Hello and welcome to the Physician Assistant Exam Review Podcast. This week we’re going to be covering GU and actually finishing up this week. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review. And this show, although it seems like it, is not about medical facts. It’s about how to think, study, and perform when you’re doing high-stakes exams. That’s the point of this.

We cover in every episode some medical content, but that’s really not the focal point. I use that as a backdrop so we can break it down and see how to recognize it on exams, how to organize it when you’re studying, and how to avoid common traps and things that cost you points on your tests. If you’re working hard, but your scores are not reflecting it, that’s what we’re here to address today. So although it’ll look like we’re covering GU, and we are, keep in mind the way that we do it. That’s where the real secret is. That’s where we’re really keying in to how to get your scores up, which is my ultimate goal. Understanding the content, remembering the content.

Facts are great, and I love facts, but that’s not really the point here. You have to have facts. That’s what PA school is all about. But what it’s even more about is thinking. What it’s more about is being able to problem solve. I’ve been talking a lot about that this week with people I work with, different areas, that the real individuals who stand out, the real individuals who are rock stars, whether those are techs, nurses, PAs, surgeons, whatever their roles, the people who really stand out and I want on my team are the people who can problem solve, the people who can think. It’s not just about regurgitating facts.

People who can regurgitate facts are useful, but they’re not the number one players. PA school is about building that foundation with facts, of course. But it’s what do you do with those facts? And that’s where I see the disconnect when it comes to test taking, when it comes to studying, when it comes to scores. That people bear down and they work harder and harder and harder on facts and less and less and less on thinking. So that’s really the focal point of this podcast, what we’ve been doing here for years, what I do inside the 33 Days to Pass the PANCE program, what I do in the email system, all of these places are designed to help you think, take initiative and connect the dots, not just have the dots, but actually connect them.

All right, with that being said, let’s jump in and finish up our discussion of GU and you’ll see how this goes along the way. We start with the priming question. Sudden testicular pain should make you suspect what condition? Painless scrotal swelling that transilluminates suggests what diagnosis? Bag of worms describes what condition? A young girl with a small bleeding mass at the urethral opening most likely has what disorder? Flank pain radiating to the groin with hematuria suggests what diagnosis?

All right, fantastic. So hopefully you had a shot at answering a few of those. Some of those should have been low-hanging fruit, although maybe if you haven’t hit this section yet, you may not know them. But hopefully you thought them through, made some solid guesses, maybe jotted them down if you’re at home or just thought about it if you’re out for a walk or in the car. We’ll get to the answers at the very end of the show where we’ll recap. Again, the point here is to help you lock in the information. That’s what the priming questions are for.

We’re setting the stage so as we go through the information, you have a place to hold it, almost like you’re building the shelves to store the information on as we come through with the hooks to hang it on. So we’re going to go through hydrocele, varicocele, testicular torsion, urethral prolapse, urethral strictures, and then finally nephrolithiasis before we hit our study tip. I’ll give you the answer to the priming questions, and then we will be done for today. Hydrocele is number one. It is a fluid accumulation surrounding the testes. It’s usually benign and painless. It’s more common in infants and older men.

This can be a congenital issue. Some risk factors would include trauma or an infection, and in adults you may see a hydrocele secondary to a testicular tumor. Clinical presentation: painless scrotal swelling. That’s going to be like the thing that should jump off the page. It’s a smooth, fluctuant mass. The testes itself may be difficult to palpate. You would think that the question stem wouldn’t describe something like a painless scrotal enlargement without systemic symptoms.

So no other symptoms. Patient’s not sick. Patient’s doesn’t have a fever. No other pains. It’s just this scrotal swelling. Diagnosis, it should transilluminate. I never really got this in PA school, but it’s such a not complicated issue.

We talk about transillumination. We’re literally just holding a flashlight up to an area, and if it glows, if you can see the light through it, that’s transillumination. So, we’ll do that a lot with laparoscopy, right? We’ll put the scope in, into an inflated abdomen, and so you can look around inside, but then one of the next steps immediately after putting in the scope is to put in the other port sites, to put in the other trocars. So, when you go to do that, a lot of times you will hold the light up from inside the abdomen, up against the anterior abdominal wall, and you’re transilluminating so that the other person who’s about to make an incision and put their other ports in can see that if there are any large vessels just beneath the skin. Same thing here. We’re holding a light up to the scrotum, and if light passes through, then that’s going to be an indication that we have a hydrocele.

