Chapter 13: Male Genitalia, Chapter 14: Female Genitalia , Chapter 15: Anus, Rectum & Prostate

A 28-year-old musician comes to your clinic, complaining of a "spot" on his penis. *He states his partner noticed it 2 days ago and it hasn't gone away. He says it doesn't hurt. He has had no burning with urination and no pain during intercourse. He has had several partners in the last year and uses condoms occasionally. His past medical history consists of nongonococcal urethritis from Chlamydia and prostatitis. His vital signs are unremarkable. On visualization of his penis there is a 6-mm red, oval ulcer with an indurated base just proximal to the corona. On palpation the ulcer is nontender. In the inguinal region there is nontender lymphadenopathy. What disorder of the penis is most likely the diagnosis?

A) Condylomata acuminata

B) Genital herpes

C) Syphilitic chancre

D) Penile carcinoma

Syphilitic chancre

A 20-year-old part-time college student comes to your clinic, complaining of growths on his penile shaft. They have been there for about 6 weeks and haven't gone away. In fact, he thinks there may be more now. He denies any pain with intercourse or urination. He has had three former partners and has been with his current girlfriend for 6 months. He says that because she is on the pill they don't use condoms. He denies any fever, weight loss, or night sweats. He is engaged to be married and has no children. On visualization of his penis you see several moist papules along all sides of his penile shaft and even two on the corona. He has been circumcised. On palpation of his inguinal region there is no inguinal lymphadenopathy.

Which abnormality of the penis does this patient most likely have?

A) Condylomata acuminata

B) Genital herpes

C) Syphilitic chancre

D) Penile carcinoma

Condylomata acuminata

A 29-year-old married computer programmer comes to your clinic, complaining of "something strange" going on in his scrotum. Last month while he was doing his testicular self-examination he felt a lump in his left testis. He waited a month and felt the area again, but the lump was still there. He has had some aching in his left testis but denies any pain with urination or sexual intercourse. He denies any fever, malaise, or night sweats. His past medical history consists of groin surgery when he was a baby and a tonsillectomy as a teenager. His parents are both healthy. On visualization the penis is circumcised with no lesions; there is a scar in his right inguinal region. There is no lymphadenopathy. Palpation of his scrotum is unremarkable on the right but indicates a large mass on the left. Placing a finger through the inguinal ring on the right, you have the patient bear down. Nothing is felt. You attempt to place your finger through the left inguinal ring but cannot get above the mass. On rectal examination his prostate is unremarkable.

What disorder of the testes is most likely the diagnosis?

A) Hydrocele

B) Scrotal hernia

C) Scrotal edema

D) Varicocele

Scrotal hernia

A 32-year-old white male comes to your clinic, complaining of aching on the right side of his testicle. He has felt this aching for several months. He states that as the day progresses the aching increases, but when he wakes up in the morning he is pain-free. He denies any pain with urination and states that the pain doesn't change with sexual activity. He denies any fatigue, weight gain, weight loss, fever, or night sweats. His past medical history is unremarkable. He notes that he and his wife have been trying to have another baby this year but have so far been unsuccessful despite frequent intercourse. He denies using tobacco, alcohol, or illegal drugs. His father has high blood pressure but his mother is healthy. On visualization of his penis, he is circumcised with no lesions. He has no scars along his inguinal area, and palpation of the area shows no lymphadenopathy. On palpation of his scrotum you feel testes with no discrete masses. Upon placing your finger through the right inguinal ring you feel what seems like a bunch of spaghetti. Asking him to bear down you feel no bulges.

A) Hydrocele

B) Scrotal hernia

C) Scrotal edema

D) Varicocele

Varicocele

A 48-year-old policeman comes to your clinic, complaining of a swollen scrotum. He states it began a couple of weeks ago and has steadily worsened. He says the longer he stands up the worse it gets, but when he lies down it improves. He denies any pain with urination. Because he is impotent he doesn't know if intercourse would hurt. He has had some shortness of breath with exertion. His past medical history consists of type 2 diabetes for 20 years, high blood pressure, and coronary artery disease. He is on insulin, three high blood pressure pills, and a water pill. He has had his gallbladder removed. He is afebrile but his blood pressure is 160/100 and his pulse is 90. His head, eyes, ears, nose, throat, and neck examinations are normal. There are some crackles in the bases of each lung. During his cardiac examination there is an extra heart sound. Visualization of his penis shows an uncircumcised prepuce but no lesions or masses. Palpation of his scrotum shows generalized swelling, with no discrete masses. A gloved finger is placed through each inguinal ring, and with bearing down there are no bulges.

