Male GU Exam

Question 1

Risk factors for erectile dysfunction

Answer 1

DM, HTN, hyperlipidemia, obesity, testoterone deficiency, prostate cancer treatment, anxiety

Medications: antidepressants (SSRIs, SNRIs), tobacco

Age 40-79

Question 2

Diagnostic testing for ED may include BP, BMI, waist circumference, genital exam, assessment of secondary sex characteristics, A1c or fasting BG, lipid panel, TSH level, etc. as well as international index of erectile function (IIEF-5).

What are some management strategies for ED?

Answer 2

Tobacco cessation, regular exercise, weight loss, improved control of DM/HTN/Hyperlipidemia/etc.

First line med = Oral PDE-5 inhibitors (avanafil, sildenafil, tadalafil, vardenafil)

Second line med = alprostadil and vacuum devices

Question 3

Gradual onset of unilateral posterior scrotal pain <6 weeks along with dysuria, urinary frequency, fever, hematuria, abd pain, etc. may indicate _____

Answer 3

Epididymitis

Question 4

Risk factors for epididymitis

Answer 4

Hx of UTI or STI, anatomic abnormalities (bladder outlet obstruction), prostate or urinary tract surgeries or instrumentation, prolonged sitting, cycling, or trauma

[reflux of urine into ejaculatory ducts is considered most common cause of epididymitis in kids <14; N.gonorrheae and C.trachomatis are most common etiologies in sexually active males 14-35]

Question 5

PE findings associated with epididymitis including diagnostic signs and reflex findings

Answer 5

Swollen and tender epididymis with testis in anatomic position

Elevating scrotum may alleviate pain (Prehn sign)

Intact cremasteric reflex

Question 6

Treatment recommendations for epididymitis in the following pt groups:

• Sexually active males age 14-35
• Men who practice insertive anal intercourse

Answer 6

• Sexually active males age 14-35 = single IM dose of ceftriaxone with 10 days of oral doxycycline
• Men who practice insertive anal intercourse = ceftriaxone with 10 days of oral levofloxacin or ofloxacin

Question 7

Aspects of penis and testes exam

Answer 7

Penis — inspect for lesions, palpate for plaques or induration

Testes — inspect, palpate for masses, equal volume, tenderness, cryptorchidism. All masses should be transluminated (light will not go through solid mass, hydrocele will glow soft red). Chronic lesions can cause testicular atrophy. Check cremaster reflex on both sides.

Question 8

Aspects of epididymis, spermatic cord, and vas deferens exam

Answer 8

Palpation to evaluate induration and to localize pain to the testicle or adjacent structures. Epididymis is posterior to testicle. Valsalva while standing evaluates dilated testicular veins in the spermatic cord forming a varicocele above and behind the testis

Question 9

Aspects of inguinal canal exam

Answer 9

Canals explored for hernias or cord tenderness. Funiculitis, inflammation of cord structures, may cause inguinal or scrotal pain, but testis is normal. Evaluate for cord lipomas or hydroceles also

Question 10

A bellclapper deformity is indicative of _____ _____

Answer 10

Testicular torsion

Question 11

Presentation of testicular torsion including exam findings

Answer 11

Presents in young to middle aged men with sudden, severe, unilateral scrotal pain often associated with nausea/vomiting

Exam reveals a tender, firm affected testis that may appear retracted upward as a result of the twisted spermatic cord. Cremaster reflex is typically ABSENT in testicular torsion

Question 12

Presentation of urethritis in men and primary pathogens involved

Answer 12

Urethral discharge, penile itching or tingling, and dysuria

Primary pathogens are C.trachomatis and N.gonorrhea

Question 13

Physical exam considerations in a male presenting with urethral symptoms

Answer 13

Examine for inguinal LAD, ulcers, or urethral discharge. Palpation of the scrotum for evidence of epididymitis or orchitis is advised. DRE of prostate may be cosnidered especially in older pts or if rectal pain is reported

The urethra should be gently “milked” by serial palpation down shaft of penis toward the urethra; any discharge should be tested/cultured

Question 14

Diagnoses of ______ may include presence of urethral discharge, positive leukocyte esterase test in first-void urine, or at least 10 WBCs per hpf in first-void urine sediment

Answer 14

Urethritis

Question 15

In what pt populations is routine syphilis screening strongly recommended by USPSTF?

Answer 15

Persons at increased risk

Pregnant women

Question 16

In what pt populations is routine GC/Chlamydia screening recommended by USPSTF?

