NMS Q&A Family Medicine

Urological Problems Unique to Males 123irregular shape of the testicle proper and nearly always isnontender. The exception is the rapidly growing tumorinto which hemorrhage occurs.9. The answer is D. Tenderness of the hernia sac indicatesthe complication of strangulation of an incarcerated hernia.This surgical emergency requires timely correction toprevent ischemic death of the tissues involved in the hernia,usually a loop of bowel. In the latter case, the specterof bowel obstruction adds a further threat. Inability toreduce the hernia confers urgency and is the precursor ofstrangulation. Direct inguinal hernias are less likely tobecome incarcerated than indirect hernias. The latter herniatedown the inguinal canal, a defined tight tunnel.10. The answer is D. Reactive arthritis (formerly calledReiter syndrome in the context of the vignette) is the mostcommon etiology for an acute inflammatory arthritis in ayoung adult. When following exposure to Yersinia or Shigellaorganisms, the incidence is equal in male and femalepatients. When following a sexually transmitted disease,the incidence in men is nine times that in women. Thejoint fluid is sterile by definition (as opposed to that inseptic arthritis). Other components of the classic tetrologyof urethritis, conjunctivitis, arthritis, and dermatitismay be present or absent.11. The answer is E, Leydig cell carcinoma. Leydig cellsproduce testosterone. Because of the dedifferentiation ofthese cells and the lack of circulating testosterone, 30% ofpatients with Leydig cell tumors exhibit gynecomastia. Allthe remaining tumors mentioned in the choices are germcell tumors. Although 97% of testicular cancers are germcell tumors and 5% of them manifest gynecomastia, allexcept seminomas among them are characterized by theelevations of alpha-fetoprotein or human chorionicgonadotropin; 60% manifest elevated lactic dehydrogenaseas well.12. The answer is D. Performing a sperm count on thehusband is the most logical initial step after a thoroughhistory and physical examination, the latter includingpelvic examination to rule out anatomic causes of femaleinfertility. Forty percent of the cases of infertility are malerelated. Polycystic ovary syndrome is unlikely because itappears to be established when the patient is ovulating sothat pelvic ultrasound is unnecessary. The other studiesare quite expensive compared with the cost of the spermcount.13. The answer is C. Varicocele is the most common causeof male infertility, accounting for 30% of cases.14. The answer is C. Prostatism may be caused by oraggravated by all the choices given, except for epididymitis.Epididymitis, though not a cause, may be associatedchronologically with prostatitis.15. The answer is E. B2 is an example of staging ofprostate cancer (PrCa), by the Whitmore-Jewett system.A microscopic presence, found at surgery: A1 focal;A2 diffuse. B palpable in rectal exam: B1 single nodule,normal lobe; B2 two nodules palpable or the lobe indurated.C contiguous spread without metastases: C1minimal, C2 (symptomatic) spread into urethra or bladder.D metastatic disease: D0 negative bone scan, butincreased alkaline phosphatase; D1 pelvic nodes; D2distant, recurrent after surgery. The Gleason sore is ameasure of pathological tumor architecture deducedapparent decreasing differentiation of the PrCa graded as0–5 based on the pattern of the primary or largest area ofcancer in a specimen and 0–5 based on the second largestarea of cancer in a specimen. The Gleason score correlateswith tumor volume and with staging of the cancerbut is not itself a measure of staging. However, the Gleasonscore has not replaced surgical staging in rendering aprognosis.16. The answer is C. Among the drugs mentioned, literaturefor albuterol does not list impotence or erectile dysfunction.As this drug is a beta-2 agonist, some patientswill complain of heart pounding if use of the drug isexcessive. Such adrenergic effects may interfere with sexualfunction because of the effect of preoccupation. However,the other medications are well known to causeimpotence to varying degrees at therapeutic levels. Itbehooves physicians to inquire directly of people whotake those medications (and many others) about thatproblem, even if the chief complaint is not related to thesymptoms of sexual dysfunction.17. The answer is A. The incorrect statement is that theupper limit of normal in PSA level is 4 ng/mL in all circumstances.This can be inferred from the other choices(i.e., that the upper limit of normal rises with age and levels 4 can be an indication of cancer in younger men).From the other correct statements, it can be inferred thatthe free as opposed to bound form of PSA should be presentat a minimum of 27% of the total. Less than that is acriterion for biopsy and is used in cases of marginal PSAlevels for age. Finally, the yearly rate of rise in PSA levels,regardless of their absolute values, should not exceed0.7 ng/mL. If it does, further investigation is critical so asnot to miss the opportunity for early diagnosis of prostatecarcinoma.