Adult Gerontology - Male Genitourinary Problems

Low- grade, localized prostate cancer can be treated successfully with A. radical prostatectomy or radiation. B. chemotherapy. C. cryosurgery (freezing) of a small part of the gland. D. watchful waiting.

Answer: A Although watchful waiting is an option for very slow- growing, localized lesions, a radical prostatectomy or radiation can be curative. The age of the client and other factors are taken into consideration, and in some cases, watchful waiting is considered a better option. Chemotherapy is palliative and reserved for later stages of metastasis. Cryosurgery is most successful when the entire gland is frozen.

Bloody penile discharge is most likely to be associated with which of the following? A. Cancer of the penis B. Herpes zoster C. Epididymitis D. Peyronie's disease

Answer: A Bloody penile discharge requires close investigation, including the length of time of the discharge. Ulcerations, neoplasms, and urethritis are all common causes of bloody penile discharge. Bloody penile discharge is not usually seen in herpes zoster, epididymitis, or Peyronie's disease.

In older adult males, which of the following is the most common cause of nocturia? A. Benign prostatic hyperplasia (BPH) B. Diminished bladder capacity C. Habit D. Overflow incontinence

Answer: A Fifty percent of men over age 50 have BPH, and the rate increases 10% for every 10 years of age; thus, BPH is the most common cause of nocturia. The occurrence of nocturia without pain is also related to diminished bladder capacity, overflow incontinence, or habit.

The nurse practitioner is rolling their fingers along the inguinal ligament of a patient and encounters small, freely mobile lymph nodes in this area. What action should be taken at this time? A. Nothing; this is not a cause for concern. B. Something is abnormal and warrants further evaluation and possible referral. C. The lymph nodes should be biopsied. D. The lymph nodes must be congenital in origin.

Answer: A Lymph nodes in the inguinal area, if small and mobile, are not considered abnormal. The lymphatics from the perineum, legs, and feet drain into this area, and thus it is not surprising that small lymph nodes are frequently encountered.

What is the medical terminology for inflammation of the glans and prepuce? A. Balanitis. B. Balanoposthitis. C. Phimosis. D. Paraphimosis

Answer: B Balanoposthitis is infl ammation of the glans and prepuce. Balanitis is inflammation of the glans. Phimosis is a tight prepuce that cannot be retracted over the glans. Paraphimosis is a tight prepuce that, once retracted, gets caught behind the glans and cannot be returned, resulting in edema.

Most lesions of the penis are nontender and painless. Which of the following conditions begins with a tender, painful lesion? A. Syphilitic chancre B. Genital herpes C. Carcinoma of the penis D. Peyronie's disease

Answer: B Genital herpes begins with a tender, painful ulcer on the penis. Most other conditions begin with nontender, painless lesions such as those found with syphilitic chancre, carcinoma of the penis, Peyronie's disease, and venereal warts.

Sildenafi l (Viagra) 50 mg PO taken 1 hour before sexual activity is ordered for Mitchell for his erectile dysfunction. What medication must you make sure he is not taking before writing the prescription? A. An antihistamine B. A nitrate C. A stool softener D. An anticoagulant

Answer: B Sildenafi l (Viagra) has shown promise in clients with erectile dysfunction. It is not effective in men with psychogenic impotence or those with neurological or arterial disease. It potentiates the hypotensive effect of nitrate and is contraindicated for clients receiving nitrates, such as nitroglycerin.

Samuel, a 62- year- old who takes many different medications, is complaining of erectile dysfunction. The nurse practitioner knows that several medications could be the cause of Samuel's problem. Which of his medications is most likely the culprit? A. Furosemide (Lasix) B. Reserpine (Serpasil) C. Omeprazole (Prilosec) D. Isosorbide (Imdur)

Answer: B The following medications have been shown to cause erectile dysfunction (ED): antiandrogens; antihypertensives, such as beta blockers and central sympatholytics (Reserpine); anticholinergics; antidepressants; antipsychotics; central nervous system depressants; and drugs of abuse such as alcohol, tobacco, and heroin. Diuretics, proton pump inhibitors, and vasodilators have not been shown to cause ED.

The single most- effective method of treating urinary calculi is A. prescribing an antibiotic. B. having the patient increase his fluid intake. C. performing lithotripsy. D. performing cystoscopy.

Answer: B The single- most effective method of treating urinary calculi is having the client increase fl uid intake to 3 to 4 L/day. If increased hydration is not effective, a cystoscopy, lithotripsy, or other surgery may need to be performed. Antibiotics are not indicated.

Erectile dysfunction (ED), which affects 18 to 30 million men in the United States, increases with age. In men older than the age of 50, what are the most commonly found contributors to ED? A. Endocrine diseases B. Vascular disorders C. Neurogenic diseases D. Psychiatric conditions

Answer: B Vascular diseases account for nearly half of all cases of erectile dysfunction. These include atherosclerosis, peripheral vascular disease, myocardial infarction, and arterial hypertension. Less frequent but nonetheless important factors include systemic diseases, such as diabetes, scleroderma, renal failure, and liver cirrhosis, and neurogenic diseases, such as epilepsy, stroke (CVA, brain attack), multiple sclerosis, and Alzheimer's disease. Other contributing factors include psychiatric conditions and penile, endocrine, nutritional, hematological, and medicationassociated causes.

The aging lower urinary tract in men undergoes which changes that can result in increased urinary symptoms? A. Bladder capacity is increased with lower postvoid residuals. B. Bladder capacity is increased with increased detrusor (bladder muscle) contractility. C. Bladder capacity is decreased with increased obstructive changes from the prostate. D. Detrusor contractility is decreased, resulting in lower postvoid residuals.

Answer: C In the aging male, the physiological changes that occur include bladder capacity reduction, a decreased ratio of density of smooth muscle to connective tissue, decreased detrusor contractility, and increased postvoid residual volumes. With benign prostatic hypertrophy, lower urinary tract symptoms increase because of obstructive changes.

What is the most common cause of male infertility? A. Azoospermia B. A problem with sperm motility C. A varicocele D. Antisperm antibodies

Answer: C The most common cause of male infertility is a varicocele. Other causes include oligospermia or azoospermia; problems with sperm function or motility; abnormalities of sperm morphology; and, rarely, an antisperm antibody.

The most common type of genitourinary dysfunction after a transurethral resection of the prostate (TURP) is A. erectile dysfunction. B. urinary incontinence. C. retrograde ejaculation. D. decreased libido.

Answer: C The most common type of genitourinary dysfunction occurring after a transurethral resection of the prostate is retrograde ejaculation (65%), followed by erectile dysfunction (15%), urinary incontinence (2.1%), and decreased libido (less than 2%).

When performing a prostate examination, the nurse practitioner notes a tender, warm prostate. What would be the most likely differential diagnosis? A. Benign prostatic hypertrophy B. Prostatic abscess C. Prostate cancer D. Bacterial prostatitis

Answer: D Bacterial prostatitis, in which the prostate feels very tender and warm, is usually caused by Escherichia coli. Clients with bacterial prostatitis usually also have a sudden onset of high fever, chills, malaise, myalgias, and arthralgias. In benign prostatic hypertrophy, the prostate gland would feel soft and nontender and would be enlarged. With prostatic abscess, the prostate feels like a firm, tender, or fluctuant mass. With prostate cancer, the prostate may have single or multiple nodules that are firm, hard, or indurated and are usually nontender.

The most common type of hernia in the male population is a(n) A. indirect inguinal hernia. B. direct inguinal hernia. C. femoral hernia. D. umbilical hernia.

Answer: A An indirect inguinal hernia is the most common type of hernia affecting all ages and both genders and accounts for 50% of hernias treated. The point of origin is above the inguinal ligament and often travels into the scrotum. A direct inguinal hernia is less common (accounts for about 25% of hernias seen) and usually occurs in men older than age 40. The point of origin is above the inguinal ligament and rarely travels into the scrotum. The femoral hernia is the least common (about 10% of hernias seen) and occurs more often in women than in men. The point of origin is below the inguinal ligament and never travels into the scrotum in men. An umbilical hernia occurs more frequently in infants and is a protrusion of part of the intestine at the umbilicus.

Jake, age 62, has a low International Prostate Symptom Score for lower urinary tract symptoms associated with his benign prostate hypertrophy. The nurse practitioner should recommend A. no treatment at this time. B. immediate referral to urology. C. balloon dilation. D. starting him on an alpha blocker

Answer: A Asymptomatic clients with benign prostatic hypertrophy (BPH) rarely require treatment. Watchful waiting is an appropriate strategy for following the disease's progression and the development of any complications. Prostate surgery offers the best choice for symptom improvement. A transurethral resection of the prostate is the most commonly used surgical treatment for BPH. Balloon dilation of the prostatic urethra has fewer complications than surgery but is not as effective in relieving the symptoms. Alpha blockers relax the bladder neck and prostate smooth muscle and offer relief for many clients, particularly in regard to nocturia.

