Robbins Ch. 21 - The Lower Urinary Tract and Male Genital System

A 32-year-old man has noticed an increased feeling of heaviness in his scrotum for the past 10 months. On physical examination, the left testis is three times the size of the right testis and is firm on palpation. An ultrasound scan shows a 6-cm solid mass within the body of the left testis. Laboratory studies include an elevated serum α-fetoprotein level. Which of the following cellular components is most likely to be present in this mass? (A) Yolk sac cells (B) Leydig cells (C) Seminoma cells (D) Cytotrophoblasts (E) Embryonal carcinoma cells (F) Lymphoblasts

(A) α-Fetoprotein (AFP) is a product of yolk sac cells that can be shown by immunohistochemical testing. Pure yolk sac tumors are rare in adults, but yolk sac components are common in mixed nonseminomatous tumors. Leydig cells produce androgens. Pure seminomas do not produce AFP. Cytotrophoblasts do not produce a serum marker, but they may be present in a choriocarcinoma along with syncytiotrophoblasts, which do produce human chorionic gonadotropin. Embryonal carcinoma cells by themselves do not produce any specific marker. Embryonal carcinoma cells are common in nonseminomatous tumors, however, and are often mixed with other cell types. Lymphoblasts may be seen in high-grade non-Hodgkin lymphomas, which do not produce hormones. BP7 661-664 BP8 690-695 PBD7 1043, 1045 PBD8 989-990

A 30-year-old man visits his physician because he has noticed increasing enlargement and a feeling of heaviness in his scrotum for the past year. On physical examination, the right testis is twice its normal size, and it is firm and slightly tender. An ultrasound examination shows a 3.5-cm solid mass in the right testis. Abdominal CT scan shows enlargement of the para-aortic lymph nodes. Multiple lung nodules are seen on a chest radiograph. Laboratory findings include markedly increased serum levels of chorionic gonadotropin and α-fetoprotein. Which of the following testicular neoplasms is the most likely diagnosis? (A) Leydig cell tumor (B) Mixed germ cell tumor (C) Pure spermatocytic seminoma (D) Choriocarcinoma (E) Metastatic adenocarcinoma of the prostate gland (F) Large diffuse B-cell lymphoma

(B) Although a modest elevation of the human chorionic gonadotropin (hCG) concentration can occur when a seminoma contains some syncytial giant cells, significant elevation of the α-fetoprotein (AFP) level never occurs with pure seminomas. Elevated levels of AFP and hCG effectively exclude the diagnosis of a pure seminoma and indicate the presence of a nonseminomatous tumor of the mixed type. The most common form of testicular neoplasm combines multiple elements; the term teratocarcinoma is sometimes used to describe tumors with elements of teratoma, embryonal carcinoma, and yolk sac tumor. The yolk sac element explains the high AFP level. Mixed tumors may include seminoma. Leydig cell tumors are non-germ cell tumors derived from the interstitial (Leydig) cells; they may elaborate androgens. Choriocarcinomas secrete high levels of hCG, but no AFP. It is unusual for a tumor to metastasize to the testis; this patient is of an age at which a primary cancer of the testis should be considered when a testicular mass is present. Lymphomas may involve the testis, usually when there is systemic involvement by a high-grade lesion. Lymphomas do not elaborate hormones. BP7 661-664 BP8 690-695 PBD7 1041-1042, 1046 PBD8 992

A 45-year-old man comes to the physician for a routine health maintenance examination. On physical examination, there are no remarkable findings. Laboratory findings include serum creatinine, 1.1 mg/dL; urea nitrogen, 17 mg/dL; glucose, 76 mg/dL; alkaline phosphatase, 89 U/L; and prostate-specific antigen (PSA), 8 ng/mL. Prostate biopsies are performed and the high-power microscopic appearance of a biopsy specimen is shown in the figure. Which of the following is the most likely risk factor for his disease? (A) Epigenetic hypermethylation of GSTP1 gene (B) Recurrent bacterial urinary tract infections (C) Exposure to naphthylamine compounds (D) Tobacco use (E) Overproduction of dihydrotestosterone

