Chapter 16: Men's Health

A 58-year-old black male presents to your clinic complaining of urinary hesitancy, frequency, and three to four episodes of nocturia per night, which have been worsening over the past few years. His urinary stream is weaker than it was a few years ago and he feels he does not empty his bladder completely. He denies any history of urinary tract infections (UTIs) or painful urination. He is otherwise well with no significant past medical or surgical history. Currently, he takes no medications and has no allergies. On reviewing his family history, he notes his father and older brother died of prostate cancer in their 50s. His general physical examination is normal and a genital examination is unremarkable. Digital rectal examination reveals a smooth prostate with no nodules or tenderness.

Question 16.1.1 Based on this patient's history and physical examination, all of the following would be appropriate at this stage EXCEPT:

A) Serum assay for prostate-specific antigen (PSA)

B) American Urological Association (AUA) symptom score

C) Post-void residual urine volume

D) Transrectal ultrasound with prostate biopsies

E) Urinalysis and microscopic examination of the urine

Answer 16.1.1 The correct answer is "D." Although your patient has an increased risk of prostate cancer, transrectal ultrasound with prostate biopsies is not indicated at this stage. This diagnostic test should be reserved for a higher suspicion of prostate cancer. Based on this patient's family history and the fact that he is black (black males have a 50% higher incidence of and mortality from prostate cancer compared with whites), PSA testing ("A") is appropriate in this setting, as opposed to general population screening, which is discussed later in the chapter. The AUA symptom score ("B") is a seven-item questionnaire about symptoms of urinary outlet obstruction, which can be used to assess severity and assist in management of prostate disease. It is not very useful for diagnosis, but on the bright side, it is freely available online. There is also the International Prostate Symptom Score, which is remarkably similar but has an additional question regarding how symptoms affect the patient's quality of life. Since your patient may not empty his bladder well, a post-void residual urine volume and urinalysis will help determine if he is experiencing urinary retention ("C") or an infection ("E").

Question 16.1.2 When considering benign prostatic hyperplasia (BPH), you reflect on the common symptoms of this syndrome, which include all of the following EXCEPT:

A) Urinary retention

B) Post-void dribbling

C) Frequency

D) Nocturia

E) Hematuria

Answer 16.1.2 The correct answer is "E." Hematuria is not usually associated with BPH. However, it can occur if a man's prostatic urethra is very enlarged and friable. Enlargement of the prostate often results in obstructive flow symptoms (e.g., hesitancy and slow, weak stream), which in turn can lead to irritative symptoms (e.g., frequency, urgency, and nocturia). Obstruction from an enlarged prostate alone can cause hypertrophy of the detrusor, or it can lead to an infection that results in detrusor instability—the cause of irritative symptoms. If irritative symptoms are present without obstructive symptoms, other diagnoses should be considered, including bladder cancer, urolithiasis, infection, and neurogenic bladder.

Your patient's urinalysis and PSA are normal. After emptying 250 mL of urine, the postvoid residual urine volume is 50 mL.

Question 16.1.3 With this information, you recommend which of the following strategies?

A) Urodynamic studies

B) Medical therapy

C) Surgical therapy

D) Scheduled bladder catheterization

E) Biofeedback

Answer 16.1.3 The correct answer is "B." You have enough information to diagnose symptomatic BPH, and further studies are not necessary. Depending on the patient's preferences, the next step is to begin treatment, and in most cases, medical therapy is initiated first. If medical therapy fails or if a patient has severe BPH with ongoing obstruction, retention of large volumes of urine, bladder stones, or recurrent UTIs, surgical therapy should be considered. The most commonly performed surgery is transurethral resection of the prostate (TURP), but other techniques can be employed as well, including transurethral incision of the prostate, minimally invasive procedures, and open surgery for very enlarged prostate glands. "D" is incorrect. Scheduled bladder catheterization is unlikely to benefit your patient since his post-void residual is not very large. A post-void residual greater than 200 mL is associated with an increased risk of UTIs, and such patients may benefit from scheduled catheterizations if medical or surgical interventions do not correct the problem or are contraindicated. Kegel exercises and biofeedback ("E") may be used to treat incontinence but are not used in BPH. Also, biofeedback is helpful for voiding dysfunction due to incomplete urinary sphincter relaxation.

Your powers of deduction lead you to the conclusion that the patient's urinary symptoms are due to BPH. Embarrassed that he is taking more bathroom stops than his wife on their road trips, your patient desires treatment.

Question 16.1.4 To give him the most immediate relief, you prescribe which of the following?

A) Finasteride

B) Oxybutynin

C) Tamsulosin

D) Imipramine

E) Furosemide

Answer 16.1.4 The correct answer is "C." Timing and type of intervention should depend on how much the patient is bothered by his symptoms and whether complications of BPH are present. If the symptoms do not significantly interfere with your patient's life, he may choose to wait and take no treatment once he is reassured that he does not have a life-threatening illness. In general, medical management begins with a selective alpha-1a receptor blocker, such as tamsulosin, which relaxes the prostate at the bladder neck. In the past, non-uroselective alpha-1 blockers (e.g., terazosin, doxazosin) were considered first-line; but this is no longer the case. Let's face it: if your patient is on an alpha-1 receptor blocker for any reason—including hypertension—he has tried a few other things first. The risk–benefit ratio does not favor them when compared with other drugs for BPH or hypertension (see next question).

If the patient does not receive sufficient relief from maximum doses of an alpha-1a blocker, consider adding a 5-alpha-reductase inhibitor (e.g., finasteride, dutasteride). These drugs work by reducing the size of the prostate gland by interfering with the effects of androgens on prostate tissue. However, it may take up to 6 months for a 5-alpha-reductase inhibitor to result in a noticeable difference in symptoms (thus, "A" should not be the first treatment); whereas the full benefit of an alpha-blocker will be apparent within 4 to 6 weeks. "B" and "D" are incorrect because these anticholinergic drugs are used for incontinence due to detrusor instability and may make urinary retention worse in patients with outlet obstruction. Furosemide, "E," is a potent diuretic and would be a cruel joke to play on this patient.

Question 16.1.5 Before you tear up the prescription for terazosin you accidentally wrote, you review its side effects. Potential side effects of alpha-blockers include all the following EXCEPT:

A) Retrograde ejaculation

B) Hypertension

C) Intraoperative floppy iris syndrome

D) Priapism

Answer 16.1.5 The correct answer is "B." Hypotension (not hypertension) is the most commonly encountered problem with terazosin and other alpha-blockers, including the uroselective alpha-blockers, although to a lesser degree. In elderly males, the hypotension can be particularly problematic as the propensity for falling may increase. Additionally, alpha-blockers in combination with phosphodiesterase inhibitors (e.g., sildenafil) can cause dangerously low blood pressures. Retrograde ejaculation ("A") and priapism ("D") are not common but have been reported. And, as if we needed it, here is more evidence for a direct link between the male ocular and genital systems: intraoperative floppy iris syndrome has been observed in men taking alpha-blockers and undergoing cataract surgery; causality has not been proven. Yes, you may have thought we made this up but we didn't.

You start tamsulosin. Unfortunately, the patient is not able to tolerate it due to dizziness. His symptoms are bothersome enough that he wishes to try something else. You consider finasteride.

Question 16.1.6 Which of the following is true of finasteride?

A) It permanently reduces prostate volume, even after the drug is stopped

B) It is approved by the Food and Drug Administration (FDA) for abnormal hair growth in women

C) It may reduce the overall risk of developing prostate cancer but increase the risk of developing high-grade prostate cancers

D) It improves symptoms within 1 week of starting the drug

E) None of the above

Answer 16.1.6 The correct answer is "C." This is important: 5-alpha-reductase inhibitors lower the overall risk of cancer but increase the risk of those cancers diagnosed being high grade. Finasteride (and dutasteride) works by inhibiting 5-alpha-reductase, which is the enzyme that converts testosterone to dihydrotestosterone. Dihydrotestosterone stimulates hyperplasia of the prostate gland, and removing this stimulus results in decreased prostate volume. However, removal of finasteride allows hyperplasia to continue, and thus answer "A" is incorrect. "B" is also incorrect because finasteride for hirsutism in women is not approved by the FDA. Additionally, finasteride is category X in pregnancy, with potential teratogenic effects on the fetus. "D" is incorrect because finasteride takes time to work—a lot of time. As previously mentioned, its peak effectiveness is not seen for 3 to 6 months after starting the medication.

You decide to add finasteride. You see him again 2 months later when he presents with a febrile illness. He thinks that he might have the flu, but his BPH symptoms worsened at the same time. For the last 2 days, he has felt feverish with back pain, perineal pain, and generalized malaise. He complains of dysuria and worsening urinary frequency and urgency.

Question 16.1.7 During your examination, you make sure NOT to:

A) Perform a rectal examination

B) Massage the prostate

C) Swab the urethra for chlamydia

D) Perform urinalysis and microscopic examination of the urinary sediment

Answer 16.1.7 The correct answer is "B." There is a risk of seeding bacteria into the bloodstream when an infected prostate is massaged. This patient has symptoms of prostatitis; thus, you should avoid prostatic massage. Nonetheless, you should perform a prostate examination. The following physical findings are associated with prostatitis: tenderness, warmth, enlargement, and bogginess.

You suspect prostatitis and obtain urine for analysis.