A) Hydrocele

B) Scrotal hernia

C) Scrotal edema

D) Varicocele

Scrotal edema

(Scrotal edema is a generalized swelling of the scrotum due to a systemic illness. No discrete masses are palpated. In this case, with the history of diabetes, hypertension, and coronary artery disease, the symptom of weight gain, and the signs of crackles in the lungs and an extra heart sound, the patient is probably suffering from congestive heart failure.)

A 36-year-old security officer comes to your clinic, complaining of a painless mass in his scrotum. He found it 3 days ago during a testicular self-examination. He has had no burning with urination and no pain during sexual intercourse. He denies any weight loss, weight gain, fever, or night sweats. His past medical history is notable for high blood pressure. He is married and has three healthy children. He denies using illegal drugs, smokes two to three cigars a week, and drinks 6-8 alcoholic beverages per week. His mother is in good health and his father had high blood pressure and coronary artery disease. On physical examination he appears anxious but in no pain. His vital signs are unremarkable. On visualization of his penis, he is circumcised and has no lesions. His inguinal region has no lymphadenopathy. Palpation of his scrotum shows a soft cystic-like lesion measuring 2 cm over his right testicle. There is no difficulty getting a gloved finger through either inguinal ring. With weight bearing there are no bulges. His prostate examination is unremarkable.

What disorder of the scrotum does he most likely have?

A) Hydrocele

B) Scrotal hernia

C) Testicular tumor

D) Varicocele

Hydrocele

A 22-year-old unemployed roofer presents to your clinic, complaining of pain in his testicle & penis. He states the pain began last night & has become worse. He states it hurts when he urinates & he has not attempted intercourse since the pain began. He has tried Tylenol & ibuprofen without improvement. He has had 4 previous sexual partners and has had a new partner for the last month. She is on oral contraceptives so he has not used condoms. His temperature is 100.2. On visualization of the penis he is circumcised, with no lesions or discharge from meatus. Visualization of scrotal skin appears unremarkable. Palpation of testes shows severe tenderness at superior pole of normal-sized left testicle. He also has tenderness when you palpate the structures superior to the testicle through the scrotal wall. The right testicle is unremarkable. An examining finger is placed through each inguinal ring without bulges being noted with bearing down. His prostate examination is unremarkable. Urine analysis shows white blood cells & bacteria. What diagnosis of the male genitalia is most likely in this case?

A) Acute orchitis

B) Acute epididymitis

C) Torsion of spermatic cord

D) Prostatitis

Acute epididymitis

A 15-year-old high school football player is brought to your office by his mother. He is complaining of severe testicular pain since exactly 8:00 am. He denies any sexual activity & states that he hurts so bad he can't even urinate. He is nauseated & throwing up. He denies any recent illness or fever. His past medical history is unremarkable. He denies any tobacco, alcohol, or drug use. On examination you see a young teenager lying on the bed with an emesis basin. He is very uncomfortable & keeps shifting his position. His blood pressure is 150/100, his pulse is 110, and his respirations are 24. On visualization of the penis he is circumcised and there are no lesions and no discharge from the meatus. His scrotal skin is tense & red. Palpation of left testicle causes severe pain & patient begins to cry. His prostate examination is unremarkable. His cremasteric reflex is absent on the left but is normal on the right. By catheter you get a urine sample and the analysis is unremarkable. You send the boy with his mother to ER for further workup. What is the most likely diagnosis for this young man's symptoms?

A) Acute orchitis

B) Acute epididymitis

C) Torsion of spermatic cord

D) Prostatitis

Torsion of the spermatic cord

A 16-year-old high school junior is brought to your clinic by his father. The teenager was taught in his health class at school to do monthly testicular self-examinations. Yesterday when he felt his left testicle it was enlarged & tender. He isn't sure if he has had burning with urination & he says he has never had sexual intercourse. He has had a sore throat, cough & runny nose for last 3 days. His past medical history is significant for a tonsillectomy as a small child. His temperature is 100.8 and his blood pressure and pulse are unremarkable. On visualization of his penis, he is uncircumcised & has no lesions or discharge. His scrotum is red & tense on left & normal appearing on the right. Palpating his left testicle reveals a mildly sore swollen testicle. Right testicle is unremarkable. An examining finger is put through both inguinal rings & there are no bulges with bearing down. His prostate examination is unremarkable. Urine analysis is unremarkable. What abnormality of the testes does this teenager most likely have?