(A) He has prostatic adenocarcinoma with back-to-back glands and prominent nucleoli. Alterations of the glutathione S-transferase (GSTP1) gene allow damage from carcinogens. Other genetic abnormalities in prostate cancer include variations in CAG repeats in the androgen receptor gene, BRCA2 mutations, and translocation of ETS family transcription genes. His prostate-specific antigen (PSA) level is twice the upper limit of normal. This is worrisome, but not an absolute indication of prostate cancer. Elevated PSA levels can occur with nodular hyperplasia or prostatitis. A higher level or a level that increases over time or an increased free PSA is more suggestive of carcinoma. Recurrent urinary tract infections and hydronephrosis are complications of obstruction more commonly from nodular prostatic hyperplasia. Naphthylamine compounds are linked to urothelial carcinomas. Tobacco use is associated with many cancers, including urothelial carcinoma and renal cell carcinoma. Increased dihydrotestosterone output from prostatic stromal cells drives nodular hyperplasia. BP7 667-669 BP8 698-700 PBD7 1055 PBD8 1001-1002

A 29-year-old man complains of a vague feeling of heaviness in the scrotum, but he has had no increase in pain for the past 5 months. He is otherwise healthy. Physical examination shows that the right testis is slightly larger than the left testis. An ultrasound scan shows the presence of a solid, circumscribed, 1.5-cm mass in the body of the right testis. The representative gross appearance of the mass is shown in the figure. A biopsy is done, and microscopic examination of the mass shows uniform nests of cells with distinct cell borders, glycogen-rich cytoplasm, and round nuclei with prominent nucleoli. There are aggregates of lymphocytes between these nests of cells. Which of the following features is most characteristic of this lesion? (A) Excellent response to radiation therapy (B) Likelihood of extensive metastases early in the course of disease (C) Elevation of human chorionic gonadotropin levels in the serum (D) Elevation of α-fetoprotein levels in the serum (E) Elevation of serum testosterone levels (F) Association with 46,X(fra)Y karyotype (G) Association with 46,XXY karyotype

(A) This is the most common form of "pure" testicular germ cell tumor that may remain confined to the testis (stage I). The prognosis is good in most cases, even with metastases, because seminomas are radiosensitive. Human chorionic gonadotropin (hCG) levels may be slightly elevated in about 15% of patients with seminoma. Elevated hCG levels suggest a component of syncytial cells; very high levels suggest choriocarcinoma. α-Fetoprotein levels are elevated in testicular tumors with a yolk sac component, and many tumors with an embryonal cell component also contain yolk sac cells. Testosterone is a product of Leydig cells, not germ cells. Fragile X syndrome is associated with mental retardation. The testes are enlarged bilaterally. Klinefelter syndrome is associated with decreased testicular size and reduced fertility. BP7 661-664 BP8 690-695 PBD7 1040-1042 PBD8 988-989

A 25-year-old man has occasionally felt pain in the scrotum for the past 3 months. On physical examination, the right testis is more tender than the left, but does not appear to be appreciably enlarged. An ultrasound scan shows a 1.5-cm mass. A right orchiectomy is performed, and gross examination shows the mass to be hemorrhagic and soft. A retroperitoneal lymph node dissection is done. In sections of the lymph nodes, a neoplasm is seen with grossly extensive necrosis and hemorrhage. Microscopic examination shows that areas of viable tumor are composed of cuboidal cells intermingled with large eosinophilic syncytial cells containing multiple dark, pleomorphic nuclei. Immunohistochemical staining of the tumor is most likely to show which of the following antigenic components in the syncytial cells? (A) Human chorionic gonadotropin (B) α-Fetoprotein (C) Vimentin (D) CD20 (E) Testosterone (F) Carcinoembryonic antigen (G) CA-125

(A) This patient has a choriocarcinoma, the most aggressive testicular carcinoma. It often metastasizes widely. The primitive syncytial cells mimic the syncytiotrophoblast of placental tissue and stain for human chorionic gonadotropin. α-Fetoprotein is a marker that is more likely to be found in mixed tumors with a yolk sac component. Vimentin is more likely to be seen in sarcomas, which are rare in the testicular region. CD20 is a lymphoid marker for B cells. Testosterone is found in Leydig cells. Carcinoembryonic antigen (CEA) is found in a variety of epithelial neoplasms, particularly adenocarcinomas. CA-125 is best known as a marker for ovarian epithelial malignant tumors. BP7 661-664 BP8 690-695 PBD7 1043-1044, 1046 PBD8 990

A 46-year-old man with a history of poorly controlled diabetes mellitus comes to the physician because he has had painful, erosive, markedly pruritic lesions on the glans penis, scrotum, and inguinal regions of the skin for the past 2 months. Physical examination shows irregular, shallow, 1- to 4-cm erythematous ulcerations. Scrapings of the lesions are examined under the microscope. Which of the following microscopic findings in the scrapings is most likely to be reported? (A) Eggs and excrement of Sarcoptes scabiei (B) Budding cells with pseudohyphae (C) Atypical cells with hyperchromatic nuclei (D) Enlarged cells with intranuclear inclusions (E) Spirochetes under dark-field examination

