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
  

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

• 
  

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.
  

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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Priming Questions

A 23-year-old with hallucinations and social decline for 8 months. What’s the most likely diagnosis?
A man disappears after trauma, later found living under a new name with no memory of his past. What disorder does this suggest?
A student feels detached, like he’s outside his body, but knows it isn’t real. What condition fits best?
A woman has seizure-like episodes with eyes closed and a normal EEG. What’s the most likely diagnosis?


Schizophrenia Spectrum
Definition/Overview

• 
  
• Disorders of distorted perception, thought, and behavior
  
• Core symptoms: delusions, hallucinations, disorganized speech/behavior, negative symptoms
  
• Exist along a time + mood spectrum
  

Clinical Presentation

• 
  
• Positive symptoms: hallucinations (auditory > visual), delusions (persecutory, grandiose), disorganized speech/behavior
  
• Negative symptoms: flat affect, anhedonia, avolition, alogia, social withdrawal
  
• Cognitive: impaired attention, executive function
  
• Onset: late teens to mid-30s; earlier in men
  

Spectrum Breakdown (time + mood = key)

• 
  
• 
  

  Brief psychotic disorder

  
  
  • 
    
  • Duration: <1 month
    
  • Sudden onset, often stress-related
    
  • Full recovery is common
    
  
  
  
• 
  

  Schizophreniform

  
  
  • 
    
  • Duration: 1–6 months
    
  • Same symptoms as schizophrenia
    
  • No functional decline required
    
  • ~⅓ recover, ~⅔ progress to schizophrenia or schizoaffective
    
  
  
  
• 
  

  Schizophrenia

  
  
  • 
    
  • Duration: ≥6 months (≥1 month active symptoms)
    
  • Requires functional decline (social/occupational)
    
  • Positive + negative symptoms
    
  • Chronic, worse prognosis
    
  
  
  
• 
  

  Schizoaffective disorder

  
  
  • 
    
  • Meets schizophrenia criteria + mood disorder (major depression or mania)
    
  • ≥2 weeks psychosis without mood symptoms
    
  • If psychosis only during mood episode → mood disorder with psychotic features (not schizoaffective)
    
  
  
  
• 
  

  Delusional disorder

  
  
  • 
    
  • ≥1 month fixed delusion
    
  • Functioning not markedly impaired
    
  • No other psychotic features
    
  
  
  

Labs, Studies, and Physical Exam Findings

• 
  
• Clinical diagnosis (DSM-5 criteria)
  
• Labs/imaging to rule out medical/substance causes: CBC, CMP, TSH, urine tox, neuroimaging if focal neuro deficits
  

Treatment

• 
  
• First-line: atypical antipsychotics (risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone)
  
• Acute agitation: haloperidol, lorazepam
  
• Clozapine: treatment-resistant schizophrenia (monitor CBC → agranulocytosis risk)
  
• Psychosocial: CBT, social skills, family therapy
  
• Hospitalization if danger to self/others
  

Schizophrenia Spectrum Timeline



Disorder
Duration
Key Features
Functional Decline
Mood Symptoms




Brief psychotic disorder
<1 month
Sudden onset, stress-related, recovery likely
No
None


Schizophreniform disorder
1–6 months
Same symptoms as schizophrenia
Not required
None


Schizophrenia
≥6 months (≥1 mo active)
Positive + negative symptoms
Required
None


Schizoaffective disorder
≥6 months

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