Male Reproductive — USMLE Step 2 CK Notes
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The acute scrotum
This is the highest-yield decision in the system, and it is a two-way discrimination made at the bedside.
| Torsion | Epididymo-orchitis | |
|---|---|---|
| Onset | Sudden, often wakes the patient | Gradual, over days |
| Cremasteric reflex | Absent | Present |
| Prehn sign (elevation) | No relief | Relieves pain |
| Lie of testis | High, transverse | Normal |
| Doppler | Reduced flow | Increased flow |
| Action | Theatre now | Antibiotics by age group |
If the story is classic, do not order the ultrasound — it only delays salvage. Surgery includes bilateral orchidopexy.
Testicular mass
Painless, firm, non-transilluminating in a man aged 15–35 is cancer until proven otherwise.
- Markers before orchidectomy: AFP, beta-hCG, LDH
- AFP is never raised in pure seminoma — a raised AFP means non-seminomatous elements
- Radical inguinal orchidectomy. Never trans-scrotal, which seeds a different lymphatic field
- Offer sperm banking before treatment
Prostate
BPH: smooth symmetrical enlargement. Alpha-blocker for fast relief; finasteride shrinks large glands over months and halves PSA — double the value before interpreting. Avoid anticholinergics, which can precipitate retention.
Cancer: hard, nodular, asymmetric. Osteoblastic bone metastases. Screening is a shared decision from about 50, not a reflex, and is not offered when life expectancy is under 10 years.
Erectile dysfunction
Often the first sign of vascular disease, preceding coronary events by years — treat it as a cardiovascular risk flag. Review culprit drugs (thiazides, beta-blockers, SSRIs, finasteride). Never combine PDE5 inhibitors with nitrates.
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