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Urology NTN > Andrology > Flashcards

Andrology Flashcards

1
Q

Definition of infertility

A

Failure to conceive after 1 year

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2
Q

Azoospermia:
i) Definition
ii) Incidence
iii) Causes Classification

A

i) No measurable sperm in ejaculate
ii) 1% of all men/ 10-15% of infertile male popuilation
iii) Non-Obstructive, Structural - Obstructive, Functional - Obstructive

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3
Q

Causes of Non-Obstructive Oligo/Azoospermia

A

Primary Testicular Failure
Chromosomal - Kinefelter’s, Y Microdeletion
Environmental - Smoking, Alcoholism
Heat - Varicocele, Fever
Post Orchitis
Undescended testis
Endocrine - Prolactin, Thyroid
Toxins - Chemotherapy, Oestrogens, Marijuana, Exogenous anabolic steroids, Cocaine.

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4
Q

Causes of functional/obstructive oligo/azoospermia

A

Functional
ED
BN Dysfunction/ Retrograde Ejaculation
Anejaculatio (SCI)

Obstructive
Vasectomy
Vasal Aplasia
Ejac Duct Obstruction - Congenital/Post infective

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5
Q

Male Infertility Assessment

A

History + Exam
Semen Analysis
Bloods:
Hormones - FSH/LH/Testosterone/Prolactin
Viral - Hep B, Hep C, HIV
Genetic Testing - Karyotype (If <10 million/ml), Microdeletions (Y) (If <5 million/ml), CFTR (If vas absent)
Imaging

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6
Q

Male Infertility:
History
Exam

A

Primary or Secondary Infertility
Partner - Age/Cycle/BMI/SH/Ix
PMH - Testicular history/Pelvic or groin surgery/ Mumps/ cancer/ Endocrine disorder/ Diabetic/ Febrile Illness
Sexual Function
Drugs - Chemotherapy/ steroids/ Recreational
SH/OH - Smoking/Alcohol/Laptops/Heated car seats/ mobile phones
FH

Sexual characteristics
Scars
Examin Genitalia - Testis (Size), Epidydmis (Present/Full), Vas, Varicocele

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7
Q

What is Johnson Score?

A

Johnson Score Histological Analysis of seminferous tubules. 10 being normal to 1 being acellular.

Score is also associated with testicular weight (lower weight/ lower score)

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8
Q

Hormone Evaluation in infertility

A

Check Prolactin if LH/Testosterone Abnormal

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9
Q

Rx for:
i) NOA
ii) OTA

A

i) Microtese + IVF (Sperm Retrieval)/ Hormonal therapy
ii)

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10
Q

Forms of OTA

A

Functional ( BN Dysfunction/Anejaculation)
Proximal - Ejaculatory Duct Obstruction
Distal - Testis/Vas/Epidydmis

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11
Q

Imaging Modality in Male infertility

A

If low ejaculate:
Testicular USS
TRUS

Findings TRUS:
DOAT - Normal SV/BN. May be ectasia
POAT - Dilated SV
BN Dysfunction - Normal SV/ BN Open
Anejaculatiion - Full SV

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12
Q

What is TURED

A

Transurethral Resection of Ejaculatory Duct
- TRUS Seminal vesicle aspirate (If sperm present the rules out EDO)
- Cystoscopic resection of ejaculatory ducts (20-30% Fertility) after giveing methylene blue into SV
- TR probe to ensure decompression of SVs

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13
Q

Surgical Mx in OTA

A

Proximal - TURED
Intra-Testicular - SSR - TESA
Epidydmal - Epidydmovasostomy ( Connecting Vas to Epidydmis ) or SSR (TESA or PESA)
Vas - Vasovasostomy / Epidydmovasostomy / SSR

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14
Q

Low Ejaculation Volume ( < 1.5 ml ) - Mx

A

Proximal/Functional Obstruction

i) Low Fructose / Acidic pH = EDO ( TURED )
ii) > 10 sperm in post ejaculation urine = RGE (Pseudoephidrine/Imipramine/Alkalanise urine)
iii) Normal pH/Fructorse = Anejaculation (Electro/Vibro Stimulation)

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15
Q

Hormone Profile in Non Obstructive Azoospermia
(FH/Testosterone/Testes/Semen)

A
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16
Q

Mx of NOA

A

**Reversible Causes Correct **
- Varicocele
- Smoking/alcohol/BMI/Drugs

Hormones
- Pulsatile LHRH (Hypogonadotrophic Hypogonadism)
- Dopamine Agonist (Hyperprolactinaemia)
- HCG / Clomid (Testicular Failure)

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17
Q

Varicocele
i) Define
ii) Semen Analysis
iii) Efficacy
iv) When to treat

A

i) Dilated, incompetent, veins of pampiniform plexus
ii) Low count, Motility, Quality
iii) If no other infertility factors - Pregnancy rate 36.4% post treatment. Improved TESE outcome, Reduced rate of DNA damage,
iv) EAU - Clinical varicocele, oligospermia, otherwise unexplained infertility.

18
Q

Peyronie’s Disease
i) What is peyronie’s disease?
ii) Disease associations
iii) Examination features

A

i) Define: Fibrous plaques within tunica albuginea -> Curvature/Erectile dysfunction
ii) Ax: Truma/?Repetitive micro-vascular injury/ CV Disease, Dupuytren’s Contracture
iii) Pain ( Active ), Hourglass deformity - ?Buckling, REsidual length (?is shortening going to be acceptable)

19
Q

Should you operate on painful penile curvature?

A

No - indicates active disease. Should wait 6 months beofre surgery and if angulation is stable.