A history of urinary tract infections in males is often seen in men with chronic bacterial prostatitis. Other signs and symptoms of chronic bacterial prostatitis include A. irritative voiding symptoms, low back pain, and perineal pain. B. nausea and vomiting, as well as fever. C. loss of appetite and weight loss. D. irritative voiding symptoms, inability to ambulate, and fever.

Answer: A Chronic bacterial prostatitis may have a variety of clinical presentations, but nausea and vomiting, loss of appetite, and weight loss, as well as an inability to ambulate, are rarely among the presenting symptoms of this disorder. Even fever is typically not present in chronic cases. Typically, there are irritative voiding symptoms that have persisted over time, low back pain, and perineal pain— any one, or all, of these symptoms may be present. Sometimes clients are completely asymptomatic, although bacteria might be present on urinalysis, and expressed prostatic secretions usually demonstrate increased numbers of leukocytes. Physical examination may be unremarkable as well, although in some cases the prostate will feel boggy or indurated. There is often a history of repeated urinary tract infections. Cystitis and/or chronic urethritis may be secondary or mimic prostatitis; however, cultures of the fractionated urine may localize the source of infection. Anal disease may share some of the symptoms of prostatitis, but physical examination should permit a distinction between the two.

What is the most common prostatitis syndrome found in males of any age? A. Nonbacterial prostatitis B. Prostatodynia C. Acute bacterial prostatitis D. Chronic bacterial prostatitis

Answer: A Chronic nonbacterial prostatitis is the most common of the prostatitis syndromes. It is eight times more frequent that bacterial prostatitis. The cause is not completely understood, though atypical organisms, viruses, inflammatory processes, and autoimmune disorders have been postulated. Prostatodynia presents with signs and symptoms of prostatitis but no evidence of infl ammation. Acute and chronic bacterial prostatitis are both caused by an infection from either aerobic gram- negative or gram- positive bacteria.

A patient presents to the practitioner with scrotal pain. The examinations of his scrotum, penis, and rectum are normal. Which of the following conditions outside of the scrotum may present as scrotal pain? A. Inguinal herniation and peritonitis B. Renal colic and cardiac ischemia C. Pancreatitis and Crohn's disease D. Polyarteritis nodosa and ulcerative colitis

Answer: A Conditions outside of the scrotum that may present with scrotal pain are abdominal aortic aneurysm, inguinal herniation, pancreatitis, renal colic, peritonitis, intraperitoneal hemorrhage, and polyarteritis nodosa. Keep in mind that any client with scrotal pain should be considered to have testicular torsion until proved otherwise, especially in the age groups of the neonate and adolescents.

If a patient presents with symptoms of benign prostatic hypertrophy, a digital rectal examination is indicated in order to A. screen for prostate or rectal malignancy. B. evaluate for hypospadias. C. rule out any neurological problems that may cause the symptoms. D. detect the presence of urethritis.

Answer: A If a client has symptoms of benign prostatic hypertrophy, a digital rectal examination (DRE) is performed to detect prostate or rectal malignancy and evaluate anal sphincter tone. Hypospadias is a disorder in which the meatus of the urethra is inferiorly located on the glans (Ventral Surface). A DRE does not rule out urethritis.

When performing a rectal examination on the aging man, the nurse practitioner may normally note A. fissures. B. a smaller prostate. C. a decrease in sphincter tone. D. a longer anal canal

Answer: C An aging person may have decreased sphincter control. You may also note a relaxation of the perianal musculature during Valsalva's maneuver. Otherwise, the examination is the same as in younger men.

Which of the following would be a considered the highest risk factor for the development of testicular cancer? A. Cryptorchidism B. Caucasian race C. HIV infection D. Hormonal imbalance in utero

Answer: A Males who have had undescended or partially descended testes, which is termed cryptorchidism, are at a much higher risk for testicular cancer, with approximately 10% of testicular cancers diagnosed associated with this condition. Other risk factors for testicular cancer include Caucasian race and sociodemographic factors, such as higher social status, being unmarried, and living in a rural area. There is weak evidence that points to hormonal imbalances associated with in utero exposure to estrogen that may increase the risk of testicular cancer later in life.

The main principle of management for prostatitis is to treat the patient on an outpatient basis if he is afebrile. All of the following antibiotics are recommended in the pharmacologic treatment in men with bacterial prostatitis except A. penicillin. B. nitrofurantoin (Macrobid). C. doxycycline (Vibramycin). D. quinolones (e.g., Ciprofloxin).

Answer: A Men with bacterial prostatitis should be treated on an outpatient basis for 4 to 6 weeks with quinolone antibiotics such as ofloxacin (Floxin), ciprofloxacin, or norfloxacin. Alternatives include trimethoprim and sulfamethoxazole, doxycycline, and vibramycin. The nitrofurantoins such as macrodantan, furalan, nitrofan, and furdantin are used to treat nonbacterial prostatitis. Penicillin is not an antibiotic of choice for bacterial prostatitis.

Tommy, age 15, comes to the clinic in acute distress with "belly pain." When obtaining his history, the nurse practitioner (NP) finds that he fell off his bike this morning and has vomited. Upon closer examination, the NP determines the belly pain to be left- sided groin pain, or pain in his left testicle. He is afebrile and reports no dysuria. The most likely differential diagnosis is A. testicular torsion. B. epididymitis. C. a hydrocele. D. a varicocele.

Answer: A Testicular torsion is a condition in which the testes twist on the spermatic cord, thereby compromising blood flow to the testes. This is a surgical emergency. Examination usually reveals a tender scrotal mass high in the hemiscrotum, and there is frequently a reactive hydrocele around the testes obscuring anatomical detail. The scrotum can become erythematous and edematous. The cremaster reflex is frequently blunted on the side of the torsion. Epididymitis usually is accompanied by fever, as well as urethral discharge, and usually occurs in boys older than Tommy. Although a hydrocele may develop secondary to the torsion, the intense discomfort and acute onset accompanied often by nausea distinguish the possibility of testicular torsion. A varicocele, which usually occurs in young men, may cause pain but does not usually develop acutely.

A patient's chief complaint is blood in the urine. The nurse practitioner knows that the most common cause of gross hematuria in the male population is A. a bladder infection. B. benign prostatic hypertrophy. C. bladder tumor. D. prostatitis.

Answer: A The most common cause of gross hematuria is bladder infection (22%), followed by bladder tumor (14.9%), benign prostatic hyperplasia (12.5%), and prostatitis (9%).

Morris, age 52, is in a new relationship and is not sure whether his erectile dysfunction is caused by stress about his performance or is organic. What simple test could you suggest to determine if he has the ability to have an erection? A. Nocturnal penile tumescence and rigidity test B. Penile duplex ultrasonography C. Intraspongiosum injection D. Serum PSA

Answer: A The nocturnal penile tumescence and rigidity test (NPTR) is a simple test the client may do at home by himself to determine if he has the ability to have a nocturnal erection, which would rule out an organic and psychogenic cause of erectile dysfunction. At night, have the client place a simple device on the penis before sleep. This device records the frequency, as well as the rigidity, of erections. Other tests that may be done to determine the cause of erectile dysfunction, but that are not as simple, include the penile Doppler test (a noninvasive procedure comparing the penile pressure with the brachial artery pressure), a penile duplex ultrasonography (to assess the penile arteries and diagnose a vascular cause of erectile dysfunction), and an intracavernosal injection (to test for an erection, thus ruling out vascular disease). A PSA does not evaluate erectile dysfunction.

A 63- year- old man presents to you with hematuria, hesitancy, and dribbling. Digital rectal examination (DRE) reveals a moderately enlarged prostate that is smooth. The client's prostate- specific antigen (PSA) is 1.2. What is the most appropriate management strategy for you to follow at this time? A. Prescribe an alpha adrenergic blocker. B. Recommend saw palmetto extract. C. Prescribe an antibiotic. D. Refer the client to urology.

Answer: A The patient's symptoms appear to be related to benign prostatic hypertrophy (BPH) and not a urinary tract infection. An alpha- adrenergic blocker will relax prostate and bladder smooth muscle to improve flow and relieve symptoms. Saw palmetto extract is an alternative treatment that has not been proven to improve urinary symptoms in men with BPH, and its long- term side effects have not been studied. BPH can be successfully treated by primary health- care providers, and a referral is not appropriate until standard treatment is no longer effective.

The most common cause of androgen deficiency in older men is decreased testosterone production by the Leydig cells within the testes. Various systemic disorders can also affect circulating testosterone levels. These disorders include A. diabetes and hyperthyroidism. B. HIV and urinary tract infection. C. hypertension and heart disease. D. tobacco use and cholecystitis.

Answer: A Various disorders, including diabetes, hyperthyroidism, and HIV infection, can affect circulating testosterone levels. Urinary tract infections, heart disease, and cholecystitis have not been known to cause androgen deficiency. Other causes include a decrease in secretion of gonadotropin- releasing hormone from the hypothalamus; certain medications; and lifestyle factors including morbid obesity, tobacco use, alcoholism, and psychological stress.