A) Acute orchitis

B) Acute epididymitis

C) Torsion of spermatic cord

D) Prostatitis

Acute orchitis

(Acute orchitis causes an inflamed, tender testicle. The scrotum will be red and tense. Orchitis is usually unilateral and often associated with viral infections such as mumps.)

A 45-year-old electrical engineer presents to your clinic, complaining of spots on his scrotum. He first noticed the spots several months ago, and they have gotten bigger. He denies any pain with urination or with sexual intercourse. He has had no fever, night sweats, weight gain, or weight loss. His past medical history consists of a vasectomy 10 years ago and mild obesity. He is on medication for hyperlipidemia. He denies any tobacco or illegal drug use and drinks alcohol socially. His mother has Alzheimer's disease and his father died of leukemia. On examination he appears relaxed and has unremarkable vital signs. On visualization of his penis, he is circumcised and has no lesions on his penis. Visualization of his scrotum shows three yellow nodules 2-3 millimeters in diameter. During palpation they are firm and nontender. What abnormality of the male genitalia is this most likely to be?

A) Condylomata acuminata

B) Syphilitic chancre

C) Peyronie's disease

D) Epidermoid cysts

Epidermoid cysts

(big pimples on balls)

Jim is a 47-year-old man who is having difficulties with sexual function. He is recently separated from his wife of 20 years. He notes that he has early morning erections but otherwise cannot function. Which of the following is a likely cause for his problem?

A) Decreased testosterone levels

B) Psychological issues

C) Abnormal hypogastric arterial circulation

D) Impaired neural innervation

Psychological issues

Which of the following conditions involves a tight prepuce which, once retracted, cannot be returned?

A) Phimosis

B) Paraphimosis

C) Balanitis

D) Balanoposthitis

paraphimosis

Induration along the ventral surface of the penis suggests which of the following?

A) Urethral stricture

B) Testicular carcinoma

C) Peyronie's disease

D) Epidermoid cysts

Urethral stricture

A tender, painful swelling of the scrotum should suggest which of the following?

A) Acute epididymitis

B) Strangulated inguinal hernia

C) Torsion of the spermatic cord

D) All of the above

Acute epididymitis

Strangulated inguinal hernia

Torsion of the spermatic cord

(medical emergency)

A young man feels something in his scrotum and comes to you for clarification. On your examination, you note what feels like a "bag of worms" in the left scrotum, superior to the testicles. Which of the following is most likely?

A) Hydrocele of the spermatic cord

B) Varicocele

C) Testicular carcinoma

D) A normal vas deferens

Varicocele

Which of the following would lead you to suspect a hydrocele versus other causes of scrotal swelling?

A) The presence of bowel sounds in the scrotum

B) Being unable to palpate superior to the mass

C) A positive transillumination test

D) Normal thickness of the skin of the scrotum

A positive transillumination test

You are examining a newborn and note that the right testicle is not in the scrotum. What should you do next?

A) Refer to urology

B) Recheck in 6 months

C) Tell the parent the testicle is absent but that this should not affect fertility

D) Attempt to bring down the testis from the inguinal canal

Attempt to bring down the testis from the inguinal canal

Francis is a middle-aged man who noted right-sided lower abdominal pain after straining with yard work. Which of the following would make a hernia more likely?

A) Absence of pain with straining

B) Absence of bowel sounds in the scrotum

C) Absence of a Varicocele

D) Absence of symmetry of the inguinal areas with straining

Absence of symmetry of the inguinal areas with straining

Frank is a 24-year-old man who presents with multiple burning erosions on the shaft of his penis and some tender inguinal adenopathy. Which of the following is most likely?

A) Primary syphilis

B) Herpes simplex

C) Chancroid

D) Gonorrhea

Herpes simplex

A 22-year-old architecture major comes to your office, complaining of severe burning with urination, a fever of 101 degrees, and aching all over. She denies any upper respiratory, gastrointestinal, cardiac, or pulmonary symptoms. Her past medical history consists of severe acne. She is currently on an oral contraceptive. She has had no pregnancies or surgeries. She reports one new partner within the last month. On examination you see a young woman appearing slightly ill. Her temperature is 100.3 and her pulse and blood pressure are unremarkable. Her head, ears, eyes, nose, throat, cardiac, pulmonary, and abdominal examinations are unremarkable. Palpation of the inguinal nodes shows lymphadenopathy bilaterally. On visualization of the perineum there are more than 10 shallow ulcers along each side of the vulva. Speculum and bimanual examination are unremarkable for findings, although she is very tender at the introitus. Urine analysis has some white blood cells but no red blood cells or bacteria. Her urine pregnancy test is negative. Which disorder of the vulva is most likely in this case?

