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A 29-year-old man comes to the clinic because he and his wife have "not been able to have a
baby". The patient states that he has been happily married for 4 years and he and his wife have
been trying to have a child for the last 13 months. He has never fathered a child and his wife has
never been pregnant. His wife has been evaluated by her physician and no abnormalities were
identified. Your patient denies any history of cryptorchidism, sexually transmitted diseases,
urinary tract infections, genital trauma, or erectile dysfunction. He has not received any
chemotherapy nor does he have any known genetic disorders. Physical examination reveals a
circumcised phallus without meatal discharge. Testicles are descended bilaterally, and are
normal in size and contour. There is a grade 3 varicocele on the left side. No varicocele is
identified on the right. On rectal examination the prostate is normal to palpation. Serum
testosterone, LH, and FSH are normal. You send the patient for semen analysis. The results are
as follows
At this time you should
A. advise them that no intervention is indicated
B. obtain a transrectal ultrasound
C. perform a testicular biopsy
D. prescribe a testosterone patch
E. refer them for in vitro fertilization
F. refer him for a varicocelectomy (ligation of varicocele)
Explanation:
The correct answer is F. A varicocele is defined as a dilated vein or set of veins in the
pampiniform plexus in the spermatic cord, and is the most common identifiable cause of male
factor infertility. It is present in 15% of the total male population, but is found in approximately
40% of men with male factor infertility. A varicocelectomy (the ligation of varicoceles)
improves semen quality in approximately two-thirds of men and doubles the chance of
conception. Varicoceles form secondary to incompetent or absent valves in the spermatic veins.
This valvular deficiency, combined with the long vertical course of the internal spermatic vein
on the left side, leads to the formation of most varicoceles on the left side. A unilateral right
sided varicocele suggests venous thrombosis (from a tumor) in the inferior vena cava. The effect
of a varicocele on fertility has to do with the prevention of efficient blood flow out of the
scrotum. There is pooling of blood in the pampiniform plexus, leading to an increase in scrotal
temperature and an adverse effect on spermatogenesis. Varicoceles tend to cause a "stress
pattern" on semen analysis. This is characterized by a low sperm concentration, low sperm
motility, low sperm count, and low sperm morphology. The technique for varicocelectomy is
varied and may be performed via an inguinal, retroperitoneal, subinguinal, laparoscopic, or
embolization approach. The subinguinal approach with aid of a microscope, (microscopic
varicocelectomy), is the approach with the fewest complications.
No intervention (choice A) is incorrect. Any couple who has been unable to conceive for over 1
year warrant investigation. In general, 90% of normal couples conceive within 1 year of trying.
Some investigators advocate a simple, basic, cost-effective evaluation of both male and female
at the time of presentation, no matter how long they have been attempting to conceive.
A transrectal ultrasound (choice B) is a valuable diagnostic tool when there is an obstructive
process causing infertility. The majority of semen volume comes from the prostate, seminal
vesicles, and Cowper's gland. The majority of ejaculated sperm comes from the distal
epididymis. Therefore, the normal volume of ejaculate and the fact that the patient is not
azoospermic (no sperm present) makes obstruction of the vas, seminal vesicles, and ejaculatory
ducts, unlikely. The patient also has a normal semen pH which is caused by the fructose within
the semen. Fructose is secreted by the seminal vesicles, therefore this patient's normal semen pH
makes seminal vesicle obstruction unlikely. In this scenario, the yield of transrectal ultrasound to
look for seminal vesicles or ejaculatory duct dilatation, is low.
Testicular biopsy (choice C) is indicated in azoospermic patients with normal FSH levels or in
patients with abnormal hormone parameters. This patient has neither.
The patient has normal hormone parameters, and there is no evidence that increasing his
testosterone (choice D) will improve his semen parameters.
Referring this couple for in vitro fertilization (choice E) is not the correct management. The
male in the relationship has a potentially reversible cause of his infertility (varicocele) and
having them go through the emotional and financial hardship of assisted reproduction is not
recommended prior to attempting correction of other causes of infertility.
A 27-year-old man comes to the emergency department because of an
"exquisitely painful" scrotum. He says that he was walking to lunch with
friends when the pain hit him "like a thunderclap." He says that he has a steady
girlfriend and that they have an "active sex life." He is "very healthy" and has
never experienced pain like this before. He regularly checks himself "there"
after that young comedian underwent testicular surgery on television. His
temperature is 37 C (98.6 F), blood pressure is 130/85 mm Hg, pulse is 86/min,
and respirations are 19/min. Physical examination shows severe scrotal
tenderness that is not relieved when the scrotum is elevated. The right testes is
high in the scrotum and riding in a horizontal position. The cord above the
testes is not tender. A urinalysis shows:
Color
straw/light
Microscopic
Specific gravity
1.020
WBC
4/hpf
pH
5.8
Glucose
absent
Protein
absent
Bacteria
absent
The most appropriate next step is to
A. administer ciprofloxacin, intravenously
B. apply ice packs and observe in the emergency department
C. measure serum HCG and AFP
D. perform a trans-scrotal testicular biopsy
E. request a urology consultation, STAT
Explanation:
The correct answer is E. This patient has the classic presentation of testicular
torsion, which is a surgical emergency, and therefore requires an immediate
urologic consultation. He requires surgical intervention to reverse the
spermatic cord torsion and restore blood flow.
Antibiotics, such a ciprofloxacin (choice A) are necessary to treat epididymitis,
which typically presents with scrotal pain, fever, pyuria, a tender cord, and a
normal positioned testes. Elevation of the testes may somewhat relieve the
pain. Ice packs, bed rest, antiinflammatory agents, and scrotal support are
typically used in conjunction with the antibiotics.
Applying ice packs and observing him in the emergency department (choice B)
is inappropriate management of testicular torsion, which requires immediate
urologic consultation.
Measuring serum HCG and AFP (choice C) is part of the evaluation for
testicular cancer, which typically presents as a painless mass. If tenderness is
present, it is often dull and aching, rarely acute and "exquisitely painful."
Performing a trans-scrotal testicular biopsy (choice D) is not useful in
testicular torsion, which is a surgical emergency, and therefore requires an
immediate urologic consultation. A trans-scrotal testicular biopsy is usually
avoided, even if a testicular malignancy is suspected, to prevent potential
tumor contamination of the lymphatics.
A 19-year-old man comes to the clinic with a gradually worsening scrotal pain
for the past week. He has no significant past medical history. He says he is
sexually active with 2 partners and uses condoms “occasionally”. General
physical examination is normal. Examination of the genitalia reveals a very
tender left epididymis. The testes are normal. There is a whitish discharge from
the penile meatus. Transillumination of the scrotum demonstrates no evidence
for a hydrocele. To exclude testicular torsion, ultrasonography of the testes is
performed. The right testicle and epididymis are normal (not shown). The left
testicle is normal. The findings from the right epididymis are shown (grayscale and color Doppler). The intervention most likely to have prevented this
condition is
A. evaluation for undescended testis
B. prophylactic antibiotics
C. regular medical check-ups
D. safe sex counseling
E. support underwear
Explanation:
The correct answer is D. Epididymitis has progressed to an epididymal
abscess in this patient. The ultrasound reveals a hypoechoic collection in the
epididymis and on Doppler images the mass has no vascular flow.
Epididymitis is caused by retrograde infection from any sexually-transmitted
organism secondary to sexual intercourse. It is rarely spread hematologically
except in some immunocompromised patients.
The testicles are not undescended (choice A) given the scrotal exam.
Undescended testes increases the risk for testicular cancer, which is not what
this patient has.
Prophylactic antibiotics (choice B) are not indicated in the general population
without a history of recurrent epididymitis.
Regular medical check-ups (choice C) would not have prevented this sporadic
disease occurrence. They are important, however, for general health
maintenance.
Support underwear (choice E) has no relation to epididymal or testicular
infections.
A 64-year-old man with hypertension, diabetes, and hyperlipidemia comes to
your office complaining of difficulty achieving erection. His medications
include nifedipine, simvastatin, losartan, metformin, and glyburide. He has
been married for 30 years and he tells you that his wife is becoming frustrated
with his "lack of interest in her." He denies ability to achieve erection with self
stimulation and no longer wakes up in the morning with an erection as he did
when he was younger. He tells you that a friend informed him that there is a
medication that can help with men who have this problem. Physical
examination shows a moderately obese man with normal size testes. Digital
rectal examination reveals a slightly enlarged, non-tender prostate without
palpable nodules. The remainder of his examination is normal. Laboratory
studies show:
The most likely underlying cause of his impotence is
A. hormonal changes
B. medications, especially nifedipine
C. neuronal injury
D. psychological factors
E. vascular disease
Explanation:
The correct answer is E. The most common cause of erectile dysfunction in
patients older than 50 is vascular disease. This patient has diabetes,
hypertension, and high cholesterol so it is very likely that that he has a physical
disruption of blood flow to his penis.
Hormonal causes of erectile dysfunction (choice A) include elevated prolactin
levels, testicular failure, pituitary dysfunction, or abnormal thyroid. These
disorders may be less likely in this patient since they typically cause a
decreased libido, which this patient does not have. In a patient with normal
testicular size, low testosterone levels would be less likely. If testosterone
levels are low, it would be worthwhile to check LH and FSH levels to evaluate
pituitary function.
Medications (choice B) are responsible for a large percentage of erectile
dysfunction. Beta blockers and thiazide diuretics are often the culprits.
Although all drugs should be suspected, calcium channel blockers and ACE
inhibitors cause these problems less frequently. In studies, 3 % (or less) of
patients taking nifedipine reported erectile dysfunction, which was the same
number of men taking a placebo that complained of this problem.
Nerve injury (choice C) can result in erectile dysfunction in patients with
pelvic surgery, pelvic trauma, spinal cord injury, MS, etc. This patient has no
history leading us to suspect nerve damage as the etiology of his erectile
dysfunction.
Psychological factors (choice D) are responsible for a small percentage of
erectile dysfunction. If you suspect psychological factors are responsible for a
patient's erectile dysfunction, referral to a specialist is warranted. Also, since
he is not able to achieve erection with self stimulation and no longer has
morning erections, psychological causes of dysfunction are less likely.
A 19-year-old man who is in the hospital because of an asthma exacerbation, has a
painful sore on his
penis. He tells you that 4 days prior to admission, he had unprotected sexual
intercourse with a new
partner. Yesterday, he began developing "painful sores" over the distal aspect of his
penis. He also
complains of dysuria, but denies fevers, chills, meatal discharge, or any previously
similar episodes.
Three months ago he had an HIV test which was negative. He has bilateral inguinal
adenopathy, which
is firm and tender to palpation. There is no discharge elicited from the meatus.
Dispersed on the penile
shaft are multiple small tender vesicles on an erythematous base. Rectal examination
shows normal
sphincter tone with a firm, appropriately sized, non-tender prostate. Urine dipstick is
negative for any
sign of infection. You send off a culture from one of the lesions. The next best step
in the management
of this patient is to
A. give 1 intramuscular injection of benzathine penicillin G
B. prescribe ceftriaxone 250 mg intramuscularly, a single dose
C. prescribe oral acyclovir
D. prescribe topical acyclovir
E. prescribe azithromycin 1gm ; orally a single dose
F. repeat the HIV test
G. wait for culture results to return
Explanation:
The correct answer is C. This patient has a classic case of primary genital herpes.