The action of a 5- alpha- reductase inhibitor in the treatment of benign prostatic hypertrophy is to A. relax the smooth muscle of the prostatic capsule. B. reduce action of androgens in the prostate. C. relieve bladder obstruction. D. improve urinary fl ow rates.

Answer: B 5- alpha- reductase inhibitors are prescribed for their ability to induce apoptosis and atrophy, as well as reduce the action of androgens in the prostate. Alpha- adrenergic blockers relax smooth muscle of the bladder and prostatic capsule, improve flow rates, and relieve obstruction.

Max, age 70, is obese. He is complaining of a bulge in his groin that has been there for months. He states that it is not painful, but it is annoying. The practitioner notes that the origin of swelling is above the inguinal ligament directly behind and through the external ring. This finding is most indicative of a(n) A. indirect inguinal hernia. B. direct inguinal hernia. C. femoral hernia. D. strangulated hernia

Answer: B A direct inguinal hernia usually occurs in middle-aged to older men and is the result of an acquired weakness caused by heavy lifting, obesity, or chronic obstructive pulmonary disease (COPD). The origin of swelling is above the inguinal ligament directly behind and through the external ring. An indirect inguinal hernia is congenital or acquired and is more common in infants younger than 1 year of age and in men ages 16 to 25. The origin of swelling is above the inguinal ligament. The hernia sac enters the canal at the internal ring and exits at the external ring. A femoral hernia, which occurs more frequently in women, is acquired and results from an increase in abdominal pressure, as well as muscle weakness. The origin of swelling is below the inguinal ligament. Because Max is not having any pain and the condition has been this way for months, you know that the hernia is not strangulated. A strangulated hernia, which requires immediate referral to a surgeon, results in no blood supply to the affected bowel and causes nausea, vomiting, and tenderness.

Transillumination of f uid in the scrotum may be seen with A. a varicocele. B. a hydrocele. C. testicular torsion. D. testicular cancer.

Answer: B A hydrocele is a collection of fluid within the scrotum around the testes. It can be assessed by transillumination of the fl uid, which should be performed in a darkened room using a penlight. The fluid will appear light pink, yellow, or red. The mass can be illuminated to show the full size and shape. Masses of the testicles, such as testicular cancer, do not transilluminate, nor do hematomas or testicular torsion. A varicocele is venous dilation of the pampiniform plexus above the testes; it is typically painful and may not be transilluminated. In infancy, observation is the therapy of choice for a hydrocele. For adults, no treatment is required unless complications are present. If the hydrocele is painful, large, unsightly, or uncomfortable, then several options are available:

Which statement is true about the use of alpha blockers in the treatment of symptomatic benign prostatic hypertrophy? A. They are safe and effective and should be given in the morning before breakfast. B. They do not lower blood pressure in normotensive clients. C. Pedal edema is the most common adverse effect. D. Blood counts should be monitored periodically for reduction in the platelet count.

Answer: B Alpha blockers are an effective treatment of symptomatic benign prostatic hypertrophy. They reduce symptoms in 60% to 70% of clients with nearly 50% improvement in urinary fl ow rates. They do not lower the blood pressure in normotensive clients. Dosing must begin with the lowest dose, preferably at bedtime, so the client will sleep through any mild adverse effects such as malaise, fatigue, dizziness, or orthostatic hypotension. Pedal edema is a rare adverse effect. Blood counts should be monitored occasionally for reduction in white or red blood cell counts.

Drew has an erectile dysfunction and says that a friend told him about a method that uses a constricting ring around the base of the penis. What is he referring to? A. Intracavernous injection therapy B. External vacuum device C. Urethral suppositories D. Surgery

Answer: B An external vacuum device is a viable method for alleviating erectile dysfunction regardless of the cause of the disorder. A plastic cylinder is placed around the penis, a vacuum pump causes cavernosal engorgement, and a constrictor ring is applied around the base of the penis, allowing the client to hold an erection for 30 minutes. Intracavernous injection therapy consists of injecting the vasoactive drug alprostadil (Caverject) directly into the corpus cavernosum of the penis, causing an erection that lasts 40 to 60 minutes. Urethral suppositories such as alprostadil are also effective in causing an erection when inserted into the urethra after voiding. Surgery involves inserting a penile prosthesis, of which there are many different types.

John asks for a prescription for sildenafil (Viagra). He says that the only medication he takes is isosorbide mononitrate (Monoket) oral tablets and that he has diabetes that he controls by diet alone. What should the nurse practitioner tell him? A. "Let's try a sample and see how you do." B. "It's contraindicated with isosorbide mononitrate; let's discuss other options." C. "Because of your history of diabetes, we can't use it." D. "I'd better refer you to a urologist."

Answer: B Because sexual stimulation leads to the release of nitric oxide in the corpus cavernosum of the penis and sildenafil (Viagra) potentiates that release, there is a double hypotensive effect between sildenafil and the presence of an existing nitric oxide such as isosorbide mononitrate (Monoket, Imdur, and Ismo). Therefore, the use of sildenafil with Monoket is contraindicated. Sildenafil is not contraindicated in clients who consume nitrates in food or those with diabetes and does not require referral to a urologist.

Gerard is complaining of a scrotal mass; however, the scrotum is so edematous that it is difficult to assess. How would the nurse practitioner (NP) best determine if the condition is a hernia or a hydrocele? A. The NP can always return a hernia's contents to the abdominal cavity. B. Bowel sounds may be heard over a hernia. C. The NP can transilluminate a hernia. D. With a hydrocele, a bulge appears on straining.

Answer: B Bowel sounds may be heard over a hernia but not over a hydrocele. Some hernias are not able to be returned to the abdominal cavity. A hernia is incarcerated when its contents cannot be returned; it is strangulated when the blood supply to the entrapped contents is compromised. Scrotal swellings containing serous fluid such as a hydrocele transilluminate, whereas those containing blood or tissue do not. A bulge that appears on straining suggests a hernia.

Urinary tract infections in the male client are divided into upper and lower tract infections. A classic example of an upper- tract infection includes A. cystitis. B. pyelonephritis. C. prostatitis. D. epididymitis.

Answer: B Pyelonephritis is a classic example of upper-tract urinary infections in the male. Pyelonephritis results from hematogenous or ascending infection. Bacteremia, particularly with virulent organisms such as Staphylococcus aureus, can result in pyelonephritis with focal renal abscesses. Prostatitis, epididymitis, cystitis, and urethritis are some of the lower- tract diseases that affect males.

The seminal vesicles secrete A. a clear mucus. B. urine. C. fluid rich in fructose. D. semen.

Answer: C The two seminal vesicles project above the prostate and secrete a fluid rich in fructose, which nourishes the sperm. They also contain and release prostaglandins. Semen is produced by the testicles. The bulbourethral (Cowper's) glands secrete clear mucus for motility of sperm.

Sidney, age 72, presents to the clinic with complaints of a weak urine stream, hesitancy, and painful ejaculation. On digital rectal examination, you note that his prostate is boggy. The most common cause of his symptoms is A. acute bacterial prostatitis. B. chronic bacterial prostatitis. C. chronic nonbacterial prostatitis with chronic pelvic pain syndrome. D. noninflammatory prostatitis

Answer: B Chronic bacterial prostatitis, a recurrent bacterial infection of the prostate and urinary tract, affects men ages 50 to 80. It is accompanied by bladder obstruction symptoms such as weak urine stream, hesitancy or dribbling, hematuria, hematospermia, and/or painful ejaculation. The most common offending pathogen is Escherichia coli . Acute bacterial prostatitis primarily affects men ages 40 to 70. It manifests with sudden onset of symptoms including fever, malaise, dysuria, low back pain, and/or perineal prostatic pain. The prostate usually feels tender, warm, and edematous. Chronic nonbacterial prostatitis with chronic pelvic pain syndrome is manifested by pelvic pain and may be accompanied by various complaints such as mild low backache and hematospermia, and it may or may not have obstructive voiding symptoms. This condition is subdivided into infl ammatory or noninflammatory prostatitis. The prostate usually feels normal on examination with noninflammatory chronic prostatitis

Cryptorchidism is a risk factor for A. cancer of the prostate. B. testicular cancer. C. bladder cancer. D. a benign testicular tumor.

Answer: B Cryptorchidism, failure of one or both of the testes to descend into the scrotum, is a risk factor for testicular cancer. Most testicular tumors are malignant. Testicular cancer is the most common solid tumor in young men ages 16 to 35. It begins as an irregular, nontender mass, fixed on the testis, that does not transilluminate. It is not a risk factor for prostate cancer or bladder cancer.

Erectile dysfunction is a complex phenomenon with a variety of causes. The predominant cause is A. psychological. B. vascular. C. neurogenic. D. drug related.