Question 16.1.8 All of the following laboratory abnormalities are consistent with the diagnosis of acute prostatitis EXCEPT:

A) Leukocytosis

B) Hematuria

C) Bacteriuria

D) Elevated creatinine

E) Elevated PSA

Answer 16.1.8 The correct answer is "D." Tests of renal function should not be abnormal in simple, acute prostatitis. Chronic partial or complete urinary outlet obstruction may cause abnormal renal function but not acute prostatitis. Abnormal serum BUN and/or creatinine in the setting of prostatitis should prompt further investigation. The urine often shows bacteriuria, pyuria, and hematuria. However, the urine may also be negative. Urine should be sent for culture and sensitivity to definitively determine the pathogen and direct further treatment. "E" is true: the PSA is often elevated in prostatitis. However, it is not necessary nor is it recommended to obtain a PSA to diagnose prostatitis. When the PSA is elevated due to acute prostatitis, it may not return to normal levels for 1 month or more after the resolution of inflammation.

On examination, you find an uncomfortable appearing male in no distress. His temperature is 38.4°C, and the rest of his vital signs are normal. The prostate on digital rectal examination is tender, enlarged, warm, and boggy. The remainder of the examination is unremarkable. Urinalysis is consistent with an infection. He has a sulfa allergy.

Question 16.1.9 Which of the following is the most appropriate treatment plan for this patient?

A) Prescribe amoxicillin 500 mg orally TID for 10 days

B) Prescribe ciprofloxacin 500 mg orally BID for 28 days

C) Admit for IV levofloxacin 500 mg daily for 14 days

D) Admit for IV levofloxacin 500 mg daily, followed by completion of therapy with oral levofloxacin 500 mg daily for 14 days when the patient is stable

E) Perform transrectal ultrasound to rule out prostatic abscess

Answer 16.1.9 The correct answer is "B." The most appropriate treatment for this patient is a fluoroquinolone, such as ciprofloxacin, for at least 28 days. Some authorities recommend longer treatment (up to 6 weeks) to reduce the risk of chronic prostatitis. In patients who are not allergic, a sulfa antibiotic could be considered as an alternative to a fluoroquinolone. In this case, "C" and "D" are overkill. Admission is appropriate for patients who appear septic, have not responded to oral antibiotics, or who have significant comorbidities. However, fluoroquinolones have 100% bioavailability PO. Thus, there is no indication for giving these drugs IV unless the oral route is unavailable (e.g., vomiting). Additionally, the treatment course for "C" and "D" is too short. "E" is incorrect because abscesses are rare and imaging for an abscess is only undertaken if the patient does not respond to appropriate antibiotics.

When you see this patient again, his symptoms of prostatitis have cleared, but he does not think that finasteride is really helping. His AUA symptoms score is 21 (severe). He is wondering if a transurethral re-section of the prostate (TURP) might help him, and he wants to discuss the downsides of the operation.

Question 16.1.10 Compared with watchful waiting, all of the following are observed at greater rates in men who undergo TURP EXCEPT:

A) Erectile dysfunction

B) Urinary incontinence

C) Urethral stenosis

D) Increased urine flow

E) Decreased post-void residual urine volume

Answer 16.1.10 The correct answer is "A." TURP is a commonly performed procedure for BPH. Indications for TURP include failure of medical therapy, recurrent infections, bladder calculi, renal insufficiency, and patient preference. Patients who undergo TURP typically experience decreased AUA symptom scores, increased urine flow rates, and decreased post-void residual volumes. There are downsides to TURP, including urinary incontinence, urethral stenosis, and the need to repeat the surgery. Strange as it may seem, several studies have shown that erectile dysfunction does NOT occur at increased rates in patients undergoing TURP compared with watchful waiting. However, men can have retrograde ejaculation status post-TURP.

Your patient is so happy with his care that he shared his story over beers, and his friend comes to see you. This patient is a 50-year-old male, in no apparent distress, who presents with a 6-month history of recurrent irritative voiding symptoms (frequency, urgency, etc.), low back and distal penile pain, and recurrent UTIs with the same organism. Today he is afebrile with a mildly tender prostate on digital rectal examination.

Question 16.1.11 Based on this patient's history and physical examination, all would be the most appropriate at this stage, EXCEPT:

A) Have the patient complete the NIH Chronic Prostatitis Symptom Index questionnaire

B) Perform a 2 glass pre- and post-prostatic massage test

C) Obtain urine culture and if positive, treat based on sensitivities for at least 4 weeks

D) Obtain a pelvic MRI

Answer 16.1.11 The correct answer is "D." There is no indication for a pelvic MRI at this time. The 2 glass pre- and post-prostatic massage test is a very useful method of diagnosing chronic prostatitis. A mid-stream voided urine specimen is collected and sent for culture. If the urinalysis has greater than 10 WBCs per high-power field, next prostatic massage is performed, and then the first 10 mL of voided urine after the massage that should include expressed prostatic secretions should be sent for culture. Treatment is based on the culture and sensitivity results. A 4- to 6-week course of treatment is recommended with an appropriate antibiotic with good tissue penetration. The most common organisms isolated in chronic bacterial prostatitis are E. coli, Klebsiella, Proteus, Pseudomonas, and Gram-positive Enterococcus. The NIH Chronic Prostatitis Symptom Index questionnaire is a reliable, valid method to assess symptoms and quality of life impact in men with chronic prostatitis (http://www.prostatitis.org/symptomindex.html).

Objectives: Did you learn to…

• Recognize the pattern of voiding dysfunction seen in BPH?

• Manage a patient with BPH and understand the potential adverse effects of medications used to treat BPH?

• Diagnose and treat acute prostatitis?

• Describe indications for and complications of TURP?

• Evaluate chronic prostatitis?

A 21-year-old college student, self-described as a "ladies' man," (interpret: jerk) presents because of a concerning spot that developed on his penis. He complains of pain at the spot but denies itching. He reports no fever. When asked further about his sexual practices, he reports no condom use because his partners are all "on the pill." He had chlamydia in high school but is otherwise healthy. His review of systems is negative. On examination of the penis, you find a 1-cm tender, erythematous papule with a deep central ulceration at the glans penis. There is some mild, tender lymphadenopathy in the inguinal area. The rest of the examination is unremarkable.

This lesion is most likely caused by:

A) Haemophilus ducreyi

B) Neisseria gonorrhoeae

C) Staphylococcus aureus

D) Treponema pallidum

The correct answer is "A." This is the lesion of H. ducreyi, otherwise known as chancroid. It can be confused with the chancre of primary syphilis, caused by T. pallidum, but the syphilis chancre is painless. Gram stain (Gram-negative rods in chains), culture, or biopsy (which this guy deserves) may confirm the diagnosis. A few more notes: chancroid is rarely diagnosed in the United States and is probably under diagnosed; it frequently co-infects with syphilis and tends to occur in clusters. A number of treatments are available including ceftriaxone (250 mg IM once), azithromycin (1 g PO once), ciprofloxacin (500 mg PO BID for 3 days), and erythromycin base (500 mg PO TID × 7 days).

A 22-year-old male presents complaining of a painless lump on his left testicle. He denies penile discharge, dysuria, or other urinary complaints. He underwent a left orchidopexy for an undescended testicle at age 6. Otherwise, his past medical history is unremarkable. On examination, the penis is circumcised with no lesion or discharge. There is adenopathy in the left inguinal area. His testicles are descended bilaterally with a 1-cm palpable, irregular mass on the mid-lateral portion of the left testicle. His examination is otherwise unremarkable. Your patient is worried about testicular cancer and wants to know if he is at risk.

Question 16.2.1 All of the following are associated with an increased risk of testicular cancer EXCEPT:

A) Vasectomy

B) HIV infection

C) Cryptorchidism

D) Klinefelter syndrome

E) Family history

Answer 16.2.1 The correct answer is "A." Epidemiologic data do not support an association between testicular cancer and vasectomy. As is true of some other malignancies, males with HIV infection have an increased risk of testicular cancer. Also, males with cryptorchidism (failure of one or both testicles to descend into the scrotum) and Klinefelter syndrome are at increased risk of testicular cancer. About 25% of testicular cancers occurring in patients with cryptorchidism arise in the contralateral (normally descended) testicle. While testicular cancer does not have as strong of a hereditary component, a positive family history is a risk factor for testicular cancer. Of note, black males have a much lower incidence of testicular cancer than do white males.

Question 16.2.2 If your patient had not had an orchidopexy to repair the undescended testicle, he would be at risk for developing all of the following problems EXCEPT:

A) Infertility

B) Inguinal hernia

C) Testicular torsion

D) Testicular malignancy

E) Impotence

Answer 16.2.2 The correct answer is "E." Organic impotence is not a consequence of cryptorchidism. All of the other problems listed occur at an increased frequency in males with an undescended testicle. The best time to begin treatment for an undescended testicle to minimize future sequelae is between 6 and 18 months of age and preferably by the end of the first year. The consequence of not treating an undescended testicle is a 20% to 40% increased risk of developing a testicular malignancy, which often presents as a painless mass (although it is not clear that fixing the undescended testicle lowers the cancer risk). Therefore, the reasons to treat cryptorchidism are (1) to better palpate the testicle to assess for potential malignant transformation; (2) to decrease the risk of malignant transformation (maybe); (3) to improve chances of fertility; (4) to decrease risk of testicular torsion; (5) to decrease psychological effects from having an empty scrotum; and (6) to repair an inguinal hernia at the same time, if it is present.

