Physician Assistant Exam Review

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146 Penile disorders, BPH and a key to focus
Erectile Dysfunction (ED) Definition Inability to achieve or maintain an erection firm enough for intercourse Very common; prevalence increases with age May be vascular, neurologic, hormonal, medication-induced, or psychogenic Risk Factors Diabetes Hypertension Cardiovascular disease Smoking Obesity Low testosterone SSRIs, beta-blockers, thiazides, spironolactone Pelvic surgery (prostatectomy) Clinical Presentation Difficulty achieving or maintaining an erection Morning erections may be preserved in psychogenic ED Gradual onset suggests organic disease; sudden onset suggests psychogenic The question stem would likely describe a man with diabetes or vascular disease reporting difficulty maintaining erections Diagnostics Clinical diagnosis Basic labs: fasting glucose/A1c, lipid panel Serum testosterone (morning level) if hypogonadism suspected If unclear: nocturnal penile tumescence testing distinguishes psychogenic vs organic Consider cardiovascular evaluation because ED may precede coronary disease Treatment Lifestyle: weight loss, exercise, smoking cessation, reduce alcohol First-line medication: phosphodiesterase-5 inhibitors (sildenafil, tadalafil) Contraindication: nitrates (causes severe hypotension) Low testosterone → testosterone replacement when indicated Vacuum erection devices, penile injections (alprostadil), or penile prosthesis if refractory Exam Keys Gradual onset + vascular risk factors → organic ED Preserved morning erections → psychogenic ED First-line therapy → PDE-5 inhibitors Never combine PDE-5 inhibitors with nitrates Evaluate for underlying cardiovascular disease Hypospadias and Epispadias Definition Hypospadias: urethral meatus opens on ventral (underside) surface of penis Epispadias: urethral meatus opens on dorsal surface (less common) Congenital conditions due to abnormal urethral development Risk Factors Family history Maternal estrogen exposure Low birth weight or prematurity Associated with cryptorchidism Clinical Presentation Abnormal location of urethral meatus Ventral penile curvature (chordee) may accompany hypospadias Abnormal urinary stream The question stem would likely describe a newborn boy with a ventral urethral opening or abnormal urine stream Diagnostics Clinical diagnosis on newborn exam Do NOT circumcise — foreskin may be needed for repair Evaluate for undescended testes if present Treatment Surgical repair at 6–12 months Goals: normal urine stream, straight penis, normal appearance Epispadias often requires more complex reconstruction Exam Keys Ventral opening = hypospadias Do NOT circumcise before evaluation Repair at 6–12 months Associated with chordee and cryptorchidism Phimosis Definition Inability to retract foreskin over the glans Physiologic in young boys; pathologic from scarring or infection
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145 GU Neoplasms. Only the pieces you need to pass.
Bladder Cancer Definition Malignancy arising from the bladder urothelium Most common type is urothelial carcinoma Often presents with painless hematuria Risk Factors Cigarette smoking Occupational chemical exposures such as dyes and rubber Chronic bladder irritation or infection Cyclophosphamide therapy (chemotherapy agent) Clinical Presentation Painless gross hematuria is classic Irritative voiding symptoms such as frequency or urgency Flank pain if obstruction occurs The question stem would likely describe an older smoker with painless blood in the urine Diagnostics Urinalysis: hematuria Urine cytology: may detect malignant cells Cystoscopy with biopsy: diagnostic test of choice CT urography or renal ultrasound: evaluate upper tracts for masses or obstruction Treatment Transurethral resection of bladder tumor for diagnosis and initial management Urology referral for cystoscopy Advanced disease may require more extensive surgery or systemic therapy Ongoing surveillance cystoscopy due to high recurrence Exam Keys Painless hematuria in older patient = bladder cancer Smoking is strongest risk factor Cystoscopy with biopsy is required for diagnosis High recurrence rate requires surveillance Penile Cancer Definition Malignancy of the penis, usually squamous cell carcinoma Rare in the United States Risk Factors HPV infection Lack of circumcision with chronic smegma accumulation Phimosis Smoking Poor hygiene Clinical Presentation Painless penile mass, ulcer, or lesion May bleed or become foul smelling Inguinal lymphadenopathy in advanced cases The question stem would likely describe an uncircumcised man with a persistent penile lesion or ulcer Diagnostics Clinical exam and biopsy of the lesion HPV testing may be supportive but not required Imaging (CT or MRI) if concerned for nodal or metastatic spread Treatment Surgical excision is mainstay Topical or laser therapy for very superficial lesions Partial or total penectomy for invasive disease Radiation or chemotherapy for advanced or metastatic cases Exam Keys Uncircumcised male with chronic lesion = think penile cancer Strongly associated with HPV and poor hygiene Diagnosis requires biopsy Treatment is surgical excision Prostate Cancer Definition Malignancy of prostate gland, usually adenocarcinoma Most common non-skin cancer in men Often slow growing and asymptomatic early Risk Factors Age over 50 African American race Family history BRCA mutations Clinical Presentation Often asymptomatic May have urinary hesitancy, weak stream, or nocturia Bone pain suggests metastasis The question stem would likely describe an older man with urinary obstructive symptoms or elevated PSA Diagnostics
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144 GU Infectious disease and getting more questions right