Answer: B Erectile dysfunction has an organic origin in approximately 70% of cases. Of those cases, approximately 80% are related to vascular problems. The most common problem is generalized atherosclerosis that interferes with normal arterial function. Other vascular etiologies include hypertension, peripheral vascular disease, arterial insufficiency, trauma, or congenital abnormalities. Neurogenic disorders of the somatic, parasympathetic (cholinergic), sympathetic, and central nervous systems can cause or contribute to erectile dysfunction. Other diseases associated with erectile dysfunction include Parkinson's disease, cerebrovascular accident (stroke and brain attack), Alzheimer's disease, and diseases that create perfusion neuropathies such as diabetes and alcoholism. Erectile dysfunction is drug related in 25% of cases, with the common offenders being antihypertensive agents, NSAIDs, digoxin, antidepressants, sedatives, and antiandrogens.

Jordan, age 32, appears with a rapid onset of unilateral scrotal pain radiating up to the groin and flank. The nurse practitioner is trying to differentiate between epididymitis and testicular torsion. Which test should be the provider's first choice? A. X- ray B. Ultrasound C. Technetium scan D. Physical examination

Answer: B If your client has a rapid onset of unilateral scrotal pain radiating up to the groin and flank and you are trying to differentiate between epididymitis and testicular torsion, an ultrasound test is useful to determine whether the swelling is in the testis or the epididymis and should be your first choice. Initially, before the swelling has reached its peak, a physical examination will probably differentiate, but within a few hours, when the testis also swells, it may not be possible to differentiate between epididymis and testis by palpation. A reactive hydrocele may also develop. A technetium scan will show an increased uptake in the case of epididymitis and decreased uptake in the case of torsion, but the least invasive and least expensive test is an ultrasound.

Which technique uses a learned method to target muscle contraction and relaxation to assist with urinary continence? A. Biofeedback B. Kegel exercises C. Bladder training D. Prompted voiding

Answer: B Kegel exercises are a learned technique of pelvic muscle exercises that help with urinary incontinence after 4 to 5 weeks of consistent daily exercise. When used with biofeedback, they can improve pelvic floor tone and reduce uninhibited bladder contractions. Biofeedback consists of capturing information about a normally unconscious physiological process and subsequently using it in an educational process to accomplish specific therapeutic results, in this case, continence. Bladder training is a form of behavioral modification that helps to restore a normal pattern of voiding and normal bladder function. Clients void at fixed intervals whether the urge to void is present or not. Prompted voiding is also a form of behavioral modification that uses a toileting schedule, verbal feedback, and reinforcement.

A patient's chief complaint is heaviness in the scrotum. The nurse practitioner assesses swelling of the testes, along with warm scrotal skin. What differential diagnosis is most probable? A. Cryptorchidism B. Orchitis C. Testicular torsion D. Epididymitis

Answer: B Orchitis is an acute, painful onset of swelling of the testicle accompanied by warm scrotal skin. The client usually complains of a heavy feeling in the scrotum. It is typically unilateral but after 1 week may progress to the other testicle. In cryptorchidism, one or both testicles are undescended. Testicular torsion is a twisting or torsion of the testis. The testicle is enlarged, retracted, in a lateral position, and extremely sensitive. The result is venous obstruction, secondary edema, and eventual arterial obstruction. It is a surgical emergency. Epididymitis is caused by a retrograde spreading of pathogenic organisms from the urethra to the epididymis. It results in an indurated, swollen, and tender epididymis. The testes are also usually enlarged and tender.

Bernard, age 59, presents to the emergency department with a diagnosis of priapism. Despite application of cold compresses and pain medications, relief is unsuccessful. What is the treatment of choice? A. Terbutaline 0.25 mg subcutaneously B. Phenylephrine injection 0.3 to 0.5 mL into the corpora cavernosa C. Doxazosin 5 mg sublingually D. Lidocaine 1% via the glans

Answer: B Phenylephrine (Neo-Synephrine) is the drug of choice for first- line treatment of low- fl ow priapism because the drug has almost pure alpha- agonist effects and minimal beta activity. In short- term priapism (less than 6 hours), especially for drug-induced priapism, intracavernosal injection of phenylephrine alone may result in detumescence. Terbutaline is considered for refractory priapism of greater than 6 hours in duration. Doxazosin is used to treat benign prostatic hypertrophy. Lidocaine is not considered to be effi cacious for relief of priapism.

The nurse practitioner percusses for pain at the costovertebral angle when examining a male patient. What condition is the provider assessing for? A. Urethritis B. Pyelonephritis C. Kidney stone D. Bladder tumor

Answer: B Pyelonephritis typically begins with costovertebral angle (CVA) pain, fever, low back pain, and general malaise, as well as often dysuria, nausea, and vomiting, or diarrhea. Physical examination may reveal flushing, tachycardia, hypotension, fever, and signs of dehydration. With urethritis, there is typically burning on urination and a urethral discharge. Kidney stones usually result in pain that "travels" as the stone moves from the kidney to the bladder to the urethra. A bladder tumor usually causes no pain, and the initial sign is typically hematuria.

Cancer of the prostate often begins with subtle symptoms that develop very slowly over time and, if left untreated, will lead to metastasis. What prognostic finding is a significant indicator of probable metastatic disease? A. Gleason score of 2 B. Sudden onset of weakness of the legs in a man with known prostate cancer C. TNM staging T1a, N0, M0 D. Bladder outlet obstruction

Answer: B Sudden onset of weakness in the lower extremities can indicate metastasis to the spine with possible cord compression. Bladder outlet obstruction (BOO) can have either a bacterial or physiological etiology and does not necessarily indicate a metastatic process. Gleason scores have been used to stage cancers— a score of 4 to 5 (not a 2) would indicate that a metastatic process is likely. Likewise, the TNM staging system (tumor, node, and metastasis) indicates tumor size and gland involvement, node metastasis, and distant metastasis. T1a, N0, M0 indicates carcinoma in 5% or less of tissue resected with a normal DRE, no regional lymph node metastasis, and no distant metastasis.

Which of the following scrotal disorders is most common in adolescents? A. Acute epididymitis B. Testicular torsion C. Atrophic testes D. Scrotal edema

Answer: B Testicular torsion or torsion of the testicle on its spermatic cord is the most common scrotal disorder in adolescents. It produces an acutely painful, tender, and swollen scrotum. Because of the potential of circulation being constricted, it is a surgical emergency. Acute epididymitis occurs chiefl y in adults and is an acutely infl amed epididymis that is tender and swollen. Atrophic testes are small, soft testes associated with several conditions, such as cirrhosis, myotonia dystrophia, administration of estrogens, and hypopituitarism. Scrotal edema is usually associated with generalized edema in adults and is usually related to cardiac or nephrotic conditions.

While cystitis is more commonly seen in women, there are specific risk factors for urinary tract infection in males, including which of the following? A. Hypospadias B. Lack of circumcision C. High sperm count D. Varicocele

Answer: B There is a higher incidence of urinary tract infections (UTIs) in the uncircumcised male. The mucosal surface of the foreskin has a propensity for colonization with P- fimbriated bacteria in a fashion analogous to that of the female introitus. Hypospadias does not increase the risk of UTI. There is no correlation between a high sperm count and UTI, although the prostate in normal males secretes zinc, a potent antibacterial agent. Varicocele is also not considered a risk factor for UTI.

Mycoses commonly affect the skin in the groin. Which fungus commonly affects the scrotum? A. Tinea cruris B. Candida albicans C. Trichomonas D. Trichophyton

Answer: B Tinea cruris ("jock itch") tends to affect the groin, whereas Candida albicans commonly affects the scrotum. Trichomonas infection does not evidence itself as a skin rash. Trichophyton causes tinea of the feet.

Milton, a 72- year- old unmarried, sexually active white man, presents to your clinic with complaints of hesitancy, urgency, and occasional uncontrolled dribbling. Although the nurse practitioner suspects benign prostatic hypertrophy, what else should the differential diagnosis list include? A. Antihistamine use B. Urethral stricture C. Detrusor hyperreflexia D. Renal calculi

Answer: B Urethral strictures may develop as a result of sexually transmitted diseases and should be considered in a sexually active individual, primarily males, no matter what the age. Antihistamine use generally will result in hesitancy and urinary retention but not in incontinence. Detrusor hyperrefl exia involves urge incontinence characterized by a strong, sudden urgency (not hesitancy), immediately followed by a bladder contraction, resulting in an involuntary loss of urine. Renal calculi commonly present as pain.

Roger, a healthy 68- year- old man, comes in to see you with a complaint of sudden episodes of an urgent need to void. He has had several episodes of moderate amounts of unintentional urine loss during these times. Other than these episodes, he is voiding in amounts "normal" for him, with no leakage when he coughs or sneezes. The practitioner's initial diagnosis is which type of incontinence? A. Stress incontinence B. Urge incontinence C. Overfl ow incontinence D. Mixed incontinence

Answer: B Urge incontinence results from overactive bladder (OAB) and has many possible etiologies, each of which causes the bladder muscle (detrusor) to contract spontaneously. Common nonneurogenic causes are bladder irritants, infection, medications, urethritis, and pelvic tumors. Neurogenic causes involve the loss of cortical inhibition of the voiding reflex; this is seen in conditions such as dementia, Parkinson's disease, multiple sclerosis, and stroke (CVA and brain attack). Stress incontinence is a result of failure of the urethral sphincter, producing leakage with maneuvers that increase intraabdominal pressure, such as coughing or sneezing. Overflow incontinence is the result of leakage when the bladder is distended due to states such as a spinal cord injury (causing abnormal innervation between the bladder and spinal cord) or obstruction from a large prostate or tumor. Mixed incontinence is a combination of stress and urge types.

