Male Reproductive System — Clinical MCQs

Question 1

A 25-year-old man and his wife undergo an infertility workup. His wife's reproductive function is normal. On physical examination he has descended testes that appear decreased in size. A sperm count shows aspermia. A testicular biopsy is performed and on microscopic examination only Sertoli cells are present in the seminiferous tubules. Which of the following laboratory test findings is he most likely to have?

Accepted Answer

Increased FSH — Such a 'Sertoli cell only' syndrome is a cause for male infertility and may be idiopathic. A similar pattern would be present in a cryptorchid testis.

Question 2

A 30-year-old man has had a feeling of heaviness in his left testis for the past 6 months. Physical examination reveals enlargement of the left testis, while the right testis appears normal. There is a palpable left inguinal lymph node. An ultrasound reveals a 4 cm solid mass within the body of the left testis. Laboratory findings included a serum beta-HCG of 5 IU/L and alpha-fetoprotein of 2 ng/mL. The left testis is removed and on sectioning reveals a firm, lobulated light tan mass without hemorrhage or necrosis. He receives radiation therapy. Which of the following neoplasms is he most likely to have?

Accepted Answer

Seminoma — The most common pure form of testicular cancer is seminoma, a type of germ cell tumor which is radiosensitive. The tumor markers are not markedly elevated. This form of testicular carcinoma has the best prognosis overall, when not mixed with other elements.

Question 3

A 35-year-old man goes to his physician for a routine examination. On physical examination there is a left inguinal mass. The right testis is palpated in the scrotum and is of normal size, but a left testis cannot be palpated in the scrotum. An ultrasound scan shows that there is a 2 cm solid inguinal mass. Which of the following approaches is most appropriate to deal with this patient's testicular abnormality?

Accepted Answer

Remove the mass — A cryptorchid testis that is not treated in early childhood no longer functions in spermatogenesis and presents a risk for subsequent development of seminoma. The earlier in life that an orchiopexy is performed, generally under the age of 5, the more likely the testis will function properly. The risk of carcinoma in the descended testis is unlikely to be increased, so it can be left to function.

Question 4

A 70-year-old healthy man has a routine check-up. On physical examination there is a firm nodule palpable in the prostate via digital rectal examination. A MRI scan confirms the presence and location of a posterior 0.4 cm nodule. Prostate biopsies are performed and on microscopic examination show small, crowded glands containing cells with prominent nucleoli within the nuclei. Which of the following is the most likely diagnosis?

Accepted Answer

Adenocarcinoma — Such a nodule at that age strongly suggests carcinoma. Most carcinomas of the prostate arise in the posterior portion of the gland where they can be palpated on digital rectal examination. Microscopically, prostatic adenocarcinomas have irregular glands without intervening stroma. Large nucleoli are a characteristic microscopic feature.

Question 5

An epidemiologic study is performed to determine potential risk factors for development of penile squamous intraepithelial neoplasia. It is observed that persons who develop this disease are elderly men. Which of the following diseases is most likely to be found to precede development of penile neoplasia in these men?

Accepted Answer

Phimosis — The chronic irritation from accumulation of secretions and smegma under the prepuce is the likely risk. Circumcision reduces the risk for development of penile carcinoma, and can reduce transmission of infections as well.

Question 6

A 32-year-old man reports increasing size and number of lesions in his genital region. On examination there are multiple 0.2 to 1 cm raised, smooth to rough-surfaced to verrucous pale pink plaques on the penis, scrotum, and perineum. No ulceration is observed. Which of the following organisms is most likely to result in his lesions?

Accepted Answer

Human papillomavirus — HPV produces genital warts and cancers, but not typically ulcers.

Question 7

A 23-year-old healthy man has been unable to father a child. He and his wife have a workup for infertility. His wife's reproductive function is normal. On physical examination both his testes are palpable in the scrotum and the testes and scrotum are normal in size, with no masses palpable. However, the spermatic cord on the left has the feel of a 'bag of worms'. Laboratory studies show oligospermia. Which of the following conditions is this man most likely to have?

Accepted Answer

Varicocele — The increased warmth from the vascularity reduces sperm production. Spermatogenesis needs to occur at a temperature below that of the body as a whole, which explains why testes are in the scrotum.

