Chapter 15

A 60-year-old coach comes to your clinic, complaining of difficulty starting to urinate for the last several months. He believes the problem is steadily getting worse. When asked he says he has a very weak stream and it feels like it takes 10 minutes to empty his bladder. He also has the urge to go to the bathroom more often than he used to. He denies any blood or sediment in his urine and any pain with urination. He has had no fever, weight gain, weight loss, or night sweats. His medical history includes type 2 diabetes and high blood pressure treated with medications. He does not smoke but drinks a six pack of beer weekly. He has been married for 35 years. His mother died of a myocardial infarction in her 70s and his father is currently in his 80s with high blood pressure and arthritis. On examination you see a mildly obese male who is alert and cooperative. His blood pressure is 130/70 with a heart rate of 80. He is afebrile and his cardiac, lung, and abdominal examinations are normal. On visualization of the anus you see no inflammation, masses, or fissures. Digital rectal examination reveals a smooth, enlarged prostate. No discrete masses are felt. There is no blood on the glove or on guaiac testing. An analysis of the urine shows no red blood cells, white blood cells, or bacteria.What disorder of the anus, rectum, or prostate is this most likely to be? A) Benign prostatic hyperplasia (BPH) B) Prostatitis C) Prostate cancer D) Anorectal cancer

A) Benign prostatic hyperplasia (BPH) BPH becomes more prevalent during the fifth decade and is often associated with the urinary symptoms of hesitancy in starting a stream, decreased strength of stream, nocturia, and leaking of urine. On examination an enlarged, symmetric, firm prostate is palpated. The anterior lobe cannot be felt. These patients may also develop UTIs secondary to the obstruction.

A 24-year-old graduate student comes to your clinic, complaining of burning during urination and increased urinary frequency. He has had a low-grade fever (100.5 degrees) and does not feel very well. He is very worried about sexually transmitted diseases because he had a drunken encounter 2 weeks ago and did not use a condom. He has had no recent weight loss, weight gain, or night sweats. His past medical history includes knee surgery in high school and genital warts in college. He does not smoke but drinks six beers every Friday and Saturday night. He denies using any IV drugs but has tried marijuana in the past. His father has high cholesterol but his mother is healthy. On examination he appears tired. His temperature is 99.5 degrees and his blood pressure is 110/70. His abdominal examination is normal. Visualization of the anus shows no masses, inflammation, or fissures. Digital rectal examination reveals a warm, boggy, tender prostate. No discrete masses are felt and there is no blood on the glove. The scrotum and penis appear normal. Urinalysis shows moderate amounts of white blood cells and bacteria. What disorder of the anus, prostate, or rectum best describes this situation? A) Benign prostatic hyperplasia (BPH) B) Prostatitis C) Prostate cancer D) Epididymitis

B) Prostatitis Prostatitis generally causes increased frequency of urination, pain with urination, and lower back pain. On digital rectal examination a warm, tender, boggy prostate will be palpated. In young men the etiology is often a sexually transmitted disease such as chlamydia or gonorrhea. This man's substance abuse problem should also be discussed with him, and you should consider further questions and screening for HIV.

A 56-year-old homosexual man presents with itching, anorectal pain, and tenesmus of 1 week's duration. Rectal examination reveals generalized tenderness without frank prostate abnormalities. Which of the following is most likely? A) Acute prostatitis B) External hemorrhoid C) Proctitis D) Colon cancer

C) Proctitis The combination of itching, anorectal pain, and tenesmus in a homosexual man should make one consider proctitis. This may be caused by a sexually transmitted infection such as gonorrhea, chlamydia, or lymphogranuloma venereum. A careful history should be taken, and counseling regarding protection from these diseases should be offered. While pain and itching are associated with hemorrhoids, the internal tenderness on examination makes this less likely than proctitis in this patient. Acute prostatitis does not usually cause itching and is usually associated with examination findings. Most colon cancers do not cause any symptoms, which is why screening for asymptomatic disease is so important.

A 45-year-old African-American minister comes to your clinic for a general physical examination. He has not been feeling very well for about 3 months, including night sweats and a chronic low-grade fever of 100 to 101 degrees. He denies any upper respiratory symptoms, chest pain, nausea, constipation, diarrhea, blood in his stool, or urinary tract symptoms. He has had some lower back pain. He has a past history of difficult-to-control high blood pressure and high cholesterol. He has had no surgeries in the past. His mother has diabetes and high blood pressure. He knows very little about his father because his parents divorced when he was young. He knows his father died in his 50s, but he is unsure of the exact cause. The patient denies smoking, drinking, or drug use. He is married and has three children. On examination he appears his stated age and is generally fit. His temperature is 99.9 degrees and his blood pressure is 160/90. His head, ears, nose, throat, and neck examinations are normal. His cardiac, lung, and abdominal examinations are also normal. On visualization of the anus there is no inflammation, masses, or fissures. Digital rectal examination elicits an irregular, asymmetric, hard nodule on the otherwise normal posterior surface of the prostate. Examination of the scrotum and penis are normal. Laboratory results are pending.What disorder of the anus, rectum, or prostate is mostly likely in this case? A) Benign prostatic hyperplasia (BPH) B) Prostatitis C) Prostate cancer D) Anorectal cancer

C) Prostate cancer Prostate cancer often presents with few symptoms and can sometimes be found on routine digital rectal examination. It is more common at a younger age in African-American men, and PSA screening, if indicated, begins at age 40, ten years earlier than in other races. Palpation on digital rectal examination can reveal a hard, irregular, asymmetric nodule, but can also reveal an asymmetry in texture between the two lobes.

Mr. Jackson is a 50-year-old African-American who has had discomfort between hisscrotum and anus. He also has had some fevers and dysuria. Your rectal examination is halted by tenderness anteriorly, but no frank mass is palpable. What is your most likely diagnosis? A) Prostate cancer B) Colon cancer C) Prostatitis D) Colonic polyp

C) Prostatitis The above examination, associated with a history of dysuria, frequency, and incomplete voiding, should lead you to suspect acute prostatitis. Prostate cancer, colon cancer, and polyps should not ordinarily cause systemic symptoms such as fever.

Which is true of prostate cancer? A) It is commonly lethal. B) It is one of the less common forms of cancer. C) Family history does not appear to be a risk factor. D) Ethnicity is a risk factor.

D) Ethnicity is a risk factor. Although prostate cancer is the most commonly diagnosed cancer in men, biologic risk and mortality are only 3%. Lung and colon cancers are more common causes of mortality. Genetics appear to account for 42% of cases in one study. The rate of prostate cancer is almost double in African-American men, which is one of the reasons to begin screening at 40 years of age rather than the standard recommendation of 50.

Which is a sign of benign prostatic hyperplasia? A) Weight loss B) Bone pain C) Fever D) Nocturia

D) Nocturia Benign prostatic hyperplasia (BPH) is usually not associated with systemic symptoms such as weight loss or fever. Bone pain is associated with prostate cancer, which often metastasizes to the lower axial skeleton. Nocturia, sensation of incomplete voiding, weak stream, and difficulty initiating urination are also common symptoms of prostate cancer.