Bill, age 43, appears with a tender, ulcerated, exudative, papular lesion on his penis. It has an erythematous halo, surrounding edema, and a friable base. The nurse practitioner should suspect A. a chancre. B. a chancroid. C. Condylomata acuminatum. D. genital herpes.

Answer: B A chancroid is a tender, ulcerated, exudative, papular lesion with an erythematous halo, surrounding edema, and a friable base. It is caused by inoculation of Haemophilus ducreyi through tiny breaks in epidermal tissue. A chancre is a small papular lesion that enlarges and undergoes superficial necrosis to produce a sharply marginated ulcer on a clean base and is the lesion of primary syphilis. Condylomata acuminatum (genital warts) range from pinhead- size papules to cauliflower-like groupings of skin- colored, pink, or red lesions. They are caused by human papillomavirus (HPV) infection of the epithelial cells. Genital herpes simplex virus appears as erythematous plaques, developing into vesicular lesions that may become pustular.

Which patient will most likely never develop prostate cancer? A. Jacob, age 79, who had a transurethral resection of the prostate for benign prostatic hypertrophy B. Jeffrey, age 11, who recently had an orchiectomy after a traumatic accident C. Sid, age 70, who has a normal prostate- specific antigen level D. Johnny, age 32, who is taking steroids for bodybuilding

Answer: B In the early stages of prostate cancer, the tumor is androgen dependent. Testosterone is the major androgen, and clients who have undergone an orchiectomy before puberty never develop adenocarcinoma of the prostate.

Herb, a 47- year- old with diabetes, is complaining of a rash on his penis. Before examining him, you suspect that he may have A. tinea cruris. B. genital herpes. C. Candida . D. intraepithelial neoplasia.

Answer: C A Candida infection is fairly common in clients with diabetes. Candida on the penis appears as multiple, discrete, flat pustules with slight scaling and surrounding edema. It is a superficial mycotic infection that occurs in moist cutaneous sites. Other predisposing factors may include moisture, antibiotic therapy, and immunosuppression. Tinea cruris is a fungal infection of the groin that appears as erythematous plaques whose scaling, papular lesions have sharp margins and occasionally clear centers. Genital herpes is caused by skin- to- skin contact with the herpes simplex virus. It causes epidermal degeneration and erythematous plaques; the plaques develop into vesicular lesions that may become pustular. Intraepithelial neoplasia is associated with chronic human papillomavirus (HPV) infection and presents as multiple red maculopapular plaque-like lesions on the glans and inner aspect of the foreskin.

Jeff, age 20, presents to the college health clinic with complaints of difficulty passing his urine and a discharge from his penis. Upon further investigation, you note that the discharge is urethral in origin. The most common cause of these symptoms in the young adult male population is A. chronic prostatitis. B. prostatic abscess. C. acute prostatitis. D. prostatic hypertrophy.

Answer: C A client presenting with a urethral discharge or difficulty voiding can include acute and chronic prostatitis and prostatic abscess. Young adult males in their 20s usually have acute prostatitis from gonorrhea or other bacterial infections. Chronic prostatitis occurs in middle- aged males as a result of nonspecifi c prostatitis or a previous gonorrhea infection. Older males may have prostatic hypertrophy or prostatic cancer, and these diagnoses are not related with urethral discharge.

Josh has a no- scalpel vasectomy and asks if he can proceed immediately with sexual relations with his wife without worrying about getting her pregnant. The nurse practitioner should educate him and state, 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 you can discontinue other precautions."

Answer: C A man is still capable of fertilizing an egg for weeks after a no- scalpel vasectomy; therefore, a sperm count should be obtained after 4 weeks. Sperm cannot survive in the ampulla of the vas for more than 3 weeks, and it takes about 15 ejaculations for most men to clear the ampulla of sperm. A repeat sperm count is done 2 weeks after the first, and if both show azoospermia, other contraceptive practices may be discontinued at that time.

Common clinical symptoms of testosterone deficiency include A. erectile dysfunction and a decrease in visceral fat. B. an increase in lean body mass and infertility. C. erectile dysfunction and a decrease in bone mineral density. D. loss of libido and increased body hair.

Answer: C A subnormal level of testosterone causes metabolic changes that produce changes in male physiology, growth, and behavior. Common clinical symptoms of testosterone defi ciency are loss of libido, erectile dysfunction, decreased lean body mass, body hair and skin alterations, decreased bone mineral density, increased visceral fat, infertility, depression, and reduced cognition.

Martin is complaining of erectile dysfunction. He also has a condition that has reduced arterial blood flow to his penis. The most common cause of this condition is A. epilepsy. B. multiple sclerosis. C. diabetes mellitus. D. Parkinson's disease.

Answer: C About 50% of men who have had diabetes for longer than 6 years develop erectile dysfunction to some extent as a result of pathological changes in the vascular wall that lead to a reduction of arterial blood fl ow to the penis. Many other conditions can cause erectile dysfunction. They include cerebrovascular accidents (strokes and brain attacks), spinal cord injury, temporal lobe epilepsy, multiple sclerosis, chronic obstructive pulmonary disease, angina, chronic renal failure, and Parkinson's disease.

Austin, age 63, has been on fi nasteride (Proscar) for 6 months for benign prostatic hypertrophy. A decrease in his prostate- specific antigen (PSA) from the original value of 5.4 has not occurred. Your initial expectation is A. that his PSA would remain stable, neither increasing nor decreasing. B. that Austin's dosage should be reduced only after he has been on the medication for approximately 12 months. C. that a significant reduction in the overall PSA would occur if the level is associated with true benign prostatic hypertrophy. D. that an elevation of the antigen would occur because of the effect of the alpha- adrenergic antagonist.

Answer: C After 6 months of therapy with fi nasteride (Proscar) for benign prostatic hypertrophy, the prostatespecific antigen (PSA) level should decrease by about 50%. Testing can then be repeated annually. If the PSA level has not decreased, you should suspect prostate cancer and proceed to evaluate for such. Finasteride is a 5- alpha- reductase inhibitor and will affect PSA levels, as opposed to other agents such as alpha- adrenergic antagonists, which do not affect PSA levels.

Harvey is complaining of stress urinary incontinence. To assess the autonomic arch innervating the bladder, the nurse practitioner should test the A. inguinal reflex. B. neuronal reflex. C. bulbocavernous reflex. D. meatal resistance.

Answer: C After palpating the prostate gland, which is the first step in evaluating a male client complaining of stress urinary incontinence, you should evaluate the autonomic arch innervating the bladder by testing the bulbocavernous refl ex. By squeezing the glans penis, you should note contraction of the anal sphincter in an individual without incontinence. An absent reflex suggests that there has been an interruption of the normal neuronal arch. If the individual is able to contract the rectal sphincter voluntarily, neuronal competence is also positive. Meatal resistance is diffi cult to evaluate, and examination of the bulbocavernous reflex as noted above is most accurate.

Which of the following is an important question that you should ask to assess for urge urinary incontinence (UUI) in men? A. "Do you frequently have strong urges to urinate?" B. "Do you urinate more than you think you should?" C. "Do you have urges to urinate that sometimes result in wetting accidents?" D. "Are you bothered by waking up at night to go to the bathroom?"

Answer: C Asking about leakage or wetting accidents are useful questions about urge urinary incontinence that will assist in the diagnosis of overactive bladder in men. The other questions also are used to diagnose the condition but are specific to urgency, frequency, and nocturia.

Balanitis may evolve into a chronic problem. If this occurs, the patient will experience severe purulence and phimosis. The treatment plan should include A. a stronger topical antifungal ointment. B. change from an antifungal ointment to a powder. C. oral antibiotics. D. an antiviral ointment

Answer: C Balanitis is a cutaneous inflammation of the glans penis, and Candida usually plays a role. Treatment usually involves a topical antifungal ointment as initial treatment if lesions show mild erythema or shallow erosions. Chronic balanitis suggests relapse, especially from a sexual partner. This suggests the partner needs to be treated. Severe purulent balanitis suggests a bacterial cause. If severe enough to cause phimosis, oral antibiotics are indicated.

Which sexually transmitted diseases are cofactors for HIV transmission? A. Syphilis and chlamydia B. Herpes and chlamydia C. Chancroid and genital herpes D. Chancroid and gonorrhea

Answer: C Chancroid, genital herpes, and syphilis are cofactors for HIV transmission. In the United States, about 10% of persons who have chancroid are co- infected with Treponema pallidum (syphilis) or HSV (herpes simplex virus). This percentage is higher in persons who have acquired chancroid outside the United States.

