Bates’ Guide to Physical Examination and History Taking, 11th Edition
Chapter 13: Male Genitalia and Hernias
Multiple Choice
1. 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. He denies any surgeries. He smokes two packs of
cigarettes a day, drinks a case of beer a week, and smokes marijuana and occasionally crack. He
has injected IV drugs before but not in the last few years. He is single and currently unemployed.
His mother has rheumatoid arthritis and he doesn’t know anything about his father. On
examination you see a young man appearing deconditioned but pleasant. 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. There is no prepuce because of neonatal circumcision. 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
Ans: C
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Feedback: Primary syphilis causes a larger ulcer that is firm and painless. Syphilis is fairly
uncommon but does occur in the highly promiscuous population, especially when coupled with
illegal drug use. You should consider further questions and workup regarding HIV status.
2. 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. His past medical history is unremarkable. In addition to college, he works part-time for his father in
construction. He is engaged to be married and has no children. His father is healthy and his
mother has hypothyroidism. On examination the young man appears healthy. His vital signs are
unremarkable. 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
Ans: A
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Feedback: Warts are generally painless papules along the shaft and corona. They are likely to
spread and are caused by the human papilloma virus, transmitted through sexual contact. You
should discuss prevention of STIs with him. Although his girlfriend’s contraceptive pill protects
her from pregnancy, he and she are unprotected from sharing STIs. She should receive regular
Pap examinations and consider the HPV vaccine.
3. 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. He eats a healthy
diet and works out at the gym five times a week. He denies any tobacco or illegal drugs and
drinks alcohol occasionally. His parents are both healthy. On examination you see a muscular,
healthy, young-appearing man with unremarkable vital signs. 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
Ans: B
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Feedback: Scrotal hernias occur when the small intestine passes through a weak spot of the
inguinal ring. The examiner cannot get a finger above the hernia into the ring. Hernias are often
caused by increased abdominal pressure, such as in weight lifting. Patients who have a hernia on
one side often have another hernia on the opposite side. In this patient’s case, a right-sided hernia
was repaired as an infant.
4. 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 is a
married hospital administrator with two children. 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 examination you see a young man appearing his stated age with unremarkable
vital signs. 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. The left inguinal ring is unremarkable, with no bulges on bearing down. His prostate
examination is unremarkable.
What abnormality of the scrotum does he most likely have?
A) Hydrocele
B) Scrotal hernia
C) Scrotal edema
D) Varicocele
Ans: D
Chapter: 13
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Feedback: Varicoceles are varicose veins surrounding the spermatic cord, coming through the
inguinal ring. These veins feel like spaghetti and are often referred to as a “bag of worms.” The
increased number of veins affects the temperature of the testes, often causing infertility
problems. Like most varicose veins in any area, varicoceles can cause a nonspecific aching.
Although usually benign, a unilateral varicocele on the right or a varicocele which does not
resolve in the supine position deserves further workup.
5. 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
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