It’s a fluid. It’s a clear fluid inside, so that makes sense, right? If it were a solid mass, you wouldn’t be able to transilluminate it. So then you’re going to move on to a scrotal ultrasound if the diagnosis is unclear or if you want to try to exclude a tumor. In an infant, you’re probably just going to watch this. It should resolve on its own from what I’ve been able to see. And it’s largely a non-issue.

In adults, if there’s some kind of underlying issue like a tumor or a mass, you’re going to want to deal with that. And if it’s symptomatic or persistent, you can do surgery. So again, this is a painless swelling that transilluminates. You’re going to be thinking hydrocele. If this occurs as new onset, you’re going to be making sure to rule out malignancy, but usually there’s no issue. Varicocele is next. This is a dilated group of veins within the scrotum.

This is caused by impaired venous drainage. And more common on the left-hand side. Risk factors would be things like an increase of intra-abdominal pressure or renal vein compression. For our clinical presentation, this is a dull, aching scrotal pain, worse with standing or exertion, right, which makes sense because then we’re going to increase that abdominal pressure even more. It improves when the patient’s laying supine, and it can feel like a bag of worms. Think about a back-filled group of veins, massive veins that you’re palpating, right? So it feels like a bag of worms inside of the scrotum.

This can be associated with infertility, so that’s a concern. And your question stem here is going to describe a younger man with infertility or an aching scrotum, right? I mean, this kind of, what else are they going to say? For diagnostics, this is a physical exam finding. This won’t transilluminate because you’re not going to be able to transilluminate through a mass of veins. The light won’t pass through. And you’re going to do a scrotal ultrasound with a Doppler if you’re not sure what’s going on here.

Treatment is going to be observation if asymptomatic, or you can surgically go in and ligate these veins. So again, it’s that bag of worms, but you’re not going to see the term bag of worms on your exam. I would be stunned and shocked and actually appalled if you saw that term. People say all the time, you know, there aren’t key terms anymore. There’s this, there’s that. Yes, I would doubt highly that you would see the term bag of worms on any of your exams. But here’s what you will hear.

You may hear that description of what you’re feeling as you palpate the scrotum, which should make you think of that. They’re just tools to help you link things together. Next we have testicular torsion. This is a twisting of the spermatic cord causing acute testicular ischemia. This is a surgical emergency. This is most common in adolescents and young adults. Risk factors here would be trauma or sudden movement, adolescence, and then a bell clapper deformity.

All this means, and I have a little trouble retaining this, but all the bell clapper deformity means is that normally the testis is sitting vertically. And in these patients, it’s sitting horizontally. And the key to that is it’s easier, it’s more mobile if it’s sitting horizontally. And this happens, I think it was somewhere in like less than 1% of males have this issue. And it doesn’t mean that they’re going to have a testicular torsion, it just means that the isn’t as tethered and is more mobile, so it’s more likely to torse than one without this issue. Clinical presentation, this is a sudden onset of severe unilateral testicular pain. You’ll often hear me talk about not memorizing symptoms, right?

Not memorizing things. Here’s a perfect place where I would not be memorizing. I mean, you can be, but I just picture this so well in my head and I can see it, right? If you suddenly cut off blood supply to one of the testes, you’re going to have sudden severe unilateral testicular pain, just like if you have a torsed ovary, right? These aren’t things that you sort of have trouble wrapping your head around. They’re pretty straightforward. You can get scrotal swelling and erythema.

Nausea and vomiting are common. You get a high riding testes with that horizontal lie like we talked about. Absent cremasteric reflex. So that’s where if you stroke the inside of the thigh, if I remember correctly, the testicles will pull upward. This is actually just a L1, L2 spinal nerve reflex. And that will be gone because that testicle won’t be able to move. So here our question stem is likely to describe something like a teenage boy with sudden severe testicular pain, maybe with some nausea, maybe with some vomiting, maybe there’s more to it if they want to give you a more dramatic example.

This is a clinical diagnosis. Do not delay surgery. This is a surgical emergency. We have no blood supply, right? So one of the few times at my hospital that we are not a trauma center, but one of the few times that we get surgical cases bumped is with a torsed ovary, right? Because it’s a surgical emergency. The tissue is dying.