A) Genital herpes

B) Condylomata acuminata

C) Syphilitic chancre

D) Epidermoid cyst

Genital herpes

A 42-year-old realtor comes to your clinic, complaining of "growths" in her vulvar area. She is currently undergoing a divorce and is convinced she has a sexually transmitted disease. She denies any vaginal discharge or pain with urination. She has had no fever, malaise, or night sweats. Her past medical history consists of depression and hypothyroidism. She has had two spontaneous vaginal deliveries and one cesarean section. She has had no other surgeries. She denies smoking or drug use. She has two to three drinks weekly. Her mother also has hypothyroidism and her father has high blood pressure and hypercholesterolemia. On examination you see a woman who is anxious but appears otherwise healthy. Her blood pressure, pulse, and temperature are unremarkable. On visualization of the perineum you see two 2- to 3-mm, round, yellow nodules on the left labia. On palpation they are nontender and quite firm. What diagnosis best fits this description of her examination?

A) Genital herpes

B) Condylomata acuminata

C) Syphilitic chancre

D) Epidermoid cyst

Epidermoid cyst

A 30-year-old paralegal analyst comes to your clinic, complaining of a bad-smelling vaginal discharge with some mild itching, present for about 3 weeks. She tried douching but it did not help. She has had no pain with urination or with sexual intercourse. She has noticed the smell increased after intercourse & during her period last week. She denies any upper respiratory, GI, cardiac, or pulmonary symptoms. Her past medical history consists of 1 spontaneous vaginal delivery. She denies tobacco, alcohol, or drug use. Her mother has high blood pressure and her father died from a heart disease. On examination of the perineum there are no lesions noted. On palpation of the inguinal nodes there is no lymphadenopathy. On speculum examination a thin gray-white discharge is seen in the vault. The pH of the discharge is over 4.5 and there is a fishy odor when potassium hydroxide (KOH) is applied to the vaginal secretions on the slide. Wet prep shows epithelial cells with stippled borders (clue cells). What type of vaginitis best describes her findings?

A) Trichomonas vaginitis

B) Candida vaginitis

C) Bacterial vaginosis

D) Atrophic vaginitis

Bacterial vaginosis

A 48-year-old high school librarian comes to your clinic, complaining of 1 week of heavy discharge causing severe itching. She is not presently sexually active & has had no burning with urination. The symptoms started several days after her last period. She just finished a course of antibiotics for a sinus infection. Her past medical history consists of type 2 diabetes and high BP. She denies tobacco, alcohol, or drug use. Her mother has high BP and her father died of diabetes complications. On examination you see a healthy-appearing woman. Her blood pressure is 130/80 and her pulse is 70. Her head, eyes, ears, nose, throat, cardiac, lung, and abdominal examinations are unremarkable. Palpation of the inguinal lymph nodes is unremarkable. On visualization of the vulva, a thick, white, curdy discharge is seen at the introitus. On speculum examination there is a copious amount of this discharge. The pH of discharge is 4.1 and KOH whiff test is negative, with no unusual smell. Wet prep shows budding hyphae.

What vaginitis does this patient most likely have?

A) Trichomonas vaginitis

B) Candida vaginitis

C) Bacterial vaginosis

D) Atrophic vaginitis

Candida vaginitis

A 55-year-old married homemaker comes to your clinic, complaining of 6 months of vaginal itching and discomfort with intercourse. She has not had a discharge and has had no pain with urination. She has not had a period in over 2 years. She has no other symptoms. Her past medical history consists of removal of her gallbladder. She denies use of tobacco, alcohol, and illegal drugs. Her mother has breast cancer and her father has coronary artery disease, high blood pressure, and Alzheimer's disease. On examination she appears healthy and has unremarkable vital signs. There is no lymphadenopathy with palpation of the inguinal nodes. Visualization of the vulva shows dry skin but no lesions or masses. The labia are somewhat smaller than usual. Speculum examination reveals scant discharge and the vaginal walls are red, dry, and bleed easily. Bimanual examination is unremarkable. The KOH whiff test produces no unusual odor and there are no clue cells on the wet prep. What form of vaginitis is this patient most likely to have?

