematuria. He is afebrile and has no other urinary symptoms. There was no history of trauma and he has no relevant medical history. He looks well. Urinary cultures are negative. What is the SINGLE most appropriate investigation that would lead to a diagnosis?

A 31 year old presents with sudden onset of flank pain, nausea and vomiting. He recently passed a 4mm stone in his urine. Urine microscopy reveals microscopic haematuria. A CT KUB shows a 3mm stone is found in the renal pelvis. His blood test shows the following:

eGFR >90 mL/min

Urea 6 mmol/L (20-7 mmol/L)

Creatinine 90 (70-150 μmol/L)

What is the SINGLE most appropriate management?

A 72 year old woman complains of urinary incontinence. She feels the urge to urinate and occasionally wets herself before she reaches the toilet. She complains of having to go to the toilet very frequently. Her symptoms have been ongoing for more than a year. She is very embarrassed when she loses control of her bladder. A urinalysis shows no evidence of blood, nitrates or leukocytes. What is the SINGLE most appropriate treatment?

A 75 year old African man presents to the Emergency Department with complaints of the inability to pass urine since last night. He travelled for 2 days in a coach and arrived yesterday. The patient has a history of nocturnal urinary frequency for the past 3 years. His regular medications include tamsulosin. He is afebrile. He has a heart rate of 96 beats/minute, respiratory rate of 18 breaths/minute and a blood pressure of 110/70 mmHg. Abdominal examination shows tenderness and a palpable mass in the suprapubic area. Per rectal examination shows an enlarged smooth prostate. His prostate-specific antigen (PSA) is 4.5 ng/mL. What is the SINGLE most likely cause of his urinary retention?

A 16 year old boy complains of having a heavy feeling in the scrotal area. He is concerned by the appearance. On physical examination, a soft painless swelling in the left scrotum is noticed. The swelling appears like a bag of worms and is less obvious when he is lying supine. What is the SINGLE most appropriate investigation?

A 33 year old woman complains of having urinary urgency for the past year. She urinates more than 8 times a day. She gives a history of having suprapubic pain if her bladder is full, resulting in the need to urinate frequently as suprapubic pain is relieved by voiding. A urine culture was sent and results have come back negative. On cystoscopy, Hunner’s ulcers were seen on the bladder wall. What is the SINGLE most likely diagnosis?

A 77 year old African-Caribbean man comes in complaining of difficulty in passing urine. He has a weak stream, and says that he is unable to completely empty his bladder. He also has lower back pain and has lost 10 kg in the last 3 months. An ultrasound shows bilateral hydronephrosis. His blood results show the following:

Haemoglobin 105 g/L

CRP 25

What is the SINGLE most likely diagnosis?

A 77 year old man has a long term indwelling urinary catheter. The catheter was inserted 4 weeks ago. A recent catheter urine sample was sent for culture and sensitivity as the nurse noticed dark coloured, cloudy urine. The results returned 3 days later with a heavy growth of Escherichia coli. He has not yet started antibiotics. What is the SINGLE most appropriate management?

A 58 year old woman has had 4 urinary tract infections confirmed with urine culture in the past 12 months. In all 4 cultures, a coliform bacteria was grown. She has no haematuria. Her menstruations had stopped when she was 51 years of age. She is unable to identify any triggers. She is not sexually active. She has no history of postmenopausal bleeding. She has no significant medical history aside from the urinary tract infections. An ultrasound has been performed and no renal stones were identified. Post voiding residual volume is minimal on a bladder ultrasound. A cystoscopy was performed which shows no abnormal defects. What is the SINGLE next most appropriate management?

A 19 year old man presents to the hospital with left scrotal pain and swelling that has lasted for the past 3 hours. He has been having intermittent testicular pain over the past 4 months. He has been having sexual intercourse with his new partner over the last 5 months. He denies any history of trauma, fever or urethral discharge. He has been fully vaccinated in the UK as a child. There is tenderness at the scrotum posterior to testes, There is mild erythema of the posterior scrotal skin with mild swelling. The testicles are similar in size. Which is the SINGLE most appropriate management?

A 25 year old man presents with left scrotal pain. The pain started 4 days ago and has gradually worsened. He is sexually active with a new partner. He denies any fever or urethral discharge. He has been fully vaccinated in the UK as a child. He has no history of any injury to the area. There is tenderness to palpation on the affected side. There is mild erythema of the scrotal skin. The testicles are similar in size. Which of the following would be part of the first-line investigations?

A 44 year old man presents with a scrotal swelling. The swelling is cystic and is non- tender. It is located in the upper pole of the posterior part of the testes. What is SINGLE most likely diagnosis?

A 49 year old woman has had 5 urinary tract infections confirmed with urine culture in the past 12 months. In all 5 cultures, Escherichia coli was grown. She has no haematuria. She still has regular menstrual cycles. She is unable to identify any triggers. She is not sexually active. An ultrasound has been performed and no renal stones were identified. Post voiding residual volume is minimal on a bladder ultrasound. A cystoscopy was performed which shows no abnormal defects. What is the SINGLE most appropriate management?

A 34 year old man attends the GP surgery with a painless left testicular enlargement. He first noticed it 6 months. It has been gradually increasing in size. On examination, the left testicle is noted to be 3 times the size of the right testicle. A 4 mm firm, non-tender lump is felt within the body of the left testicle. There is no redness. What is the SINGLE most likely diagnosis?

A 55 year old man attends the GP surgery with difficulty voiding. He has to void often and wakes up in the middle of the night to void as well. Each time passing small amounts of urine. He has to stand at the toilet for awhile before he can initiate a urinary stream and finds that he has to strain a lot. He also describes a weak stream. His last recorded blood pressure is 110/80 mmHg. On digital rectal examination, he has a smooth enlarged prostate. There are no nodules and the median sulcus can be defined. What is

the SINGLE most appropriate management?

A 79 year old African American male complains of thirst and fatigue. He has symptoms of frequency, urgency and terminal dribbling. He has lost 8 kg over the last 3 months. Laboratory findings show a serum calcium level of 3.0 mmol/L and haemoglobin of 90g/L. What is the SINGLE most likely underlying diagnosis?