(B) Genital candidiasis can occur in individuals without underlying illnesses, but it is far more common in individuals with diabetes mellitus. Warm, moist conditions at these sites favor fungal growth. Scabies mites are more likely to be found in linear burrows in epidermis scraped from the extremities. Neoplasms may ulcerate, but such lesions are unlikely to be shallow or multiple without a mass lesion present. Intranuclear inclusions suggest a viral infection; however, diabetes is not a risk factor for genital viral infections. These lesions are too large and numerous to be syphilitic chancres. BP7 658 BP8 688 PBD7 1035 PBD8 982

A 33-year-old man has noted asymmetric enlargement of the scrotum over the past 4 months. On physical examination, the right testis is twice its normal size and has increased tenderness to palpation. The right testis is removed. The epididymis and the upper aspect of the right testis have extensive granulomatous inflammation with epithelioid cells, Langhans giant cells, and caseous necrosis. Which of the following is the most likely cause of these findings? (A) Mumps (B) Syphilis (C) Tuberculosis (D) Gonorrhea (E) Sarcoidosis

(C) Tuberculosis is an uncommon infection in the testes, but it can occur with disseminated disease. The infection typically starts in the epididymis and spreads to the body of the testis. Mumps produces patchy orchitis with minimal inflammation, which heals with patchy fibrosis. Syphilis involves the body of the testis, and there can be gummatous inflammation with neutrophils, necrosis, and some mononuclear cells. Gonococcal infections produce acute inflammation. Sarcoidosis produces noncaseating granulomas that are not likely to be found in the testis. BP7 660 BP8 690 PBD7 1039 PBD8 986

The mother of a 2-year-old boy notices that he has had increasing asymmetric enlargement of the scrotum over the past 6 months. On physical examination, there is a well-circumscribed, 2.5-cm mass in the left testis. A left orchiectomy is performed, and histologic examination of this mass shows sheets of cells and ill-defined glands composed of cuboidal cells, some of which contain eosinophilic hyaline globules. Microcysts and primitive glomeruloid structures also are seen. Immunohistochemical staining shows α-fetoprotein in the cytoplasm of the neoplastic cells. What is the most likely diagnosis? (A) Choriocarcinoma (B) Seminoma (C) Yolk sac tumor (D) Teratoma (E) Leydig cell tumor

(C) Yolk sac tumors are typically seen in boys younger than 3 years old. The primitive glomeruloid structures are known as Schiller-Duval bodies. Choriocarcinomas contain large, hyperchromatic, syncytiotrophoblastic cells. Seminomas have sheets and nests of cells resembling primitive germ cells, often with an intervening lymphoid stroma. Teratomas contain elements of mature cartilage; bone; or other endodermal, mesodermal, or ectodermal structures. Embryonal carcinomas with yolk sac cells contain α-fetoprotein, but they are seen in adults. They are composed of cords and sheets of primitive cells. Leydig cell tumors may produce androgens or estrogens or both. BP7 661-664 BP8 690-695 PBD7 1043-1044 PBD8 989-990

A 48-year-old man has noticed a reddish area on the penis for the past 3 months. He has had no sexual intercourse for more than 1 month. On physical examination, there is a solitary 0.8-cm, plaquelike, erythematous area on the distal shaft of the penis. A routine microbiologic culture with a Gram-stained smear of the lesion shows normal skin flora. Microscopic examination of a biopsy specimen of the lesion shows dysplasia involving the full thickness of the epithelium. What is the most likely diagnosis? (A) Primary syphilis (B) Balanitis (C) Soft chancre (D) Bowen disease (E) Condyloma acuminatum

(D) Bowen disease is a form of squamous cell carcinoma in situ. Similar to carcinoma in situ elsewhere, it has a natural history of progression to invasive cancer if untreated. Poor hygiene and infection with human papillomavirus (particularly types 16 and 18) are factors that favor development of dysplasias and cancer of the genital epithelia. Syphilis is a sexually transmitted disease that produces a hard chancre, which heals in a matter of weeks. Balanitis is an inflammatory condition without dysplasia. A soft chancre may be seen with Haemophilus ducreyi infections. Condylomas are raised, whitish lesions. BP7 658 BP8 688-689 PBD7 1036 PBD8 983-984

