Male GUChapter 14November 16, 2014
14-1 When teaching Tom how to do a testicularself-examination, which of the following do you tellhim?
A. “Examine your testicles when you are coldbecause this makes them more sensitive.”
B. “Make sure your hands are dry to createfriction.”
C. “If you feel firmness above and behind the testicle, make an appointment.”
D. “Make an appointment if you note any hard lumps directly on the testicle, whether they are tender or not.”
14-1 Answer D: Men should be advised to perform a monthlytesticular self-examination and to call if they noticeany hard lumps directly on the testicle, whetherthe lumps are tender or not. Testicles should beexamined when taking a warm shower or bathwith soapy hands to allow easy manipulation of thetissue. If parts of the testicle above and behind feelrather firm, this is the epididymis and is normal.The spermatic cord, a small, round, movable tube,extends up from the epididymis and feels firm andsmooth.
14-2 Sidney states that he was recently givena diagnosis of prostate cancer and that he hasto return to the urologist for staging. He doesn’tunderstand why because he says, “Cancer isstill cancer. I just want to get rid of it.” Youtell him,
A. “Staging determines the type of tests required.”
B. “You have time to decide on treatment until the cancer gets to the last stage.”
C. “Staging will determine the extent of the spreadof the cancer and treatment options.”
D. “You already know you have prostate cancer; youdon’t need another test unless you want to knowhow long you’ve had it.”
14-2 Answer C: Staging will determine the extent of the spread ofthe cancer. The prostate cancer tissue is sometimesgraded histologically, but the most widely usedsystem is the Gleason system, which grades thearchitectural pattern of the cancer in the largestsegment of the specimen and in the second-nextlargest area occupied, rather than histology. Fivegrades, which correlate to tumor volume, pathologicstage, and prognosis, are possible in each area. Thescores are added together to produce a Gleason scoreon a scale of 1 to 10 with a score of 8 – 10 indicatinga poorly differentiated cancer that is aggressive innature. Another method is the TNM classificationof the American Joint Cancer Committee. TheTNM judges the size of the primary tumor (T),regional lymph nodes (N), and distant metastases(M). Staging does not determine the type oftreatment required but helps the provider andthe client discuss options available. Clients withlocalized prostate cancer should probably eitherhave a surgical prostatectomy or radiotherapy.Watchful waiting has also been used at this stage.Advanced disease requires systemic chemotherapyor hormonal manipulation. Staging will not beable to establish how long a client has had prostatecancer.
14-3 Austin has been on finasteride (Proscar)for 6 months for benign prostatic hypertrophy. Adecrease in his prostate-specific antigen (PSA) fromthe original value of 5.4 has not occurred. Yourinitial expectation is
A. that his PSA would remain stable, neitherincreasing nor decreasing.
B. Austin’s dosage should be reduced only after hehas been on the medication for approximately12 months.
C. that a significant reduction in the overall PSAwould occur if the level is associated with truebenign prostatic hypertrophy.
D. that an elevation of the antigen would occur becauseof the effect of the alpha-adrenergic antagonist.
14-3 Answer C:After 6 months of therapy with finasteride (Proscar)for benign prostatic hypertrophy, the prostatespecificantigen (PSA) level will decrease by about
50%. Testing can then be repeated annually. If thePSA level has not decreased, you should suspectprostate cancer and proceed to evaluate for such.Finasteride is a 5-alpha-reductase inhibitor and willaffect PSA levels, as opposed to other agents suchas alpha-adrenergic antagonists, which do not affectPSA levels.
14-4 Which technique uses a learned method totarget muscle contraction and relaxation to assistwith urinary continence?
A. Biofeedback
B. Kegel exercises
C. Bladder training
D. Prompted voiding
14-4 Answer B: Kegel exercises are a learned technique ofpelvic muscle exercises that help with urinaryincontinence after 4 – 5 weeks of consistent dailyexercise. When used with biofeedback, they canimprove pelvic floor tone and reduce uninhibitedbladder contractions. Biofeedback consists ofcapturing information about a normally unconsciousphysiological process and subsequently using itin an educational process to accomplish specifictherapeutic results, in this case, continence. Bladdertraining is a form of behavioral modification thathelps to restore a normal pattern of voiding andnormal bladder function. Clients void at fixedintervals whether the urge to void is present ornot. Prompted voiding is also a form of behavioralmodification that uses a toileting schedule, verbalfeedback, and reinforcement.
14-5 Which statement is true about the use ofalpha blockers in the treatment of symptomaticbenign prostatic hypertrophy?