Typically, this
presents as penile lesions of grouped vesicles on an erythematous base that do not
follow a neural
distribution. The lesions are tender to touch and the associated adenopathy is
bilateral, mildly tender,
non-fixed, and slightly firm. The primary episode is more severe, than recurrent
attacks and the
incubation period is 2-10 days. The herpes simplex virus is a double-stranded DNA
virus capable of
causing persistent and latent infections. Most genital herpes are caused by type 2
virus, however, up
to 25% of genital herpes may be caused by type 1 virus. Partners of infected
patients are at risk of
transmission, even when the virus is asymptomatic. Acyclovir is the only drug that
has shown efficacy
in the treatment of the signs and symptoms of genital herpes, however, there is no
known cure. The
medication works by acting as an inhibitor of viral DNA polymerase and acts as a
chain terminator. It
treats the symptoms by decreasing the duration of viral shedding, the time of
crusting of the lesions,
and the time for healing of the lesions. Topical acyclovir (choice D) is much less
effective than oral or
IV therapy and is therefore discouraged.
Benzathine penicillin G(choice A) is used for the treatment of primary syphilis.
Syphilis is caused by
the spirochete Treponema pallidum and the primary disease presents as a painless,
firm, indurated
chancre. Adenopathy may be tender or non-tender and is typically firm and
"rubbery".
IM ceftriaxone (choice B) is used in the treatment of chancroid. The causative agent
in this disease is
Haemophilus ducreyi. The ulcer associated with chancroid is deep with an
undermined border and a
friable base that bleeds easily. The adenopathy in painful and with chronic infection
may cause
lymphatic obstruction. One gram of azithromycin (choice E) may also be utilized in
the treatment of
chancroid.
Repeating the HIV test (choice F) in this patient with high-risk behavior is
appropriate. However, it
may be performed after treatment of his herpes is initiated. This test should not
delay the necessary
immediate intervention.
The most sensitive technique for diagnosing herpes is to isolate the virus in a
culture. However,
results take 5 days and therapy should not be withheld if clinical suspicion for
herpes is high (choice
G).
A 58-year-old man comes to the office because of difficulty with erections for the
past few years. He
says that he has a great relationship with his wife and is still very sexually aroused
by her. He is
occasionally able to initiate an erection, but he is unable to sustain it. The remainder
of his medical,
sexual, and psychological history is unremarkable. He takes isosorbide mononitrate
for chest pain. His
blood pressure is 130/90 mm Hg. Physical examination is unremarkable. Prolactin
and testosterone
levels are within normal limits. He asks for the "little blue pill" that is so often
advertised on television
commercials. At this time you should
A. advise him to discontinue the isosorbide mononitrate
B. explain that he cannot take sildenafil because of his current medication
C. prescribe sildenafil citrate tablets for him to take an hour before sexual
activity
D. recommend implantation of an inflatable prosthesis
E. tell him that his erectile dysfunction is psychogenic
Explanation:
The correct answer is B. Erectile dysfunction (ED) is a very common problem. The
evaluation
typically includes a detailed history and physical examination, serum testosterone
and prolactin
levels, and a medication review. This patient's evaluation is unremarkable. He is
specifically asking
for a prescription for sildenafil, but it is contraindicated in patients taking any
medications that contain
nitrates because the combination can lead to life-threatening hypotension, a heart
attack, or stroke.
This should be explained to him and other options should be considered. Sex
therapy and/or a
vacuum device (that draws blood into the penis) should be offered.
Since this patient is taking isosorbide mononitrate for angina, which can be a
serious problem, he
should not be advised to discontinue it (choice A). Also, this agent is not typically
associated with
ED. Some cardiovascular drugs that have been associated with ED are thiazides,
spironolactone,
calcium channel blocks, methyldopa, beta blockers, clonidine, and digoxin.
Since this patient takes a nitrate medication, it is incorrect to prescribe sildenafil
citrate tablets for
him to take an hour before sexual activity (choice C). Sildenafil is contraindicated
in patients taking
nitrates.
Since there are other less invasive options for this patient to try, it is inappropriate
to recommend
implantation of an inflatable prosthesis (choice D) at this time. Sex therapy and a
vacuum device
should be offered.
It is incorrect to tell him that his erectile dysfunction is psychogenic (choice E)
because a full
evaluation was not performed. Nocturnal penile tumescence testing, vascular
testing, neurologic
testing, and psychological testing can help determine the exact cause. All of these
tests are not
usually necessary because they may be expensive and invasive.
You are taking care of a 49-year-old woman who was admitted to the hospital
because of progressive
numbness of the right arm and difficulty in seeing objects in the left visual field. She
is known to be HIV
positive, but has not consistently taken medications in the past. On examination she
is healthy
appearing, has a right homonymous hemianopia, and decreased sensory perception
in her left upper
extremity and face. Her CD4 count is 60 cells/mm3 and her MRI is consistent with a
demyelinating
lesion of the left parietooccipital area. CSF PCR for the JC virus is positive. The
most appropriate
treatment is
A. amphotericin B
B. cranial radiation
C. highly active antiretroviral therapy (HAART)
D. intravenous acyclovir
E. intravenous ceftriaxone
Explanation:
The correct answer is C. This patient has progressive multifocal
leukoencephalopathy. It is caused
by the JC virus, which is a double stranded DNA virus. The prognosis is poor, but
HAART has been
known to be effective in improving survival. The JC virus is ubiquitous and may be
transmitted through
respiratory secretions.
Amphotericin B (choice A) is used to treat fungal infections, it is not used to treat
progressive
multifocal leukoencephalopathy or the JC virus.
Cranial radiation (choice B) is used to treat malignancies. This patient has a
demyelinating lesion of
the brain and a positive CSF PCR for the JC virus, not a malignancy.
Intravenous acyclovir (choice D) is not effective against JC virus, but is used to
treat the herpes
simplex virus encephalitis.
Intravenous ceftriaxone (choice E) is used to treat bacterial meningitis. Bacterial
meningitis typically
presents with a fever, nuchal rigidity, and a headache. This patient's presentation
and findings are
inconsistent with bacterial meningitis.
You are performing a discharge examination on a 1-day old healthy newborn. He
was born by a normal
spontaneous vaginal delivery at 39 weeks gestation. During the routine physical
examination you
identify the right testicle, but are unable to palpate the left testicle. Palpation of the
left inguinal canal
does not reveal a mass. The rest of the examination is normal. The most appropriate
management at
this time is to
A. do a CT scan of the pelvis to search for an undescended testis
B. follow up as an outpatient and if no testis are present at one year of age, then
refer
to urology for possible orchiopexy
C. follow up as an outpatient and if no testis is present at ten years of age, refer
to urology for
possible orchiopexy
D. reassure the parents that this is common and no treatment or follow-up is
necessary
E. refer to urology for orchipexy prior to discharge
Explanation:
The correct answer is B. This patient has an absent testis in the left hemiscrotum.
The differential
diagnosis for this is cryptorchidism (i.e. undescended testis), retractile testis (i.e.
child with a brisk
cremasteric reflex causing retraction of testis into inguinal canal), or absent testis
(sometimes thought
to be due to intrauterine torsion). The most likely diagnosis is cryptorchidism.
Cryptorchidism, literally
meaning hidden testis, is very common. It is present in approximately 5% of term
male babies and up
to 30% of premature male babies. The majority descend spontaneously by one year
of age
decreasing the incidence to only 0.8% that are truly undescended. At that point,
where the testis is felt
to be undescended, it should be treated with a procedure called orchipexy to bring it
down into the
scrotum. Not doing this greatly increases the risk of testicular malignancy, torsion,
and infertility. The
appropriate management is to follow up as an outpatient to evaluate for testicular
presence. If no
testis are present at one year of age, then referral to urology for possible orchiopexy
is necessary.
A CT scan of the pelvis (choice A) particularly as a newborn is unlikely to reveal
the location of the
testicle and furthermore exposes the child to unnecessary radiation. An ultrasound
of the inguinal
canal region is either performed prior to discharge or as an outpatient, but this does
not usually end
up changing management.
Because cryptorchidism increases the risk of testicular malignancy, torsion, and
infertility, waiting to
treat it, until age 10 (choice C) or not treating at all (choice D) is not acceptable.
Furthermore, it is
not appropriate to treat too early (i.e. treating as a newborn) (choice E) because of
the number of
children who have spontaneous resolution.
A 54-year-old man presents to his primary care physician's office over a concern
regarding prostate
cancer. The patient has no history of the disease, but his father died of prostate
cancer at the age of 61
and the patient was told that he has an increased risk for developing the cancer. The
patient reports
that he has had digital rectal examinations each year, but that he would like to be
"screened" for
prostate cancer. He has no other medical history and takes only a low-dose aspirin
daily. He denies
smoking and illicit substance abuse and admits to drinking alcohol socially.The
most appropriate
response to this patient is:
A. "Normal digital rectal examinations exclude any likelihood of prostate
cancer."
B. "PSA blood tests are available."
C. "PSA blood tests are available but only for patients with known cancer."
D. "PSA urine tests are available for all men over the age of 50."
E. "There is no effective screening test for prostate cancer."
Explanation:
The correct answer is B. Men have between a 15-20% lifetime risk of developing
prostate cancer.
The PSA test was introduced in the late 1980s and quantifies a glycoprotein
produced by the
prostate that spills over into the blood. Although current guidelines differ by
society, clinical practice
and standard of care is to test high-risk men over the age of 40 for PSA levels. Any
level greater than
4.0 ng/mL requires a prostate biopsy. The positive and negative predictive values of
the test vary
tremendously with patient population, but roughly 30% of patients with elevated
PSA levels will have
prostate cancer. These tests are also used to follow therapy in patients with known
prostate cancer
(choice C).
Although digital rectal examinations (choice A) are capable of detecting enlarged
prostates and
nodules, they do not effectively exclude small tumors, which fail to distort the gland
or that present in
areas of the gland which are not peri-urethral.
PSA tests are for detection of PSA in blood, not urine (choice D). There is no PSA
present in
ejaculate or in urine although ejaculation does transiently increase serum PSA
levels for up to 48
hours.
Although the PSA test has variable sensitivity and specificity, it is a fairly robust
test when used to
screen patients at high risk or with enlarged prostate glands on physical
examination. Therefore, it is
an effective screening (choice E) test, but the efficacy depends very much on the
population being
tested and specific characteristics of the patient such as the presence or absence of
benign
hypertrophy.
A 27-year-old man comes to the emergency department because of right-sided
scrotal pain and
swelling which has worsened during the past 12 hours. He complains of severe pain,
10 out of 10 on
the pain scale, which developed suddenly. The pain is radiating up to his right
inguinal region. He
denies any history of a similar problem in the past and reports no history of any
genitourinary disease.