Question 16.2.3 After an appropriate history and physical examination, which of the following tests is the initial diagnostic study of choice in your patient with a scrotal mass?

A) CT scan

B) Ultrasound

C) Complete blood count (CBC)

D) Alpha fetoprotein (AFP)

E) Pelvic x-ray

Answer 16.2.3 The correct answer is "B." The best initial diagnostic test would be a scrotal ultrasound to determine if this mass is cystic or solid. If it is determined to be a solid mass suspicious for malignancy, then other diagnostic studies would be warranted, such as β-hCG and AFP. In conjunction with a radical inguinal orchiectomy for testicular cancer, a CT scan would be indicated to evaluate for metastatic disease, but it is not the test of choice for initial diagnosis, so "A" is incorrect. CBC ("C") would have a role in suspected infection. X-ray ("E") has no role in the evaluation of this patient since this is a soft tissue mass.

Question 16.2.4 In taking this patient's history, if he had described a painful lump in his scrotum, the LEAST likely cause would be:

A) Chlamydia

B) Inguinal hernia

C) Hydrocele

D) Testicular torsion

Answer 16.2.4 The correct answer is "C." Spermatoceles and hydroceles are usually not painful. When a young, sexually active male presents with a painful scrotal mass or swelling, epididymitis from chlamydia or gonorrhea should be considered. Testicular torsion often has a very abrupt onset of pain and is a surgical emergency. Inguinal hernias can be intermittently painful if moving freely in the inguinal canal. However, if one becomes incarcerated, intense pain occurs. Of note, varicoceles are usually an incidental finding; however, large varicoceles may occasionally be painful. Likewise, testicular cancers are usually not painful but can become so if the tumor growth is rapid.

Your patient's ultrasound is concerning for testicular cancer, and you refer him to a urologist.

The next day the patient's 15-year-old brother presents with scrotal pain. You wonder if you are on the cusp of discovering an infectious cause of testicular cancer, but alas, it appears to be coincidence.

This patient's pain is on the right and he can localize it well to the front of the testicle. It has been present for 3 days and seemed to occur gradually over a few hours. There is no radiation of the pain. Running makes it worse, and cool packs seem to help. Yesterday he noticed a slight swelling of the scrotum on the same side. He denies trauma to the area, any history of sexual activity, other genitourinary complaints, fever, nausea, or vomiting. On examination, you find normal vitals. He has a well-localized tender spot at the anterior superior right scrotum with a bluish discoloration under the skin … as if it were some sort of sign … a blue dot sign.

Question 16.2.5 Which of the following is the most likely diagnosis?

A) Torsion of the appendix testis

B) Torsion of the testicle

C) Varicocele

D) Abscess

E) Spermatocele

Answer 16.2.5 The correct answer is "A." This is the classic presentation of a torsed appendix testis. The appendix testis is a pedunculated, vestigial structure at the anterior superior testicle. Torsion of the appendix testis is one of the most common causes of scrotal pain in children. The pain is usually well localized. There may be a reactive hydrocele. Diagnosis is confirmed by ultrasound. Unlike a torsed testicle, a torsed appendix testis is not an emergency. It may be treated by conservative therapy (rest, NSAIDs, ice) or surgical excision.

Objectives: Did you learn to…

• Recognize potential causes of a painless scrotal mass?

• Evaluate a testicular mass?

• Recognize the significance of cryptorchidism?

• Identify torsion of the appendix testis?

A 28-year-old male presents to your office looking quite concerned. Several days ago after sexual intercourse with his girlfriend, he noticed bloody ejaculate in the condom. Since then he has masturbated twice ("just to check") and has not seen any more blood. He denies pain, hematuria, dysuria, fevers, night sweats, and weight loss. He reports that he is otherwise healthy. His examination, including genitourinary and rectal examination, is normal. A urinalysis is negative.

What is your next step in the evaluation and management of this patient?

A) Reassurance and follow-up

B) Scrotal ultrasound

C) Pelvic CT scan

D) Transrectal ultrasound

E) PSA

The correct answer is "A." Hematospermia, the name given to bloody penile ejaculate, is fairly uncommon. It can occur in men of any age and is perhaps most common after prostate biopsy or prostate surgery. In otherwise healthy young men, the cause is most often idiopathic and is almost always benign. History should focus on traumatic causes (e.g., long bicycle ride), symptoms of prostate disease, and symptoms of infection. A genital and prostate examination should be performed. Urinalysis is helpful to exclude infection. Consider gonorrhea and chlamydia cultures in the appropriate patients, for example, those with symptoms of urethritis. In this patient, reassurance is adequate. Persistent hematospermia, with symptoms present for over a month, may require further evaluation with PSA, imaging, and urologic consultation. Some experts recommend a more aggressive work-up, especially in older males, but there is no evidence to support more extensive evaluations. Also ask about recent travel: schistosomiasis is a frequent cause of hematospermia and hematuria in other parts of the world. In most cases of hematospermia, semen analysis is not warranted, but it can be diagnostic in patients with schistosomiasis.

A couple you have known for a few years comes to your office to announce that they are expecting and that they want you to be the baby's doctor (strange that they didn't ask you to be the mother's doctor, but you let it slide). According to an ultrasound, the fetus is male. The couple is ambivalent about neonatal circumcision and wants your advice.

Question 16.3.1 You start the conversation by saying:

A) "Circumcision is a relic of history and should be illegal."

B) "All major medical organizations (e.g., AAFP, AAP, AMA) recommend routine neonatal circumcision."

C) "The decision to perform circumcision is a personal one, influenced by a number of factors—but primarily by cultural, religious, and familial issues."

D) "Do whatever you want. I don't really care what you do with a tiny piece of skin"

Answer 16.3.1 The correct answer is "C." One of the strongest predictors of whether a newborn in the United States will be circumcised is the circumcision status of the father. There are other reasons cited by parents as well (discussed later in the case). "A" is incorrect simply because the statement is effused with emotion and lacks logic. "B" is incorrect. The AAFP has no policy statement on circumcision. In 2012 the American Academy of Pediatrics changed its statement on circumcision (since 1999 the AAP did not find the data sufficient to recommend routine neonatal circumcision) to the following: the health benefits outweigh the risks, and circumcision should be made available to all families who choose it. However, 'routine' universal circumcision is still not recommended. If you chose "D," you need to work on your bedside manner!

Question 16.3.2 Consequences of circumcision include which of the following?

A) Overall reduction in mortality of circumcised infants compared with uncircumcised infants

B) Reduction in UTIs in the first year of life

C) Reduction in the number of sexual partners

D) All of the above

Answer 16.3.2 The correct answer is "B." The rate of UTIs in uncircumcised males in the first year of life is about 10 times greater than the rate for circumcised males. In order to prevent one UTI in the first year of life, about 100 circumcisions need to be performed. The effect of circumcision on rates of UTI later in life is not well studied. The rate of UTI may be higher shortly after circumcision (within the first 2 weeks). "A" is incorrect because there is no data showing any difference in mortality between circumcised and uncircumcised infants. "C" is incorrect; some surveys have shown increased frequency and variety of sexual practices in circumcised males compared with uncircumcised (note that this is an association, not a causal relationship).

Question 16.3.3 Neonatal circumcision is associated with all of the following EXCEPT:

A) Risk of hemorrhage with the procedure

B) Psychological trauma and decreased sexual satisfaction later in life

C) Reduced risk of infection with STIs, such as HIV

D) Reduced risk of penile cancer

Answer 16.3.3 The correct answer is "B." Despite what some anti-circumcision websites maintain, circumcision does not appear to result in any significant psychological trauma or decreased sexual satisfaction for most men later in life. "A" is true. There is a small but real risk of hemorrhage with the procedure, and this occurs mostly in patients who have an unknown or unrealized coagulopathy. In fact, abnormal bleeding after circumcision is a common way in which sporadic cases of hemophilia are discovered (including one case discovered this way by one of the editors—and he still feels bad!). "C" is true. Several studies have demonstrated that circumcised men are less likely to have HPV infection. The data for the risk of other sexually transmitted infections (STIs) are somewhat contradictory, but generally favor a reduced risk of STIs in circumcised males. "D" is true. There is evidence that circumcision may decrease the transmission of HPV and penile cancer. Retrospective studies have shown that the rate of squamous cell carcinoma of the penis is about threefold higher in uncircumcised men, at least in the United States. However, penile cancer is exceedingly rare (about 0.6 cases/100,000) and the number of circumcisions needed to prevent 1 case of penile cancer is about 300,000. However, the American Cancer Society does not recommend routine neonatal circumcision for the prevention of penile cancer but does recommend that all risk factors be addressed.

You have a nice, long conversation with the couple, discussing the potential benefits and risks, and they decide to have their son circumcised. After the birth, you are performing a thorough examination when you find something slightly abnormal with the penis.

Question 16.3.4 Neonatal circumcision is indicated for:

A) Congenital phimosis

B) Micropenis

C) Hypospadias

D) Ambiguous genitalia

Answer 16.3.4 The correct answer is "A." Significant congenital phimosis rarely occurs and is an indication for circumcision. Phimosis is defined as the inability to retract the foreskin (prepuce) over the glans. This is a normal finding in uncircumcised infants. However, significant congenital phimosis may completely cover the urethra and not allow the normal passage of urine. "B," "C," and "D" are reasons to avoid routine circumcision and to call on the aid of a urologist.