Urethritis Inflammation or infection of the urethra, usually from a sexually transmitted infection (STI). Most common pathogens: Chlamydia trachomatis and Neisseria gonorrhoeae. Can also result from chemical irritation or catheter use. Risk Factors Multiple or new sexual partners Unprotected intercourse Prior STI history Men under 35 years old Clinical Presentation Dysuria, burning, or itching at urethral meatus Urethral discharge: Clear or mucoid → Chlamydia Thick yellow-green → Gonorrhea Urethral redness or irritation The question stem would likely describe a young sexually active man with dysuria and discharge after unprotected sex. Diagnostics NAAT (nucleic acid amplification test): Urethral swab or first-catch urine → most sensitive for Chlamydia and Gonorrhea. Urinalysis: Pyuria without bacteriuria (“sterile pyuria”) — WBCs in urine but no bacterial growth due to intracellular organisms like Chlamydia. Consider Trichomonas vaginalis or Mycoplasma genitalium if persistent symptoms. Screen for HIV and syphilis. Treatment Empiric therapy for both C. trachomatis and N. gonorrhoeae: Ceftriaxone 500 mg IM single dose plus Doxycycline 100 mg PO twice daily for 7 days If doxycycline contraindicated → Azithromycin 1 g PO single dose Treat all sexual partners. Abstain from sexual activity for 7 days after treatment. Retest at 3 months due to high reinfection rate. Exam Keys Dysuria + urethral discharge = Urethritis (STI until proven otherwise). Gonorrhea: Purulent yellow-green discharge. Chlamydia: Clear or mucoid discharge. Sterile pyuria: WBCs present but no bacterial growth → Chlamydia. Always treat both pathogens empirically. Urinary Tract Infection (Cystitis) Infection of the bladder (lower urinary tract) most often caused by Escherichia coli. Common in women due to short urethra and proximity to anus. Classified as uncomplicated (healthy, nonpregnant women) or complicated (men, pregnancy, diabetes, obstruction, catheters). Risk Factors Female sex, sexual activity, diaphragm or spermicide use. Postmenopausal estrogen loss, pregnancy, diabetes. Indwelling catheters or urinary obstruction (BPH, stones). Clinical Presentation Dysuria, frequency, urgency, suprapubic pain, hematuria, cloudy urine. No systemic symptoms (no fever, chills, or flank pain). If fever or costovertebral tenderness → think pyelonephritis. The question stem would likely describe a young woman with burning urination, frequency, and no fever. Diagnostics Urinalysis: Pyuria, positive leukocyte esterase, and nitrites (Gram-negative organisms). Urine culture: >100,000 CFU/mL of a single organism confirms diagnosis. Urine dipstick: Often sufficient in uncomplicated cases. Men or recurrent infections: Consider ultrasound to assess for obstruction or stones. Treatment Uncomplicated: Nitrofurantoin, Trimethoprim-Sulfamethoxazole (TMP-SMX), or Fosfomycin.
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143 Bladder disorders – How you’ll see them on your exam
Urinary Incontinence Involuntary loss of urine due to dysfunction of bladder storage, outlet control, or both. Classified as stress, urge (overactive bladder), overflow, functional, or mixed types. Very common in women after menopause or childbirth. Overflow type occurs more often in men with benign prostatic hyperplasia or neurologic disease. Clinical Presentation Stress Incontinence: Leakage with increased intra-abdominal pressure (cough, sneeze, laugh); common postpartum or post-menopause. The question stem would likely describe a postmenopausal woman who reports urine leakage when she exercises, laughs, or coughs. Urge Incontinence: Sudden, strong urge to void with inability to reach the toilet in time; caused by overactive detrusor muscle; nocturia is common. The question stem would likely describe a patient who feels an abrupt urge to urinate and cannot make it to the bathroom in time, often awakening several times at night. Overflow Incontinence: Dribbling and incomplete emptying due to bladder outlet obstruction or detrusor underactivity; seen with benign prostatic hyperplasia, neurogenic bladder, or diabetes. The question stem would likely describe an older man with benign prostatic hyperplasia who reports dribbling urine and a sensation of incomplete emptying. Functional Incontinence: Normal bladder function but impaired mobility or cognition (dementia, post-stroke). The question stem would likely describe an elderly nursing home resident with dementia who is unable to reach the bathroom before urinating. Mixed Incontinence: Combination of stress and urge symptoms; common in older women. The question stem would likely describe an older woman with both leakage when coughing and episodes of urgency. Diagnostics Urinalysis and urine culture: First step to rule out urinary tract infection. Serum BUN and creatinine: Assess renal function in chronic or severe cases. Post-void residual measurement: Less than 50 mL is normal. Greater than 200 mL suggests overflow incontinence. In older adults, a residual up to about 100 mL can be normal. Bladder stress (cough) test: With a full bladder, immediate leakage after a single cough confirms stress incontinence. Voiding diary (48–72 hours) and medication review: Identify transient or medication-related causes (e.g., diuretics, anticholinergics, calcium-channel blockers, opioids, alpha-blockers). Urodynamic studies: A small catheter measures bladder pressure and urine flow during filling and emptying; used to identify detrusor overactivity, impaired contractility, or outlet obstruction when the diagnosis is uncertain or before surgery. Neurologic evaluation: Consider if diabetic neuropathy or spinal cord involvement is suspected. Treatment Step 1: Behavioral and Lifestyle Measures Bladder training: Scheduled voiding at gradually longer intervals to increase bladder capacity and reduce urgency episodes. Timed voiding and fluid management; limit caffeine, alcohol, and bladder irritants. Kegel (pelvic floor) exercises for stress incontinence. Weight loss and smoking cessation. Topical vaginal estrogen for postmenopausal atrophic urethritis or vaginitis contributing to symptoms. Step 2: Pharmacologic Management (Type-Specific) Urge / Overactive bladder: Antimuscarinic agents (oxybutynin,
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142 The Comeback: From 222 to Passing the PANCE in One Giant Leap
Nichole got devastating news. A 222! She had a ton of ground to make up. More than I would have thought possible. But… She did it. She went up 137 points! Listen to her story.
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