His past medical and surgical histories are noncontributory. He takes no medications
and has no
known drug allergies. His social history reveals social alcohol use on the weekends
and an occasional
marijuana cigarette. He is sexually active with his girlfriend, has no other partners,
and does not use
protection. His temperature is 38.3 C (101.0 F), blood pressure is 150/80 mm Hg,
pulse is 98/min, and
respiratory rate is 22/min. Physical examination shows a soft, non-tender abdomen
with normal active
bowel sounds. His right testicle and epididymis are both enlarged and extremely
tender. When the
scrotum is gently elevated, the pain is mildly relieved. The rest of his physical exam
is normal.
Laboratory studies show a white blood cell count of 15,500/mm3 and a urinalysis
positive for moderate
leukocyte esterase and moderate nitrite. A scrotal ultrasound reveals enlargement of
the right testicle
and epididymis as well as increased blood flow to the right hemiscrotum. You make
a diagnosis of
acute epididymoorchitis. The most appropriate pharmacotherapy for this patient is
A. ceftriaxone
B. doxycycline
C. doxycycline and ceftriaxone
D. metronidazole
E. metronidazole and ceftriaxone
Explanation:
The correct answer is C. Epididymoorchitis is a common condition seen in the
emergency
department. In sexually active men under the age of 35, a sexually transmitted
disease is the most
common etiology, specifically urethritis. These patients may present with
epididymoorchitis without
any history of symptoms of urethritis. In this population, urethritis is most
commonly caused by N.
gonorrhea and C. trachomatis. It is recommended that antibiotic treatment cover
both organisms
especially since gonococcal urethritis is associated with concomitant C. trachomatis
infection in
approximately 30-50% of cases. Treatment consists of a simple one time
intramuscular injection of
250 mg of Rocephin to cover gonorrhea in addition to doxycycline 100 mg PO bid
for 10 days to
cover chlamydia.
Ceftriaxone(choice A) only is insufficient treatment due to common concomitant
gonococcal and
chlamydial infection. Ceftriaxone only covers a gonococcal infection.
Doxycycline(choice B) only is insufficient treatment as well. It only covers a
chlamydial infection.
Metronidazole(choice D) only covers anaerobic organisms. These organisms do not
commonly
cause epididymoorchitis, therefore, metronidazole is a poor choice.
Metronidazole and ceftriaxone (choice E) in combination is a poor choice due to the
lack of antibiotic
coverage for chlamydia.
A 65-year-old man comes to the office because he constantly feels like he needs to
urinate, even after
he just went. He states that over the past few months, he has been waking up a few
times a night to
urinate, and he needs to "push very hard to get that urine out." The urinary stream is
typically weak, and
he turns red when he says that he often "dribbles" when he is done. You have been
treating him for
typical "colds", "backaches", and gout over the years, and lately you have been
monitoring his blood
pressure, which has ranged from 140/90 mm Hg to 150/90 mm Hg in the past 8
months. He has been
the "ideal patient." He started a moderate exercise program, quit smoking,
eliminated all alcohol, and
cut down on salt and fat, but his blood pressure has remained elevated. All studies,
including a
urinalysis, complete blood count, electrolytes, BUN and creatinine, cholesterol,
glucose, plasma uric
acid, chest x-ray, and electrocardiogram were normal at the time of the initial
hypertension work-up. His
temperature is 37 C (98.7 F), blood pressure is 145/85 mm Hg, and pulse is 65/min.
Digital rectal
examination shows an enlarged, prostate gland. Funduscopic examination and
urinalysis are normal.
His prostate-specific antigen is 3 ng/mL. You discuss treatment options for his
conditions, and he
decides that he wants to take the "least amount of pills possible." Based on his
statement, the most
appropriate pharmacotherapy at this time is
A. enalapril
B. finasteride
C. hydrochlorothiazide
D. nifedipine
E. terazosin
Explanation:
The correct answer is E. This patient has benign prostatic hyperplasia (BPH) and
hypertension,
which can both be treated with terazosin. Terazosin is a long acting selective alpha1 adrenergic
blocker that is useful in treating essential hypertension and symptomatic benign
prostatic hyperplasia.
The symptoms of BPH are typically due to bladder outlet obstruction and urinary
stasis. Terazosin
most likely provides symptomatic relief of BPH by antagonizing the contraction of
the bladder
sphincter and relaxing the smooth muscle of the bladder neck. It is an effective
treatment for
hypertension because of its vasodilatory properties.
Enalapril (choice A) is an angiotensin-converting enzyme inhibitor that is useful in
treating
hypertension, but not BPH.
Finasteride (choice B) is a 5-alpha reductase inhibitor that blocks the conversion of
testosterone to
dihydrotestosterone, and is used to treat BPH, not hypertension.
Hydrochlorothiazide (choice C) is a diuretic that is used to treat hypertension, but
has no effect on
BPH. It may actually be uncomfortable for him to have to urinate even more than
he is already. Also,
thiazides cause hyperuricemia, which can lead to gout. This patient has a history of
gout, which is a
reason to not give him thiazides.
Nifedipine (choice D) is a calcium-channel blocker that is used to treat
hypertension, but is not
effective for BPH.
A 19-year-old man comes to the clinic for a periodic physical examination. He has
no complaints and
no significant past medical history. He is on no medications and reports no allergies
to medicines.
Similarly, the family, social, and health risk history is unremarkable as well. You
start a complete
physical checkup and are surprised to find a third lump in his testicular region. On
questioning, he tells
you that he has noticed it before, but was too embarrassed to bring it up. A testicular
ultrasound is
performed and reveals the lump to be consistent with testicular cancer. To clarify the
picture further, you
order an alpha-fetoprotein (AFP) and the beta subunit of the human chorionic
gonadotropin (hCG). The
AFP level is normal, but the hCG level is elevated. A CT scan of the chest,
abdomen, and pelvis show
no retroperitoneal node involvement and no metastases to distant areas. Based on the
findings above,
you tell him that the tumor is most likely
A. nonseminoma type, Stage 1, and a retroperitoneal lymph node dissection is
indicated
B. nonseminoma type, Stage 2, and chemotherapy is indicated
C. seminoma type, Stage 1, and an orchiectomy with adjuvant radiation therapy
is
indicated
D. seminoma type, Stage 2, and either radiotherapy or chemotherapy is
indicated
Explanation:
The correct answer is C. Testicular cancer is the most common cancer in men 20-40
years of age.
Lifetime incidence is .4% for white male and .08% in black males. Cryptoorchidism
is the biggest risk
factor for testicular cancer and it increases the risk about fourfold. Nearly 95% of
all malignant
testicular cancers are of the germ cell type that are divided into the seminoma and
nonseminoma.
Various tumor markers can help distinguish between the two types of germ cell
tumors. Elevated AFP
is produced by embryonal and yolk sac elements which are found only in
nonseminomas. HCG
however, is produced by both seminomas and nonseminomas. A lactate
dehydrogenase (LDH) can
also be used, but is less specific. Staging is done to assess the extent of disease and
to guide
therapy. Stage 1 cancer is confined to the testis, epididymis, or spermatic cord.
Stage 2 is limited to
the retroperitoneal nodes, subclassified by the size of the nodes into < 2 cm,
between 2-5 cm, and > 5
cm in diameter. Stage 3 involves metastases to the supradiaphragmatic nodes or
visceral sites.
Based on the above information, this patient has a seminoma type, Stage 1 process.
The standard of
therapy is postorchiectomy adjuvant radiotherapy. Since there is no retroperitoneal
node involvement,
his case is not stage 2 (choice D). If it was stage 2, radiotherapy or chemotherapy
can usually cure
the cancer.
Since the patient's cancer does not secrete AFP, his cancer is not of the
nonseminoma type. Staging
was described previously. In general, retroperitoneal lymph node dissection is the
standard of care for
patients with Stage 1 nonseminoma cancer (choice A). Stage 2 (choice B) and 3
disease requires
early retroperitoneal lymph node dissection and either close conservative
surveillance or immediate
chemotherapy afterwards.
A 32-year-old man comes to the clinic with complaints of "swelling in his left
testicle". He states that for
the past several months he has noticed a lump in his left hemiscrotum. He denies
any pain or
tenderness. He denies erythema and there has been no fever, dysuria, or urgency.
He is married and
claims to be monogamous. His temperature is 37 C (98.6 F), blood pressure is
120/80 mm Hg, pulse
is 60/min, and respirations are 16/min. His abdominal examination is benign. The
scrotum appears
normal. However, on palpation there is fullness in the left hemiscrotum. A
urinalysis is normal. An
ultrasound shows normal appearing testes bilaterally and a moderately sized left
hydrocele. The most
appropriate next step in management is to
A. admit the patient for drainage of the fluid collection
B. explain that no specific treatment is necessary at this time but he should
follow up
in 6 months
C. order a CT scan of the abdomen and pelvis to rule out other abnormalities
D. prescribe ciprofloxacin 500 mg twice daily for 2 weeks and then reassess
E. refer the patient to urology for an orchiectomy
Explanation:
The correct answer is B. The diagnosis in this case is easily made with an
ultrasound. A hydrocele
is simply a fluid collection between the layers of the tunica vaginalis. They are
typically idiopathic and
require no treatment. Hydroceles can fluctuate in size, which typically means that
they are in some
communication with the peritoneal cavity, and thus represent an indirect inguinal
hernia. If it does
persist or does represent an indirect hernia, referral to urology for surgical
evaluation is warranted.
There is certainly no need at this time for acute treatment (choice A).
CT scan of the abdomen and pelvis (choice C) would not be indicated in this case as
the patient's
symptoms are referable directly to a palpable abnormality in the testicle. There are
no signs or
symptoms of intraabdominal pathology at this time.
Ciprofloxacin (choice D) is commonly used in genitourinary tract infections. This
patient has no signs
of infection at this time. Sometimes in the setting of an epididymitis, a hydrocele
with particulate
matter within it, will be present and be seen on ultrasound examination. This is
referred to as a
pyocele and may need to be drained surgically, much like an abscess would, in
order to adequately
treat this patient's infection.
An orchiectomy (choice E) would be performed for testicular malignancies or
possibly in a torsed
testicle that is necrotic.
A 65-year-old man comes to the clinic for a periodic health maintenance
examination. He claims to be
healthy and has not seen a physician in almost 10 years. His only complaint is of
recent onset lower
back pain. He has no significant past medical history, has never had surgery, does
not take any
medications, and has no known drug allergies. His family history reveals maternal
death at age 75 of a
heart attack and paternal death at age 54 of colon cancer. He feels generally well and
is very active. He
is happily married and plays tennis 3 times a week. His temperature is 36.9 C (98.4
F), blood pressure
is 142/78 mm Hg, pulse is 70/min, and respirations are 22/min. Physical
examination is unremarkable.
Laboratory values are within normal limits except that his PSA, which he pressured
you to order, is 45.