Objectives: Did you learn to…

• Discuss the benefits and risks of circumcision with parents?

• Identify indications and contraindications for neonatal circumcision?

• Employ appropriate pain control measures for the procedure of circumcision?

A 32-year-old male presents to discuss permanent sterilization. He clearly states that he wants a vasectomy, and sooner is better than later. He is married and has three children at home. His wife just gave birth to twins. He is healthy and takes no medications. He looks tired and anxious. You examine him and find no abnormalities. The vas deferens is easily isolated bilaterally.

Question 16.4.1 What is your next step?

A) Refer him for psychological counseling as he is clearly under a great deal of stress

B) Provide him with detailed counseling on vasectomy, give him written material on the procedure, and ask him to discuss it with his wife

C) Do the vasectomy right now; the next patient can wait

D) Tell him that he is not an appropriate candidate for vasectomy

Answer 16.4.1 The correct answer is "B." Patient education, counseling, and selection are very important aspects of vasectomy. When you counsel him on vasectomy, you should explore his reasons for wanting the procedure. You should not schedule a vasectomy without providing counseling and assuring that he understands the procedure in detail. This patient appears to be fatigued—an issue that should be explored further … and he has newborn twins at home. Who the heck wouldn't be tired! So, immediate referral for psychological counseling without investigating the underlying cause is not appropriate.

Question 16.4.2 While counseling this patient, you discuss which of the following issues?

A) Partner's desire for permanent sterility

B) Effect of the procedure on sexual function

C) Reversibility of the procedure

D) Complications

E) All of the above

Answer 16.4.2 The correct answer is "E." All these issues are important to discuss prior to scheduling the procedure. It is important that the couple agree on this procedure because it is the couple—not just your patient—who will be sterile. Aside from psychological effects of vasectomy, the procedure should not directly affect sexual function, orgasm, or ejaculation. Patients should be aware that vasectomy results in permanent sterility and that reversal procedures are only successful about half of the time. Potential complications include failure and unwanted pregnancy, infection, pain, bleeding, hematoma, etc.

Your patient decides to "get snipped" as he puts it. You perform the vasectomy using a no-scalpel technique. The procedure was fairly easy, and the patient tolerated it well. One month after the procedure, the patient calls to complain about a painful swelling that has developed superior and slightly posterior to the left testis. He has no other symptoms.

Question 16.4.3 Which of the following is the most likely diagnosis?

A) Hematoma

B) Varicocele

C) Congestive epididymitis

D) Abscess

Answer 16.4.3 The correct answer is "C." Without any further information, congestive epididymitis is the most likely cause of this patient's current complaint. Congestive epididymitis occurs in about 3% of patients post-vasectomy, and the onset is usually within weeks to months after the procedure. "A," hematoma, can be avoided in most cases if hemostasis is achieved during the procedure and the patient does not overexert himself immediately post-operation. A hematoma is more likely to develop early rather than a month later. Likewise, an infection ("D") would be unlikely so far out from the procedure. "B" is incorrect because varicoceles do not develop after vasectomy (unless you are operating far away from where you are supposed to be). Overall, the most common scrotal pathology after vasectomy is sperm granuloma, which occurs in up to 40% of patients but is generally asymptomatic.

Two months after the vasectomy, your patient returns with a semen sample, showing no sperm. His surgery was successful, but failures do occasionally occur.

Question 16.4.4 Vasectomy failure is usually due to:

A) Failure to identify and transect the vas at the time of surgery

B) Recanalization

C) Left-handed doctors

D) Infection

E) Immaculate conception

Answer 16.4.4 The correct answer is "B." Although "redundant systems" (removing a segment of the vas deferens, clipping or suturing the free ends, cauterizing the transected vas, suturing fascia around one free end while leaving the other outside the fascia) are employed to avoid this complication, recanalization can occur. A new pathway can form between the free ends of the transected vas deferens, allowing sperm into the ejaculated semen. Therefore, all patients should return post-vasectomy for semen analysis. "A" and "D" are potential, but infrequent, causes of failure. "C" is incorrect. What have you got against lefties? As to "E," only God knows.

Your patient is ultimately pleased with his vasectomy results. He returns to see you several years later because of concerns that he is balding. On examination, you find non-scarring hair loss at the vertex. The scalp appears normal otherwise.

Question 16.4.5 You should entertain all of the following diagnoses EXCEPT:

A) Androgenetic alopecia (yes, it is "androgenetic" and not "androgenic")

B) Telogen effluvium

C) Alopecia areata

D) Hypothyroidism

E) Tinea capitis

Answer 16.4.5 The correct answer is "E." Hair loss is common in males, affecting up to two-thirds of all men. Alopecia is often divided into scarring and non-scarring forms. Most infectious causes of hair loss (e.g., tinea capitis and folliculitis) are scarring if not treated, whereas the other causes listed ("A" through "D") are non-scarring. Without any signs of inflammation or hyperkeratosis, tinea capitis is unlikely. "A," androgenetic alopecia, is quite common in adult males (male balding). "B," telogen effluvium, presents with diffuse hair loss usually secondary to metabolic (including dieting) or emotional stress. This occurs as an abnormal percentage of hair enters the telogen phase during which they are shed. Grab some hair: if more than five hairs in telogen phase come out, you have your diagnosis. "C," alopecia areata, results in patchy hair loss in round or oval shapes. Metabolic conditions should also be in the differential diagnosis of hair loss, and these might include hypothyroidism ("D"), hyperthyroidism, and iron deficiency.

The patient reports a strong family history of baldness. On your examination, the patient has thin hair at the vertex and recession of the hairline in an "M" shape at the frontotemporal area. On the basis of the history and examination, you diagnose androgenetic alopecia. He would like to do something about his hair loss.

Question 16.4.6 Regarding androgenetic alopecia, which of the following statements is true?

A) Minoxidil must be used for at least 2 years to achieve permanent hair regrowth.

B) Lower doses of 5-α-reductase inhibitors (e.g., finasteride) are used in treating androgenetic alopecia compared with BPH.

C) Hair transplant should be avoided unless all other therapeutic attempts have failed.

D) Topical steroids are an effective therapy for androgenetic alopecia.

E) A toupee looks great on anyone.

Answer 16.4.6 The correct answer is "B." Finasteride (Propecia) is FDA approved for androgenetic alopecia, and the dose is 1 mg/day rather than the 5 mg/day dose used to treat BPH symptoms. Minoxidil applied to the scalp is also an effective therapy for androgenetic alopecia. Both minoxidil and finasteride must be continued indefinitely to be effective. Hair transplant is a viable option for men and women with androgenetic alopecia, and it is sometimes used as a first-line therapy. Thus, "C" is incorrect. Topical steroids are not effective for this type of hair loss. "E" is clearly wrong; there are a lot of bad toupees out there.

Objectives: Did you learn to…

• Provide pre-vasectomy counseling?

• Recognize complications of vasectomy?

• Identify causes of hair loss in men?

• Describe current treatment options for androgenetic alopecia?

For all the following causes of death, the age-adjusted death rate is higher for males than for females EXCEPT:

A) Liver disease

B) Alzheimer disease

C) Coronary artery disease

D) Suicide

E) Cancer

The correct answer is "B." When it comes to Alzheimer disease, men get a break; the death rate is higher for females. All of the other causes of death listed have greater death rates in males. For example, compared with women with liver disease, same age men with liver disease are twice as likely to die of their liver disease.

The relative risk of death for males is greater throughout the life span. Compared with same age females, at what age range is the relative risk of death greatest for males?

A) <1 year

B) 5 to 14 years

C) 15 to 24 years

D) 25 to 34 years

E) >85 years

The correct answer is "C." Unfortunately, males aged 15 to 24 years have a relative risk of death of greater than 2.5 compared with same age females (usually preceded by a cry of "Hey, look what I can do!"). Mother Nature has a way of making up for boys and young men dying: more male fetuses are conceived than female. However, the miscarriage rate is also greater for male fetuses. Nonetheless, about 105 males are born in the United States for every 100 females. By age 35, enough males have died off that the number of males and females at that age is about equal, and thereafter the number of females exceeds the number of males (in other words, the singles scene improves markedly for the remaining males).

A 14-year-old male presents with his mother, who is worried that he has growing breasts. Over the last 2 or 3 months, the patient has developed swellings beneath both nipples. He denies discharge or pain, but the nipples are tender at times.

Question 16.5.1 You can tell this patient that physiologic gynecomastia (subareolar breast tissue) is a condition that affects:

A) Newborns

B) Adolescents

C) Elderly males

D) All of the above

Answer 16.5.1 The correct answer is "D." The incidence of physiologic gynecomastia is trimodal, with peaks in the neonatal period, adolescence, and old age. Data can be contradictory at times, but clinically palpable breast tissue (either fat or true breast tissue) may be present in more than 50% of males in each of these three age groups.

Question 16.5.2 Which of the following hormones is responsible for the proliferation of breast tissue?