A. They are safe and effective and should be given inthe morning before breakfast.
B. They do not lower blood pressure innormotensive clients.
C. Pedal edema is the most common adverse effect.
D. Blood counts should be monitored periodicallyfor reduction in the platelet count.
14-5 Answer B: Alpha blockers are an effective treatment ofsymptomatic benign prostatic hypertrophy. Theyreduce symptoms in 60% – 70% of clients with nearly
50% improvement in urinary flow rates. Theydo not lower the blood pressure in normotensiveclients. Dosing must begin with the lowest dose,preferably at bedtime, so the client will sleepthrough any mild adverse effects such as malaise,fatigue, dizziness, or orthostatic hypotension. Pedaledema is a rare adverse effect. Blood counts shouldbe monitored occasionally for reduction in white orred blood cell counts.
14-6 You are performing a school physicalexamination on Damon, age 5. You are unableto retract his foreskin over the glans penis whileinspecting his penis. This is referred to as
A. phimosis.
B. paraphimosis.
C. microphallus.
D. priapism.
14-6 Answer A: An unusually long foreskin or a foreskin thatcannot be retracted over the glans penis duringphysical examination is referred to as phimosis. Itoccurs in uncircumcised males and is normal in infancy. At Damon’s age, however, one should beable to retract the foreskin. He needs referral to aurologist. Paraphimosis occurs when the foreskin isretracted and is unable to be returned to the originalposition. The penis distal to the foreskin usually willbecome swollen and gangrenous. A microphallus isa normally formed penis that is smaller in size thanexpected. Priapism is a continuous and pathologicalerection of the penis that does not occur as a resultof sexual desire.
14-7 Which of the following statements is trueabout older men with HIV?
A. They have a slower disease progression whencompared with their younger cohorts.
B. They have a more rapid disease progression whencompared with their younger cohorts.
C. They are rarely if ever injection drug users.
D. They cannot undergo treatment withantiretrovirals.
14-7 Answer B: Men have been affected by HIV/AIDS at asignificantly higher rate than women amongboth younger and older people but that is slowlychanging. Physiologically, older adults experiencea natural decline in their immune systems inaddition to the process of HIV infection; there isa more rapid loss of naive CD4 cells and decreasein T-lymphocyte proliferation. Consequently,there is a more rapid disease progression foundamong older persons. HIV-transmission riskfactors in the late middle-aged and older adultpopulation continue to be injection drug use andsame-sex relations. Transfusion of blood productshas decreased to negligible as a risk factor in theUnited States. Recent research finds that olderadults are prescribed antiretroviral therapy at equalproportions to their younger counterparts, and thesetreatments are equally as effective. However, personswith liver problems and on certain medications thataffect the liver need to be monitored carefully.
14-8 The bladder tumor antigen test may also bepositive with
A. testicular torsion.
B. the use of steroids for bodybuilding.
C. scrotal trauma.
D. symptomatic sexually transmitted disease.
14-8 Answer D: Bladder tumor antigen in urine is a qualitativeagglutination test for bladder cancer that detectsbasement membrane proteins. It tests positive forsymptomatic sexually transmitted disease and isalso positive within 14 days of prostate biopsy orresection, with renal or bladder calculi, and withgenitourinary tract cancers.
14-9 Milton, a 72-year-old unmarried, sexuallyactive white man, presents to your clinic withcomplaints of hesitancy, urgency, and occasionaluncontrolled dribbling. Although you suspectbenign prostatic hypertrophy, what else should yourdifferential diagnoses include?
A. Antihistamine use
B. Urethral stricture
C. Detrusor hyperreflexia
D. Renal calculi
a sexually active individual no matterwhat the age. Antihistamine use generally willresult in
14-9 Answer B: Urethral strictures may develop as a result ofsexually transmitted diseases and should beconsidered in hesitancy and urinary retention but notin incontinence. Detrusor hyperreflexia involvesurge incontinence characterized by a strong, suddenurgency (not hesitancy), immediately followed by abladder contraction, resulting in an involuntary lossof urine. Renal calculi commonly present as pain.
14-10 Joe comes in for an evaluation after atesticular self-examination. He states that it isprobably nothing to worry about because his testicleis not tender, but he does have a tiny, hard noduleon the testicle. You confirm that there is a hard,fixed nodule on his testicle. Your next course ofaction would be to
A. order a urinalysis.
B. schedule Joe for a recheck next month.
C. refer Joe to a specialist.
D. tell Joe that it is a cyst and if it does not resolveby itself, he will have to have it excised.
14-10 Answer C: Testicular cancer is suspected if a hard, fixed,nontender area or nodule is palpated on the testicle.The client should be referred for further evaluationand probably surgery. Testicular self-examinationshould be taught to all male clients beginning inadolescence. Testicular cancer is most commonamong men ages 16 – 35.