You refer him to a urologist who performs a transrectal ultrasound-guided biopsy
which reveals an
adenocarcinoma Gleason 4+4=8 on both sides of the prostate. A bone scan shows
areas of increased
uptake diffusely, especially in the lumbar spine region, which is suspicious for
metastatic disease. The
most appropriate first-line treatment for this patient is
A. brachytherapy
B. chemotherapy
C. external beam radiation
D. hormone therapy
E. prostatectomy
Explanation:
The correct answer is D. This patient has metastatic prostate cancer, a clinical
dilemma. The
current mainstay of treatment for metastatic prostate cancer is androgen deprivation
therapy using a
leuteinizing hormone-releasing hormone (LHRH) agonist such as leuprolide or
goserelin or by
performing a bilateral orchiectomy. Prostate cancer depends on androgen
stimulation for neoplastic
activity. LHRH agonists cut off testicular testosterone secretion and thereby,
decrease the activity of
metastatic lesions. LHRH agonists must initially be given with an androgen blocker
such as flutamide
due to the initial flare reaction, which causes an increase in serum testosterone and
may increase
bony pain. The dilemma of metastatic prostate cancer is that the disease eventually
becomes
hormone refractory, meaning it no longer is suppressed by androgen deprivation.
The disease
typically becomes hormone refractory within 3 years of the onset of treatment.
Therefore, many
patients with metastatic disease are not started on hormone therapy right away.
Many clinicians wait
until the patient becomes symptomatic with bone pain, before initiating therapy.
Brachytherapy (choice A), or interstitial radiation, is used for organ-confined
disease. Iodine125 or
palladium103 seeds are implanted into the prostate controlling local disease. The
results of
brachytherapy have been comparable to surgery in terms of disease-free survival.
Chemotherapy (choice B) plays a very limited role in the treatment of prostate
cancer. It is
occasionally used for patients with hormone refractory disease. However, it has not
been shown to
have any survival benefit.
External beam radiation (choice C) is used as a treatment for localized prostate
cancer, especially
for patients who are poor surgical candidates. It is also used as adjuvant therapy for
positive surgical
margins and recurrent localized disease after prostatectomy.
Prostatectomy (choice E) is an ideal treatment for patients who have organ-confined
disease.
Organ-confined disease is suggested by a negative metastatic workup and negative
pelvic lymph
node dissection. Patients with lower PSA and lower Gleason scores are more likely
to have
organ-confined disease and are therefore, better surgical candidates.
A 27-year-old heavy vehicle driver comes to the office because he is "not feeling
well and has been
losing weight" during the past few months. He also reports that he is feeling
increasingly tired. He
drives long hours on his job, smokes heavily, and admits to "moderate" amounts of
alcohol intake. He
has never seen a doctor before and denies any past medical or surgical history. His
temperature is
37.0 C (98.6 F), blood pressure is 110/80 mm Hg, pulse is 70/min, and respirations
are 16/min.
Abdominal examination shows a vague abdominal mass in the midline that is not
pulsatile and
non-tender. Rectal examination is unremarkable. Scrotal examination shows an
enlarged right testicle
without sensation. The factor in this patient's history and examination that is most
helpful for diagnosing
the etiology of the abdominal mass is
A. alcohol intake
B. his job
C. non-pulsatile nature of abdominal mass
D. scrotal examination findings
E. smoking
Explanation:
The correct answer is D. Loss of testicular sensation and enlarged testis is
diagnostic of testicular
carcinoma. In advanced stages, testicular carcinoma spreads by lymphatics to the
paraaortic lymph
nodes. These lymph nodes are palpable in the midline of a thin person without any
prominent
pulsations.
Alcohol (choice A) and smoking (choice E) have no diagnostic value in evaluating
paraaortic
lymphadenopathy.
Increased temperature in the scrotum for a long time as in heavy vehicle long
distance drivers may
predispose them to testicular carcinoma. Job history (choice B) by itself is not
diagnostic, hence it is
incorrect.
Palpable, non-pulsatile paraaortic lymph nodes (choice C) may be seen with other
cancers, but are
not diagnostic of the specific primary pathology.
A 43-year-old Caucasian man comes to the emergency department because of a 6hour persistent
erection. He complains of some discomfort within the penis, but denies any trauma
associated with
intercourse. He does have some dysuria. He has never experienced anything similar
to this and his
facial expression displays his concern. He has no significant medical history, and is
not taking any
medication, prescribed or illicit. On physical examination, the corpora cavernosum
is rigid and tender,
while the glans penis and corpus spongiosum are soft. There is no curvature
associated with the
erection, and there are no palpable abnormalities along the length of the penile
shaft. The testicles are
descended and normal to palpation. Rectal examination reveals good sphincter tone
and a normal
sized, smooth prostate. Urinalysis and blood counts are all within normal limits.
The most likely
diagnosis is
A. epididymitis
B. hypospadias
C. paraphimosis
D. penile chordee
E. penile fracture
F. Peyronie's disease
G. priapism
Explanation:
The correct answer is G. This patient is suffering from priapism. Priapism is defined
as an
abnormally prolonged, and usually painful, erection that does not result from sexual
desire. It generally
involves only the corpora cavernosum and not the corpora spongiosum. The
disorder is idiopathic in
60% of the cases, while the remaining 40% of cases are associated with diseases
(i.e., leukemia,
sickle-cell disease, pelvic tumors, and pelvic infections). The patient usually
presents with a history of
several hours of painful erection. As in this patient, the glans penis and corpus
spongiosum are soft
and uninvolved in the process. The corpora cavernosa are tense with congested
blood and tender to
palpation. Priapism can be classified as low-flow or high-flow. High-flow is
associated with trauma, is
non-ischemic, and non-painful. The penis is not fully rigid and the cause is due to
unregulated arterial
inflow. Low-flow priapism is associated with ischemia, veno-occlusion and stasis
of blood, resulting in
a painful, rigid erection. There is a build-up of highly viscous, poorly oxygenated
blood within the
corpora cavernosa. If this persists then interstitial edema and fibrosis of the corpora
cavernosa will
develop and ultimately lead to impotence.
Epididymitis (choice A) is due to infection and inflammation of the epididymis. The
patient complains
of heaviness and discomfort in the affected hemi-scrotum.
Hypospadias (choice B) occurs when the urethral meatus opens on the ventral
aspect of the penis
and not the tip of the glans. It is due to abnormal development in utero.
Paraphimosis (choice C) is a urological emergency. It occurs when the foreskin is
retracted and not
replaced back into its normal position. The retracted foreskin acts as a tourniquet on
the glans, and if
it is not reduced, may lead to ischemia of the glans penis.
Penile chordee (choice D) is congenital fibrosis of the tunica albuginea. It leads to
curvature of the
penis. It is frequently seen in association with hypospadias, and may occur on the
ventral (more
common) or dorsal side of the penis.
Penile fracture (choice E) occurs with traumatic intercourse. A tear in the tunica
albuginea, while the
penis is erect leads to rapid detumescence with penile edema, pain, and hematoma.
Peyronie's disease (choice F) is defined as an abnormal thickening (or plaque) of
the tunica
albuginea. It differs from chordee in that it is an acquired condition. It is usually
associated with
traumatic intercourse. It leads to painful erection, curvature of the penis, and poor
erection distal to the
involved area. Plaques are palpable, dense, varying in size, and may be located on
the dorsal or
ventral aspect of the penile shaft.
A 55-year-old man comes to the emergency department with pain on urination, fever
and chills. He also
complains of perineal and suprapubic tenderness as well as dysuria and hesitancy.
His allergies include
codeine, sulfonamides, and quinidine. Temperature is 38.5 C (101.3 F), blood
pressure is 132/90 mm
Hg, pulse is 88/min, and respirations are 18/min. Abdominal examination is
remarkable for suprapubic
tenderness. Digital rectal examination demonstrates a swollen, boggy, and
exquisitely painful prostate
gland. Laboratory studies show a leukocyte count of 11,500/mm3, creatinine of 0.9
mg/dL, and blood
urea nitrogen of 16 mg/dL. A urinalysis shows too numerous to count white blood
cells and
Gram-negative rods. The most appropriate treatment for this patient is
A. amoxicillin/clavulanate 875 mg by mouth twice daily for 14 days
B. ceftriaxone 1 gram intravenously daily for 5 days
C. ciprofloxacin 500 mg by mouth twice daily for 14 days
D. clindamycin 300 mg 4 times daily for 10 days
E. trimethoprim-sulfamethoxazole 1 double strength tablet twice daily for 14
days
Explanation:
The correct answer is C. This patient is presenting with fever, dysuria, and a very
tender prostate on
examination. These findings are classic for acute prostatitis. The question posed is
basically the
appropriate treatment for this condition, which is either a fluoroquinolone, such as
ciprofloxacin, or a
sulfa-based drug such as trimethoprim-sulfamethoxazole (to which he is allergic)
(choice E).
Ciprofloxacin clearly makes the best choice.
The other antibiotics mentioned in the remaining options (choices A, B, and D)
simply are not first
line, or appropriate agents for this disease and are thus incorrect choices.
A 54-year-old African American man comes to the office complaining of swelling
in his left scrotum. He
states that the swelling has slowly gotten worse over the past 6 months and he can
no longer feel his
left testicle. As per the patient, the swelling itself does not cause pain. However, the
swollen scrotal skin
is rubbing against his thigh causing an irritation. The patient's urologic history is
significant for 2
episodes of epididymitis in the past 5 years. He denies any trauma to the scrotum,
dysuria, hematuria,
infertility, or prior similar episodes. There are no constitutional symptoms elicited
with further
questioning. The patient is afebrile and on examination the left hemi-scrotum is
obviously enlarged and
the scrotal skin is tense. There is no erythema of the scrotum. The left testicle is
non-palpable. You are
able to transilluminate light through the left scrotal mass. The mass is not reducible
through the inguinal
ring and it does not change in size or consistency with Valsalva or when the patient
lies down. The right
testicle is descended and normal to palpation. There is no urethral discharge,
inguinal adenopathy, or
abnormalities on rectal examination. Urinalysis and laboratory values are normal.
The most likely
underlying cause of this patient's scrotal swelling is
A. dilatation of the pampiniform plexus
B. fluid collection within the tunica vaginalis
C. renal-cell carcinoma with invasion into the left renal vein
D. testicular neoplasm
E. torsion of the spermatic cord
Explanation:
The correct answer is B. This patient has a hydrocele. A hydrocele is a collection of
fluid within the
tunica (or processus) vaginalis. The diagnosis is made by finding a rounded cystic
intrascrotal mass
that is not tender unless underlying inflammatory disease is present. The mass
transilluminates,
helping to differentiate it from a testicular neoplasm. If the fluid is allowed to
continue to build up, then
it may eventually become large enough to prevent appropriate evaluation of the
testicle. If a hydrocele
develops in a young man, without apparent cause, then careful evaluation of the
testicle and
epididymis should be done in order to rule out cancer or infection. If the exact
diagnosis is in
question, then a scrotal ultrasound should be performed.
Varicocele is caused by dilatation of the pampiniform plexus (choice A). It is more
common on the
left side. On exam these patients have a mass of dilated, tortuous veins lying
posterior to and above
the testis. It may extend up to the external inguinal ring and is often tender. The
degree of dilatation
can be increased by the Valsalva maneuver. In the recumbent position, venous
distention disappears.
The sudden development of a varicocele in an older man is sometimes a late sign of
a renal tumor
that has invaded the left renal vein, thereby obstructing left spermatic vein drainage
(choice C).