A) Testosterone

B) Estrogen

C) Androstenedione

D) Growth hormone

E) Progesterone

Answer 16.5.2 The correct answer is "B." Estrogens induce ductal hyperplasia and growth of glandular tissue. Testosterone and androstenedione inhibit the actions of estrogens on the breast tissue. Some men with gynecomastia have increased sensitivity of breast tissue to circulating estrogens. Others may have an increased proportion of estrogens compared with androgens. Yet, others may have a mixture of both processes or another process altogether.

Question 16.5.3 Potential causes of gynecomastia include all of the following EXCEPT:

A) Renal failure

B) Marijuana use

C) Testicular cancer

D) Hypothyroidism

E) Phenothiazines

Answer 16.5.3 The correct answer is "D." Hyperthyroidism, not hypothyroidism, can cause gynecomastia through increased aromatization of testosterone to estradiol and androstenedione to estrone. A number of drugs are associated with gynecomastia, including marijuana, alcohol, 5-alpha-reductase inhibitors, phenothiazines, tricyclic antidepressants, androgens, estrogens, growth hormone, calcium channel blockers, and spironolactone. Other causes of gynecomastia include: hypogonadism, hyperprolactinemia, testicular tumors (some secrete estrogens), renal failure, and liver diseases (cirrhosis). Obesity is associated with gynecomastia, but obese patients may also appear to have gynecomastia while simply having excess fat deposition in the area of the breast (sometimes called "pseudogynecomastia").

A thorough drug history is negative. On physical examination, you find palpable, nontender tissue beneath the nipples, with slightly more prominent tissue mass on the right. The tissue is about 2 to 3 cm in diameter, and no discrete masses are palpable. There is no nipple discharge. An adult male's hair growth pattern is evident in the axillary and inguinal areas. The testicles are normal size without masses.

Question 16.5.4 At this point in time, you recommend which of the following?

A) Observation

B) Referral to a surgeon

C) Limited laboratory studies, including thyroid-stimulating hormone (TSH), testosterone, and liver enzymes

D) Biopsy of the tissue

E) Mammogram and/or ultrasound

Answer 16.5.4 The correct answer is "A." As previously mentioned, physiologic gynecomastia is quite common in adolescent males. The findings on examination are reassuring. This patient does not display any other signs of testosterone deficiency, and further workup is not indicated at this time. If there are no discrete masses on examination, a mammogram, ultrasound, or biopsy is not likely to be helpful. Referral to a surgeon is premature, as 90% of these patients experience spontaneous involution of the breast tissue over 3 years.

You provide the patient and his mother with reassurance and have them return in a year. At follow-up, there is no palpable tissue. When you see the patient again, he is 17 years old. He told his mother that he was having abdominal pain, but really he is worried that he may have contracted an STI. He has become fairly promiscuous and does not use condoms (after the gynecomastia disappeared, his mojo returned). In the last week, he has developed dysuria and a yellowish urethral discharge. He has no other symptoms.

Question 16.5.5 Which of the following is the most likely diagnosis?

A) HPV

B) Syphilis

C) Gonorrhea

D) Trichomonas

E) Herpes simplex

Answer 16.5.5 The correct answer is "C." This patient's symptoms are typical of gonococcal urethritis. However, N. gonorrhoeae may be present in the urethra without any symptoms and Chlamydia trachomatis can present with a purulent discharge that is classically thought of as gonorrhea; gonorrhea and chlamydia cannot be reliably distinguished on clinical grounds. "A" is incorrect as HPV causes genital warts, not urethritis. "B," syphilis, may present as a painless ulcer (primary syphilis). "D" is incorrect because most men infected with Trichomonas vaginalis are asymptomatic, although some will have mild urethritis. Finally, "E," herpes simplex, presents with painful vesicles at the area of inoculation.

You obtain urine for PCR for gonorrhea and chlamydia. You discuss other STIs and decide to perform some other tests (e.g., HIV, hepatitis B, RPR/VDRL).

Question 16.5.6 At this point in time, you are compelled to do all of the following EXCEPT:

A) Recommend safe sexual practices

B) Inform the public health services if he tests positive

C) Treat him with antibiotics now

D) Encourage him to contact his partners and tell them to get tested

E) Inform his mother of your findings

Answer 16.5.6 The correct answer is "E." In general, adolescents can seek care for STIs and be treated without parental consent. However, clinicians should refer to the laws of the state in which they practice for ultimate legal authority in this matter. Of course, the time of diagnosis and treatment should be used as an opportunity to educate the patient regarding safe sexual practices. "B" is true. Gonorrhea and chlamydia are reportable diseases in every state. Again, clinicians should refer to the laws of their state and the reporting protocols of the clinic in which they practice. Empiric treatment is the rule here, so "C" is correct. "D" is also correct since all of this patient's partners should be contacted, tested, and treated. There are several ways to contact the partners, and allowing the patient to do so is only one way. The clinician or the public health authorities could contact the partners as well.

Question 16.5.7 Which of the following methods maintains a high degree of sensitivity and is also the quickest and least expensive way to diagnose gonococcal urethritis in a symptomatic male?

A) Culture

B) Gram stain

C) Serologic antibody assay

D) PCR

E) DNA probe

Answer 16.5.7 The correct answer is "B." In symptomatic males, Gram stain of a urethral sample can identify Gram-negative diplococci (N. gonorrhoeae) with a sensitivity of about 90% to 95%. The sensitivity drops to about 70% in asymptomatic males. If the materials and expertise are readily available, a Gram stain is quick and inexpensive. Culture of a urethral specimen on Thayer–Martin agar takes longer and false-negative tests can occur with high frequency (due to the need to have a CO₂-rich environment and to keep the culture in a narrow temperature range). PCR and other nucleic acid testing are more sensitive than cultures but still not 100%. PCR is particularly attractive as a screening test, as it can be performed on urine specimens instead of urethral swab specimens. Serologic assays for gonorrhea would not be helpful in diagnosing urethritis.

Question 16.5.8 Your clinical suspicion of gonorrhea is high. What is your next step?

A) Single doses of ceftriaxone 125 mg IM

B) A single dose of penicillin G 1.2 million units IM and erythromycin 500 mg orally QID for 7 days

C) Tetracycline 500 mg orally QID for 10 days

D) Single doses of ciprofloxacin 500 mg orally and cefixime 400 mg orally

E) Single dose of ceftriaxone 250 mg IM and azithromycin 1 g orally

Answer 16.5.8 The correct answer is "E." If there is any concern for compliance, it is best to treat the patient in the office if you have access to the appropriate antibiotics. As of 2015, the CDC recommends ceftriaxone 250 mg IM as a single dose (rather than 125 mg, due to increasing resistance) PLUS azithromycin 1 g PO for uncomplicated gonococcal urethritis. The azithromycin is given for two reasons: increasing resistance among gonococcal isolates and to cover for possible chlamydia co-infection. If ceftriaxone is not available, cefixime 400 mg PO is an acceptable alternative. Fluoroquinolones are not recommended for gonorrhea due to high rates of resistance in some communities. "A" is incorrect because ceftriaxone alone will not provide empiric coverage for chlamydia, and the dose is too low anyway. "B" is incorrect because penicillin should never be used to treat gonorrhea (due to the prevalence of penicillinase-producing strains of the bacteria). "C" is incorrect. Tetracycline antibiotics provide adequate coverage for chlamydia and some strains of N. gonorrhoeae, but other strains of N. gonorrhoeae are resistant to tetracyclines, so these drugs are not used as first-line agents in treating gonorrhea. "D" is incorrect because fluoroquinolones are not recommended for gonorrhea and it contains nothing for the treatment of chlamydia.

You treat this patient with ceftriaxone and azithromycin and tell him to contact his partners so that they can get treated. When your patient returns to discuss his lab tests, he is feeling much better. You tell him that he was infected with both gonorrhea and chlamydia but that the rest of his tests were negative. He is relieved that he does not have HIV, but he wonders what problems chlamydia can cause.

Question 16.5.9 C. trachomatis has been implicated in which of the following?

A) Reiter syndrome

B) Lymphogranuloma venereum

C) Proctitis

D) Epididymitis

E) All of the above

Answer 16.5.9 The correct answer is "E." A small percentage of men with chlamydia urethritis develop reactive arthritis, and a subset of these will go on to have the triad of Reiter syndrome (urethritis, arthritis, and uveitis). Lymphogranuloma venereum is also due to a particularly virulent strain of C. trachomatis, but it produces genital ulcers and lymphadenitis and is generally seen in tropical areas. Lymphogranuloma venereum is treated with extended courses of doxycycline (100 mg PO BID for 21 days) or azithromycin (1 g PO weekly for 3 weeks). Chlamydia proctitis occurs almost exclusively in homosexual men and presents with rectal pain, bleeding, and discharge. Diagnosis is confirmed by rectal swab, and the treatment is the same as for chlamydia urethritis. "D," epididymitis is most often the result of infection with C. trachomatis or N. gonorrhoeae. Urethral strictures are also commonly related to prior STIs.

Objectives: Did you learn to…

• Define gynecomastia and understand its causes?

• Identify when to initiate further evaluation in a patient with gynecomastia?

• Recognize symptoms of gonorrhea and chlamydia?

• Initiate treatment in a male with urethritis?

• Recognize manifestations of chlamydia infection in men?

A 36-year-old male diabetic patient presents with a 3-day history of irritation, itching, dysuria, and redness at the tip of his penis. He is monogamous with his wife, and he denies any history of high-risk sexual behavior or STIs. On examination, you find an afebrile patient in no acute distress. The penis is circumcised, and the glans penis is red, tender, and edematous. There are numerous small, white papules on the glans.

