21 The Lower Urinary Tract and Male Genital System
1 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?
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(F) 2 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?
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(F) 3 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?
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(G) 4 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?
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(F) 5 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?
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(E) 6 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?
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(F) 7 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?
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(G) 8 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?
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(E) 9 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?
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(E) 10 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?
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(E) 11 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?
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(E) 12 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?
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(E) 13 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?
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(E) 14 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?
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