Testicular neoplasm (choice D) as previously stated does not transilluminate. Also,
the history
associated with a testicular tumor usually involves a dull, heavy feeling within the
testicle. These
masses have the potential to grow rapidly. Some testicular tumors are associated
with a small
hydrocele. With a testicular tumor, the testicle is hard, enlarged, and irregular in
shape.
Testicular torsion (choice E) occurs when the spermatic cord twists, causing
strangulation of the
blood supply to the testis. Examination reveals a swollen, tender testicle that is
retracted upward. It is
more common in young boys who develop acute testicular pain.
A previously healthy 15-year-old boy is brought to your emergency department with
a 3-hour history of
right testicular pain. He states that the pain began after football practice this
afternoon. He does not
remember any trauma to the area during practice. He appears to be in a significant
amount of pain. His
blood pressure is 128/80 mm Hg and his pulse is 110/min. Physical examination
shows an
erythematous, swollen right scrotum with significant tenderness to palpation on that
side. You also note
that the cremasteric reflex is absent on the right side. A urinalysis was sent from
triage and is negative.
The most appropriate next step is a
A. CT of the abdomen
B. surgical consultation
C. urine for gonorrhea and chlamydia
D. testicular biopsy
E. voiding cystourethrogram
Explanation:
The correct answer is B. The patient in this vignette has torsion of the right testicle.
In any patient
with testicular swelling and pain, surgical consultation should be sought as soon as
possible because
delay in the diagnosis of testicular torsion can result in loss of that testis due to
absent blood flow. If
the diagnosis is delayed >6 hrs without intervention, there is a significant risk of
necrosis of that testis.
An ultrasound with color Doppler will evaluate the blood flow to the affected testis
and also assess the
morphology of the testicle. However, it often delays the management of the
condition, which could
have disastrous effects.
A CT scan of the abdomen (choice A) will not be helpful in assessing this patient's
scrotum.
Sending urine for gonorrhea and chlamydia (choice C) is an important consideration
in a sexually
active adolescent who presents with symptoms of epididymitis. Epididymitis is one
of the main
causes of acute painful scrotal swelling in sexually active young men. Usually the
urinalysis will reveal
pyuria. This is not a diagnostic test that should supercede the ultrasound with the
Doppler, due to the
importance of early identification of reduced/absent blood flow.
Testicular biopsy (choice D) is not part of the evaluation of testicular torsion.
A voiding cystourethrogram (choice E) is a procedure used to diagnose
vesicoureteral reflux. This
test is used as part of the work-up of a child with a urinary tract infection.
A 24-year-old man comes to the emergency department with a 3&ndash;day history
of urethral
discharge and burning when he urinates. He initially noticed a milky discharge from
the penis, that is now
more yellowish in color. He has no known drug allergies. He is sexually active with
multiple different
partners per month. His temperature is 37 C (98.6 F). A yellowish discharge can be
expressed from the
urethral meatus. A digital rectal examination demonstrates a normal feeling prostate
gland without
tenderness. Laboratory studies are remarkable for a leukocyte count of 8,000mm3,
creatinine of 0.9
mg/dL, and blood urea nitrogen of 16 mg/dL. A urethral swab shows multiple white
blood cells with
Gram-negative intracellular diplococci. The most appropriate treatment for this
patient is
A. azithromycin 1 gm orally once
B. ceftriaxone 125 mg intramuscularly once
C. ceftriaxone 125 mg intramuscularly once plus azithromycin 1 gm orally once
D. ciprofloxacin 500 mg by mouth twice daily for 14 days
E. trimethoprim-sulfamethoxazole 1 double strength tablet twice daily for 14
days
Explanation:
The correct answer is C. This patient is presenting with a classic case of gonococcal
urethritis.
There is a yellowish discharge, which can be expressed from the penis and Gram
stain shows
intracellular Gram-negative diplococci. Thus the main question left to answer is how
should this be
treated. One important thing to know is that there are many choices in therapy.
However, all therapy
should address not only the gonococcal infection, but also the possibility of a
chlamydial infection.
Concomitant C. trachomatis occurs in up to 50% of patients. The ceftriaxone alone
(choice B) would
be adequate for the gonorrhea, but the azithromycin should be added for chlamydial
treatment.
Similarly azithromycin alone (choice A) is not enough. Another choice besides
azithromycin would be
doxycycline. However, it requires a 10-day course of therapy. One other important
issue in these
cases, is that the partner of the person should be treated as well, or else the two will
continue to infect
each other.
Ciprofloxacin (choice D) can be used in the treatment of gonococcal urethritis, but
only a one time
dose is required, and it too does not address the possibility of a chlamydial infection.
Trimethoprim-sulfamethoxazole (choice E) is not effective in this disease.
A 76-year-old man with diabetes and hypertension is admitted to the hospital for
intravenous antibiotic
therapy to treat pneumonia. He had been improving during the first few days he was
in the hospital.
However, 5 days later, he is now having problems with urinary retention. His Foley
catheter was
removed 24 hours ago and the patient is unable to void. This morning the nurse
reinserted a catheter,
which drained 900 cc of cloudy urine. Tonight, the patient began complaining that
the catheter bothers
him and he keeps pointing to his penis. You ask the nurse appropriate questions and
learn that he is
and has been afebrile, and is currently completing a course of cephalosporins for his
pneumonia. The
nurse who placed the catheter is no longer in the hospital, but by report, there was
no difficulty with
Foley catheter insertion. Over the last 12 hours, the patient has drained 750 cc of
urine. Upon entering
the patient's room, you see an elderly man who is obviously uncomfortable. He
states that the catheter
really hurts and he has never felt anything like this before. He denies any abdominal
pain, stating that all
the pain is at the point where the catheter enters the penis. The patient tells you that
he has never been
circumcised. On physical examination, his abdomen is soft and non-distended
without any suprapubic
discomfort. Examination of his penis shows that the glans is exposed, edematous,
red and tender to
touch. At the level of the coronal sulcus is a piece of edematous tissue that looks as
though a ring has
been placed over his penile shaft. The proximal aspect of the penis is also swollen,
but not to the
degree of the tissue at the coronal sulcus. His testicles are descended bilaterally, and
there is mild
tenderness over the right epididymis. Rectal examination reveals an enlarged
prostate with a hard,
raised nodule over the right base. The most appropriate next step in this patient's
management is to
A. adjust his antibiotics for better urinary coverage
B. obtain a scrotal ultrasound
C. order PSA
D. reduce the foreskin
E. remove the Foley catheter
F. schedule a prostate biopsy
G. send for a urinalysis and culture
Explanation:
The correct answer is D. This patient is suffering from a paraphimosis. This occurs
in
uncircumcised males who have their foreskin retracted beyond the coronal sulcus,
so that it is not
subsequently reduced. This has the potential to become an emergency, as the
retracted foreskin will
act as a tourniquet around the penis, leading to pain, edema, and possibly, vascular
compromise.
With time the penis will appear as though there is a ring around the distal aspect of
it. Important
components to the diagnosis of this condition include history and physical. A high
level of suspicion is
necessary and asking the patient about a history of circumcision is very important.
Treatment of this
urologic emergency involves attempted manual reduction. This is done with manual
compression of
all edema out of the glans followed by reduction of the foreskin. If this cannot be
accomplished, then
the patient will need surgical correction with either a dorsal slit or circumcision.
This scenario is a perfect example of why a physical exam is so important. While
Foley catheters may
be uncomfortable, they should not be excruciatingly painful once in appropriate
position. Changing
antibiotics (choice A) does not address the emergent issue. Urinary tract infection
may cause urinary
retention as this patient had. If one is concerned for UTI, then a urinalysis and urine
culture (choice G)
would be appropriate after reduction of the foreskin.
The mild epididymal pain, the patient has, may be a bout of epididymitis, which can
happen in
patients with an in-dwelling catheter. Obtaining a scrotal ultrasound (choice B) will
help in this
diagnosis but plays no role in evaluation and treatment of a paraphimosis.
A PSA (choice C) and prostate biopsy (choice F) are both utilized in the work-up of
prostate cancer.
A hard nodule on prostate exam, does raise the suspicion for prostate cancer.
However, these tests
can be performed at a later date.
Removing this patient's catheter (choice E) is the wrong management for
paraphimosis. The
foreskin can be reduced with the catheter in place. Physical exam is so important in
this case, or else
the diagnosis will be missed. Besides, it is unlikely that this patient will be able to
void on his own so
soon after his bladder was allowed to distend with 900 cc of urine.
A 56-year-old man with coronary artery disease comes to the clinic for follow up of
a prostate specific
antigen test (PSA). He was seen 3 weeks ago and a screening PSA level was drawn.
The test result
came back at 9.4 ng/mL and the patient returns to discuss this result. His
medications are atenolol,
pravastatin, enalapril, and aspirin. He denies any symptoms of urinary retention,
hesitancy, pain on
urination, and post-void dribbling. The most appropriate next step in management is
to
A. arrange for a prostate biopsy
B. follow up with the patient in 6 months and obtain a second PSA level
C. inform the patient that he has benign prostatic hypertrophy
D. inform the patient that he has prostate cancer
E. reassure him that he does not have prostate cancer
Explanation:
The correct answer is A. Men have between a 15-20% lifetime risk of developing
prostate cancer.
The PSA test was introduced in the late 1980s and quantifies a glycoprotein
produced by the
prostate that spills over into the blood. Although current guidelines differ by
society, clinical practice
and standard of care is to test high risk men over the age of 40 years for PSA levels.
Any level
greater than 4.0 ng/mL requires a prostate biopsy. The positive and negative
predictive values of the
test vary tremendously with patient population, but roughly 30% of patients with
elevated PSA levels
will have prostate cancer.
Although some physicians follow marginal elevations in PSA levels for a few
months (choice B), this
patient has a nearly 3-fold increase above that required for further workup
(4.0ng/mL).
Just as the PSA test has poor sensitivity, its specificity (false positives) is also
variable, ranging from
80-97%. For this reason, elevations may not indicate the presence of cancer, but
perhaps are due to
benign prostatic hypertrophy (choice C). However, until the biopsy is performed, a
determination as
to the cause of the PSA elevation is not possible (choice D). As stated above,
roughly 30% of
patients with elevated PSA levels will have prostate cancer (the probability of
prostate cancer given
an elevated PSA is 30%).
Since the incidence of false-negative results is approximately 30-50% (sensitivity),
there is no
possible way to determine that this patient is cancer free unless biopsies are taken
(choice E).