Which of the following is the most appropriate treatment?

A) Sitz baths and improved hygiene

B) Oral doxycycline

C) Topical bacitracin

D) Topical miconazole

E) Topical steroids

The correct answer is "D." This patient has balanitis, which is defined as an inflammatory condition of the glans penis (balanoposthitis is the name applied to inflammation of the glans and foreskin). Some authors believe that balanitis is a noninfectious, inflammatory condition. Others implicate infectious causes. Of infectious causes, the most common is Candida albicans, especially in diabetic patients. This patient has classic findings of candidal balanitis and is diabetic. Therefore, the most appropriate therapy is a topical antifungal agent, such as miconazole. Fluconazole is an option. Topical and oral antibiotics will not help, and topical steroids should be avoided. Sitz baths and improved hygiene should be encouraged, but they should not be employed without an antifungal agent.

While covering the emergency department (ED), a 40-year-old male presents with a painful erection that began 4 hours ago "out of the blue" (perhaps after he took a little "blue pill").

Question 16.6.1 Which of the following is true regarding priapism and normal erections?

A) Normal erections can last up to 12 hours, so this is not priapism

B) Abnormally prolonged sexual desire can "convert" a normal erection into priapism

C) The corpus spongiosum and glans penis are not involved in priapism

D) Acute urinary retention may lead to priapism and vice versa

E) All of the above are true statements

Answer 16.6.1 The correct answer is "C." Priapism is defined as the prolonged engorgement of the penis (or—rarely—the clitoris in females), unrelated to sexual desire or stimulation. The word priapism comes from the Greek god Priapus, apparently well known for his lasciviousness and generous genital endowment. In most cases of priapism, the corpus spongiosum and glans penis are not involved. Only the corpora cavernosa are engorged and rigid. Priapism typically lasts longer than 6 hours, whereas normal erections last minutes to hours. With normal erections, detumescence occurs after ejaculation or after the stimulus is removed. This is not the case with priapism, and sexual desire does not play a role in the development of priapism; thus, "B" is incorrect. "D" is also incorrect. Urinary retention is not thought to cause priapism, and priapism does not lead to urinary retention.

Question 16.6.2 Priapism may be secondary to all of the following EXCEPT:

A) Sickle cell disease

B) Penile trauma

C) Leukemia

D) Iron deficiency anemia

E) Trazodone use

Answer 16.6.2 The correct answer is "D." A number of different disease states and drugs have been implicated in the etiology of priapism. In one way or another, these diseases and drugs affect the balance of blood flow into the penis, leading to increased arterial blood flow and/or decreased venous outflow. Local malignancies, such as bladder and prostate cancers, can cause obstruction. Likewise, any condition that increases blood viscosity (e.g., sickle cell disease, polycythemia, leukemia) or results in thromboembolic phenomena (e.g., vasculitis) can cause priapism. Penile trauma that results in laceration of penile arteries can cause priapism. Numerous drugs have also been implicated (see Table 16-1), but in most cases, the cause is not identified.

Question 16.6.3 What is your next step in management of this patient?

A) Reassurance

B) Call for emergent urologic consultation

C) Give oral alpha-blockers

D) Engage patient in guided imagery to lead his thoughts away from sex

Answer 16.6.3 The correct answer is "B." Priapism is a urologic emergency and needs to be treated ASAP. All the other answers could result in your undesired new title of "defendant." Until the urologist arrives, conservative measures are probably best, and you should try to make the patient comfortable using analgesics, oxygen, and hydration. Check a CBC since leukemia can rarely present with priapism. Some patients will respond to analgesics and ice packs. Oral or subcutaneous terbutaline may be helpful. Some authors recommend sedatives, such as benzodiazepines.

Objectives: Did you learn to…

• Recognize priapism and its causes?

• Manage a patient with priapism?

Which of the following groups has the highest rate of death by suicide?

A) Black males

B) White males

C) Black females

D) White females

E) Hispanic males

The correct answer is "B." In the United States, white males make up about 70% of all deaths due to suicide. Although females account for more suicide attempts, males are at greater risk of death from suicide. Men tend to use deadlier means, such as guns, hanging, and car collisions. In other words, men are very efficient at suicide. White men older than 85 years have one of the highest rates of death due to suicide: 59/100,000 (with the rate in the general public being 10.6/100,000). As a group, black males have the second highest rate of suicide. Of those groups listed above, black females have the lowest risk of death from suicide.

A 78-year-old male presents for follow-up after an emergency department visit last week. He sustained a fall that resulted in a T11 compression fracture. You obtained a DEXA scan to confirm that he has osteoporosis and found that his T-score is indeed osteoporotic-range. Just to be on the safe side, you order a bunch of laboratory tests, all of which are normal except for serum testosterone. Lo and behold, his testosterone level is very low. He's also been tired, felt weak, and lost his libido. Because he knows we need to cover testosterone supplementation in this book, he asks you, "Should I be on one of those fancy testosterone supplements?"

Question 16.7.1 Which of the following testosterone supplementation products would you AVOID?

A) Transdermal testosterone patches

B) Buccal testosterone tablets

C) Oral testosterone tablets

D) Intramuscular testosterone injections

E) Transdermal testosterone gel

Answer 16.7.1 The correct answer is "C." Oral testosterone should be avoided due to significant first-pass metabolism and potential liver toxicity. The other choices listed are viable options for testosterone replacement (see Table 16-2). The IM option is not the best for a steady state. Patients often like it due to the peaks.

Question 16.7.2 Which of the following is true regarding testosterone supplementation in older men with testosterone deficiency?

A) Testosterone supplementation has markedly beneficial effects on depression

B) The effects of testosterone supplementation in young hypogonadal males and older testosterone-deficient males are the same

C) In testosterone-deficient older males with erectile dysfunction, testosterone supplementation dramatically improves erections

D) In testosterone-deficient older males with poor libido, testosterone supplementation improves libido

E) Testosterone supplementation has no effect on lean muscle mass or grip strength

Answer 16.7.2 The correct answer is "D." In testosterone-deficient older males, testosterone supplementation does improve libido. Unfortunately, "C" is incorrect: its effects on erectile dysfunction are not impressive. Even in testosterone-deficient men with erectile dysfunction, a phosphodiesterase inhibitor (e.g., sildenafil) is more likely to be successful. In terms of the neuropsychiatric effects of testosterone, many questions are as yet unanswered. However, testosterone supplementation does not appear to significantly affect depression, so "A" is incorrect. "B" is not true. Young hypogonadal males who are treated with testosterone have increased peak bone mass and virilization. But the effects on older males are different: older males have improved strength, libido, and sense of well-being without some of the effects seen in the young hypogonadal males. "E" is incorrect because testosterone has been shown to consistently improve lean muscle mass and grip strength. Testosterone replacement does not replace the need for antidepressants if depression is the cause of symptoms.

You have a conversation with your patient about starting testosterone therapy. He would like to try it. Those direct-to-consumer marketing campaigns really work!

Question 16.7.3 You tell him about adverse effects and monitoring and tell him it is important to periodically check:

A) Hematocrit

B) Potassium

C) Alanine aminotransferase

D) A and B

E) A and C

Answer 16.7.3 The correct answer is "E." There are good reasons behind the recommendation for periodic monitoring with certain serum tests. Testosterone increases erythropoietin production and can cause erythrocytosis. In fact, testosterone should not be started in a patient with a hematocrit greater than 50% (or severe heart failure or untreated sleep apnea). Testosterone can cause elevated liver enzymes, increased cholesterol, and growth of prostate and breast tissue, including prostate and breast cancers. Prostate examination and PSA are recommended prior to starting therapy and periodically while on testosterone. Of course, it makes sense to periodically monitor serum testosterone levels to assure that the patient is in the normal range and not sub- or supratherapeutic. Potassium ("B") is not directly affected and no monitoring is recommended.

Objectives: Did you learn to…

• Identify testosterone replacement products and discuss how older males might benefit (or not) from them?

• Recognize some of the risks associated with testosterone supplementation?

A 50-year-old male presents for a "get acquainted" visit. He has a history of hyperlipidemia treated with lovastatin. He takes no other medications and states that he is otherwise healthy. After watching a television feature called "What's Killing Us Now: Prostate Cancer," he thought he should be screened.

Question 16.8.1 In order to assess his risk for prostate cancer, you should take into account all of the following factors EXCEPT:

A) Age

B) Race

C) Family history

D) Cigarette smoking

E) Ultraviolet light exposure

Answer 16.8.1 The correct answer is "E." Ultraviolet light exposure increases the risk of skin cancer but not prostate cancer (it is where "the sun don't shine"). Advancing age is strongly and directly associated with the development of prostate cancer. Between ages 50 and 70 years, the incidence of prostate cancer more than quadruples, and it continues to increase thereafter. Black ancestry and positive family history carry the strongest associations with prostate cancer. Cigarette smoking has been linked to an increased risk of prostate cancer, but not with the strength of association of age or family history. Interestingly, dietary factors may have a role in the development of prostate cancer, although the associations are not strong and studies conflict. A diet rich in fish and vegetables and low in red meat may reduce the risk of prostate cancer.

