Wednesday, May 11, 2011

Step 3 Questions

A question from QBank:

A 29 year old man comes to the office because one of his 3 sexual partners recently had a Pap smear that showed dysplasia and koilocytic changes. Her physician recommended that all her sexual partners be evaluated. He has always been healthy and has never had any sexually transmitted diseases. All of his partners are "on the pill" so they do not use condoms. Physical exam is completely unremarkable. There are no visible leasions on his anogenital region. He is still very concerned that he has an infection that you cannot see. The most appropriate next step is to

(A) advise him to return if he develops any lesions

(B) apply vinegar to his penis and scrotum

(C) recommend that he use condoms during all sexual activity

(D) Send for a fluorescent treponemal antibody absorption serology

(E) take random biopsies of the penis

(F) tell him that he is healthy

Answer: (B)

Now I know that acetic acid (which is in vinegar) can bring out lesions caused by HPV, but I've only heard of it being used in women and symptomatic males. In fact, when I looked it up on uptodate and emedicine, there was nothing mentioned about vinegar being used to diagnose men. When I finally googled "vinegar" and "HPV", they said that vinegar could be used when a guy is complaining of symptoms of warts if no lesions can be seen, however it's not that useful because it's neither sensitive nor specific. Furthermore, I've never seen a little bottle of vinegar anywhere in clinic that could be used for this purpose... maybe you have to run down to the cafeteria to get it.

So are there any guys reading this who are willing to try a little experiment? Go to your PMD, tell them that your girlfriend has dysplasia and koilocytic changes and see if they apply vinegar to your penis and scrotum. If they don't, you could tell them that they're ill-prepared for Step 3.


  1. Yeah, but what if they try to do E instead? I mean, it's not like I have a spare.

  2. I didn't think there was anything they could do for males who were asymptomatic...
    I hope there aren't questions like that on step 1!

  3. Personally, I thought they were going for E as the fastest way to get him to stop bugging the doctor about it.

  4. Honestly, B involves way more shaving than is probably necessary. I can just see some CNA going for my throat when I put in that order. Double bonus- vinegar is a mild irritant! Three cheers for microabrasions!

  5. So B trumps C?

    Why do medical exams always have the weirdest bloody answers.

    Quite apt that the random word for this is 'studx'

  6. After the acetic acid is applied the use of a hand magnifier or even a colposcope if one is available can identify lesions too small to be seen with the naked eye. I don't recommend the use of a slit lamp however.

    Or you could be lazy and just give him a prescription for Imiquimod and boot him out the door.

  7. I would have thought it would be a combo of a and c - as the providers I know have not worried too much about partners of HPV postive ladies, as long as they are asymptomatic.