14-11 Josh has a no-scalpel vasectomy and asksif he can proceed immediately with sexual relationswith his wife without worrying about getting herpregnant. You tell him,
A. “Yes, you are now sterile.”
B. “You must use protection for at least 2 weeks after the procedure.”
C. “You must use protection for at least 6 weeks after the procedure.”
D. “In 6 months, we’ll do a sperm count to see if youcan discontinue other precautions.”
14-11 Answer C: A man is still capable of fertilizing therefore, a spermcount should be obtained after 4 weeks. Spermcannot survive in the ampulla of the vas an egg for weeksafter a no-scalpel vasectomy; for morethan 3 weeks, and it takes about 15 ejaculationsfor most men to clear the ampulla of sperm. Arepeat sperm count is done 2 weeks after the first,and if both show azoospermia, other contraceptivepractices may be discontinued at that time.
14-12 Urinary tract infections in the male clientare divided into upper- and lower-tract infections. Aclassic example of an upper-tract infection includes
A. cystitis.
B. pyelonephritis.
C. prostatitis.
D. epididymitis.
14-12 Answer B: Pyelonephritis is a classic example of upper-tracturinary infections in the male. Pyelonephritisresults from hematogenous or ascending infection.Bacteremia, particularly with virulent organismssuch as Staphylococcus aureus, can result inpyelonephritis with focal renal abscesses. Prostatitis,epididymitis, cystitis, and urethritis are some of thelower-tract diseases that affect males.
14-13 Bill appears with a tender, ulcerated,exudative, papular lesion on his penis. It has anerythematous halo, surrounding edema, and afriable base. What do you suspect?
A. A chancre
B. A chancroid
C. Condylomata acuminatum
D. Genital herpes
14-13 Answer B: A chancroid is a tender, ulcerated, exudative,papular lesion with an erythematous halo,surrounding edema, and a friable base. It is causedby inoculation of Haemophilus ducreyi throughtiny breaks in epidermal tissue. A chancre is asmall papular lesion that enlarges and undergoessuperficial necrosis to produce a sharply marginatedulcer on a clean base and is the lesion of primarysyphilis. Condylomata acuminatum (genital warts)range from pinhead-size papules to cauliflower-likegroupings of skin-colored, pink, or red lesions. Theyare caused by papillomavirus infection of theepithelial cells. Genital herpes simplex virus appearsas erythematous plaques, developing into vesicularlesions that may become pustular.
14-14 Which type of urinary incontinence resultsfrom Parkinson’s disease and multiple sclerosis?
A. Overflow incontinence
B. Stress incontinence
C. Urge incontinence
D. Functional incontinence
14-14 Answer C: There are five types of urinary incontinence:overflow, stress, urge, and functional, which areconsidered established causes of incontinence, andtransient or potentially reversible causes of urinaryincontinence. Overflow incontinence is caused bydetrusor underactivity. There is frequent leakageof urine from the failure to fully empty the bladder,such as occurs with prostatic hypertrophy. Stress incontinence is a failure to store urine related tourethral incompetence. It may be caused by weakpelvic musculature or intrinsic or neurogenicsphincter deficiency and is commonly seen in menafter radical prostatectomy. Urge incontinencecaused by detrusor overactivity results in thefailure to store urine, and can coexist with urethralobstruction from benign prostatic hypertrophy orbe due to conditions such as Parkinson’s disease,multiple sclerosis, urinary tract infection, bladderstones or tumors. Functional incontinence is causedby the effects of medications, fecal impaction,manual dexterity, or immobility. Transient incontinence is characterized by a sudden onset. Itscauses in older males can include delirium, infection,pharmacologic agents, psychological factors,excess urinary output, restricted mobility, and stoolimpaction in hospitalized or immobile persons.
14-15 The action of a 5-alpha-reductase inhibitorin the treatment of benign prostatic hypertrophy is to
A. relax smooth muscle of the prostatic capsule.
B. reduce action of androgens in the prostate.
C. relieve bladder obstruction.
D. improve urinary flow rates.
14-15 Answer B: 5-Alpha-reductase inhibitors are prescribed fortheir ability to induce apoptosis (cell death) and atrophy (partial or complete wasting away of a part of the body or cells), as wellas reduce the action of androgens in the prostate.Alpha-adrenergic blockers relax smooth muscleof the bladder and prostatic capsule, improve flowrates, and relieve obstruction.
14-16 Which of the following medicationscauses retention of urine by inhibiting bladdercontractibility and may cause overflow incontinencein certain individuals?