A) Trichomonas vaginitis

B) Candida vaginitis

C) Bacterial vaginosis

D) Atrophic vaginitis

Atrophic vaginitis

A 28-year-old married clothing sales clerk comes to your clinic for her annual examination. She requests a refill on her birth control pills. Her only complaint is painless bleeding after intercourse. She denies any other symptoms. Her past medical history consists of two spontaneous vaginal deliveries. Her past six Pap smears have all been normal. She is married and has two children. Her mother is in good health and her father has high blood pressure. On examination you see a young woman appearing healthy and relaxed. Her vital signs are unremarkable and her head, eyes, ears, throat, neck, cardiac, lung, and abdominal examinations are normal. Visualization of the perineum shows no lesions or masses. Speculum examination shows a red mass at the os. On taking a Pap smear the mass bleeds easily. Bimanual examination shows no cervical motion tenderness and both ovaries are palpated and nontender.

What is the most likely diagnosis for the abnormality of her cervix?

A) Carcinoma of the cervix

B) Mucopurulent cervicitis

C) Cervical polyp

D) Retention cyst

Cervical polyp

An 18-year-old college freshman comes to your clinic, complaining of severe left-sided lower abdominal pain & foul yellow discharge. Pain began last night while she was having intercourse with her boyfriend. Afterward pain became more severe & discharge started. By this morning she had a fever of 101 degrees & walking was making pain worse. Only lying very still makes pain better. She has tried ibuprofen & acetaminophen without any improvement. She denies any nausea, vomiting, diarrhea, or constipation. She has had 2 past sexual partners. She uses birth control patch instead of condoms. She smokes a half pack of cigarettes a day & drinks four to five beers per weekend night. She denies any illegal drug use. Her temperature is 102 degrees & her pulse is elevated at 110. She is tender in left lower quadrant but has no guarding or rebound. Speculum examination reveals yellow purulent drainage from the os. On palpation there is cervical motion tenderness & left adnexa is swollen & tender. A urine analysis is unremarkable and urine pregnancy test is pending. What is the best choice of diagnosis for this adnexal swelling?

A) Ovarian cyst

B) Tubal pregnancy

C) Pelvic inflammatory disease

Pelvic inflammatory disease

A 34-year-old married daycare worker comes to your office, complaining of severe pelvic pain for last 6 hours. She states that pain was at first cramp-like but now sharp. Nothing makes pain better or worse. She has had no vaginal bleeding or discharge. She has had no pain with urination. She has had some nausea for last few days but denies vomiting, constipation, or diarrhea. She states she feels so bad that when she stands up she has fainted. Her PMH consists of 2 cesarean sections & appendectomy. She denies any tobacco, alcohol, or drug use. On examination you find a pale young woman who is obviously in a great deal of pain. She is lying on her right side with her eyes closed. Her blood pressure is 90/60 & pulse is 110. She is afebrile. She has bowel sounds & her abdomen is soft. The speculum examination reveals a bluish cervix but no blood or purulent discharge at the os. There is a mild amount of tenderness with palpation of cervix. The uterus is nongravid but right adnexal area is swollen & very tender. Urine analysis is normal & urine pregnancy test is pending. What type of adnexal disorder is causing her pain?

A) Ovarian cyst

B) Tubal pregnancy

C) Pelvic inflammatory disease

Tubal pregnancy

A 23-year-old waitress comes to your clinic complaining of severe pelvic pain radiating to right side. The pain began yesterday & getting much worse. She has had no burning with urination & denies recent sexual activity. She has no nausea, vomiting, constipation, diarrhea, fever, or vaginal discharge. Her last period was 3-4 weeks ago. Her PMH consists of severe acne depression & mild obesity. She smokes 1 pack of cigarettes a day, drinks 3-5 beers 2-3x a week, and denies illegal drug use. Her mother is diabetic and her father has coronary artery disease. On exam you see a mildly obese female in moderate distress. Her BP is 130/80 & pulse is 90. She is afebrile. On auscultation she has active bowel sounds. She has no rebound or guarding in any abdominal quadrant. Speculum examination shows no lesions on cervix and no discharge or bleeding from os. During bimanual exam she has no cervical motion tenderness, but her right adnexal area is swollen and tender. A urine analysis is normal & pregnancy test pending. What disorder of adnexa is most likely the diagnosis?