There is a time limit when you have no blood supply. You can do a Doppler ultrasound, which will show that decreased or absent blood flow. If you have, you know, adequate time and you’re waiting on the OR and you want to prove it, that kind of thing. Normally, urinalysis helps distinguish from an infection. Treatment. This is immediate surgical exploration and detorsion. So you cut in and actually turn the testicle and actually just unwind it, just like we do with an ovary.

I do it much more frequently in my practice with ovaries because I do a lot more GYN than I do urology, but I have done this once or twice in my career. You can, if there is not the ability to take the patient to the OR, they can be manually manually detorsed without opening the scrotum, but it’s not really going to be nearly as effective. So this would be more like you have this problem and you have no way to get to the OR. You are on an island or something. You can try to manually detorse the ovary, but really not nearly as effective. Keys to your exam here, sudden severe testicular pain. You’re thinking torsed ovary until proven otherwise.

Why? Because it’s an emergency. You always want to be looking for those things that are emergencies that you can’t fix later, right? So you always want to err on the side of caution here in the sense that if you have sudden severe testicular pain, you’re thinking, I’m taking this patient to the OR. If you have an absent cremasteric reflex, that should really increase that, your suspicions. And again, you’ve got like a six hour-ish window, right? When we have ischemia, that’s kind of what we’re looking at.

All right, next we have the urethral prolapse. This is a circumferential protrusion of the urethral mucosa through the external meatus. That seems like a lot of big words, really not too complicated. You guys probably all have that kind of vocabulary. It just sounds like more than it is. This is a circumferential protrusion of the urethral mucosa through the external meatus. So you have the urethra protruding out through the external meatus.

This is pretty rare and is seen most commonly in prepubescent girls and postmenopausal women. I’ll get it. Don’t worry. Risk factors would be an estrogen deficiency, increased intra-abdominal pressure, so think coughing and constipation, and obesity. Clinical presentation. This is a visible round reddish or purple mass at the urethral opening. You can see some bleeding from there.

You can get dysuria or urinary frequency. It can also be painless. So there’s sort of a little bit of a wide array here. The question is, then, is likely to describe a young girl or postmenopausal woman with a small bleeding mass of the urethral opening. That’s really going to be the giveaway. If they don’t give you that, how else are you going to know? There’s no other way you’re going to know what this is unless they tell you that you can see at the meatus that tissue protruding and probably a little bit, maybe a little bleeding.

This is a clinical diagnosis. And you’re just going to want to make sure that you are making sure that this isn’t a sexual trauma issue or something like that. But the reality is it’s going to be a clinical diagnosis. Treatment is going to be topical estrogen cream, sitz bath, and then you can do a surgical excision if it’s persistent or severe. I do a lot of work with GYNs and urogyns, and we have done this on occasion where you trim back some of that tissue in a severe case.

Exam keys. So this is a young girl or postmenopausal woman with a urethral mass, right? Pretty straightforward. Initial treatment is going to be estrogens and surgery only if you really, really have a problem.

Next, we have urethral strictures. This is a narrowing of the urethra due to scarring, causing obstruction of the urinary outflow, and it’s more common in men. Risk factors here would be prior trauma to the area. Things like catheterization and cystoscopy would be risk factors, but you know those are it’s pretty pretty rare from just a straight catheterization or a straight cystoscopy. This is more like someone who’s had a catheter in for months and months, that kind of thing. Sexually transmitted infections can be a risk factor, and pelvic surgery can be a risk factor. A clinical presentation here would be a weak urinary stream, spraying or split stream.

So again, we’ve got a stricture in that urethra, so we’ve narrowed down that that tubing, essentially. Straining or urinary retention. Recurrent UTIs. I mean, again, just think about this. If the If the urethra is narrowed and you have trouble emptying, you’re going to increase your rate of UTIs. So the question stem would likely describe a man with prior catheterization and progressive difficulty urinating. Something like that.

But you’re going to have to keep this away from something like BPH, right? So those are what’s going to be compared. So when I’m studying, that’s what I’m thinking is how is this going to come up? What’s going to fool me here? Well, what this might fool me with, if we’re talking about urinary stream and outflow obstructions and those kinds of things, it’s going to be something like BPH, right? So I’m going to have to separate those two things. You can do a retrograde urethrogram or cystoscopy to look at this.

You can do a urethral dilation, an endoscopic urethrotomy, and then lastly, surgical reconstruction for severe cases. So, basically, this is a, you know, regardless, this is a surgical referral. If you’re a general practitioner.