Manny has been taking fi nasteride (Proscar) and states that he has had dramatic relief. He previously took terazosin (Hytrin), which also helped, and he asks the nurse practitioner (NP) about taking that again. The NP should tell him, A. "Yes, let's try the combination therapy because two are better than one." B. "No, they are absolutely contraindicated together." C. "There is no evidence to support combination therapy." D. "When symptoms get so bad that you need two different medications, it's time for surgery."

Answer: C Combination therapy with an alpha blocker such as terazosin (Hytrin) or finasteride (Proscar) is not supported by the literature. One study showed no improvement when combination therapy was tried. Combination therapy involves extra expense and increased risk of adverse effects and has unproven effectiveness; therefore, it should not be used until successful trials have ensued.

Which drug reduces the size of the prostate, reduces the risk of urinary retention by increasing urinary flow rate, and reduces some of the symptoms of benign prostatic hypertrophy? A. Doxazosin (Cardura) B. Prazosin (Minipress) C. Finasteride (Proscar) D. Terazosin (Hytrin)

Answer: C Finasteride (Proscar) is a 5- alpha- reductase inhibitor that blocks conversion of testosterone to dihydrotestosterone. It reduces the size of the prostate, relieves pressure on the bladder and urethra, reduces the risk of urinary retention, and results in a reduction of the symptoms of benign prostatic hypertrophy. Usually 6 months or more of treatment are required for maximal effects. Doxazosin (Cardura), prazosin (Minipress), and terazosin (Hytrin) are all alpha- adrenergic receptor blockers that relax the bladder neck and prostate smooth muscle. They also relieve some of the symptoms but do not affect the size of the prostate.

Jeb, a 72- year- old male, is seen at the practice for follow- up of several episodes of orthostatic hypotension. It also appears through a review of his systems and a digital rectal examination that he has benign prostatic hypertrophy (BPH) with lower urinary tract symptoms. The nurse practitioner reviews his recent ultrasonic evaluation that reports a prostate over 40 ml and the results of the American Urological Association (AUA) symptom index for BPH, which shows his score to be 12. Based on the preceding information and the patient's desire for noninvasive medical therapy, what management should be offered? A. Prazosin (Minipress) B. Doxazosin (Cardura) C. Finasteride (Proscar) D. Phenoxybenzamine (Dybenzyline)

Answer: C Finasteride is a 5- alpha reductase inhibitor and recommended for individuals with prostate greater than 40 ml to help decrease its size. According to the current AUA guideline for the management of benign prostatic hypertrophy (BPH), there is insufficient evidence to support the use of either phenoxybenzamine or prazosin in the management of BPH with lower urinary tract symptoms. Doxazosin is associated with a risk of orthostatic hypotension and thus would not be recommended in this client.

George states that he heard that if he takes a certain pill, it is less likely he will need surgery for his benign prostatic hypertrophy, as well as less likely he will develop acute urinary retention. Which of the following medications has these positive outcomes because it is actually disease modifying? A. Terazosin (Hytrin) B. Sildenafil citrate (Viagra) C. Finasteride (Proscar) D. Tamsulosin (Flomax

Answer: C In a long- term (4- year) study in men with symptoms of urinary obstruction and prostatic enlargement, treatment with finasteride (Proscar), a 5- alpha-reductase inhibitor, reduced symptoms and prostate volume, increased urinary flow rate, and reduced the probability of surgery and acute urinary retention. No other pharmacological therapies have been shown to decrease the incidence of acute urinary retention in long- term studies. Reducing the risk of acute urinary retention has implications for reducing morbidity, as well as reducing the number of men who need surgery. Previously, finasteride was used only for short intervals, but current data show that it is safe for long- term trials. Although alpha- adrenergic blockers (terazosin, tamsulosin) also provide symptomatic relief, they have not been shown to reduce the need for surgery

Jack and Jane have been married for 6 months and are unable to conceive. They ask the nurse practitioner if referral to an infertility specialist is needed. What would be the nurse practitioner's best response at this time? A. "Infertility cannot be diagnosed unless unprotected sex has occurred for at least 1 year." B. "Let's run some routine tests first; then I'll recommend someone." C. "Tell me about your sexual experiences." D. "It's usually a problem with the woman, so let's have Jane examined fi rst."

Answer: C Infertility is defined as 1 year of unprotected intercourse in which conception has not occurred. Although routine tests, such as thyroid studies, may be performed, a specialist will usually not see a couple until they have been trying to conceive for 1 year. Although you may ask how often they have been having intercourse— because once a month is certainly different from three times a week— the definition of infertility remains the same. The cause of infertility is found in the man 26% to 30% of the time, and most specialists perform a comprehensive diagnostic evaluation on both members of the couple.

Tim asks the nurse practitioner about returning to his normal sex life after surgery for benign prostatic hypertrophy. He should be told, A. "You probably won't be able to have an erection after surgery; we need to discuss alternative ways of lovemaking." B. "You need to wait several months after surgery to make sure the site has healed." C. "You may resume sexual activity 4 to 6 weeks after surgery." D. "You'll have to ask the surgeon."

Answer: C Many clients feel more comfortable talking to their primary care provider, with whom they have an established relationship, than to their surgeon, and the question of when to resume sex after prostate surgery for benign prostatic hypertrophy is no exception. They may not feel comfortable asking their surgeon; thus, they may resume sexual activity too early or wait an exorbitant amount of time. Within 4 to 6 weeks after surgery, it is safe to resume a full sex life including intercourse. Before this time, the spasmodic contractions that occur in the prostatic urethra at the time of ejaculation could trigger delayed bleeding. After 6 weeks, the risk of delayed bleeding is very slight. There may be slight discomfort because of the spasm if the area has not completely healed. The surgery does not interfere with the ability to have an erection; the NP is able to address this question, and it does not have to be discussed with surgeon except in unusual instances. Several months is longer than necessary to wait to resume sexual activities.

Benign prostatic hypertrophy is a common finding as men age. Classically, this condition may begin with difficulty initiating the urinary stream, hesitancy, urgency, postvoid dribbling, urinary frequency, nocturia, urinary retention, sensation of a full bladder immediately after voiding, and incontinence. These preceding symptoms would also cause the nurse practitioner to consider what other condition as a differential diagnosis? A. Epididymitis B. Testicular cancer C. Cancer of the prostate D. Balanitis

Answer: C Other differential diagnoses for symptoms classically seen in men with benign prostatic hypertrophy, such as difficulty initiating stream, hesitancy, urgency, postvoid dribbling, frequency, nocturia, retention, sensation of a full bladder immediately after voiding, and incontinence, include diabetes mellitus, cancer of the prostate, and some neurological diseases that can lead to voiding disorders. Testicular cancer, balanitis, and epididymitis do not typically cause this array of symptoms.

Which of the following can cause phimosis? A. Paraphimosis B. Smegma C. Adhesions from infection D. Priapism

Answer: C Phimosis, defined as inability to retract the foreskin of the penis, may be caused by a congenital malformation or, secondarily, by adhesions resulting from infections. It normally takes until age 1 year for complete retraction of the foreskin. Paraphimosis is the term used to refer to the inability to replace the foreskin, once retracted, because of edema of the glans. (If examining an unconscious patient be sure to return the foreskin to its usual state; failure to do this may result in severe edema). Smegma refers to the cheesy, white material under the foreskin, which does not, in and of itself, cause phimosis. Priapism is a prolonged, generally painful erection, usually unaccompanied by sexual desire.

Sidney, age 76, states that he was recently given a diagnosis of prostate cancer and that he has to return to the urologist for staging. He does not understand why because he says, "Cancer is still cancer. I just want to get rid of it." You tell 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 spread of the cancer." D. "You already know you have prostate cancer; you don't need another test unless you want to know how long you've had it."

Answer: C Staging will determine the extent of the spread of the cancer. The prostate cancer tissue is sometimes graded histologically, but the most widely used system is the Gleason system, which grades the architectural pattern of the cancer in the largest segment of the specimen and in the second- largest area occupied rather than histologically. Five grades, which correlate to tumor volume, pathologic stage, and prognosis, are possible in each area. The scores are added together to produce a Gleason score on a scale of 1 to 10, with a score of 8 to 10 indicating a poorly differentiated cancer that is aggressive in nature. Another method is the TNM classification of the American Joint Cancer Committee. The TNM judges the size of the primary tumor (T), regional lymph nodes (N), and distant metastases (M). Staging does not determine the type of treatment required but does helps the provider and the client discuss options available. Clients with localized prostate cancer should probably either have a surgical prostatectomy or radiotherapy. Watchful waiting has also been used at this stage. Advanced disease requires systemic chemotherapy or hormonal manipulation. Staging will not be able to establish how long a client has had prostate cancer.

Joe, age 29, comes in for an evaluation of his testes. He states that it is probably nothing to worry about because his testicle is not tender, but he does have a tiny, hard nodule on the testicle. The nurse practitioner confirms that there is a hard, fixed nodule on the patient's testicle. The next course of action 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 resolve by itself, he will have to have it excised.