A) Ovarian cyst

B) Tubal pregnancy

C) Pelvic inflammatory disease

Ovarian cysts

A 24-year-old travel agent comes to your clinic, complaining of pain and swelling in her vulvar area. She states that 2 days earlier she could feel a small tender spot on the left side of her vagina but now it is larger and extremely tender. Her last period was 1 year ago and she is sexually active. She uses the Depo-Provera shot for contraception. She denies any nausea, vomiting, constipation, diarrhea, pain with urination, or fever. Her past medical history is significant for ankle surgery. Her mother is healthy and her father has type 2 diabetes. On examination she appears her stated age and is standing up. She states she cannot sit down without excruciating pain. Her blood pressure, temperature, and pulse are unremarkable. On visualization of her perineum, a large, red, tense swelling is seen to the left of her introitus. Palpation of the mass causes a great deal of pain. What disorder of the vulva is most likely causing her problems?

A) Bartholin's gland infection

B) Vulvar carcinoma

C) Secondary syphilis

D) Condylomata acuminata

Bartholin's gland infection

Which of the following represents metorrhagia?

A) fewer than 21 days between menses

B) excessive flow

C) infrequent bleeding

D) bleeding between periods

bleeding between periods

Jean has just given birth 6 months ago and is breast-feeding her child. She has not had a period since giving birth. What does this most likely represent?

A) Primary amenorrhea

B) Secondary amenorrhea

C) Oligomenorrhea

D) Dysmenorrhea

Secondary amenorrhea

Mrs. Jaeger is a 67-year-old who went through menopause at age 55. She has now had some vaginal bleeding. Which of the following should be considered?

A) Endometrial cancer

B) Hormone replacement therapy

C) Uterine or cervical polyps

D) All of the above

Endometrial cancer

Hormone replacement therapy

Uterine or cervical polyps

Abby is a newly married woman who is unable to have intercourse because of vaginismus. Which of the following is true?

A) This is most likely due to lack of lubrication.

B) This is most likely due to atrophic vaginitis.

C) This is most likely due to pressure on an ovary.

D) Psychosocial reasons may cause this condition.

Psychosocial reasons may cause this condition.

Which of the following is true of human papilloma virus (HPV) infection?

A) Pap smear is a relatively ineffective screening method.

B) It commonly resolves spontaneously in 1-2 years.

C) It is the second most common STI in the United States.

D) HPV infections cause a small but important number of cervical cancers.

It commonly resolves spontaneously in 1-2 years

Which of the following is true of the HPV vaccine?

A) Ideally it should be administered within 3 years of first intercourse.

B) It covers against every HPV type.

C) It can be used as adjuvant therapy in cervical cancer.

D) It can protect against anogenital lesions.

It can protect against anogenital lesions

A 36-year-old married bank teller comes to your office, complaining of pain with defecation & occasional blood on toilet paper. She states last week she had food poisoning w/ nausea, vomiting, diarrhea. She had runny stools but no black or bloody stools. Ever since her illness, she has severe pain with BMs. She tries to put off defecation as long as possible. Although she is having constipation she denies further diarrhea or leakage of stool. She has PMH of hypothyroidism & 2 spontaneous vaginal deliveries. She has had no other surgeries. She does not smoke & rarely drinks. There is no family history of breast or colon cancer. She has had no weight gain or loss, fever, or night sweats. On exam she is afebrile, with BP of 115/70 & pulse of 80. On abdominal exam she has active bowel sounds, nontender in all quadrants & no hepatosplenomegaly. Inspection of anus reveals inflammation on posterior side with erythema. Digital rectal examination is painful for patient but no abnormalities are palpated. Anoscopic examination reveals no inflammation or bleeding. What is the anal disorder that best describes her symptoms?

A) Anorectal fistula

B) External hemorrhoids

C) Anal fissure

Anal fissure

A 42-year-old house painter comes to your clinic, complaining of pain with defecation & profuse bleeding in the toilet after BM. 2 weeks ago, he was injured in a car accident. After accident he began taking prescription narcotics for pain in his shoulder. Since then he has had very few BMs. His stool is hard & pebble-like. His diet has not changed but he states that he is exercising less since accident. His PMH includes HTN & on a low-dose diuretic. He has family history of HTN, coronary heart disease, and DM but no cancer. He smokes 2 packs of cigarettes per day & quit drinking more than 10 years ago. He has had no recent weight loss or gain, fever, or night sweats. On exam he appears healthy; afebrile. His BP is 135/90 with pulse of 80. His cardiac, lung, & abdominal exams are normal. On observation of his anus you find a swollen bluish ovoid mass that appears to contain a blood clot. Digital rectal examination is extremely painful for patient. No other mass is palpated within the anus or rectum. What disorder of the anus is this patient likely to have?