Exam keys. A weak or spraying stream, a history of instrumentation, meaning something like a like long-term catheter use, would be a urethral stricture until proven otherwise. Diagnosed with retrograde urethrogram, treated with dilation or surgery. I’m just slowed down just a little because we’re already through so much of this today. We’re doing next, our last topic for today is nephrolithiasis, which is the formation of a stone in the kidney or urinary tract. I’m not even going to try and say it. I give up.

Most stones originate in the kidney and may migrate into the ureter. This can cause acute obstruction and severe pain. Your most common stone types that you get asked about are calcium oxalate. That’s the most common. Uric acid stone, struvite stone, which would be more infection-related, and then cystine, which is a genetic, pretty rare issue. You probably have an idea of risk factors for kidney stones. What are we talking about?

What are we thinking about here? Number one on the list is dehydration, right? If we don’t put enough fluid through the kidney, that can be an issue. High sodium or protein intake, prior kidney stones is always a risk factor. Always think about that. It’s always prior, the same condition, right? Obesity, gout, and then recurrent UTIs.

Our clinical presentation would be sudden onset of severe flank pain radiate into the groin, severe, severe pain. These tend to be incredibly painful, excruciatingly painful. This is colicky pain that comes in waves. If you think about the ureters, I’m just trying to think of how to describe this. The ureters, I forget what the word is, it’s not peristals, but they essentially peristals like the bowel does, and it compresses and moves the fluid along. And you can watch this when we do a laparoscopic surgery, when we do a hysterectomy, for example, we’re watching to see where the ureters are to make sure that they were nowhere near them when we’re ligating the uterine vessels, right? We don’t want to cut through the ureters.

And you can easily identify them in most cases because of that peristaltion, because of that movement that they have. So you can picture that colicky pain that comes in waves. If you have a stone and some sharp edges inside this small, tender tube, and every time you get that peristaltion of that tissue, it compresses around that. That’s where your pain is going to be coming in waves. You can get hematuria, obviously. It’s very common. Nausea and vomiting.

And the patients here just can’t get comfortable. They’re always on the move. They’re trying to find a spot that’s comfortable. They just can’t do it. Your question stems here. We’ll likely have something like a patient is pacing around. They’re in your office.

They won’t sit down, and they’ve got excruciating flank pain that goes into their groin. And then maybe some hematuria or something like that. The test of choice here is going to be a non-contrast CT of the abdomen and pelvis, so we can actually see that stone and get a location on it. Urinalysis might show hematuria, may or may not have crystals. If you can’t do a CT, like the patient’s pregnant, you can do an ultrasound. Treatment here is going to be pain control. Is going to be very important to the patient.

That you’re working with. So NSAIDs are first line and then opiates after that. Hydration, hydration, hydration is going to be next. If the stones are relatively small, so less than five millimeters, they may pass on their own. This doesn’t feel real good, but obviously it’s not a bad situation. So hydration is the key to that. After that is going to be a referral to urology, and they’re going to go in and get that stone one way or another.

Our keys here are flank pain radiating to the groin plus hematuria equals kidney stone. Non-contrast CT is our best diagnostic test, NSAIDs are first line pain. Struvite stones are recurrent UTIs. And that’s the thing that you should really, really be holding on to.

Fantastic. All right. Before we get into the answers to our priming questions, I want to go through today’s study tips. Today’s study tip, I’m finding maybe especially this time of year, I don’t know, that the anxiety game tends to be a big part of this. A big part, and I’m going to back away from the PANCE and talk about PA school for a second. And a big part of PA school is managing the anxiety. You know, if you see what people write online about PA school, it’s the overwhelm.

It’s not even that the material is incredibly difficult. It’s hard. It’s absolutely hard. But it is not, you know, organic chemistry. It is not differentials. It is not crazy hard. It’s difficult.

It’s the volume. It’s the mass of information. There’s so much to learn, so much to do, so much to know. And then there’s always more and then more and then more. And the anxiety builds and builds because there’s no end point. And that’s what makes it really tough. One way to help with that is to think about PA school as instead of looking at the whole picture and how much you have to do and how hard it is.

And then you have this and then you have that. And then you have something else right on the heels of that. Then you have another test. And it can be overwhelming. And a lot of times that makes us want to stop. Or do something that’s not helpful, like watch TV or drink or play video games or do things that aren’t going to move us forward. One way to beat that, one way to reframe that is to look at the entire thing like a series of 24-hour games.