Question 8

A 72-year-old man gets up several times during a football match to urinate, even though he has had only one beer. This is a problem that has plagued him for 4 years. On physical examination he has a diffusely enlarged prostate. His serum PSA is 6 ng/mL. Which of the following pathologic findings is most likely to be present in this man?

Accepted Answer

Nodular hyperplasia — Benign prostatic hyperplasia (BPH) is a common finding in older men. The lateral lobes are typically involved (in contrast to carcinomas which are most often found in the posterior lobe), and the increasing prostatic urethral obstruction leads to the classic symptoms of frequency and hesitancy with urination. The PSA can be mildly elevated with hyperplasia, but the level tends not to increase significantly over time.

Question 9

A 19-year-old university student notes the sudden onset of severe discomfort in his scrotum late one evening. No position is comfortable. He is brought to the emergency room. His left testis is slightly enlarged and exquisitely tender. A doppler ultrasound scan shows decreased blood flow in the left testis. Which of the following conditions is he most likely to have?

Accepted Answer

Torsion — Testicular torsion often has a sudden onset and must be treated immediately, as lack of blood flow can lead to hemorrhagic infarction. An ultrasound can be used to help identify this condition, demonstrating lack of blood flow.

Question 10

A 20-year-old man has noted a penile discharge with some pain on urination for the last 2 days. A small amount of whitish exudate can be expressed from the urethral meatus. Culture of the penile discharge reveals Neisseria gonorrheae. If untreated, which of the following complications is he most likely to develop?

Accepted Answer

Epididymitis — When the testis is involved by gonorrhea, it is typically the epididymis. Many male gonorrheal infections are asymptomatic and not followed by significant complications. Urethritis with stricture is a possible complication.

Question 11

A 31-year-old man has had a feeling of heaviness in his scrotum for over 6 months. An ultrasound reveals a solid 5 cm mass in the body of the right testis. Laboratory studies show serum AFP of 81 ng/mL and HCG of 15 IU/L. On gross examination the testicular mass is soft and reddish brown. Microscopic examination shows cords and sheets of primitive cells with large nuclei. Which of the following is the most likely diagnosis?

Accepted Answer

Embryonal carcinoma — The embryonal carcinoma is likely to have an elevated AFP. Many malignant testicular neoplasms produce some detectable HCG, but this does not mean that choriocarcinoma is present.

Question 12

A 77-year-old man has a routine check-up. The only finding is slight nodularity of his prostate on digital rectal examination. Serum PSA is 6 ng/mL. A prostate biopsy shows prostatic intraepithelial neoplasia (PIN). Which of the following is the best medical care option to offer this man?

Accepted Answer

Monitoring PSA levels — PIN is a potential precursor of prostatic adenocarcinoma, but by itself does not warrant therapy.

Question 13

A 27-year-old man has complained of continuing 'jock itch' for the past year. On physical examination there are small whitish scaling patches on the skin of his perineum. A scraping shows Trichophyton rubrum organisms. Which of the following lesions is he most likely to develop?

Accepted Answer

Angiokeratoma — The chronic rubbing and scratching from this dermatophyte infection can result in epidermal hyperplasia and chronic inflammation.

Question 14

A subset of sexually active 30–45-year-old men are found to have a history of pelvic pain with enlarged, tender prostates on digital rectal examination. However, routine microbiologic cultures from prostatic secretions show no growth. Which of the following infectious agents is most likely to produce this condition?

Accepted Answer

Chlamydia trachomatis — C. trachomatis, the leading cause of non-gonococcal urethritis, is the most frequent form of prostatitis in young adult men. There is typically no history of chronic urinary tract infection.

Question 15

A 30-year-old sexually active man has experienced burning pain with urination for the past 5 days. There is a profuse yellowish urethral discharge. He is afebrile and is treated with ceftriaxone. He is most likely to be infected with which of the following organisms?

Accepted Answer

Neisseria gonorrheae — Gonorrhea is a common cause of urethritis in males. Culture of the purulent discharge is possible, but microbial culture of this fastidious organism is challenging, so molecular methods such as a DNA probe or PCR can be used for diagnosis.

Question 16

A term male infant is born with incomplete development of the dorsal aspect of the penile urethra, with the defect extending to the bladder, which is open onto the lower abdominal wall. Which of the following is the most likely diagnosis?