A 59-year-old man notices gradual enlargement of the scrotum over the course of 1 year. The growth is not painful, but produces a sensation of heaviness. He has no problems with sexual function. Physical examination shows no lesions of the overlying scrotal skin and no obvious masses, but the scrotum is enlarged, boggy, and soft bilaterally. The transillumination test result is positive. What is the most likely diagnosis? (A) Varicocele (B) Elephantiasis (C) Orchitis (D) Seminoma (E) Hydrocele

(E) Hydrocele is one of the most common causes of scrotal enlargement. It consists of a fluid collection within the tunica vaginalis. Most cases are idiopathic, although some may result from local inflammation. A varicocele is a collection of dilated veins (pampiniform plexus) that may produce increased warmth, which inhibits spermatogenesis. Elephantiasis is a complication of parasitic filarial infections involving the inguinal lymphatics. Orchitis involves the body of the testis without marked enlargement, but with tenderness. A seminoma is typically a firm unilateral mass. BP7 659 BP8 689 PBD7 1047 PBD8 993

An 85-year-old man comes to the physician because he had experienced urinary hesitancy and nocturia for the past year. He has had increasing back pain for the past 6 months. On digital rectal examination, there is a hard, irregular prostate gland. A bone scan shows increased areas of uptake in the thoracic and lumbar vertebrae. Laboratory studies show a serum alkaline phosphatase level of 300 U/L, serum prostatic acid phosphatase level of 8 ng/mL, and serum prostate-specific antigen (PSA) level of 72 ng/mL. The blood urea nitrogen concentration is 44 mg/dL, and the serum creatinine level is 3.8 mg/dL. Transrectal biopsy specimens of all lobes of the prostate are obtained. Microscopic examination shows that more than 90% of the tissue has a pattern of cords and sheets of cells with hyperchromatic pleomorphic nuclei, prominent nuclei, and scant cytoplasm. Which of the following is the best classification for this patient's disease? Stage Gleason grade (A) A1 1, 1 (B) A2 1, 2 (C) B1 2, 3 (D) B2 3, 3 (E) C1 3, 4 (F) C2 4, 4 (G) D1 4, 5 (H) D2 5, 5

(H) The presence of a hard irregular nodule, along with the extremely high prostate-specific antigen (PSA) level, points most clearly to prostate carcinoma. Modest elevations of the PSA concentration can occur in nodular hyperplasia of the prostate and prostatitis. Symptoms of urinary obstruction are more prominent in nodular hyperplasia because the nodules are in the periurethral region, but this sign is insufficient to distinguish cancer from hyperplasia. Similarly, renal failure owing to obstruction or infiltration is most common with nodular hyperplasia, but can occur with cancer as well. Levels of alkaline phosphatase are elevated when prostate carcinoma gives rise to osteoblastic metastases. Although staging and grading schemes for malignant disease seem daunting, they are applied intuitively. The lowest stage is the smallest, most localized tumor; higher stages represent larger tumors or spread of the disease inside or outside of the primary organ site. Grading schemes also start with the lowest, most well-differentiated tumor, as seen with the microscope. Higher grade tumors have increasingly abnormal-appearing cells and structures so poorly differentiated that they hardly resemble their site of origin. In this case, the prostate cancer has the highest grade (it does not have glandular structures) and the highest stage (it has metastasized to the spine). BP7 667-669 BP8 698-700 PBD7 1050-1056 PBD8 997-1000

A 5-year-old boy has a history of recurrent urinary tract infections. Urine cultures have grown Escherichia coli, Proteus mirabilis, and enterococcus. Physical examination now shows an abnormal constricted opening of the urethra on the ventral aspect of the penis, about 1.5 cm from the tip of the glans penis. There also is a cryptorchid testis on the right and an inguinal hernia on the left. What term best describes the child's penile abnormality? (A) Hypospadias (B) Phimosis (C) Balanitis (D) Epispadias (E) Bowen disease

(A) Hypospadias is a congenital condition seen in about 1 in 300 male infants. The inguinal hernia and the cryptorchidism are abnormalities that may accompany this condition. Phimosis is a constriction preventing retraction of the prepuce. It can be congenital, but more likely is the result of inflammation of the foreskin of the penis (e.g., balanitis, a form of local inflammation of the glans penis). Epispadias is a congenital condition in which the urethra opens on the dorsal aspect of the penis. Bowen disease, which is squamous cell carcinoma in situ of the penis, occurs in adults. BP7 658 BP8 687-688 PBD7 1035 PBD8 982