You are seeing a 63&ndash;year-old man on rounds in the medical intensive care
unit who was
admitted with sepsis related to an infected diabetic foot ulcer. During his admission,
he has had
multiple complications including respiratory failure, a large perioperative
myocardial infarction during a
left below the knee, amputation, and atrial fibrillation, which resulted in an embolic
stroke. He has been
intubated and ventilator dependent since admission. Over the past 3 days his
condition has been
slowly improving and he is starting to regain consciousness. He now indicates that
he is having pain in
his scrotum. His temperature is 37.0 C (98.6 F), blood pressure is 112/76 mm Hg,
pulse is 92/min,
respirations are 22/min (on ventilator). His jugular veins are distended, and his heart
is irregularly
irregular with an S3 gallop. His lungs have course breath sounds bilaterally,
abdomen is mildly
distended, and his scrotum is markedly and symmetrically enlarged to
approximately four times normal
size. There is 4+ pitting edema in the lower extremities bilaterally. An ultrasound of
the scrotum is
performed which shows normal testes and diffuse thickening of the scrotal skin and
a small to
moderate sized hydrocele on the left and a small hydrocele on the right. The most
appropriate course of
treatment for his scrotal pain is
A. ciprofloxacin 500 mg via nasogastric tube twice daily for 14 days
B. diuresis as tolerated by his volume status
C. no specific treatment would help
D. percutaneous aspiration of the hydroceles
E. percutaneous aspiration of the hydroceles followed by placement of drainage
tubes
bilaterally to prevent reaccumualtion
Explanation:
The correct answer is B. Many patients who are volume overloaded for various
reasons, whether it
is due to massive volume resuscitation or congestive heart failure, will develop
some degree of
scrotal edema. Often times, it can be very impressive and can also cause the patient
pain. This
patient definitely has signs of heart failure and has likely been heavily volume
loaded, because of his
sepsis. The only real treatment is to optimize the patient's volume status and let the
body reabsorb the
fluid with diuresis as tolerated.
There are no signs of infection mentioned in the clinical scenario, thus treatment
with an antibiotic is
not necessary (choice A). Occasionally these patients will get some cellulitic type
symptoms in the
scrotum, but the treatment of choice for that would be something other than
ciprofloxacin.
No specific treatment would help (choice C) is incorrect as he should be treated
with diureses to
improve his volume status.
The hydroceles seen in this patient are not likely to be contributing to the markedly
increased size of
the testicles, and percutaneous aspiration (choice D) is not necessary. Placing a
drainage tube in the
scrotum (choice E) is completely unnecessary and not done.
A 54-year-old man comes to your office for his yearly physical examination. You
have been his primary
care physician for the last 18 years. He is in good health without any chronic
medical conditions. His
social history includes a 45-pack-year history of tobacco use and 20 years of
working in a textile
factory. His father has prostate cancer and diabetes. His mother, brother, and sister
are all healthy.
Review of his urologic history is noncontributory. In the past, his rectal examination
and prostate
specific antigen (PSA) have always been normal. Examination of his genitourinary
system today
reveals a circumcised penis without discharge or lesions, and testicles that are
descended and normal
bilaterally. On digital rectal examination you palpate a hard nodule over the left
apex of the prostate.
Stool is guaiac positive. PSA is 7.4 ng/mL. The findings that indicate the need for
this patient to
undergo a prostate biopsy is/are
A. elevated PSA and/or nodule on prostate
B. elevated PSA only
C. exposure to risk factors at work
D. family history of prostate cancer
E. family history of prostate cancer and elevated PSA
F. guaiac-positive stool
G. history of smoking
H. history of smoking and work exposure
I. nodule on prostate only
J. nodule on prostate and family history of prostate cancer
Explanation:
The correct answer is A. The screening tests for prostate cancer are digital rectal
exam and serum
PSA levels. If either one of these is abnormal then the patient needs to undergo
transrectal ultrasound
with prostate biopsy. This procedure can be done as an outpatient without
anesthesia. Utilizing
transrectal ultrasound allows for visualization of the prostate at the time of biopsy
so that each
specimen is from a different anatomic location within the prostate. In general,
normal PSA levels are
<4 ng/mL. Some investigators believe in "age-adjusted PSA." In that case, the
upper limits of normal
PSA for men ages 40-49 is 2.5 ng/mL, ages 50-59 is 3.5 ng/mL, ages 60-69 is 4.5
ng/mL, and ages
70-79 is 6.5 ng/mL. Under either system, this patient's PSA of 7.4 ng/mL is
abnormal and warrants
further investigation. The fact that this patient has both an abnormal rectal exam
and an elevated PSA
are even stronger indications for prostate biopsy. The urologic literature is filled
with a variety of blood
tests/imaging studies that may be performed in an attempt to limit the number of
men undergoing
transrectal ultrasound and prostate biopsy. To date none of these have been
uniformly accepted. This
leaves only the digital rectal exam and serum PSA levels as the initial screening
tools for prostate
cancer.
Elevated PSA (choice B) and nodule of the prostate (choice I ) are both indications
for prostate
biopsy. As stated, if either is abnormal then the patient is a candidate for biopsy.
However, (choice
A) is the correct answer because it acknowledges that both are abnormal in this
patient.
This patient's history of tobacco use (choices G and H) and exposure while working
in a textile
factory (choice C) are risk factors for development of transitional cell carcinoma of
the urinary tract
(ureter/bladder). Neither of these are indications for prostate biopsy.
The fact that this patient's father has prostate cancer (choices D, E, J) is concerning.
This patient is
eligible for earlier and perhaps more frequent screening tests. However, a family
history of prostate
cancer is not an indication to perform prostate biopsy. In choice J, the presence of a
nodule on DRE
is indication for biopsy; however, the family history is not an indication.
Guaiac-positive stool (choice F) is an important finding on this patient's physical
exam. It will warrant
further investigation but is not an indication for prostate biopsy.
An 18-year-old man comes to the clinic with complaints of "scrotal discomfort" for
the past several
months. He also feels that there may be a mass around the testicle that he has felt for
several years, but
it never bothered him prior to this. He denies fever, dysuria, or urgency. He is not
sexually active. His
temperature is 37.2 C (99 F), blood pressure is 112/70 mm Hg, pulse is 64/min, and
respirations are
14/min. His abdominal examination is unremarkable. The scrotum appears normal.
However, on
palpation, there is an extrascrotal mass, which feels somewhat like a "bag of worms".
Urinalysis is
normal. A testicular ultrasound shows multiple dilated veins in the left hemiscrotum,
which increase in
size and in Doppler color flow with Valsalva maneuver. The left testicle is slightly
smaller than the right.
The most appropriate next step in management is to
A. explain that no treatment is necessary at this time and a follow up is not
necessary
B. prescribe trimethoprim-sulfamethoxazole tablets, 1 by mouth daily for 1
week then reassess
C. prescribe trimethoprim-sulfamethoxazole tablets, 1 by mouth twice daily for
1 month and then
reassess
D. refer him to a urologist for evaluation for a possible orchiectomy
E. refer him to a urologist for an evaluation for surgical repair
Explanation:
The correct answer is E. This patient has the classic physical ("bag of worms") and
ultrasonographic
findings, (dilated veins which distend on Valsalva) of a varicocele. A varicocele is
an abnormal dilation
of the spermatic veins within the scrotum. It can occur in up to 15% of adult and
adolescent males. They
can present with scrotal discomfort, but are often asymptomatic and the patient may
just feel a mass.
They also may be discovered in the workup of infertility, as varicoceles are a known
contributing factor.
The role in infertility is postulated to be due to several possible factors including
increased
temperature, increased hydrostatic pressure, and reflux of adrenal metabolites to
name a few. The
left-sided predominance of these lesions is thought to be because of the increased
length of the left
spermatic vein and its insertion at a right angle into the left renal vein. Adolescents
with varicoceles are
at a risk of losing testicular volume on the affected side as this patient is showing
signs of. Surgical
repair has been shown to decrease this growth retardation. For these reasons, no
treatment or follow
up (choice A) is not appropriate.
Trimethoprim-sulfamethoxazole (choices B and C) is commonly used in
genitourinary tract infections.
This patient has no signs of infection at this time.
An orchiectomy (choice D) would be performed for testicular malignancies or
possibly in a torsed
testicle that is necrotic. It is not typically performed for a varicocele.
A 25-year-old man is admitted to the hospital after sustaining head injuries in a
motor vehicle accident.
On his 2nd day in the hospital, he shows you a sore on his penis that he developed a
few days ago. He
proudly admits to numerous sexual encounters in the past 5 years, and tells you that
he has been tested
for HIV every 6 months, and that the last negative test only was about 3 months ago.
He is otherwise
generally healthy, and does not take any medications on a regular basis. He denies
any penile discharge
in the past or present, and no history of other sexually transmitted diseases. On
physical examination,
there is painful lymphadenopathy of the left groin region. On the distal penis, there
are 2 tender, ragged
ulcers that appear punched out with surrounding hyperemia. The base of the ulcers
are covered with a
purulent, dirty exudate, which bleeds easily during the examination. This patient
most likely has
A. chancroid and should be treated with azithromycin 1g orally in a single dose,
while
cultures and tests for other sexual transmitted diseases are performed
B. gonorrhea dermatitis and he should receive therapy for both gonorrhea and
chlamydia, while
cultures and tests for other sexual transmitted diseases are performed
C. granuloma inguinale and should be treated with trimethoprimsulfamethoxazole, while cultures
and tests for other sexual transmitted diseases are performed
D. lymphogranuloma venereum and should be treated with doxycycline, while
cultures and tests
for other sexual transmitted diseases are performed
E. a primary syphilitic chancre and serum RPR should be checked to confirm
the diagnosis,
while cultures and tests for other sexual transmitted diseases are performed
Explanation:
The correct answer is A. Chancroid is correct because it usually presents as an
inflammatory papule
that ruptures early with the formation of a ragged ulcer that lacks the induration of a
chancre. The ulcers
have undermined irregular edges surrounded by mild hyperemia, and the base is
usually covered with
purulent, dirty exudate. This is an infectious, contagious, ulcerative, sexually
transmitted disease
caused by the Gram-negative bacillus Haemophilus ducreyi. It is characterized by 1
or more deep or
superficial tender ulcers on the genitalia and painful unilateral inguinal adenitis.
However, the diagnosis
of chancroid does not rule out syphilis and the subsequent development of syphilis
should be
anticipated since the incubation time for a chancre is longer than that of chancroid.
Gonococcal dermatitis (choice B) is incorrect because it is a rare infection that
occurs mostly as
erosions on the median raphe without urethritis. Grouped pustules on an
erythematous base is the
usual presentation.
Granuloma inguinale (choice C) is incorrect because it is a mildly contagious,
chronic, granulomatous,
locally destructive disease characterized by progressive indolent, serpiginous
ulcerations of the groins,
pubis, genitalia, and anus. The disease begins as single or multiple subcutaneous
nodules, which
erode through the skin to produce clean, sharply defined lesions, which are usually
painless. The
lesions typically demonstrate hypertrophic, vegetative granulation tissue which is
soft, has a beefy-red
appearance, and bleeds readily. The regional lymph nodes are usually not enlarged.
This is caused by
Calymmatobacterium granulomatis.
Lymphogranuloma venereum (choice D) is incorrect, because it is a sexually
transmitted disease
characterized by suppurative inguinal adenitis with matted lymph nodes, inguinal
bubo with secondary
ulceration, and constitutional symptoms. The primary lesion consists of herpetiform
vesicle or erosion
develops on the glans penis followed by bilateral lymphadenopathy. It is caused by
Chlamydia
trachomatis, serotypes L1, L2 and L3.