Accepted Answer

Epispadias — Epispadias is a rare congenital anomaly that may be mild or, as in this case, severe with a large open defect that must be repaired. The failure to close the bladder is termed exstrophy.

Question 17

A 35-year-old healthy man desires a permanent form of contraception and has a vasectomy performed with no complications. Which of the following is most likely to result from prior vasectomy?

Accepted Answer

Testicular torsion — Also called vasitis nodosa, a sperm granuloma results from a foreign body granulomatous reaction to extravasated sperm at the vasectomy site. The granulomatous reaction is typically not florid.

Question 18

A study documents testicular abnormalities in adult males with infertility, some having a patchy pattern of atrophy of testicular tubules. Which of the following infections is most likely to produce these findings?

Accepted Answer

Mumps virus — This is a very common childhood infection (when vaccinations are not done) resulting in orchitis as well as parotitis. The inflammation rarely causes enough damage to produce a significantly reduced sperm count if acquired in childhood. The virus tends to produce more testicular damage when adults are infected.

Question 19

A 21-year-old sexually active man is notified that his last sexual contact 3 weeks prior has a positive serologic test for syphilis. Which of the following findings is most likely to be indicative of his acquisition of this infection?

Accepted Answer

Penile chancre — This would be the typical finding for primary syphilis from recent infection by Treponema pallidum.

Question 20

A 40-year-old man has noted gradual enlargement of his scrotum, more on the right side, for the past 2 years. There is no pain. The right side is enlarged to three times the size of the left testis. This mass transilluminates. Ultrasound reveals a 5 cm thin-walled cystic fluid-filled area. Which of the following is the most likely diagnosis?

Accepted Answer

Hydrocele — A hydrocele is a fluid-filled sac that gradually enlarges. It represents fluid collection between the parietal and visceral layers of the tunica vaginalis. If congenital, it is the result of failure of the processus vaginalis to obliterate.

Question 21

A healthy 17-year-old circumcised adolescent has pearly penile papules noted at the edge of the glans penis. There is no erythema or urethral discharge. He is not sexually active. Which of the following is the most likely diagnosis?

Accepted Answer

Normal variation — This is really a normal variation, but some patients may be concerned when they notice that other men do not have them.

Question 22

A 55-year-old man has experienced pain with urination for the past week. His prostate is slightly enlarged and mildly tender. Temperature is 37.5°C. WBC count is 12,910/microliter. Urine culture grows 100,000/mL E. coli. Serum PSA is 7 ng/mL. He improves with antibiotics but the condition recurs 5 times in the next 6 months. Which of the following diseases is he most likely to have?

Accepted Answer

Chronic bacterial prostatitis — Chronic bacterial prostatitis should be considered in men who have a history of recurrent bacteriuria. A chronically infected prostate can serve as the source of pathogens for recurrent UTIs. E. coli is a typical organism associated with urinary tract infection. The PSA can be slightly elevated with prostatic inflammation.

Question 23

A 95-year-old man has had difficulty with urination for the past 15 years. His prostate is diffusely enlarged. A transurethral resection shows glandular hyperplasia and a focus of grade 1,2 adenocarcinoma. Which of the following is the next most appropriate treatment plan?

Accepted Answer

Anti-androgen therapy — A Gleason 1,2 adenocarcinoma is so low grade that it is unlikely to progress. At least half of men his age probably have a focus of prostatic adenocarcinoma.

Question 24

A group of subjects is found to have Chlamydia trachomatis infection. Which of the following laboratory methods is most likely to be useful in diagnosis of C. trachomatis?

Accepted Answer

Enzyme immunoassay — This is the easiest and most cost-effective method, since C. trachomatis cannot be easily cultured by routine methods.

Question 25

A term male infant has an abnormal opening of the urethra onto the ventral surface of the penis for a distance of 0.3 cm. Which of the following is the most likely diagnosis?

Accepted Answer

Hypospadias — This is a congenital anomaly. Infection is a common complication, and partial urethral stricture may lead to urinary tract obstruction.

Question 26

A 45-year-old uncircumcised man complains of dysuria for the past week. On physical examination he has erythema and edema of the glans penis, with inability to retract the foreskin. Which of the following infectious agents is most likely to be associated with these findings?

Accepted Answer

Staphylococcus aureus — He has balanitis with paraphimosis, and staphylococcal or streptococcal infections are most likely to be present.

