Old Q&A – Male Reproductive System

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).

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.

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 OB-GYNs 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.

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.

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.

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.

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.

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.

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.

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.

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.

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).

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.

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.

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.

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.

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 hypothalamic-pituitary axis. Ultimately, this leads to a decrease in testosterone production. With these medications, testosterone reaches castrate levels in 30 days.

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.

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.

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.

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.

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 self-limiting.

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.

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.

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 alpha-1 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 self-limiting.

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.