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MaleReproductiveSystemMain1-10Q1A28-year-oldmancomestothephysicianforevaluationofinfertility.Heishealthyandhasnoothercomplaints.Heeatsahigh-proteindietandexercisesdailyinordertobemuscular.Heweighs85kg(187lb)andis175cm(5'8”）all.Histemperatureis37.2。C(98.9°F)andbloodpressureis130/82mmHg.Physicalexaminationshowssmalltestes.Theremainderoftheexaminationshowsnoabnormalities.Initiallaboratorystudiesshow:Whichofthefollowingisthemostlikelycauseofhisinfertility?A.KlinefeltersyndromeB.MumpsorchitisC.ExogenoussteroiduseD.MyotonicdystrophyE.VaricoceleF.CryptorchidismG.TesticulartorsionH.ChronicmedicalillnessA1Correctanswer:CThispatientpresentsforevaluationofinfertilitylikelyduetoanabolicsteroid(eg.,testosteroneanalog)abuse.Anabolicsteroidsarecommonlyusedbymanybodybuildersandathletestoenhanceperformanceandmusclemass.AnabolicsteroidscontainexogenousandrogensthatinhibitGnRHreleasebythehypothalamus(duetofeedbackinhibition),whichcausesdecreasedLHandFSHreleasebythepituitaryglandandleadstodecreasedspermandtestosteroneproductionbythetestes.Theexogenousandrogensuppressesnativetestosteroneproductionbutisdetectedastestosteronebycurrentassays,sopatientscanhavenormalserumtestosteronelevels.Otheradverseeffectsincludeacne,gynecomastia(duetoconversionoftheandrogenstoestrone),decreasedtesticularsize,aggressiveness,andpsychoticsymptoms.Laboratoryfindingscanshowerythrocytosis(duetoincreasederythropoiesis)withelevatedhemoglobin,cholestasis,hepaticfailure：dyslipidemia,andslightlyelevatedcreatinine(duetoincreasedmusclemass).(ChoiceA)Klinefeltersyndrome(i.eMXXYseminiferoustubuledysgenesis)isaninheriteddisordercharacterizedbytesticularfibrosis(primaryhypogonadism),azoospermia,gynecomastia：decreasedintelligence：increasedaxialskeletalgrowth：andhighFSHandLHlevels.(ChoiceB)Mumpsorchitisisapotentialcauseofinfertilitythatischaracterizedbyacutetesticularpainandinflammationduringtheacuteviralillness.(ChoiceD)Myotonicdystrophyischaracterizedbytesticularatrophyaswellaswidespreadmuscularatrophy：weakness,lower-than-normaltestosteronelevel,andhighFSHandLHlevels.(ChoiceE)Varicoceleresultsinscrotalswelling,withabagofworms'sensationonpalpation.(ChoiceF)Cryptorchidismmanifestsininfancy,withafailuretopalpatetwotestesinthescrotumonexamination.Patientsareatanincreasedriskoftesticularcancer.(ChoiceG)Testiculartorsionproducesacutetesticularpain.(ChoiceH)ChronicmedicalillnesstypicallyresultsSnanemiaofchronicdiseaseratherthanerythrocytosis.Educationalobjective:AnabolicsteroidusebyamancanproduceinfertilitybysuppressingtheproductionofGnRH,LH,andFSH.'Q2A67-year-oldmancomestotheofficeduetoworseningurinaryfreque门cy,hesitancy,andnocturiaforthepastyear.Hewakesup2or3timesanighttovoid.Thepatientalsosaysthattheforceofhisurinarystreamisdecreasedandhefeelsthathisbladderisnotcompletelyevacuatedaftervoiding.Hehasahistoryofhypertensionandosteoarthritis.Thepatienthasa35-pack-yearsmokinghistorybutsloppedsmoking10yearsago.丁emperatureis37.1G(98.8F),bloodpressureis130/80mmJHg:andpulseis78/min.Physicalexaminationshowsasoftandnontenderabdomen.Rectalexaminationrevealsanenlarged,smoothprostatewithnonodulesandnormalrectalsphinctertone.Postvoidbladderscanshows75mLofurine(normal,12mL).Serumcreatinineandurinalysisarenormal.Serumprostate-specificantigenis2.8ng/mL(age-adjustedreferencevalue4.5ng/mL).Whichofthefollowingisthebestnextstepinmanagementofthispatient?A.5-alpha-reductaseinhibitorB.α-adrenoreceptorblockerC.IntermittenturinarycatheterizationD.TransrectalprostatebiopsyE.TransurethralprostateresectionF.UrodynamicstudiesA2Correctanswer:BThispatient'spresentationisconsistentwithbenignprostatichyperplasia(BPH).BPHtypicallyaffectsmenage50andisthemostcommoncauseoflowerurinarytractsymptoms(egrurinaryfrequency,urgency,weakstream,nocturia)inthesepatients.Prostatecancer(which丨sassociatedwithelevatedprostate-specificarrtigenlevels)canalsocauselowerurinarytractsymptoms.However,prostatecancermoreofteninvolvestheperipheryoftheglandandpresentswithfirmasymmetricornodularenlargement,whereasBPHinvolvesthecenter(transitionalzone)andpresentswithsmooth:nonindursted,symmetricenlargement.ThepreferredinitialtreatmentforuncomplicatedBPHincludesalpha-1blockers(eg,terazosin,tamsulosin),whichcanproviderapidreliefofsymptomsbyrelaxingbladderneckandprostaticsmoothmuscle.5-alpha-reductaseInhibitors(eg:finasteride)canbeusedinadditiontoalphablockersforpatientswithpersistentsymptomsorasanalternatetherapyforthosewhodonottoleratealphablockers(eg,hypotension).However,theyactbyreducingprostatesizeandhaveamuchsloweronsetofaction(ie;months)(ChoiceA).(ChoiceC)Intermittenturinarycatheterizationcanbeusedforpatientswith巳PHwhodevelopacute,severeurinaryretention(eg;duetoinfection,anticholinergicmedication).However,catheterizationcancausesignificantdiscomfortinpatientswithprostaticenlargementandisnotadvisedforthosewithmildtomoderateobstruction.(Choice0)Prostatebiopsyisindicatedforpatientswithsignsofprostatecancer,suchasgrosslyasymmetricenlargementoftheprostate：palpablenodules,orpersistentlyelevatedprostate-specificantigenlevels.(Choic