Answer: C Testicular cancer is suspected if a hard, fi xed, nontender area or nodule is palpated on the testicle. The client should be referred for further evaluation. Testicular cancer is most common among men ages 16 to 35.

The most common gram- negative bacteria that causes both acute and chronic bacterial prostatitis is A. Staphylococcus aureus . B. Klebsiella . C. Escherichia coli . D. Enterobacteriaceae .

Answer: C The most common gram- negative bacterium that causes both acute and chronic bacterial prostatitis is Escherichia coli. Other aerobic gramnegative bacteria include Klebsiella, Pseudomonas, Enterobacteriaceae, Proteus mirabilis, and Neisseria gonorrhoeae. Occasionally other bacteria (Staphylococcus aureus and Streptococcus faecalis ) are causes.

The nurse practitioner has just treated a patient's condylomata acuminata with podophyllum in benzoin. What instructions should be given to him as part of patient teaching? A. "Refrain from sexual relations for 48 hours." B. "Don't take a shower until tomorrow morning." C. "Wash the medication off within 1 to 2 hours." D. "Go into the bathroom now and wash the medication off."

Answer: C The treatment of choice for the client with condylomata acuminata (warts) on the external genitalia is to "paint" them with podophyllum in benzoin. The client should wash the medication off in 1 to 2 hours because normal tissue may be destroyed along with the warts. Sometimes a repeat treatment is necessary. Carbon dioxide laser treatment might be more effective.

A patient is being treated for erectile dysfunction. The patient is morbidly obese and is also being treated for cardiovascular disease and coagulopathy. Which of the following medications would be contraindicated? A. Topical testosterone (Androgel) B. Sildenafil (Viagra) C. Alprostadil (Caverjet) D. Subcutaneous pellet testosterone (Testopel)

Answer: C The vasoactive injectable alprostadil (Caverjet) should not be used in patients with sickle cell anemia, coagulopathy, severe cardiovascular disease, myeloma, leukemia, morbid obesity or penile deformity, fibrosis, or implants. Androgel is a transdermal testosterone topical gel (hormone replacement therapy) and may transfer to a partner with close contact. Sildenafi l (Viagra) is an oral vasoactive agent and contraindicated in patients taking nitrates or alpha blockers. Testopel is another form of hormone replacement that is delivered as an implantable pellet and must be implanted in the subcutaneous tissue every 3 to 4 months.

Which type of urinary incontinence results from Parkinson's disease and multiple sclerosis? A. Overflow incontinence B. Stress incontinence C. Urge incontinence D. Functional incontinence

Answer: C There are four types of urinary incontinence that are considered established— overflow, stress, urge, and functional— and one type that is considered transient or potentially reversible. Overflow incontinence --> detrusor underactivity. There is frequent leakage of urine from the failure to fully empty the bladder, such as occurs with prostatic hypertrophy. Stress incontinence is a failure to store urine related to urethral incompetence. It may be caused by weak pelvic musculature or intrinsic or neurogenic sphincter deficiency and is commonly seen in men after radical prostatectomy. Urge incontinence --> detrusor overactivity --> failure to store urine and can coexist with urethral obstruction from benign prostatic hypertrophy or be due to conditions such as Parkinson's disease, multiple sclerosis, urinary tract infection, bladder stones, or tumors. Functional incontinence is caused by the effects of medications, fecal impaction, and immobility. Transient incontinence is characterized by a sudden onset. Its causes in older males can include delirium, infection, pharmacologic agents, psychological factors, excess urinary output, restricted mobility, and stool impaction in hospitalized or immobile persons.

Michael complains of a urinary tract infection (UTI). Which of the following is a risk factor for a UTI in men? A. A history of circumcision B. A history of testicular torsion C. Unprotected anal sex D. Presence of a left inguinal hernia

Answer: C Young men can develop a urinary tract infection (UTI) similar to the type of uncomplicated UTI seen in women, which does not require any additional work- up. Risk factors include unprotected anal sex, lack of circumcision, a history of prostatitis, unprotected intercourse with a woman who harbors pathogens in her vagina, and unprotected sex with men with AIDS with a CD4 count less than 200/mL. Testicular torsion, a surgical emergency, is not a risk factor. Inguinal hernias have no documented impact on the development of urinary tract infections.

The initial diagnostic and/or laboratory testing that a nurse practitioner should order to rule out organic causes of erectile dysfunction in men includes A. color Doppler sonography. B. CBC, blood chemistry profile, TSH, and PSA. C. nocturnal penile tumescence and rigidity test (NPTR). D. FBS, lipid profile, TSH, and testosterone

Answer: D A fasting blood sugar to rule out diabetes mellitus, lipid profile to rule out dyslipidemia, and thyroidstimulating hormone and testosterone levels are the initial laboratory tests that should be done to rule out causes of erectile dysfunction (ED). If the testosterone level is below 300 ng/dL, then a serum prolactin level is warranted. In a male with established ED, a CBC, blood chemistry profile including fasting glucose or glycosylated hemoglobin level, TSH, and PSA are frequently recommended. Specialized tests, such as the color Doppler sonogram or NPRT, can be done if the cause of ED is not apparent from the above standard tests.

The most accurate diagnostic tool for prostate cancer is A. a digital rectal examination. B. a prostate- specific antigen test. C. a transrectal ultrasound examination. D. a needle biopsy.

Answer: D A needle biopsy takes a histological sampling of the prostate gland and is diagnostic for prostate cancer. Digital rectal examination (DRE) detection rates are low and fi nd most cancers in the later stages. Additionally, a large number of actual prostate cancers are associated with a normal DRE. An extremely elevated prostatic- specific antigen (PSA) level usually indicates prostate cancer; however, about 25% of men with prostate cancer will have a normal PSA level. Other conditions, such as benign prostatic hypertrophy, may raise the PSA level. Transrectal ultrasound is most commonly used to guide the needle biopsy; however, it is not a very accurate screening or diagnostic tool in and of itself.

A male patient presents for evaluation of infertility to the clinic. Subjectively, the patient complains of pain and fullness of the testes and states, "My testicles feel like a bag of worms." On objective physical examination, the nurse practitioner notes tortuous veins posterior and above the testes that extend up into the external inguinal ring. Based on the preceding assessment, the nurse practitioner refers the patient to surgery based on a diagnosis of A. hydrocele. B. orchitis. C. urethritis. D. varicocele.

Answer: D A varicocele is caused by abnormal venous dilation of the pampiniform plexus above the testes, which results in pain and swelling. A patient often describes the sensation as feeling like a "bag of worms." A hydrocele is a collection of fluid within the scrotum around the testes. Orchitis is an acute inflammatory reaction of the testis secondary to infection, while urethritis is inflammation of the urethra. Pain with urination is the main symptom of urethritis, which is commonly due to infection by bacteria.

Which of the following medications causes retention of urine by inhibiting bladder contractibility and may cause overflow incontinence in certain individuals? A. Antispasmodics B. Drugs that affect the sympathetic nervous system C. Diuretics D. Antihistamines

Answer: D Antihistamines cause retention of urine by inhibiting bladder contractibility and may cause overflow incontinence in certain individuals. Other medications that may cause overflow incontinence include anticholinergics, antipsychotics, and antidepressants. Antispasmodics may cause excessive muscular relaxation and sphincter incompetency. Drugs that affect the sympathetic nervous system, such as alpha blockers, may relax the smooth muscle of the sphincter and decrease urethral pressure, which increases bladder emptying. Alpha stimulants may increase urethral closure pressure, which may lead to urinary retention. Diuretics may affect continence by causing frequent and large bladder volume that overwhelms the ability of the individual to reach the toilet in time.

A bladder tumor antigen test may be positive with A. testicular torsion. B. the use of steroids for bodybuilding. C. scrotal trauma. D. symptomatic sexually transmitted disease

Answer: D Bladder tumor antigen in urine is a qualitative agglutination test for bladder cancer that detects basement membrane proteins. It tests positive for symptomatic sexually transmitted disease and is also positive within 14 days of prostate biopsy or resection, with renal or bladder calculi, and with genitourinary tract cancers. It does not test positive for use of steroids, scrotal trauma, or testicular torsion.

Urinary stone disease, or urolithiasis, afflicts a large number of clients every year, exceeded in frequency as a urinary tract disorder only by infections and prostate disease. This disorder affects men more frequently than women with a ratio of 3 to 1. Common presenting signs and symptoms include which of the following? A. Guarding of the abdomen B. Fever C. Pain that is present during the daytime hours D. Nausea and vomiting

Answer: D Colic is the main presenting symptom of urinary stone disease and usually occurs suddenly, even awakening clients from sleep. The pain is sudden and severe and often accompanied by nausea and vomiting. These clients are constantly moving in contrast to those with acute abdominal pain who "guard" their abdomen and try not to move, each movement eliciting increased pain. Although the pain may occur episodically, it is not a chronic pain

A patient is being followed by the nurse practitioner for disease progression or remission after treatment for testicular cancer. Which of the following biochemical markers would be ordered and analyzed? A. Human chorionic gonadotropin (hCG) B. Alpha- fetoprotein (AFP) C. Lactate dehydrogenase (LDH) D. All of the above

Answer: D Human chorionic gonadotropin (hCG), alphafetoprotein (AFP), and lactate dehydrogenase (LDH) are all biomarkers that can aid in the diagnosis of testicular cancer and be used to follow disease progression or remission post treatment.