Primary syphilitic chancre (choice E) is incorrect, because it typically presents as a
crusted superficial
erosion that becomes a round or oval, indurated, slightly elevated papule, with an
eroded, but not
ulcerated surface that exudes a serous fluid. The lesion is usually painless. The
regional lymph nodes
on one or both sides are usually enlarged, firm, nontender and do not suppurate.
With this said, when a
patient presents with a penile ulcer, it is wise to obtain a serum RPR since patients
can often times
have more than one sexually transmitted disease.
An 18-year-old man comes to the clinic complaining of heaviness in his left testicle.
He noticed this for
the first time 3 weeks ago after "pulling his groin" in a high school football game.
The groin pull has
improved but the discomfort in the testicle has not. He also states that he has noticed
the left testicle is
larger than the right testicle. His pain is non-radiating, dull in character, and not
associated with any
dysuria or discharge. He admits to an episode of unprotected intercourse with a new
partner
approximately 1 month ago. There is no weight loss, fever, cough, or headaches.
Physical examination
is significant for a left testicle that is non-tender, hard, increased in size as compared
to the right,
irregular in contour, and without transillumination. There is no inguinal adenopathy.
The right testicle is
normal in size and shape. No discharge is expressed per urethra. Urinalysis and
urine culture are
negative. Beta-human chorionic gonadotropin (bHCG) level and alpha-fetoprotein
(AFP) levels are
normal. The next most appropriate management for this condition is
A. to administer chemotherapy
B. external beam radiation therapy to scrotum
C. external beam radiation therapy to retroperitoneum
D. left radical orchiectomy via a scrotal incision
E. left radical orchiectomy via an inguinal incision
F. open testicular biopsy
G. prescribe antibiotics
H. recommend scrotal support, antiinflammatory drugs, and reevaluation in 2
weeks
I. schedule incision and drainage of scrotal abscess
Explanation:
The correct answer is E. This patient has testicular cancer until proven otherwise.
The most
common symptom of testicular cancer is painless enlargement of the testis. Patients
frequently
complain of a sensation of testicular heaviness. 10% of patients will present with
acute testicular pain
as a result of intratesticular hemorrhage or infarction and 10% of patients will
present with symptoms
related to metastatic disease (back pain from retroperitoneal metastases involving
nerve roots, cough
or dyspnea from pulmonary metastases, etc). And 10% of patients are asymptomatic
at presentation
and the mass may be picked up incidentally following trauma or by the patient's
sexual partner. An
incorrect diagnosis is made at the initial examination in up to 25% of patients with a
testicular tumor
and may result in delay in treatment or surgery via a scrotal approach. It is
important not to violate the
scrotal skin in the presence of testicular cancer. The lymphatic drainage of the testis
is the
retroperitoneum, while the scrotal skin drains via the inguinal nodes. Violating the
scrotal skin has the
potential to extend the spread of metastases outside the normal anatomic path. This
patient's
symptoms and physical findings are classic for testicular carcinoma. While bHCG
and AFP may be
elevated in a variety of testicular cancers, they do not have to be. The normal levels
in this patient
should not discourage one from making the proper diagnosis. Epididymitis or
epididymoorchitis are
the most common misdiagnoses in patients with testis cancer. These patients
typically have an
enlarged tender epididymis that is separable from testicle. In advanced stages the
inflammation may
spread to the testis and enlarge the testicle as well. There is usually an acute onset
of symptoms
associated with fever, urethral discharge, and irritative voiding symptoms.
Hydrocele is also a
common misdiagnosis. Transillumination of the scrotum may reveal a translucent,
fluid-filled hydrocele
versus a solid tumor. Since approximately 5-10% of testicular tumors may be
associated with
hydroceles, if there is any question, then a scrotal ultrasound is mandatory.
Further therapy of testicular cancer depends on the type of tumor and clinical stage.
Chemotherapy
(choice A) and retroperitoneal external beam radiation therapy (choice C) both play
a role in the
adjuvant treatment of testicular cancer. However, neither is appropriate
management prior to radical
orchiectomy.
Radiation therapy to the scrotum plays no role in the treatment of testicular cancer
(choice B).
Initial treatment for all testicular cancer or presumed cancer is inguinal exploration
and high ligation of
the spermatic cord with removal of the testicle and spermatic cord (radical
orchiectomy). As
previously stated, scrotal approaches (choice D) and open testicular biopsy (choice
F) should be
avoided so as not to disrupt the lymphatic drainage system.
Antibiotics (choice G), scrotal support, and antiinflammatories (choice H) are all
appropriate therapy
for patients with epididymitis or epididymoorchitis. As previously explained, this
patient does not have
these diagnoses and providing this form of treatment will only delay appropriate
care.
Drainage of an abscess (choice I) is appropriate for any patient who has this
diagnosis. Patients with
scrotal abscess have swelling, tenderness, erythema, fluctuance, and possibly fever.
This patient
does not have any of these symptoms, making this diagnosis extremely unlikely.
A couple who you have been treating for many years for various "colds and viruses"
comes to the office
because they have been unsuccessfully trying to conceive for the past 3 years. They
say that they are
enjoying the "act of trying" but are getting a bit concerned that there is something
"wrong". The wife is
32 years old, has never had a sexually transmitted disease and has never been
pregnant before. She
has had regular menstrual periods since she was 14 years old and usually has
cramping and breast
tenderness a few days before menses. The husband is 36 years old and denies any
sexually
transmitted diseases. He is an avid cyclist and goes on 10-mile rides each day.
Neither of them takes
any medications. You perform a complete physical examination on both of the
patients and find no
abnormalities. During the pelvic examination, you obtain a Pap smear, gonorrhea
and chlamydia
cultures. You order thyroid function tests, prolactin levels, and a mid luteal serum
progesterone level in
the wife and advise her to record her basal body temperature. The couple returns to
the office 1 month
later to go over the test results. All of the studies that you ordered were normal, and
the results of the
basal body temperature show a 0.6% temperature rise at day 14 that remains
elevated until 13 days
later. The temperature drops and menses occurs 24 hours later. The most appropriate
next step is to
A. advise him to stop bicycling so often
B. determine his testosterone concentration
C. inform them that she is not ovulating
D. obtain a semen sample for analysis
E. schedule a hysteroscopy
Explanation:
The correct answer is D. Infertility is usually defined as the failure to conceive after
a year of
unprotected intercourse and it affects up to 15% of reproductive-aged couples. 60%
of the time there
is a female factor such as ovulation disorders or anatomical defects in the genital
tract and the other
40% of the time it is due to male disorders of spermatogenesis. The initial work-up
of an infertile
couple usually includes a complete history and physical examination, a basal body
temperature chart,
laboratory studies, and semen analysis obtained by masturbation. The semen
analysis evaluates the
sperm count, volume, viscosity, motility, and differential. A hysterosalpingogram,
which is an x-ray of
the female genital tract after an opaque dye is injected into the uterine cavity, is
useful in evaluating the
anatomy and is sometimes included in the initial work-up. However, many OBGYNs will order this
study only after the results of the previously mentioned studies are normal.
The most appropriate next step is to obtain a semen sample for analysis, not to
advise him to stop
bicycling so often (choice A). While some believe that the pressure and heat
generated by sitting on
a bicycle seat can affect sperm count, you must first order a semen analysis to
determine if the
infertility is due to a male factor.
Determining his testosterone concentration (choice B) is not a typical part of the
evaluation of
infertility. Semen analysis is important to determine the sperm count, volume,
viscosity, motility, and
differential.
It is incorrect to inform them that she is not ovulating (choice C) because she has
regular menstrual
cycles with menstrual symptoms and the results of the basal body temperature
recording are
completely normal and indicate that she is most likely ovulating. Also, the mid
luteal progesterone is
normal.
It is inappropriate to schedule a hysteroscopy (choice E) at this time. A
hysteroscopy allows the
physician to directly evaluate the endometrial cavity through an endoscope and to
possibly biopsy or
remove any lesions that are present. A semen analysis should be performed before
an invasive
procedure, such as this, is ordered.
A 26-year-old man comes to the office because of a 3-day history of left-sided
scrotal pain and
swelling. He states that he is "very sexually active" and has had many sexual
partners. He recently
returned from a week-long Caribbean cruise, where he met "lots of other eligible
partners." His
temperature is 38.2 C (100.8 F), blood pressure is 120/70 mm Hg, and pulse is
80/min. Examination
shows unilateral intrascrotal tenderness. The scrotal skin is erythematous, warm, and
there is a partial
obliteration of the rugal folds. Testicular support makes the pain less intense. There
is mucoid
discharge present at the urethral opening. The most appropriate next step is to
A. give him an immediate referral to a local urologist
B. obtain a urethral culture and prescribe a 10-day course of oral ofloxacin
C. order testicular ultrasonography
D. send him to the emergency department for immediate surgical evaluation
E. recommend scrotal elevation, ice packs, and nonsteroidal anti-inflammatory
drug
Explanation:
The correct answer is B. This patient has epididymitis, most likely due to
Chlamydia trachomatis.
Epididymitis is the inflammation of the epididymis, which leads to unilateral
intrascrotal pain, swelling,
and fever. Testicular support usually relieves the pain to some extent.
Asymptomatic urethritis can be
associated with epididymitis due to C. trachomatis or N. gonorrhoeae. The
discharge is mucoid in
chlamydia and purulent in gonorrhoeae. Urinalysis may reveal pyuria. Urethral
culture and urine PCR
or LCR can confirm the diagnosis. The specific treatment of a C. trachomatis
infection is
azithromycin, doxycycline, or tetracycline, and the treatment for N. gonorrhoeae is
a single dose of
Ceftriaxone, given intramuscularly. A 10-day course of oral ofloxacin can treat both
infections. The
sexual partners should be treated to avoid reinfection.
A referral to a urologist (choice A) is unnecessary for a case of epididymitis or
urethritis. A physical
examination, urethral culture, and antibiotics are indicated and this can be done by a
primary care
physician and does not require a specialist.
A testicular ultrasound (choice C) is part of the initial evaluation of a testicular
tumor, which often
presents in this age group with a mass. A dull, aching pain may be present. This
patient's acute
symptoms and urethral discharge make the diagnosis more consistent with an
infectious process than
a tumor. An ultrasound is also sometimes used to evaluate for testicular torsion.
Testicular torsion (choice D) is a surgical emergency, which is caused by twisting
of the spermatic
cord and vascular compromise. It is typical in young adults who present with acute,
unilateral testicular
pain and normal urinalysis results. Testicular support does not relieve the pain. If
this is suspected, an
immediate surgical evaluation is necessary.
In addition to antibiotic therapy, it is appropriate to recommend scrotal elevation,
ice packs, and
nonsteroidal anti-inflammatory drugs (choice E) to a patient with epididymitis. A
urethral culture and
antibiotics should be the initial steps before this treatment.
A 51-year old married man comes to the office complaining of blood in his semen.
He states that
approximately 2 weeks prior to presentation he noticed bloody ejaculate. There were
2 episodes within
3 days of each other. Since the last episode he has had normal ejaculations on
multiple occasions.
There is no associated pain, penile discharge, erectile dysfunction, abdominal pain,
or history of
trauma. His medical history is significant for diet-controlled diabetes and eczema.
