Surgery MCQs Q6

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SURGERY • URO-ONCOLOGY

A 76-year-old man is brought to the physician because he is now unable to walk (“off his legs”). He reports a 3-month history of worsening back pain. On examination, there is loss of perineal sensation and bilateral lower limb weakness. Digital rectal examination reveals a large, hard, craggy prostate. His serum PSA is 20 ng/mL.

What is the most likely diagnosis?

A Benign prostatic hypertrophy

B Metastatic prostate cancer

C Chronic prostatitis

D Obstructive uropathy

E Prostatic abscess

Metastatic Prostate Cancer. The combination of a hard, craggy prostate, elevated PSA (20 ng/mL), and new-onset neurological deficits (saddle anesthesia/weakness) confirms metastatic disease with spinal cord compression.

Decoding Clue

1

CLUE "Elderly + back pain + neuro deficit"

TRANS Think spinal metastasis causing malignant cord compression (MCSC).

2

CLUE "Hard, craggy prostate + PSA 20"

TRANS The "craggy" texture is pathognomonic for malignancy. PSA >10 is highly suspicious.

Explanation

A. BPH: Usually presents with smooth enlargement and LUTS (urgency/nocturia). It does not cause bone pain or neurological deficits.

C. Chronic prostatitis: Typically presents with pelvic pain and dysuria in younger/middle-aged men; prostate is usually normal or boggy.

D. Obstructive uropathy: A consequence of BPH or cancer, but doesn't explain the "off his legs" neurological presentation.

E. Prostatic abscess: An acute febrile illness with a severely tender, fluctuant prostate, not a hard craggy mass.

🧠 High-Yield Pearls

Metastatic Site	Lesion Type	Emergency
Axial Skeleton	Osteoblastic (Sclerotic)	Cord Compression
DRE Finding	Hard, Irregular (Craggy)	Malignancy
PSA < 4 ng/mL	Normal range	Age-adjusted needed
Management	Steroids + MRI	Standard for MCSC

Integrated Clinical Questions

1. Most common site of metastasis in prostate cancer?

Answer: Bone, specifically the vertebral column (spine).

2. Typical nature of bone metastasis on X-ray?

Answer: Osteoblastic (sclerotic/dense) lesions.

3. Red flag symptom of spinal cord compression?

Answer: New-onset back pain + neurological deficits (e.g., leg weakness, saddle anesthesia, bowel/bladder dysfunction).

4. Immediate medical management in suspected cord compression?

Answer: High-dose corticosteroids (Dexamethasone) + Urgent MRI.

5. Classical DRE finding in prostate cancer?

Answer: Hard, irregular, craggy prostate with loss of the median sulcus.

⚡ Exam Pearls

• Elderly male + back pain + neuro deficit = metastasis until proven otherwise.
• Spinal cord compression is a surgical/oncological emergency.
• PSA is a useful marker but biopsy (TRUS-guided) is required for definitive diagnosis.

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