What can I do in 24 hours to move the ball down the field? What can I do right now? What can I do today to get me towards my goals? Because obviously you’re not going to do everything. You can’t. There’s way too much. It’s kind of like saying I’m going to go to the gym and I’m going to do all of it today.

Right? You can’t do that. It’s going to take months, weeks to months to get to where you want to go. And it’s the same thing here. Obviously there’s a structure. Obviously there’s a path. Obviously, thousands and thousands of people have gone through it before you.

So, the path works, but you can’t look at the whole thing. Not all the time, not all at once. You can from time to time to make sure that you’re making the progress you need to be making. But if you break it down and look at it like it’s a 24-hour game, what do I do with this 24 hours? And if you can win, and then you can win again the next day, and then you can win again the next day, things start to line up. For me, I run into trouble when I look at the bigger picture, and I start to put things off because I’m overwhelmed. I don’t want to look at something.

Or I think I have time when the reality is I don’t. You know, one of the things we do inside the 33 Days to Pass the PANCE program is it’s the smallest thing we do, and it’s funny because I see people on Reddit talk about passing it around and thinking it’s the whole program, and it’s like 1% or less of the program. But one of the things we do is I provide a study calendar for people taking their PANCE. So picture someone who’s failed the PANCE and has three months to get ready for the PANCE and they don’t know how to do this because it’s such a big, big thing. And all I do is I break it down into a 33 day schedule of what to do, what to spend time on each and every day. And it’s not complicated. But it’s one of the things I get a ton of feedback on as to how helpful it is.

Because it takes that huge overwhelm and breaks it down into day by day by day. And it works the same way in PA school. It’s just win the day. Because that’s all, honestly, it’s all you can do anyway. But it’s when you don’t win the day, it’s when you don’t move the ball down the field, it’s when you don’t do those things on a given day that the anxiety builds. Because you know it. Even if you don’t want to know it, you know it.

It’s in the back of your head building and building and building. But even if you didn’t get as far as you wanted to, even if you didn’t finish everything on the entire project, on the entire blueprint, if you moved forward about the things you said you were going to do on any given day, you get to go to bed and that anxiety clears out because you’ve done the work. You’ve done what you can do for that time, for that day. So a lot of times we talk here about how to study better, how to improve test scores, how to focus, how to look at exams. One of the big questions I get constantly is on anxiety management. And there’s so much, obviously, there’s so much more to go into on this topic. I mean, it’s a huge part of the 33 Days program.

There’s just a ton we can talk about. But a really solid reframe, a major, major one, is the 24-hour game.

All right, let’s move on and answer our our priming questions. Sudden testicular pain should make you suspect what condition? This should be pretty easy right now. Testicular torsion. Painless scrotal swelling that transilluminates suggests what diagnosis? Hydrocele. A bag of worms describes what condition?

Varicocele. Again we’re not going to see the term bag of worms. I’m just trying to drive it home here. A young girl with a small bleeding mass at the urethral opening most likely has what disorder? Urethral prolapse. Flank pain radiating to the groin with hematuria suggests what diagnosis? Nephrolithiasis.

Sweet. All right, great. If this episode helped, here’s the important, important piece. This is not about memorizing these facts. That’s not what we’re doing here. I want you to notice how to organize it, how we thought about it, how to compare things, how to move back and forth. That’s what we do here.

We’re not just handing out facts. You can get facts anywhere. That’s really, really not the point. We teach all of this in much more depth inside the 33 Days to Pass the PANCE program. We train you to study, the way you approach questions, the way you manage yourself on exam day, all of these things so that you get the points you deserve. If you’re working hard, but your scores aren’t reflecting of it, that’s the gap that we’re closing. That’s what we’re looking to help you to fix.

That’s where we’re trying to take every student and turn them into test taking monsters so that they are ready and prepared for how they’re going to be evaluated. You can learn more about the program and see if it’s a good fit for you at physicianassistantexamreview.com/33. The 2026 cohorts will be running in February, April and June for sure. As the year wears on, I will fill in the rest of those dates, but February, April and June for sure. Until next time, keep showing up, keep practicing the right way. And remember, this is a skill and skills can be trained and skills can be improved upon. So do not think it’s an IQ problem.

These tend to be skills and management problems. So that’s what we address here. Best of luck this week. Take care and I will talk to you again soon.