There is no family
history of prostate cancer. Physical examination reveals no abnormalities of the
penis or scrotum. On
digital rectal examination, his prostate is smooth, non-tender, firm, normal in size,
and without nodule.
Serum prostate specific antigen (PSA) is 1.4 ng/mL. Urinalysis and urine cytology
are both negative.
The next best step in management is
A. observation and reassurance
B. obtain a semen analysis
C. order a transrectal ultrasound
D. perform cystoscopy or cystourethroscopy
E. prescribe ciprofloxacin for 7 days
F. repeat PSA
G. schedule a prostate biopsy
Explanation:
The correct answer is A. Hematospermia, the presence of blood in the seminal fluid,
is usually the
result of nonspecific inflammation of the urethra, prostate, or seminal vesicles. It is
almost always
self-limiting and resolves within several weeks. Occasionally, hematospermia may
be associated with
infection, particularly tuberculosis, cytomegalovirus, and schistosomiasis, but rarely
is it associated
with malignancy. All patients with this complaint should undergo careful physical
exam to exclude
hypertension which may cause hematospermia, a rectal exam, and a PSA test to
exclude prostatic
carcinoma, and a urine cytology to rule out the possibility of transitional cell
carcinoma of the prostate.
This patient has had a complete work-up for initial presentation of hematospermia.
There is no need
to do anything but reassure the patient that his condition is almost always selflimiting.
Semen analysis (choice B) evaluates semen for volume and sperm concentration,
quantity, motility,
and morphology. Its utility is in the evaluation of infertility.
Transrectal ultrasonography (choice C) can evaluate the prostate, seminal vesicles,
or ejaculatory
ducts. It may be utilized for persistent hematospermia. It does not play a role in
evaluation of a single
episode of hematospermia.
Cystoscopy, or cystourethroscopy (choice D), allows for visualization of the
pendulous, bulbar and
prostatic urethra and bladder, and is not indicated unless hematospermia persists
and there is
concern for the underlying pathology.
Antibiotics (choice E) can be utilized in the treatment of prostatitis. There is no
evidence that reveals
utility of such agents in the current clinical scenario. When treating prostatitis,
antibiotics should be
used for at least 21 days. Patients with prostatitis normally have a soft, boggy, and
tender prostate on
rectal exam and have associated urinary complaints (dysuria and frequency).
Prostate specific antigen (PSA) (choice F) is a useful screening tool for prostate
cancer. In general, a
normal PSA is any value less than 4. Some urologists also believe in age-adjusted
PSA with a normal
value being slightly lower for younger patients. A repeat exam is not necessary in
light of this patient's
normal level.
Prostate biopsy (choice G) is an invasive procedure that is performed in patients
who have a clinical
suspicion of prostate cancer (i.e., abnormal digital rectal exam or elevated PSA).
This patient has
neither, and subjecting him to an unnecessary invasive test is not indicated.
A 19-year-old man comes to the clinic with a gradually worsening scrotal pain for the
past week. He has no
significant past medical history. He says he is sexually active with 2 partners and uses
condoms
&ldquo;occasionally&rdquo;. General physical examination is normal. Examination
of the genitalia reveals
a very tender left epididymis. The testes are normal. There is a whitish discharge from
the penile meatus.
Transillumination of the scrotum demonstrates no evidence for a hydrocele. To
exclude testicular torsion,
ultrasonography of the testes is performed. The right testicle and epididymis are
normal (not shown). The
left testicle is normal. The findings from the right epididymis are shown (gray-scale
and color Doppler). The
intervention most likely to have prevented this condition is
A. evaluation for undescended testis
B. prophylactic antibiotics
C. regular medical check-ups
D. safe sex counseling
E. support underwear
Explanation:
The correct answer is D. Epididymitis has progressed to an epididymal abscess in this
patient. The
ultrasound reveals a hypoechoic collection in the epididymis and on Doppler images
the mass has no
vascular flow. Epididymitis is caused by retrograde infection from any sexuallytransmitted organism
secondary to sexual intercourse. It is rarely spread hematologically except in some
immunocompromised
patients.
The testicles are not undescended (choice A) given the scrotal exam. Undescended
testes increases
the risk for testicular cancer, which is not what this patient has.
Prophylactic antibiotics (choice B) are not indicated in the general population without
a history of
recurrent epididymitis.
Regular medical check-ups (choice C) would not have prevented this sporadic disease
occurrence.
They are important, however, for general health maintenance.
Support underwear (choice E) has no relation to epididymal or testicular infections.
A 34-year-old man comes to the office because of "erectile problems." He says that
he and his wife
have not had sexual intercourse in months because he has not been able to have an
erection. He says
that it is so upsetting that they have basically stopped trying because it just makes
both of them
"depressed". He has seen so many television commercials lately that he expects a
cure in the form of a
"little blue pill." He is married, has 3 kids (age 1,3, and 6), works as a narcotics
police officer, and
competes in triathalons on the weekends. He takes no medications, rarely drinks
alcohol, and has had
no serious medical conditions. Physical examination is normal. The most
appropriate next step in
evaluating this patient's erectile disorder is to ask him
A. "Are you feeling unusually anxious lately?"
B. "Are you sexually attracted to your wife?"
C. "Do you have nocturnal or early morning erections?"
D. "Do you love your wife?"
E. "How often do you ride your bicycle?"
Explanation:
The correct answer is C. The main issue in evaluating impotence is distinguishing
between
psychological causes and organic causes. The presence of nocturnal or early
morning erections
basically eliminates the organic causes and leads to a diagnosis of psychological
impotence. Up to
90% of erectile disorders are due to psychogenic factors. The most common
psychological causes
include anxiety and depression. Nocturnal penile tumescence, which occurs during
REM sleep, can
be assessed in a sleep lab or by a stamp test (wrapping stamps around the penis
before bedtime
and checking in the morning if the "ring" is broken at any of the perforated areas).
If nocturnal
erections are not present, the impotence is most likely due to an organic cause. The
most likely
causes are testicular failure, hyperprolactinemia, medications, alcohol, opioids,
nicotine, trauma,
priapism, diabetes, vascular disease, and neurologic diseases, such as diseases of the
spinal cord,
and loss of sensory input. Physical examination should include a detailed genital
exam, evaluation for
signs of feminization, neurologic, and vascular exams. "The little blue pill" (Viagra)
is not indicated in a
patient with psychogenic erectile disorders.
"Are you feeling unusually anxious lately?" (choice A) is a good question to follow
the question about
nocturnal erections (if he is having them).
"Are you sexually attracted to your wife?" (choice B) is a relevant question if the
patient is having
nocturnal erections and is not depressed or anxious. "Do you love your wife?"
(choice D) is a
question that may be asked if he is having nocturnal erections and is anxious and
depressed. It may
be a little blunt and can probably be asked in a more subtle manner.
"How often do you ride your bicycle?" (choice E) may be relevant because of
neurologic and vascular
compromise caused by the seat. However, it is not the most helpful question to
distinguish between
organic and psychologic causes.
A 68-year-old man is admitted to the hospital for intravenous antibiotic therapy for
cellulitis of the elbow.
After 3 days of therapy, he is feeling better, but now complains of difficulty
walking. He has a known
history of prostate cancer that was treated with radical retropubic prostatectomy 6
years ago. His
recovery from surgery was uneventfu,l and initially his prostate specific antigen
(PSA) remained
undetectable. Because he had been feeling well, he stopped his follow up with his
urologist. He has
received no treatment for his cancer since his surgery. He has not had a complete
urologic examination
in over 2 years. The patient states that approximately 2 days prior to admission, he
noticed that he had
some mild difficulty lifting his left leg off the ground. His symptoms did not
improve, and today he
developed weakness of the right leg as well. He denies any trauma, falls, loss of
bowel or bladder
control or prior similar episodes. However, he does state that his lower back has
been "bothering" him
for the last 2 months. Vital signs are within normal limits. Physical examination
shows good anal
sphincter tone, and an empty prostatic fossa. Neurologic examination demonstrates
decreased motor
sensation of the lower extremities below the L2 level. Sensation is diminished below
the L2 level as
well. Plain films of the spine do not display any osteoblastic lesions. Serum PSA
level is 726 ng/mL.
The hormonal treatment that may prevent further neurologic deterioration in the
shortest period of time
is
A. bilateral adrenalectomy
B. bilateral orchiectomy
C. intravenous diethylstilbestrol (DES)
D. ketoconazole
E. luteinizing hormone releasing hormone (LHRH) agonist
Explanation:
The correct answer is B. This patient is suffering from spinal cord compression
secondary to
metastatic prostate cancer. This is a medical emergency, and if left untreated may
lead to significant
morbidity, including paraplegia and autonomic dysfunction. Pain usually precedes
the diagnosis of
spinal cord compression by up to 4 months. However, symptoms can progress
rapidly to neurologic
dysfunction in a matter of hours to days. The combination of the patient's history,
clinical exam, and
dramatically elevated PSA level confirm his diagnosis. The diagnosis of spinal cord
compression is
usually made with a combination of physical exam, plain films, and bone scans.
Once the diagnosis is
made, immediate androgen deprivation is required (assuming the patient has never
been treated with
hormones). The goal with androgen deprivation is to "starve" the prostate cancer of
the hormone
testosterone, which it uses to flourish. Once the diagnosis of spinal cord
compression is made and
androgen deprivation is begun, the patient should also be placed on steroid therapy.
Steroids help to
decrease vasogenic edema as well as provide analgesic benefit. Other treatment
modalities may be
required in conjunction with androgen deprivation and steroids. These include
radiation and possible
surgery for those patients with spinal instability. Bilateral orchiectomy is
permanent. It removes all
testicular production of testosterone, which is more than 90% of total testosterone
produced by men.
Castrate levels of serum testosterone are achieved in approximately 3 hours after
surgery.
Bilateral adrenalectomy (choice A) will only remove the adrenal production of
testosterone
(approximately 10% of total testosterone production). Not only is this not adequate
androgen
deprivation for this patient, but it is no longer necessary now that pharmacological
agents are
available.
Diethylstilbestrol (DES) (choice C) is a synthetic, non-steroidal form of estrogen. In
24 hours, it only
causes a 50% reduction in total testosterone. DES has many side effects including
pulmonary
embolism, myocardial infarction, and deep venous thrombosis.
Ketoconazole (choice D) is a direct inhibitor of testosterone production. It works by
blocking
cytochrome P-450, thereby directly halting the production of both adrenal and
gonadal testosterone.
Castrate levels of testosterone are produced in 8 hours. This is a good alternative in
patients who are
unfit for surgery, refuse surgery, or will not be able to get to the operating room in
an expeditious
manner.
Luteinizing hormone-releasing hormone (choice E) medications work by agonizing
LHRH receptors
in the pituitary. They produce an initial increase in release of LH and FSH causing
an increase in
testosterone production ("flare phenomenon"). Therefore, they are contraindicated
in this setting,
because the increase in testosterone will make the patient's condition worse. With
time, these
medications suppress LH and FSH production by inhibiting the hypothalamicpituitary axis. Ultimately,
this leads to a decrease in testosterone production. With these medications,
testosterone reaches
castrate levels in 30 days.