Your patient is Caucasian and denies any family history of prostate cancer. He has no urinary symptoms and denies sexual dysfunction.

Question 16.8.2 If he did have urinary symptoms, which of the following could be used to reliably distinguish BPH from prostate cancer?

A) Urgency

B) Nocturia

C) Frequency

D) Hesitancy

E) None of the above…or a functional crystal ball

Answer 16.8.2 The correct answer is "E." A male who presents with urinary symptoms of urgency, nocturia, frequency, and/or hesitancy is more likely to have BPH and not prostate cancer. These urinary symptoms are incredibly common in older persons in general and most often are benign in nature. In fact, "BPH symptoms" (better termed lower urinary tract symptoms or "LUTS") are common in older women as well. However, urinary tract cancers (including prostate and bladder cancers) can present with these symptoms and must be considered. The point is that we cannot always attribute urinary symptoms in an older male to BPH.

You discuss prostate cancer screening with him, presenting the controversial and conflicting guidelines, discussing positive and negative values of lab tests and what they signify, using a dry erase board and giving a mini-lecture. Twenty minutes later, he says, "It's just a blood test right? I think I want one ounce of prevention, you understand, Doc." He gets "the works": digital rectal examination and PSA. The examination is remarkable for a slightly enlarged, smooth, nontender prostate without nodules. The PSA level is 16 ng/mL (reference range for your lab 0–4 ng/mL).

Question 16.8.3 The most appropriate next step is to:

A) Repeat the PSA in 3 to 6 months

B) Order a transrectal ultrasound of the prostate

C) Refer to urology for further evaluation and prostate biopsy

D) Repeat the rectal examination and try to find the nodule that you missed

E) Order a free PSA

Answer 16.8.3 The correct answer is "C." To use the Monopoly line: go directly to the urologist; do not pass GO. If he had symptoms of prostatitis, you might try treating with an appropriate antibiotic for 4 weeks and repeat the PSA to confirm elevation before referral. But this patient is completely asymptomatic. He is at relatively high risk of having prostate cancer based on his PSA level (16—that's high, in case you were uncertain) and age at presentation. Sending him to a urologist for prostate biopsy is the most prudent step. Follow-up PSA alone ("A") would be more defensible if the PSA level were <10 ng/mL and/or the patient were much older. "B," a transrectal ultrasound, is likely to miss more than it would find in this case. With this patient's PSA and current life expectancy, ultrasound should only be used as part of a larger urologic evaluation, including biopsy. "D," repeating the rectal exam, is just nuts. There is no need for this. Did you miss a nodule? Maybe. Would it hurt your ego? Who cares! You will eventually get over it. More likely, there was no palpable nodule. This patient could have stage T1 prostate cancer in which, by definition, no nodules are palpable. He could have a nodule located anteriorly in the prostate—a location you cannot palpate. He also may have a PSA elevation for reasons other than prostate cancer. Finally, "E" is incorrect. The free PSA is most helpful when the total PSA is in the intermediate risk zone (4.01–10 ng/mL). When the PSA is higher (>10 ng/mL), the risk of cancer is too great to make the free PSA useful. The fraction of PSA that is "free" (not bound to plasma proteins) is inversely proportional to risk of prostate cancer: the lower the free PSA compared with total PSA, the greater the risk of prostate cancer (cutoff percentages vary from 10% to 25%).

Question 16.8.4 Which of the following is true of the PSA test when used for screening purposes?

A) The positive predictive value approaches 100%

B) Since PSA testing has become widespread, prostate cancer incidence and mortality have increased

C) The false-negative rate is 20% to 25%

D) Age-specific cutoff values for PSA have proven to increase positive predictive value and specificity

E) Race-specific cutoff values for PSA have proven to increase positive predictive value and specificity

Answer 16.8.4 The correct answer is "C." There is a substantial false-negative rate—from 20% to 25%—limiting the use of PSA for screening purposes. "A" is incorrect by a long shot. The positive predictive value (likelihood of a positive test indicating true prostate cancer) ranges from about 20% to 60%, depending on the PSA level. The positive predictive value increases with increasing PSA level. "B" is incorrect. Since the PSA test has come into widespread use, the incidence of prostate cancer has increased, but mortality due to the disease has decreased. The reason for these trends has not been completely explained, and the role of the PSA test in these trends is not known. "D" and "E" are incorrect. Since older males seem to have higher PSA values in the absence of prostate cancer and black males tend to have prostate cancer found at lower PSA levels, age-specific and race-specific cutoff values have been proposed and investigated. However, the use of age-specific and race-specific PSA cutoff values is of questionable value.

Again your winning personality and reputation for thorough care has won you a referral. Your patient refers a friend to you. This patient is a 60-year-old male who presents to your clinic for advice regarding treatment after recently being diagnosed with prostate cancer. A urologist recommended surgery but he wants to know what you think. (Don't let it go to your head.)

Question 16.8.5 Possible treatment options for prostate cancer include all the following, EXCEPT:

A) External beam radiation

B) Saw palmetto

C) Active surveillance

D) Robotic prostatectomy

Answer 16.8.5 The correct answer is "B." While over-the-counter saw palmetto is sometimes taken by patients for BPH even though it has not been proven to be effective, it is not used for prostate cancer treatment. External beam radiation, brachytherapy, surgery (open, laparoscopic, or robotic prostatectomy), and androgen deprivation therapy are options considered for higher-risk prostate cancers. Watchful waiting and active surveillance are options considered for lower-risk prostate cancers. Active surveillance consists of scheduled PSA testing and digital rectal examinations every 3 to 6 months and repeat prostate biopsies at 1- to 3-year intervals.

Objectives: Did you learn to…

• Identify risk factors for prostate cancer?

• Discuss prostate cancer screening with a patient?

• Interpret an elevated PSA?

• Recognize the limitations of prostate cancer screening?

• Recognize various treatment options for prostate cancer?

A 32-year-old male accompanied by his wife presents for evaluation of infertility. They have been married for 5 years and have been attempting conception for 3 years without success. The patient's wife has a 7-year-old daughter from a previous marriage. The patient has no significant past medical or surgical history. He does not smoke but drinks a six-pack of beer and one cup of coffee daily—not necessarily in that order. He relaxes after work and on weekends by sitting in their hot tub for hours at a time. His BMI is 32 kg/m². He has normal facial and body hair and his testicles are descended bilaterally and of normal size. You note a moderate sized varicocele on the left.

Question 16.9.1 Which of the following is not a modifiable risk factor for male subfertility?

A) Alcohol intake

B) Hot tub usage

C) Varicocele

D) Tobacco use

E) Obesity

Answer 16.9.1 The correct answer is "D." We should note that the study of infertility risk factors and treatments is complicated by inconsistent outcome measures (e.g., sperm count, sperm motility, conception, pregnancy resulting in live birth). However, there are no conclusive studies correlating tobacco use with male subfertility. The other answers are modifiable risk factors and have been directly linked to subfertility, either in decreased sperm count or decreased sperm motility. It is important to ask about alcohol use ("A"). Other drug use, such as marijuana, should be investigated as well since it can affect sperm quality and motility. "B" is true. Hot tub usage, febrile illnesses, and the presence of a varicocele raise the temperature of the testicles, thereby decreasing the optimal environment for the maturation of sperm. But how about the boxers versus briefs controversy? Type of underwear does not seem to affect scrotal temperature significantly, and more to the point, tight underwear is not associated with decreased fertility. The presence of a varicocele ("C") is an interesting issue. It is certainly modifiable in that the patient could undergo a varicocelectomy, which might help if the varicocele is moderate to large in size. However, the degree to which a varicocele contributes to infertility is not well-known. Varicoceles are noted to occur more commonly in infertile men, but they also occur in 10% to 15% of the normal, fertile male population. Obesity ("E") contributes to the increased peripheral aromatization of testosterone into estradiol in fatty tissue.

Other factors that contribute to subfertility/infertility include a history of cryptorchidism, hypospadias, viral orchitis after puberty, prior chemotherapy or radiation, intake of calcium channel blockers, and retrograde ejaculation associated with diabetes and multiple sclerosis.

Question 16.9.2 You order a seminal fluid analysis, and the sperm density is 12 million/mL with a motility of 35%. This finding is:

A) Normal for both sperm count and motility

B) Normal for sperm count but abnormal for motility

C) Abnormal for sperm count but normal for motility

D) Abnormal for both sperm count and motility

E) Scary; that seems like a lot of sperm

Answer 16.9.2 The correct answer is "D." As a general rule, normal sperm concentration for fertility is considered to be 15 million/mL or greater. However, as they say, it only takes one sperm to make a baby, so men with lower sperm counts can be fertile. At least 40% or more should be motile. Another finding of importance on SFA is the sperm morphology. Using strict criteria, normal morphology should be 4% or more (yes, unfortunately for men, only 4%).

You repeat the SFA 2 weeks later, and again it is abnormal. His testosterone level is low for his age, and his FSH and LH are high.

Question 16.9.3 Which of the following is most likely to be the cause of his decreased fertility?