A) Anal fissure

B) External hemorrhoid

C) Anorectal cancer

D) Internal hemorrhoid

External hemorrhoid

A 75-year-old retired construction worker comes to your clinic, complaining of bright red blood in the toilet for last several months. He has no pain with defecation but has occasional constipation. He states he eats a healthy diet with fruits & veggies & walks 2 miles a day. He has had a 10-pound weight loss over last 3 months. He denies fever or night sweats. His PMH includes high BP, CAD, and arthritis. He had an appendectomy. He smoked for 40 years, 2 packs a day, but quit 15 years ago. He used to drink alcohol. His father died in his 60s of a MI and his mother had breast cancer in her 70s. On exam he appears his stated age & sits comfortably on examining table. His BP is 150/85 & pulse is 88. He is afebrile. His cardiac, lung, & abdominal exams are normal. Visualization of anus shows no erythema, masses, or inflammation. Digital rectal examination elicits an irregular, firm mass on posterior side of rectum. After you remove your finger you notice frank blood on your glove. What anal or rectal disorder is this patient most likely to have?

A) Anal fissure

B) Internal hemorrhoid

C) Prostate cancer

D) Anorectal cancer

Anorectal cancer

A 60-year-old coach comes to your clinic, complaining of difficulty starting to urinate for several months. He believes problem is steadily getting worse. When asked he says he has a very weak stream & it feels like it takes 10 minutes to empty bladder. He has urge to go to bathroom more often than he used to. He denies blood or sediment in urine & pain with urination. No fever, weight gain or loss, or night sweats. His PMH includes type 2 DM and high BP treated with meds. He does not smoke but drinks a 6 pack of beer weekly. His mother died of a MI in her 70s & his father is currently in his 80s w/ high BP & arthritis. On exam you see a mildly obese male. His BP is 130/70 with HR of 80. He is afebrile & his cardiac lung & abdominal exams are normal. On visualization of anus you see no inflammation masses or fissures. Digital rectal examination reveals smooth, enlarged prostate. No discrete masses are felt. There is no blood on glove or on guaiac testing. An analysis of urine shows no RBC, WBC, 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

Benign prostatic hyperplasia (BPH)

A 24-year-old graduate student comes to your clinic, complaining of burning during urination & increased urinary frequency. He has had a low-grade fever (100.5 degrees) & does not feel well. He is worried about STDs because he had a drunken encounter 2 weeks ago & did not use a condom. He has had no recent weight loss or gain, or night sweats. His PMH includes knee surgery in HS & genital warts in college. He does not smoke but drinks 6 beers every Friday and Saturday night. He denies using any IV drugs but has tried marijuana in past. His father has high cholesterol but his mother is healthy. On exam he appears tired. His temp is 99.5 degrees and his BP is 110/70. His abdominal exam is normal. Visualization of anus shows no masses inflammation or fissures. Digital rectal exam reveals warm boggy tender prostate. No discrete masses are felt & no blood on glove. The scrotum & penis appear normal. Urinalysis shows moderate amounts of WBCs 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

Prostatitis

A 45-year-old African-American minister comes to your clinic for a general physical exam. He has not been feeling very well for about 3 months, including night sweats & chronic low-grade fever of 100-101. He denies upper respiratory symptoms, chest pain, nausea, constipation, diarrhea, blood in stool, or UTI symptoms. He has had some lower back pain. He has PMH of difficult-to-control high BP & high cholesterol. He has had no surgeries. His mother has DM and high BP. He knows his father died in his 50s, but he is unsure of exact cause. The patient denies smoking drinking or drug use. His temperature is & BP is 160/90. His HENT & neck exams are normal. His cardiac lung & abdominal exams are also normal. On visualization of anus there is no inflammation masses or fissures. Digital rectal examination elicits an irregular asymmetric hard nodule on otherwise normal posterior surface of prostate. Exam of scrotum & penis are normal. Lab 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

Prostate cancer

A 26-year-old woman comes to your clinic, complaining of leakage of stool despite normal, pain-free BMs. She denies blood in her stool or on toilet paper. She has had no recent episodes of diarrhea. Her PMH includes spontaneous vaginal delivery 3 months ago. She had a fourth-degree tear of perineal area (from vagina through rectum) that was surgically repaired after delivery. A few days later patient developed abscess in anal area that had to be incised & drained. She denies using tobacco alcohol or illegal drugs. She denies any weight gain or loss, fever, or night sweats. She is still breast-feeding without problems. On exam you visualize a small opening anterior to anus with some surrounding erythema. There is not a mass or other inflammation on inspection. Digital rectal exam reveals smooth rectal walls with no blood. She has no pain during the rectal exam. Bimanual vaginal exam is also normal.