Answer 16

Sexually active women age 24 and younger, and in older women who are at increased risk for infection

Question 17

Polymicrobial cellulitis with genital, groin, or perineal involvement, characterized by signs or symptoms of infection followed by suppuration and necrosis of overlying skin. Not sexually transmitted but associated with/secondary to epididymitis

Answer 17

Fournier’s gangrene

Question 18

Presentation of prostatitis

Answer 18

Acute onset of irritative (dysuria, urinary frequency, urinary urgency) or obstructive (hesitancy, incomplete voiding, straining to urinate, weak stream) voiding symptoms

Pts may report suprapubic, rectal, or perineal pain

Painful ejaculation, hematospermia, and painful defecation may also be present in addition to systemic symptoms such as fever, chills, nausea, emesis, and malaise

Question 19

Presentation of cystitis in males

Answer 19

Acute onset of irritative urinary symptoms or other signs/symptoms including cloudy or strong smelling urine, hematuria, feeling of pressure in lower abdomen, pelvic discomfort

Question 20

Most common causes of genital ulcers in the US

Answer 20

1. HSV 1 and 2
2. Syphilis
3. Chancroid

[other causes include granuloma inguinale, lymphogranuloma venareum (C.trachomatis types L1, L2, L3)]

Question 21

What tests should be considered in pts who present with genital ulcers?

Answer 21

Serologic tests for syphilis (VDRL or RPR) and darkfield microscopy OR direct fluorescent antibody testing for treponema pallidum

Culture or PCR for HSV

Culture of H.ducreyi in settings with high prevalence of chancroid

Question 22

Etiology of the following genital ulcer:

Usually multiple vesicular lesions that rupture and become painful, shallow ulcers. Constitutional symptoms, LAD in first time infections

Answer 22

HSV

Question 23

Etiology of the following genital ulcer:

Single painless well-demarcated ulcer with a clean base and indurated border. Mild or minimally tender inguinal LAD.

Answer 23

Syphilis (primary chancre)

Question 24

Etiology of the following genital ulcer:

Nonindurated, painful with serpiginous border and friable base; covered with a necrotic, often purulent exudate. Tender, suppurative, unilateral inguinal LAD or adenitis

Answer 24

Chancroid

[H.ducreyi — gram-negative slender rod or coccobacillus in “school of fish” pattern]

Question 25

Etiology of the following genital ulcer: Small, shallow, painless, genital or rectal papule or ulcer; no induration. Unilateral, tender inguinal or femoral LAD “Groove sign”

Answer 25

LGV [RARE and primarily occurs in men who have sex with men]

Question 26

Fungal infection that affects genital skin, inner thighs, and buttocks, causing an itchy, red, often ring-shaped rash in warm, moist areas of your body

Answer 26

Tinea cruris

Question 27

Most common of all STIs

Answer 27

HPV

Question 28

Any sexually active person is at risk for getting HPV. However, genital warts are more common in what pt populations?

Answer 28

``` Age <30 Smoking Weakened immune system Hx of child abuse Children of a mother who had virus during childbirth ```

Question 29

Birth defect in which opening of urethra is on underside of penis instead of the tip

Answer 29

Hypospadias

Question 30

Development of fibrous scar tissue inside penis that causes curved, painful erections; may develop suddenly or more gradually, typically due to trauma

Answer 30

Peyronie’s disease

Question 31

Most common male birth defect, characterized by failed descent of one or both testes from the abdomen into the scrotum

Answer 31

Cryptorchidism

Question 32

Do you need to do male genital exams for preparticipation sports physicals?

Answer 32

Insufficient evidence exists to recommend for or against screening genital exams for boys playing sports Given the low risk of harm, screening for hernias as a part of preparticipationphysical eval is recommended by several specialty organizations [Am Fam Physician states genital exam is not recommended for females but may be indicated in males with symptoms or a history of GU problems]

Question 33

Differentiate hydrocele, varicocele, and spermatocele

Answer 33

Hydrocele — collection of fluid presents as painless scrotal swelling that can be transluminated; may worsen throughout the day. New hydrocele or one that hemorrhages after minor trauma may signal cancer Varicocele — most commonly on the left side. Mass lying posterior to and above the testis. Classic description is “bag of worms” Spermatocele — painless cystic mass separate from the testis located superior and posterior to the testis

Question 34

Signs and symptoms of testicular cancer

Answer 34

Lump or enlargement in either testicle, feeling of heaviness in the scrotum, dull ache in abdomen or groin, sudden collection of fluid in scrotum, pain or discomfort in testicle or scrotum, enlargement or tenderness of breast tissue, back pain [risk factors include cryptorchidism, personal or family hx of testicular cancer, age, ethnicity, and infertility]

Question 35

Testicular cancer is the most common solid tumor among males 15-34 years. What is the recommendation regarding testicular cancer screening?

Answer 35

There is inadequate evidence that screening asymptomatic patients by means of self-exam or clinician exam has greater yield or accuracy for detecting testicular cancer at more curable stages [Grade D evidence]

Question 36

What screening should be considered in men with ED?

Answer 36

Screen for cardiovascular disease, because symptoms of ED present on average 3 years earlier than symptoms of coronary artery disease