Question 27

A pathologic study is performed in men aged 50–100 years with PSA levels above 15 ng/mL who underwent prostatectomy. The sites of adenocarcinomas are mapped within the prostate. In which of the following regions are these adenocarcinomas most likely to arise?

Accepted Answer

Peripheral zone — Most prostatic adenocarcinomas arise in the peripheral zone posteriorly where they can potentially be palpated by digital rectal examination.

Question 28

A 22-year-old man notes the presence of a lesion on his penis for the past week. There is a solitary 0.7 cm diameter circumscribed area of ulceration on the dorsal aspect of his penis just proximal to the glans, with a firm erythematous base containing minimal grey exudate. Which of the following is the most cost effective method for laboratory diagnosis?

Accepted Answer

Darkfield microscopy — The findings suggest a chancre of primary syphilis, and a scraping of the lesion examined by darkfield microscopy will allow identification of spirochetes within minutes. However, other than in STD clinics, a darkfield microscope is unlikely to be found.

Question 29

A clinical study is conducted to determine survival following treatment for testicular neoplasms. Treatments included surgery, chemotherapy, and radiation therapy. Which of the following types of testicular neoplasm is most likely to have responded best to radiation therapy?

Accepted Answer

Seminoma — Seminomas are the most radiosensitive of testicular carcinomas.

Question 30

A 35-year-old man has a routine check of his health status. On physical examination the prepuce cannot be fully retracted from the glans of his penis. No other abnormalities are noted. Which of the following is the most likely diagnosis?

Accepted Answer

Hypospadias — Inflammation with scarring may prevent full retraction. There is an increased risk for phimosis and for balanitis in uncircumcised males.

Question 31

A double blind study involves men with urinary frequency and hesitancy for 5+ years. One group receives a pharmacologic agent designed to reduce the synthesis of dihydrotestosterone in prostatic stromal cells. The drug group has a statistically significant decrease in symptoms. Which of the following enzymes is this pharmacologic agent most likely to block?

Accepted Answer

5-alpha-reductase — Dihydrotestosterone (DHT) is synthesized from circulating testosterone by the action of 5-alpha-reductase type 2. It is DHT which binds to nuclear antigen receptors to stimulate cell growth and proliferation in the prostate.

Question 32

A 2-year-old boy has enlargement of the left testis. An ultrasound scan shows a 2 cm solid mass within the body of the testis. Serum AFP is 226 ng/mL. Which of the following neoplasms is this child most likely to have?

Accepted Answer

Teratoma — The most common testicular tumor under the age of 3 is a yolk sac tumor (infantile embryonal carcinoma). However, finding any testicular tumor in children is uncommon. The prognosis is good in most cases.

Question 33

A 43-year-old uncircumcised man has noted a lesion on his penis for the past year. On physical examination there is a 0.9 cm diameter rough, tan, firm, slightly raised area at the right lateral base of the glans, with difficulty in retracting the foreskin. Which of the following is the most likely diagnosis?

Accepted Answer

Bowen disease — This is squamous cell carcinoma in situ. If excised at this stage, it is curable. If not treated, it can progress to an invasive carcinoma.

Question 34

A 32-year-old has noted bilateral breast enlargement over the past 7 months. On physical examination there is bilateral gynecomastia. An ultrasound scan reveals a 1 cm solid mass within the body of the right testis. Serum testosterone is 550 ng/dL, estradiol 36 pg/mL, AFP 9 ng/mL, and HCG non-detectable. Which of the following neoplasms is this man most likely to have?

Accepted Answer

Leydig cell tumor — A Leydig cell tumor is most often seen in adult men. It may produce androgens and/or estrogens, leading to gynecomastia and/or feminization. It is histologically benign. Most are small in size.

Question 35

A 35-year-old man and his wife are unable to conceive for the past year. On physical examination his height is at the 80th percentile. Palpation of his scrotum reveals that testes are small. Breasts are slightly enlarged. Laboratory studies show oligospermia. Which of the following is the most likely problem leading to infertility in this man?

Accepted Answer

Klinefelter syndrome — His height, gynecomastia, and infertility are features of Klinefelter syndrome. About 1 in 500 males has a 47, XXY karyotype. Oligospermia does not preclude fertility; assisted reproduction techniques could be employed.

Male Reproductive System — Clinical MCQs

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