A 35-year-old man and his 33-year-old wife are childless. They have tried to conceive a child for 12 years, and now they undergo an infertility work-up. On physical examination, neither spouse has any remarkable findings. Laboratory studies show that the man has a sperm count in the low-normal range. On microscopic examination of the seminal fluid, the sperm have a normal morphologic appearance. A testicular biopsy is done. The biopsy specimen shows patchy atrophy of seminiferous tubules, but the remaining tubules show active spermatogenesis. Which of the following disorders is the most likely cause of these findings? (A) Mumps virus infection (B) Cryptorchidism (C) Hydrocele (D) Klinefelter syndrome (E) Prior chemotherapy

(A) Mumps is a common childhood infection that can produce parotitis. Adults who have this infection more often develop orchitis. The orchitis is usually not severe, and its involvement of the testis is patchy; infertility is not a common outcome. Cryptorchidism results from failure of the testis to descend into the scrotum normally; the abnormally positioned testis becomes atrophic throughout. A hydrocele is a fluid collection outside the body of the testis that does not interfere with spermatogenesis. Klinefelter syndrome and estrogen therapy can cause tubular atrophy, although it is generalized in both cases. Patchy loss of seminiferous tubules indicates a local inflammatory process. Many chemotherapeutic agents are particularly harmful to rapidly and continuously proliferating testicular germ cells, but the effect would not be patchy within the testicular parenchyma. Patients who wish to father children may want to store sperm in a sperm bank before undergoing chemotherapy. BP7 660 BP8 690 PBD7 1039 PBD8 986

For the past year, a 65-year-old man has had multiple, recurrent urinary tract infections. Escherichia coli and streptococcal organisms have been cultured from his urine during several of these episodes, with bacterial counts of more than 105/mL. He has difficulty with urination, including starting and stopping the urinary stream. Over the past week, he has again developed burning pain with urination. Urinalysis shows a pH of 6.5, and specific gravity of 1.020. No blood or protein is present in the urine. Tests for leukocyte esterase and nitrite are positive. Microscopic examination of the urine shows numerous WBCs and a few WBC casts. Which of the following is the most likely diagnosis? (A) Neisseria gonorrhoeae infection (B) Prostatic nodular hyperplasia (C) Phimosis (D) Epispadias (E) Adenocarcinoma of the prostate gland (F) Vesicoureteral reflux

(B) Of the diseases listed, prostatic nodular hyperplasia is the most common in older men. When it causes obstruction of the prostatic urethra, it can predispose to bacterial infections. Gonorrhea is more likely to be seen in younger, sexually active men, and obstruction is not a key feature. Phimosis can occur in uncircumcised men. It may be congenital or acquired from inflammation, usually at a much younger age. Epispadias is a congenital condition, observed at birth. Prostatic adenocarcinomas are less likely than hyperplasia to cause obstructive symptoms. Vesicoureteral reflux is more likely to be present at an earlier age, and it does not account for the obstructive symptoms the patient has on urination. BP7 665-666 BP8 696-697 PBD7 1048-1050 PBD8 994-996

A 71-year-old, currently healthy man visits his physician for a checkup because he is worried about his family history of prostate cancer. Physical examination does not indicate any abnormalities. Because of the patient's age and family history, his prostate-specific antigen (PSA) level is immediately measured, and the PSA level is 5 ng/mL. Six months later, the PSA level is 6 ng/mL. A urologist obtains transrectal biopsy specimens, and microscopic examination shows multifocal areas of prostatic intraepithelial neoplasia and glandular hyperplasia. Based on these findings, what is the most appropriate course of management for this patient? (A) Antibiotic therapy (B) Monitoring PSA levels (C) Multiagent chemotherapy (D) Radiation therapy (E) Radical prostatectomy (F) Transurethral prostate resection

(B) Prostatic intraepithelial neoplasia (PIN) is a potential precursor of prostatic adenocarcinoma. By itself, it does not warrant therapy because only about one third of patients diagnosed with PIN develop invasive cancer within 10 years. Conversely, in about 80% of cases in which prostate cancer is present, PIN can be found in the surrounding tissue. PIN usually does not increase the PSA levels. In this case, the elevation in PSA levels was probably caused by the coexistent hyperplasia. Following the patient with PSA tests can aid in determining if cancer has developed. Antibiotic therapy is appropriate in the treatment of an infectious process, not for PIN. Radiation and chemotherapy are reserved for malignancies, not for a preneoplastic condition. Surgical resection of the prostate gland is considered when a diagnosis of adenocarcinoma is established. BP7 668 BP8 699 PBD7 1053 PBD8 999