A) Congenital absence of the prostate gland

B) Primary hypogonadism

C) Bilateral complete vas deferens obstruction

D) Androgen resistance

Answer 16.9.3 The correct answer is "B." A low testosterone level accompanied by elevated LH and FSH could indicate testicular failure, or primary hypogonadism. "A" is not a known cause of infertility, and in fact it is not a known disorder as far as the editors can determine. The prostate gland's only important function is to provide a subject for an endless debate over screening so that epidemiologists have something to do. Just kidding…. The prostate gland actually has a role in producing important substances that are part of the seminal fluid and assist sperm in their migration through the female genital tract. However, prostate problems do not seem to cause infertility. "C," an obstruction of the vas deferens, would most likely result in azoospermia with normal or high testosterone levels. "D" is incorrect. You would expect to see elevated testosterone levels in patients with androgen resistance. See Table 16-3 for a list of causes of infertility in males.

Question 16.9.4 How can you now best help this patient achieve fertility, assuming that there are no problems with his partner?

A) Empiric treatment for gonorrhea and chlamydia

B) Empiric treatment with testosterone injections

C) Empiric treatment with gonadotropin-releasing hormone

D) Referral to an infertility treatment center

Answer 16.9.4 The correct answer is "D." At this point of time, you have performed a reasonably complete evaluation and even arrived at a potential cause of infertility. However, treatments for male infertility are the subject of much debate, and the patient is probably best served by referral to an infertility treatment specialist. "A" is incorrect. Genital infections are not thought to play a major role in male subfertility/infertility, so without clear evidence of gonorrhea and/or chlamydia, treating for these diseases is not recommended. "C" is incorrect because this patient does not appear to have a hypothalamic source for his infertility. "B," testosterone injection, can actually make the problem worse. The most effective therapy for patients with infertility and primary hypogonadism (i.e., this patient) may be sperm retrieval for intracytoplasmic sperm injection (not typically thought of as an office procedure for the family physician).

You refer this gentleman to an infertility treatment center in your neck of the woods. He is so pleased with your attention to detail and well-reasoned approach that he refers his best friend to you for the same problem—infertility. This new patient reports never conceiving, although his wife has had one child from a previous marriage. On physical examination, you note a thin frame, mild symmetric gynecomastia, and small, firm testicles. He has complete azoospermia on two semen analyses.

Question 16.9.5 His most likely diagnosis is:

A) Cystic fibrosis

B) Psychosomatic azoospermia

C) Klinefelter syndrome

D) Testicular cancer

E) Turner syndrome

Answer 16.9.5 The correct answer is "C." The triad of small firm testicles, gynecomastia, and azoospermia are classic findings in patients with Klinefelter syndrome. Klinefelter syndrome occurs in 1 in 1,000 live male births and is responsible for 14% of cases of azoospermia. The most common (90%) chromosomal abnormality in Klinefelter syndrome is 47,XXY. "A" is incorrect. Although males with cystic fibrosis can have congenital absence of the vas deferens, these patients usually have normal-sized testicles and no gynecomastia. "B" is, of course, not a real thing. "D" is incorrect. Patients with testicular cancer usually have an enlarged testicle with a mass on the surface or inside the testicle. Although the treatments for testicular cancer may result in infertility, patients with testicular cancer do not typically present with infertility. "E" is incorrect. Turner syndrome (45,X) is associated with unambiguously female genitalia with no breast development.

Objectives: Did you learn to…

• Define modifiable risk factors for male subfertility/infertility?

• Recognize the significance (or lack of significance) of a varicocele?

• Identify the appropriate indications for obtaining laboratory studies in male patients with infertility concerns?

• Recognize some important causes of infertility?

A 63-year-old male with a history of insulin-dependent diabetes complains of decreased libido and difficulty maintaining an erection, worsening over the past few years. He does have occasional erections sufficient for penetration and awakens with an erection at times. His medical history is also significant for hypertension and an appendectomy. His medications include insulin, lisinopril, and hydrochlorothiazide. He has been married for 30 years and has two grown children, ages 24 and 26.

Question 16.10.1 Which of the following historical elements is NOT likely to contribute to this patient's erectile dysfunction?

A) Diabetes

B) Depression

C) Hypertension

D) History of appendectomy

E) Antihypertensive medications

Answer 16.10.1 The correct answer is "D." We're checking to see if you're still awake. All the other options could cause some degree of erectile dysfunction. Any disease process that affects the nervous, vascular, endocrine, or smooth-muscle systems can result in erectile dysfunction. A partial list of other risk factors for erectile dysfunction includes advancing age, prostate disease or surgery (if the nerves are cut … not an issue with TURP), pelvic fracture, alcohol or other substance abuse, medications (addressed later), spinal radiculopathy or spinal cord injury, multiple sclerosis, endocrine disorders (e.g., hypothyroidism, hyperthyroidism), smoking, cardiovascular disease, chronic renal failure, and Peyronie disease (a localized plaque-like fibrosis leading to possible erectile dysfunction, penis curvature, shortening of the penis).

Question 16.10.2 What further historical element(s) is/are useful in the evaluation of erectile dysfunction?

A) Rapidity of onset of sexual dysfunction

B) Presence of nocturnal erections

C) Status of relationship with the sexual partner

D) Partner's interest in sex

E) All of the above

Answer 16.10.2 The correct answer is "E." Further history should involve all the elements listed. Patients with a sudden onset of erectile dysfunction often have a primary psychogenic erectile dysfunction. The presence of nocturnal erections establishes that the patient's neurologic and vascular mechanisms work to produce an erection. An organic disorder may still be playing a role, but the circuit is working. The status of the relationship with the patient's partner, his attraction to that partner, and the partner's interest in sex are important. If the patient and his partner are having relationship problems outside of the sexual arena, counseling may be the best first step in trying to address the erectile dysfunction.

Question 16.10.3 All of the following drugs or classes of drugs can adversely affect male sexual function EXCEPT:

A) Cimetidine

B) Chlorthalidone

C) Prednisone

D) Clonidine

Answer 16.10.3 The correct answer is "C." There are many drugs, prescription and recreational, that affect sexual function, and some of these include antihypertensives, antidepressants, antipsychotics, anxiolytics, hormonal agents (e.g., antiandrogens, estrogens, progestational agents, and anabolic steroids), and the H₂ blocker cimetidine (but apparently not ranitidine or famotidine). The effects range from decreased libido to impotence and/or ejaculatory dysfunction. Various recreational drugs such as alcohol, marijuana, heroin, and cocaine may initially cause a state of disinhibition and enhanced libido. However, excessive or chronic use leads to erectile dysfunction. Prednisone is not known to cause significant erectile dysfunction.

On physical examination, you find normal genitalia, normal femoral and dorsalis pedis pulses, appropriate virilization, and slightly diminished sensation at the plantar aspects of the feet with an otherwise intact neurological examination.

Question 16.10.4 Which of the following will be most useful in evaluating a cause for his erectile dysfunction and directing further therapy?

A) BUN and creatinine

B) TSH

C) PSA

D) Nocturnal penile tumescence study

E) Arterial and venous Doppler studies

Answer 16.10.4 The correct answer is "B." With the advent of safe and efficacious therapy for erectile dysfunction, many clinicians proceed directly to a medication trial without laboratory studies. In many patients, this approach is acceptable. Other patients may benefit from a limited laboratory evaluation—especially those men with other symptoms and/or comorbidities. Initial labs might include TSH, testosterone, and prolactin. If not done already, screening for diabetes and vascular risk (e.g., lipids) is appropriate. The role of nocturnal penile tumescence is debated, but it is not necessary prior to a therapeutic trial and this patient reported having nocturnal erections anyway. BUN, creatinine, and PSA are not likely to be helpful. Doppler flow studies of femoral vessels are unlikely to change therapy as long as the physical examination demonstrates normal distal blood flow. In this patient, you know that he has vascular disease (diabetes, hypertension, and now erectile dysfunction), so his treatment should already involve lowering his vascular risk factors.

Question 16.10.5 Concurrent use of which of the following drugs is an absolute contraindication to taking a phosphodiesterase type 5 inhibitor (e.g., tadalafil, vardenafil, sildenafil)?

A) Hydrochlorothiazide

B) Isosorbide dinitrate

C) Testosterone

D) Finasteride

E) Saw palmetto

Answer 16.10.5 The correct answer is "B." In patients who take nitrates for coronary heart disease, phosphodiesterase inhibitors are contraindicated. The combination has been shown to cause hypotension, in rare cases severe enough to result in stroke. While concurrent use of finasteride is safe, the alpha-blockers used to treat BPH are another story (see below). Drugs that inhibit cytochrome P450 isoenzyme, such as cimetidine, erythromycin, clarithromycin, itraconazole, ketoconazole, and HIV protease inhibitors, may warrant phosphodiesterase inhibitor dosage reductions. Caution with phosphodiesterase inhibitors is advised in patients with uncontrolled hypertension, recent stroke or myocardial infarction, life-threatening arrhythmias, unstable angina, or heart failure. Other potential medical therapies for erectile dysfunction include testosterone supplementation and yohimbine. There are even more treatment modalities: sex therapy, vacuum erection devices, intracavernosal injection therapy, intraurethral pharmacotherapy, arterial revascularization (not routinely performed strictly for ED), penile prosthesis implantation, and combined therapy.

You start the patient on sildenafil. He discovers love again, but his wife finds out. Now you're in trouble!

Objectives: Did you learn to…

• Evaluate a patient with erectile dysfunction?

• Describe various etiologies of erectile dysfunction?

• Identify medications that affect erectile function?

• Recognize indications, contraindications, and side effects of therapeutic modalities for erectile dysfunction?