What anal or rectal disorder is the most likely cause of her symptom?

A) Anal fissure

B) External hemorrhoids

C) Internal hemorrhoids

D) Anorectal fistula

Anorectal fistula

A 22-year-old nurse comes to your clinic, complaining of severe constipation and pain during defecation. She has also seen blood on the toilet paper. She states that she eats a healthy diet and does some light exercising. She is currently at the beginning of her third trimester of an unremarkable pregnancy. Her past medical history is unremarkable. Her mother has high cholesterol but her father is in good health. She does not smoke, drink alcohol, or use illegal drugs. She is married and expecting her first child. On examination she appears healthy and is afebrile, with a blood pressure of 110/60. Her abdominal examination reveals a gravid uterus but is otherwise unremarkable. On visualization of the anus there is a slight red, moist-appearing protrusion from the anus. As you have her bear down, the protrusion grows larger. On digital rectal examination you can feel an enlarged tender area on the posterior side. There is some blood on the glove after the examination. What disorder of the anus or rectum best fits this presentation?

A) Anal fissure

B) External hemorrhoids

C) Internal hemorrhoids

D) Anorectal fistula

Internal hemorrhoids

A 55-year-old retired property manager comes to your clinic, concerned that she may have a tumor in her rectum. When asked why, she states that after straining at a BM she felt a mass around her rectum. She denies any blood in her stool, black stools, or pain w/ defecation. She admits to having had chronic constipation for 30 years. She often uses laxatives to be able to have a BM. She denies any recent weight gain or loss, fever, or night sweats. Her PMH consists of hypothyroidism & she has had 2 spontaneous vaginal deliveries. Her mother died recently of colon cancer & her father has high BP but is otherwise healthy. She denies any smoking & only occasionally drinks alcohol. On exam she seems nervous. Her BP is 140/90 & pulse is 100. Her cardiac lung & abdominal exams are normal. On visualization of her anus, no inflammation masses or fissures are noted. When she is asked to bear down, you see a rosette of red mucosa prolapsing from anus. On digital rectal exam there are no masses & no blood is found on glove. What disorder of the anus or rectum is this likely to be?

A) Prolapse of the rectum

B) Internal hemorrhoids

C) Anorectal cancer

D) Prostate cancer

Prolapse of the rectum

A 50-year-old truck driver comes to your clinic for a work physical. He has had no upper respiratory, cardiac, pulmonary, gastrointestinal, urinary, or musculoskeletal system complaints. His past medical history is significant for mild arthritis and prior knee surgery in college. He is married and just changed jobs, working for a different trucking company. He smokes one pack of cigarettes a day, drinks less than six beers a week, and denies using any illegal drugs. His mother has high blood pressure and arthritis and his father died of lung cancer in his 60s. On examination, his blood pressure is 130/80 and his pulse is 80. His cardiac, lung, and abdominal examinations are normal. He has no inguinal hernia, but on his digital rectal examination you palpate a soft, smooth, nontender pedunculated mass on the posterior wall of the rectum.

What anal, rectal, or prostate disorder best fits his presentation?

A) Internal hemorrhoid

B) Prostate cancer

C) Anorectal cancer

D) Rectal polyp

Rectal polyp

Which is a sign of benign prostatic hyperplasia?

A) Weight loss

B) Bone pain

C) Fever

D) Nocturia

Nocturia

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

Ethnicity is a risk factor

(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.)

Important techniques in performing the rectal examination include which of the following?

A) Lubrication

B) Waiting for the sphincter to relax

C) Explaining what the patient should expect with each step before it occurs

D) All of the above

Lubrication

Waiting for the sphincter to relax

Explaining what the patient should expect with each step before it occurs

Dawn is a 55-year-old woman who comes in today for her yearly wellness examination. You carefully perform the rectal examination in the lithotomy position and feel a mass against the bowel wall which is firm and immobile. Which of the following is most likely?

A) Colon cancer

B) Hemorrhoid

C) Anal fissure

D) Valve of Houston

Colon cancer

Mr. Jackson is a 50-year-old African-American who has had discomfort between his scrotum 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

Prostatitis

An elderly woman with dementia is brought in by her daughter for a "rectal mass." On examination you notice a moist pink mass protruding from the anus, which is nontender. It is soft and does not have any associated bleeding. Which of the following is most likely?

A) Rectal prolapse

B) External hemorrhoid

C) Perianal fistula

D) Prolapsed internal hemorrhoid

Rectal prolapse

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

Proctitis