An otherwise healthy, 72-year-old man has had increasing difficulty with urination for the past 10 years. He now has to get up several times each night because of a feeling of urgency, but each time the urine volume is not great. He has difficulty starting and stopping urination. On physical examination, the prostate is enlarged to twice its normal size, but is not tender to palpation. One year ago, his serum prostate-specific antigen (PSA) level was 6 ng/mL, and it is still at that level when retested. Which of the following drugs is most likely to be effective in treatment of this man? (A) Estrogen (hormone) (B) Finasteride (5-α-reductase inhibitor) (C) Mitoxantrone (chemotherapy agent) (D) Nitrofurantoin (antibiotic) (E) Prednisone (corticosteroid)

(B) The clinical features are typical of nodular hyperplasia of the prostate, and slight elevation of the PSA level can occur. A PSA level that remains unchanged for 1 year, as in this case, is less likely to be found with a prostate cancer. Finasteride is a 5-α reductase inhibitor that decreases formation of dihydrotestosterone (DHT) that binds to androgen receptors in prostatic stromal and epithelial cells, driving proliferation with prostate gland enlargement. However, α-1-adrenergic blockers that diminish smooth muscle tone are somewhat more effective in treating nodular hyperplasia. Estrogen therapy has been used as antihormonal therapy in prostate cancer. Mitoxantrone is a chemotherapy agent which when given with prednisone has been shown effective in treating advanced prostate cancers. Nitrofurantoin is an antibiotic that is often used in treating urinary tract infections. BP7 665-666 BP8 696-698 PBD7 1047-1050 PBD8 994-996

A 70-year-old, previously healthy man comes to his physician for a routine health examination. On palpation, his prostate is normal in size. Laboratory studies show a serum prostate-specific antigen (PSA) level of 17 ng/mL, however, twice the value he had 1 year ago. A routine urinalysis shows no abnormalities. Which of the following histologic findings in a subsequent biopsy specimen of the prostate is most likely to account for the patient's current status? (A) Acute prostatitis (B) Adenocarcinoma (C) Chronic abacterial prostatitis (D) Nodular hyperplasia (E) Prostatic intraepithelial neoplasia

(B) The prostate-specific antigen (PSA) level is significantly elevated in this patient. The increase over time is more likely to be indicative of carcinoma. Typically, prostatic carcinomas are adenocarcinomas that form small glands packed back to back. Many adenocarcinomas of the prostate do not produce obstructive symptoms and may not be palpable on digital rectal examination. Inflammation and nodular hyperplasias can increase the PSA level, although not to a high level that increases significantly over time. Prostatic intraepithelial neoplasia, although an antecedent to adenocarcinoma, is not likely to increase the PSA significantly over time. BP7 667-669 BP8 698-700 PBD7 1054-1056 PBD8 1001-1002

A 19-year-old man comes to his physician for a routine health maintenance examination. On physical examination, there is no left testis palpable in the scrotum. The patient is healthy, has had no major illnesses, and has normal sexual function. In counseling this patient, which of the following statements regarding his condition would be most appropriate? (A) You will be unable to father children (B) You are at increased risk of developing a testicular tumor (C) This is a common finding in more than half of all men (D) This is an outcome of childhood mumps infection (E) This is an inherited disorder

(B) This patient has cryptorchidism, which results from failure of the testis to descend from the abdominal cavity into the scrotum during fetal development. One or both testes may be involved. It is associated with an increased risk of testicular cancer. An undescended testis eventually atrophies during childhood. Unilateral cryptorchidism usually does not lead to infertility, but it may be associated with atrophy of the contralateral descended testis. Mumps infection tends to produce patchy testicular atrophy, usually without infertility. Isolated cryptorchidism is a developmental defect that is usually sporadic and is not inherited in the germline. BP7 659-660 BP8 689-690 PBD7 1037-1038 PBD8 984-984

A 19-year-old man comes to his physician complaining of worsening local pain and irritation with difficult urination over the past 3 years. He has become more sexually active during the past year and describes his erections as painful. Physical examination shows that he is not circumcised. The prepuce (foreskin) cannot be easily retracted over the glans penis. What is the most likely diagnosis? (A) Epispadias (B) Bowenoid papulosis (C) Phimosis (D) Genital candidiasis (E) Paraphimosis