In deciding whether to treat 63- year- old Morrison, who has benign prostatic hypertrophy, the nurse practitioner uses the American Urological Association (AUA) scale. No treatment is indicated if the AUA score is A. 36 or higher. B. 20 to 35. C. 8 to 19. D. 7 or lower.

Answer: D If surgery for benign prostatic hypertrophy is not mandated by obstruction or severe symptoms, it is based on the results of the client's American Urological Association (AUA) scale and the client's choice. If the AUA score is 7 or lower, no treatment is indicated. If the score is 8 to 19 (moderate) or 20 to 35 (severe), then medical treatment or surgery can be presented to the client as an option.

Regular testicular self- exams have not been studied enough to show if they lower the risk of dying from testicular cancer. This is why the American Cancer Society and other agencies do not have a recommendation about regular testicular self- exams for all men. Still, some practitioners do recommend that all men examine their testicles monthly after puberty. If teaching a patient how to do a testicular self- examination, which of the following do you tell him? A. "Examine your testicles when you are cold because this makes them more sensitive." B. "Make sure your hands are dry to create friction." 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."

Answer: D If you advise men to perform a monthly testicular self- examination, instruct them to call if they notice any hard lumps directly on the testicle, whether the lumps are tender or not. Testicles should be examined when taking a warm shower or bath with soapy hands to allow easy manipulation of the tissue. If parts of the testicle above and behind feel rather firm, this is the epididymis and is normal. The spermatic cord, a small, round, movable tube, extends up from the epididymis and feels fi rm and smooth.

Harris, age 68, is complaining of crooked, painful erections. He has palpable, nontender, hard plaques just beneath the skin of his penis. Based on the chief complaint and assessment, what is the most likely differential diagnosis? A. Carcinoma of the penis B. Genital herpes C. Syphilitic chancre D. Peyronie's disease

Answer: D In Peyronie's disease, the client has palpable, nontender, hard plaques just beneath the dorsal skin of the penis and usually complains of crooked, painful erections. With carcinoma of the penis, there is usually an indurated, nontender nodule or ulcer, and usually the man is uncircumcised. Genital herpes appears as a cluster of small vesicles, followed by shallow, painful, non- indurated ulcers on red bases. They may appear anywhere on the penis, and the initial outbreak is usually the worst. A syphilitic chancre is an oval or round, dark red, painless erosion or ulcer with an indurated base. It feels like a button that is lying directly underneath the skin. It may also be associated with nontender, enlarged inguinal lymph nodes

Barry, a 32- year- old patient, has a history of unprotected intercourse with numerous sexual partners. He has been diagnosed with epididymitis. Initial treatment for this inflammatory condition includes A. use of a scrotal support and warm compresses. B. epididymectomy. C. a spermatic cord block with local anesthetics. D. bedrest with scrotal elevation and antibiotics

Answer: D Initial treatment of epididymitis includes bedrest with scrotal elevation and ice-packs along with antibiotics. A spermatic cord block with local anesthetics may be necessary to relieve pain in severe cases. Drainage of an abscess or referral for surgical intervention may also be needed depending on severity of the case.

The nurse practitioner is seeing a male patient in the clinic and suspects testosterone deficiency, or Low T. When ordering testosterone levels, it is understood that testosterone levels are best assessed A. in the evening between 6:00 p.m. and 9:00 p.m. B. in the afternoon between 12 noon and 3:00 p.m. C. anytime— time has no effect on testosterone levels. D. in the morning between 7:00 a.m. and 10:00 a.m.

Answer: D Normal testosterone levels are best assessed in the morning between 7:00 a.m. and 10:00 a.m.

What differentiates prostate cancer symptoms from benign prostatic hypertrophy (BPH) symptoms? A. Urinary frequency, hesitancy, and intermittency are much worse with prostate cancer. B. Nocturia is worse with BPH. C. Dribbling and a weak stream are more indicative of BPH. D. Symptoms of prostate cancer in general tend to progress more rapidly than those of BPH.

Answer: D Symptoms of prostate cancer can mimic the symptoms of benign prostatic hypertrophy (BPH); however, with prostate cancer in general, the symptoms tend to progress more rapidly as compared with those of BPH. Symptoms of both prostate cancer and BPH include urinary frequency, hesitancy, intermittency, nocturia, dribbling, and a weak urinary stream.

The nurse practitioner (NP) is debating prescribing testosterone therapy for a male patient with a low testosterone level. In reviewing the contraindications to this this treatment, the NP notes that the hormone is contraindicated in which of the following conditions? A. Men with breast or prostate cancer B. Men with palpable prostate nodules C. Men with untreated obstructive sleep apnea D. All of the above

Answer: D Testosterone therapy is contraindicated in men with breast or prostate cancer, palpable prostate nodules or induration, untreated obstructive sleep apnea, severe lower urinary tract symptoms with an International Prostate Symptom Score of greater than 19, and New York Heart Association Class III or IV heart failure.

The U.S. Preventive Services Task Force (USPSTF) recommends against prostate- specific antigen (PSA)-based screening for prostate cancer. They grade the evidence related to PSA screening as A. A B. B C. C D. D

Answer: D The USPSTF recommends against the use of the PSA as a screening tool. There is moderate or high certainty that the prostate- specific antigen blood test has no net benefi t or that the harms outweigh the benefits in the general population of males. The inevitability of overdiagnosis and overtreatment of prostate cancer as a result of screening means that many men will experience the adverse effects of diagnosis and treatment of a disease that would have remained asymptomatic throughout their lives.

Harry, age 60, has benign prostatic hypertrophy and complains of some incontinence. The nurse practitioner's first step in diagnosing overflow incontinence would be to order a A. urinalysis. B. cystometrogram. C. cystoscopy. D. postvoid residual (PVR) urine measurement.

Answer: D The first step in diagnosing overflow incontinence is to perform a postvoid residual (PVR) urine measurement. Clients with overflow incontinence cannot empty their bladders completely, so after voiding, residual urine remains and this measurement is elevated. A urinalysis, cystometrogram, and cystoscopy are also commonly performed to confirm the cause and diagnosis, but a PVR measurement is the most important component of the diagnosis.

An obstructive cause of lower urinary tract symptoms in males is A. bladder cancer. B. bladder stones. C. infection. D. prostate cancer.

Answer: D The obstructive causes of lower urinary tract symptoms (LUTS) are bladder outlet obstruction from benign prostatic hypertrophy, a poorly contractile bladder, prostate cancer, bladder neck or urethral strictures, and neurogenic bladder. Bladder cancer, bladder stones, and infection are classified a irritative or storage causes of LUTS.

Abnormalities of the scrotum are usually painless or nontender. Which of the following is an exception and is usually tender? A. Hydrocele B. Tumor of the testis C. Spermatocele D. Tuberculous epididymitis

Answer: D Tuberculous epididymitis is a chronic inflammation of tuberculosis. It produces a fi rm enlargement of the epididymis, which is usually tender, and thickening or beading of the vas deferens. A hydrocele is a nontender, fl uid- fi lled mass that is in the space within the tunica vaginalis. A spermatocele is a painless, movable cystic mass just above the testis. A tumor of the testis is usually a painless nodule.

Lower urinary tract symptoms (LUTS) in males can present as a constellation of storage or voiding symptoms. Storage symptoms include A. hesitancy and poor flow. B. intermittency and post- void dribble. C. straining and dysuria. D. urgency and nocturia.

Answer: D Urgency, frequency, nocturia, stress incontinence, and urgency incontinence are all related to storage symptoms associated with overactive bladder in men. Voiding symptoms are related to issues with the urethra and sphincter control and include hesitancy, poor fl ow, intermittency, straining, and dysuria. Postmicturition symptoms include postvoid dribble and a sense of incomplete emptying.

According to the American Urological Association (AUA) Guideline on the Management of Benign Prostatic Hyperplasia: Diagnosis and Treatment Recommendations, when is referral for invasive surgery automatically warranted? A. With an AUA symptom index of 7 or lower B. With an AUA symptom index 8 or greater C. With irritative symptoms such as urgency, frequency, or nocturia D. With presence of refractory retention and bladder stones

Answer: D With mild symptoms of benign prostatic hyperplasia (BPH) and an AUA index of 7 or lower, watchful waiting is recommended. If a client has moderate to severe symptoms and an AUA index of 8 or higher, noninvasive medical therapy is still an option, as is minimally invasive therapies or surgery. The presence of refractory retention or any of the following clearly related to BPH require referral to surgery: persistent gross hematuria, bladder stones, recurrent urinary tract infections, and/or renal insufficiency. Irritative symptoms are usually what the client will present with for further assessment to diagnosis BPH or other conditions.