A. Antispasmodics
B. Drugs that affect the sympathetic nervous system
C. Diuretics
D. Antihistamines
14-16 Answer D: Antihistamines cause retention of urine byinhibiting bladder contractibility and may causeoverflow incontinence in certain individuals. Othermedications that may cause overflow incontinenceinclude anticholinergics, antipsychotics, andantidepressants. Antispasmodics may causeexcessive muscular relaxation and sphincterincompetency. Drugs that affect the sympatheticnervous system, such as alpha blockers, may relaxthe smooth muscle of the sphincter and decreaseurethral pressure, which increases bladder emptying.Alpha stimulants may increase urethral closurepressure, which may lead to urinary retention.Diuretics may affect continence by causing frequentand large bladder volume that overwhelms theability of the individual to reach the toilet in time.
14-17 The most common type of genitourinarydysfunction after a transurethral resection of theprostate is
A. erectile dysfunction.
B. urinary incontinence.
C. retrograde ejaculation.
D. decreased libido.
14-17 Answer C: The most common type of genitourinarydysfunction occurring after a transurethral resectionof the prostate is retrograde ejaculation (65%),followed by erectile dysfunction (15%), urinaryincontinence (2.1%), and decreased libido (lessthan 2%).
14-18 Transillumination of fluid in the scrotummay be seen with
A. a varicocele.
B. a hydrocele.
C. testicular torsion.
D. testicular cancer.
14-18 Answer B: A hydrocele is a collection of fluid within thescrotum around the testes. It can be assessed bytransillumination of the fluid, which should beperformed in a darkened room using a penlight.The fluid will appear light pink, yellow, or red. Themass can be illuminated to show the full size andshape. Masses of the testicles, such as testicularcancer, do not transilluminate, nor do hematomasor testicular torsion. A varicocele is venous dilationof the pampiniform plexus above the testes; it istypically painful and may not be transilluminated.In infancy, observation is the therapy of choice fora hydrocele. For adults, no treatment is requiredunless complications are present. If the hydroceleis painful, large, unsightly, or uncomfortable, thenseveral options are available: surgery, sclerotherapy,or an endoscopic procedure.
14-19 Harry has benign prostatic hypertrophy andcomplains of some incontinence. Your first step indiagnosing overflow incontinence would be to order a
A. urinalysis.
B. cystometrogram.
C. cystoscopy.
D. postvoid residual (PVR) urine measurement.
14-19 Answer D: The first step in diagnosing overflow incontinenceis to perform a postvoid residual (PVR) urinemeasurement. Clients with overflow incontinencecannot empty their bladders completely, soafter voiding, residual urine remains andthis measurement is elevated. A urinalysis,cystometrogram, and cystoscopy are also commonlyperformed to confirm the cause and diagnosis,but a PVR measurement is the most importantcomponent of the diagnosis.
14-20 Precocious puberty is present if
A. a delay in any of the Tanner stages takes longerthan 2 years from one stage to the next.
B. the adolescent has had sexual relations.
C. puberty starts before age 9.5 years.
D. an adolescent rushes through all Tanner stages inless than 2 years.
14-20 Answer C: Precocious puberty is present if puberty starts beforeage 9.5 years. Puberty is considered delayed if notesticular increase has occurred by age 13 ½ and ifpubic hair has not reached Tanner stage 2. Pubertaldelay also occurs if the boy has not reached stage 3within 4 years of reaching stage 2.
14-21 Erectile dysfunction is a complex phenomenonwith a variety of causes. The predominant cause is
A. psychological.
B. vascular.
C. neurogenic.
D. drug related.
14-21 Answer B: Erectile dysfunction has an organic origin inapproximately 70% of cases. Of those cases,approximately 80% are related to vascularproblems. The most common problem isgeneralized atherosclerosis that interferes withnormal arterial function. Other vascular etiologiesinclude hypertension, peripheral vascular disease,arterial insufficiency, trauma, or congenitalabnormalities. Neurogenic disorders of the somatic,parasympathetic (cholinergic), sympathetic, andcentral nervous systems can cause or contribute toerectile dysfunction. Other diseases associated witherectile dysfunction include Parkinson’s disease,cerebrovascular accident, Alzheimer’s disease, anddiseases that create perfusion neuropathies such asdiabetes and alcoholism. Erectile dysfunction is drugrelated in 25% of cases, with the common offendersbeing antihypertensive agents, NSAIDs, digoxin,antidepressants, sedatives, and antiandrogens.
14-22 You are referring a 73-year-old client formanagement of his prostate cancer with hormonaltherapy. It is understood that goserelin acetate(Zoladex) acts as a method of androgen ablation by
A. blocking the release of follicle-stimulatinghormone (FSH) and luteinizing hormone (LH).