(C) Phimosis can be congenital, but is more often a consequence of multiple episodes of balanitis (inflammation of the glans penis or foreskin). Balanitis leads to scarring that prevents retraction of the foreskin. Forcible retraction may result in vascular compromise, with further inflammation and swelling (paraphimosis). Epispadias is a congenital condition in which the penile urethra opens onto the dorsal surface of the penis. Bowenoid papulosis is a premalignant lesion of the penile shaft resulting from viral infection. Candidiasis is most likely to produce shallow ulcerations that are intensely pruritic. BP7 658 BP8 688 PBD7 1035 PBD8 982

A 23-year-old, sexually active man has been treated for Neisseria gonorrhoeae infection several times during the past 5 years. He now comes to the physician because of the increasing number and size of warty lesions slowly enlarging on his external genitalia during the past year. On physical examination, there are multiple 1- to 3-mm sessile, nonulcerated, papillary excrescences over the inner surface of the penile prepuce. These lesions are excised, but 2 years later, similar lesions appear. Which of the following conditions most likely predisposed him to development of these recurrent lesions? (A) Candida albicans infection (B) Circumcision (C) Human papillomavirus infection (D) Neisseria gonorrhoeae infection (E) Paraphimosis (F) Phimosis

(C) The patient's lesions are characteristic of condyloma acuminatum, which is typical of human papillomavirus (HPV) infection. A condyloma acuminatum is a benign, recurrent squamous epithelial proliferation resulting from infection with HPV, one of many sexually transmitted diseases that can occur in sexually active individuals. Koilocytosis is particularly characteristic of HPV infection. Candidiasis can be associated with inflammation, such as balanoposthitis, but not condylomata. Recurrent gonococcal infection indicates that the patient is sexually active and at risk for additional infections, but is not the cause for the condylomata. Gonococcal infection causes suppurative lesions in which there may be liquefactive necrosis and a neutrophilic exudate or mixed inflammatory infiltrates with chancroid. Circumcision generally reduces risks for infections. Phimosis is a nonretractile prepuce, and paraphimosis refers to forcible retraction of the prepuce that produces pain and urinary obstruction. BP7 677 BP8 709 PBD7 1035-1036 PBD8 982-983

A 25-year-old, previously healthy man suddenly develops severe pain in the scrotum. The pain continues unabated for 6 hours, and he goes to the emergency department. On physical examination, he is afebrile. There is exquisite tenderness of a slightly enlarged right testis, but there are no other remarkable findings. The gross appearance of the right testis is shown in the figure. Which of the following conditions is most likely to cause these findings? (A) Disseminated tuberculosis (B) Invasive germ cell tumor (C) Lymphedema (D) Obstruction of blood flow (E) Previous vasectomy

(D) The markedly hemorrhagic appearance results from testicular torsion that obstructs venous outflow to a greater extent than the arterial supply. Doppler ultrasound shows reduced or no vascular flow in the affected testis. An abnormally positioned or anchored testis in the scrotum is a risk factor for this condition. Tuberculosis can spread from the lung through the bloodstream, producing miliary tuberculosis, seen as multiple pale, millet-sized lesions, most often involving the epididymis. Testicular carcinomas do not obstruct the blood flow. Parasitic infestation, typically filariasis, obstructs the flow of lymph, leading to gradual enlargement of the scrotum with thickening of the overlying skin. A previous vasectomy may lead to a small leakage of fluid and sperm, producing a localized sperm granuloma. PBD7 1040 PBD8 987

A 35-year-old man has noticed bilateral breast enlargement over the past 6 months. On physical examination, both breasts are enlarged without masses. His right testis is 1.5 times larger than his left testis; both are firm and round. His serum estrogen is increased. An ultrasound scan shows a circumscribed 2-cm mass in the body of the right testis, and a right orchiectomy is performed. The mass has a grossly uniform, brown cut surface. On microscopic examination, the cells are large and round with granular eosinophilic cytoplasm along with rod-shaped crystalloids of Reinke. What is the most likely diagnosis? (A) Choriocarcinoma (B) Embryonal carcinoma (C) Gonadoblastoma (D) Leydig cell tumor (E) Seminoma (F) Teratoma (G) Yolk sac tumor

(D) The patient has a Leydig cell tumor of the testis. These tumors are most often small, benign masses that may go unnoticed. Some patients have gynecomastia, however, caused by androgenic or estrogenic hormone production (or both) by the tumor. Most patients are young to middle-aged men; sexual precocity may occur in the few boys who have such tumors. Choriocarcinomas are grossly soft and hemorrhagic masses that have large bizarre syncytiotrophoblast and cytotrophoblast cells and are aggressive. Embryonal carcinomas are large, aggressive tumors that have a variegated gross appearance and primitive cells with large, hyperchromatic nuclei. Gonadoblastomas are rare testicular tumors that arise in the setting of gonadal dysgenesis. A pure seminoma can be uniformly brown on cut surface, but often has a lymphoid stroma, and is not likely to secrete androgens or estrogens. Pure teratomas are rare and contain elements of three germ layers. Yolk sac tumors have cells that organize into primitive endodermal sinuses (Schiller-Duval bodies). BP8 690, 695 PBD7 1046 PBD8 982-983

