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MaleReproductiveSystemMain11-18Q11A54-year-oldmancomestothephysicianwitha2-dayhistoryoffever，chills,andperinealpain.Hehasrepeatedurgestourinatealongwithpainonmicturition.Heisnotsexuallyactive.Histemperatureis37.8C(100F)，bloodpressureis120/70mmHg:pulseis94/minrandrespirationsare18/min.Rectalexaminationshowsaboggyandtenderprostate.Laboratoryresultsareasfollows:Dipstickurinalysisispositiveforleukocyteesterase.Whichofthefollowingisthemostappropriatenextstepinmanagementofthispatient?A.Alpha-adrenergicblockingagentsB.ComputedtomographyscanofthepelvisC.Cultureofmid-streamurinesampleD.ProstatespecificantigenmeasurementE.UrethralcatheterizationA11Correctanswer:CThispatient'surinarysymptomswithfever,!euhocytosis:andprostatetendernesssuggestacutebacterialprostatitis.Acutebacterialprostatitisistypicallycausedbythesameorganismsthatcauseotherinfectionsoftheurinarytract(especiallyEscherichiaco//),andinitialsymptomsmayresemblecystitis.However：acutebacterialprostatitiscanbedifferentiatedfromcystitisbymorepronouncedsystemicsymptoms(eg:fever,chills：illappearance)：associatedregionalpain,andtendernessonprostateexamination.Obtainingamid-streamurinesamplewouldbethemostappropriatenextsteptohelpdirectantibiotictherapy.Prostatemassagetoincreasecultureyieldhasbeenrecommendedinsomereferences,butitispainfulandmayinducebacteremia.Empiricantibiotictherapywithtrimethoprim-sulfamethoxazoleorafluoroquinoloneshouldbestartedwhileawaitingcultureresults,andtreatmentshouldbecontinuedfor4-6weeksinmostcases.(ChoiceA)Alpha-adrenergicblockingagentsareusedtotreatbenignprostaiichyperplasia(BPH).AlthoughurgencyisacommoncomplaintamongpatientswithBFH,thispatient'sinfectioussymptomsmakeacutebacterialprostatitismuchmorelikely.(ChoiceB)Acomputedtomographyscanofthepelvisisnotneededforadiagnosisofacutebacterialprostatitis,andtheresultsarelikelytobenonspecific.Computedtomographyscancanbeusefultodiagnoseaprostaticabscess,whichwouldbesuspectedifapatientwithacutebacterialprostatitiscontinuestohavefeverdespiteappropriateantibiotictherapy.(ChoiceD)Prostatespecificantigencanbeelevatedinacutebacterialprostatitis,butthisfindingisnonspecificaselevationcanalsobeseeninBPHfprostatecancer,sterileprostateinflammation,andperinealtrauma.(ChoiceE)Urethralcatheterizationshouldbeavoidedinpatientswithacutebacterialprostatitisastheremaybe丨nflammationinvolvingtheurethra,Patientswithacutebacterialprostatitiswhodevelopurinaryretentionmayrequiresuprapubiccatheterizationofthebladder.Educationalobjective:Acutebacterialprostatitispresentsinamannersimilartootherurinarytractinfections,butwiththeadditionofperinealpainrpronouncedsystemicsymptoms(fever:chills,acuteillness),andatender,boggyprostateonexamination.Urinecultureshouldbeobtainedtohelpdirectantibiotictherapy.Q12A28-year-oldmalecomesforcompletephysicalexaminationforanewjobheisstartingnextweek.Heishealthyandhasnocomplaints.Hesmokes1pack/daycigarettesforthelast10years.Hedrinks4ozofalcoholdaily.Hismotherhashypertensionandfatherhasheartproblems.Vitalssignsarewithinnormallimits.Physicalexaminationiswithinnormallimitsexceptforapainless,hardmassinthelefttesticle.Ultrasoundshowshighlikelihoodofatesticulartumor.Whatisthenextbeststepinmanagemenf?A.ObserveandrecheckthemassafteronemonthB.PlatinumbasedchemotherapyC.Trans-scrotalbiopsyD.FineneedleaspirationcytologyE.RadicalorchiectomyA12Correctanswer:EAfterthediagnosisofasolidtesticularmasshasbeenmade,(apainlesshardmassIntesticle+suggestiveultrasound),theinitialmanagementisremovalofthetestisanditsassociatedcordforchiectomy.Thisisdonethroughasmallinguinalincision.Theprocedureiscalledhighinguinalorchiectomy.Thetestisandabnormaltissuepresentisthenexaminedunderthemicroscopetodeterminethetypeofcancer.Dependingonthecelltypeofthecancerpresentothertherapies,i.e.additionalsurgery,radiationtherapy,orpossiblychemotherapymaybeindicated.Usingacombinationofthesetherapies,testicularcancerhasoneofthehighestcureratesofallcancers.Thishasbeenachievedusingacombinationofsurgeryandchemotherapy,aswellasradiationincertaininstances.Curefromtesticularcancercanevenbeachievedinindividualswhohavehadthecancerspreadintootherpartsofthebody.Thisisthetumorthatwekillfirstandinvestigatelater.Soobservation,chemotherapy,andbiopsiesarenotthenextbeststepinthiscase,FNAC:ortransscrotalbiopsy,iscontraindicatedbecauseoftheriskofspillageofcancercells,whichcanpotentiallyspreadthroughlymphaticsandbloodvessels.EducationalObjective:Afterthediagnosisofasolidtesticularmasshasbeenmade,(apainlesshardmassintesticle+suggestiveultrasound),theinitialmanagementisremovalofthetestisanditsassociatedcord.Q13A35-year-oldmalepresentstothefamilyphysicianforbilateralgynecomastia.Heobservedprogressiveincreaseinhisbreastsizsstarting6monthssgo.Heissexuallyactiveanddeniesanydruguse.Physicalexaminationrevealsbilateralgynecomastiaandtenderness.Thegenito-urinaryexaminationshowsa1cmnoduleintherighttestis.Otherwise,theexaminationiswithinnormallimitsThelaboratoryreportshows:LH3U/L;FSH2U/L,testosterone270ng/dL(Normal3-10ng/dL),estradiol115pg/mL(Normal20-60pg/mL),betaHCGunde