A 55-year-old man has dysuria, increased frequency, and urgency of urination for the past 6 months. He has sometimes experienced mild lower back pain. On physical examination, he is afebrile. There is no costovertebral angle tenderness. The prostate gland feels normal in size; no nodules are palpable. Laboratory studies show that expressed prostatic secretions contain 30 leukocytes per high-power field. What is the most likely diagnosis? (A) Benign prostatic hyperplasia (B) Acute bacterial prostatitis (C) Syphilitic prostatitis (D) Chronic abacterial prostatitis (E) Metastatic prostatic adenocarcinoma

(D) The patient has more than 10 leukocytes per high-power field, indicating prostatitis. Chronic abacterial prostatitis is the most common form of the disorder. Patients typically do not have a history of recurrent urinary tract infections. Nodular prostatic hyperplasia by itself is not an inflammatory process. Patients with acute bacterial prostatitis, most often caused by Escherichia coli infection, have fever, chills, and dysuria; on rectal examination, the prostate is very tender. Syphilis is a disease of the external genitalia, although the testis may be involved. Prostate carcinomas generally do not have a significant amount of acute inflammation, and metastases are most often associated with pain; most prostatic conditions causing dysuria are benign. BP7 664-665 BP8 695-696 PBD7 1047-1048 PBD8 993-994

Over the past 9 months, a 30-year-old man has noticed increased heaviness with enlargement of the scrotum. On physical examination, there is an enlarged, firm left testis, but no other remarkable findings. An ultrasound scan shows a 5-cm solid mass within the body of the left testis. An orchiectomy of the left testis is performed. Microscopic examination of the mass shows areas of mature cartilage, keratinizing squamous epithelium, and colonic glandular epithelium. Laboratory findings include elevated levels of serum human chorionic gonadotropin (hCG) and α-fetoprotein (AFP). Despite the appearance of the cells in the tumor, the surgeon tells the patient that he probably has a malignant testicular tumor. The surgeon's conclusion is most likely based on which of the following factors? (A) Size of the tumor (B) Age of the patient (C) Presence of colonic glandular epithelium (D) Elevation of hCG and AFP levels (E) Location of the mass in the left testis

(D) The tumor has elements of all three germ layers and is a teratoma. It is uncommon for teratomas in men to be completely benign. The most common additional histologic component is embryonal carcinoma. The elevated levels of human chorionic gonadotropin and α-fetoprotein indicate that this is a mixed tumor with elements of choriocarcinoma and yolk sac cells. The size of the tumor, age of the patient, location of the tumor (e.g., right, left, cryptorchid), and differentiation of the glandular epithelium are not markers of malignancy. On examining more histologic sections from the mass, the pathologist would find the malignant elements. BP7 661-664 BP8 690-695 PBD7 1044-1045 PBD8 990-991

A clinical trial of two pharmacologic agents compares one agent that inhibits 5α-reductase and diminishes dihydrotestosterone (DHT) synthesis in the prostate with another agent that acts as an α1-adrenergic receptor. The subjects are 40 to 80 years old. The study will determine whether symptoms of prostate disease are ameliorated in the individuals who take these drugs. Which of the following diseases of the prostate is most likely to benefit from one or both of these drugs? (A) Acute prostatitis (B) Adenocarcinoma (C) Leiomyoma (D) Chronic prostatitis (E) Nodular hyperplasia

(E) Androgens are the major hormonal stimuli of glandular and stromal proliferation resulting in nodular prostatic hyperplasia. Although testosterone production decreases with age, prostatic hyperplasia increases, probably because of an increased expression of hormonal receptors that enhance the effect of any dihydrotestosterone that is present. The 5α-reductase inhibitors, such as finasteride, diminish the prostate volume, specifically the glandular component, leading to improved urine flow. The α1-adrenergic receptor blockers, such as tamsulosin, cause smooth muscle in the bladder neck and prostate to relax, which relieves symptoms and improves urine flow immediately. The other listed conditions are not amenable to therapy with these drugs. BP7 665-666 BP8 696-698 PBD7 1048-1049 PBD8 994-995