20
Q

Treatment Options for Peyronie’s

A

Acute: ESWL (for pain), Traction (Vacuum/ Extender), Potassium Para-aminobenzoate
Stable: PDE5i, Intra-lesion injection (verapabmil, IFN-a, Collagenase clostridium histolyticum), Traction (Vacuum, Extender)

21
Q

Rx for Peyronie’s Disease with curature <30%

A

No treatment required. Only treat if >30% or if severe deformity but can consider traction devices

22
Q

Surgical Management of Peyronioe’s Algorithm

A
23
Q

Priapism
- Definition
- Types

A

Definition - >4o Erection in absence of stimulation despite orgasm
Types:
i) Low Flow (Ischaemia / Veno-Occlusive)
ii) High FLow (Non-Ischaemic/ Arterial)

24
Q

High vs Low Flow Priapism -> Features

A
25
Q

Causes of Priapism

A

Idiopathic
Haematological - SCD, Thalassaemia, MM, Haemodialysis etc.
Infections - Toxin mediated
Metabolic - Amyloid, Gout
Neurological - Syphilis, SCI, Cauda Equina, Stroke, SOL
Neoplastic - Prostate, Urethra, Testis, Bladder
Medication - Intracavernosal injection, alpha adrenergic antagonists, anticoagulant, psychoactive medication, B Blockers, Exogenous hormones, Recreational Drugs

26
Q

Mx of low flow priapism

A

i) < 48 hours
Penile Block. 19g needle (lateral shaft/glans), Sample for blood gas. Aspirate until blood is bright red. Flush corpora with normal saline. Phenylephrine (maximum 1000 micrograms). If fails distal shunt.
ii) 48-72 hours
As above. Except may need T shunt +/- Tunneling.
**iii) >72 hours **
May need acute prosthesis.

27
Q

How to give phenylephrine in priapism

A

1 ml vial containing 10 mg
Mix with 49 ml 0.9 % NaCl - > now containing 200 microgramls/ml
Ensure connected to cardiovascular monitoring
Administer 1 ml every 5 to 10 minutes
Maximum 1000 micrograms

28
Q

Types of shunt

A

Winter’s Shunt (Biopsy needle)
Ebbehej (No 11 scalpel)
T Shunt (No 10 scalpel then twist )
Tunnelled T Shunt

29
Q

Other considerations in ischaemic priapism:
i) Other investigations

A

Idipathic -> Chest X Ray ant CT AP
After emergency treatment -> MRI and Penile Duplex (If show perfusion then can have furhter washouts with shunt, If NO perfusion -> Insertion of implant)

30
Q

High Flow Priapism
i) Patho
ii) Mx

A

i) Lacerated cavernosal artery, Pernieal/genital trauma, Intravernosal Injections,
ii) Spontanoues resolution, Conservative Mx (Ice packs + Compression), Embolisation

31
Q

Stuttering Priapism:
Ix/Dx

A

Can herald impending full priapism
Related to - SCD, Drugs, Idiopathic

Need - Haematological, vasculitis, biochemical assessment. CTCAP to exclude malignancy.

32
Q

Penile Fracture
i) Classic history
ii)Examination findings
iii) associated history
iv) When do you image

A

i) Sound, Pain, Immediate detumescence
ii) Aubergine Penis, Butterfly pattern, Palpable defect, Haematuria
iii) Ax with - Recreational drugs/ alcohol, viagra, sexual position
iv) Image - clinical doubt (MRI Penis/ Penile Doppler)

33
Q

Penile Fracture Repair
i) incision
ii) choice of suture material
iii) Timing of intervention/ Intervention vs conservative

A

i) Circumferential Degloving, Ventral midline if medial injury, Transverse Scrotal for proximal injury
ii) 2-0 PDS to close defect
iii) Repair within 24 hours (note no SD between early or late repair) . 80% complication rate with managing conservatively versus 10 % in operative group

34
Q

Erectile Dysfunction
i) RFs
ii) Drug Causes
iii) Assessment + Ix

A

i) Cardiovascular risk factors -> Atherosclerosis. ED Preced CAD symptoms by 3 years.

35
Q

How does CVD manifest in ED

A

Endothelial Dysfunction in atherosclerosis -> Prevents Vasodilation during sexual stimulation preventing erections.

36
Q

erectile dysfunction
Drug Causes

A

Diuretics
Anti HTN
Psychiatric
H2 Antag
Hormones (Finasteride)
Cytotoxics.

37
Q

Erectile Dysfunction
Assessment

A

Penile deformities/ LUTS/ Hypogonadism/ Cardiovascular and neurological status

Vascular Exam/ Penile Exam/DRE, BP/HR

Ix - Hba1c, Testosterone (If Low LH/FSH/Prolactin), PSA if DRE abnormal

38
Q

Further ED Investigation:
Indications
Indication Modality

A

Indications
- Young (unexplained organic ED)
- Non responder to medical treatment
- Post perineal/pelvic trauma
- Peyronie’s disease pre-correction

Modality
- Penile doppler after PGE1 injection

39
Q

What is NPT?

A

Nocturnal Penile Tumescence:
Overnight study measuring erections

Normal: >2 erections at night with >60% rigidity for >10 mins

Helps differentiate between psychogenic and organic ED

40
Q

ED Mx

A

1) Lifestyle Modification
2) Dyslipidaemia/ HTN/ T2DM
3) Modify Pharmacology / Endocrine abnormality
4) PDE5i/ Vacuum/ Intracavernosal injections/Intraurethral Aprostadil
5) If fail -> Re-assess use of intervention/training/combination therapy
6) Penile Prosthesis

41
Q

i)Side effects of PDE5i
ii) MOA PDE5i
iii) PDE5i CI

A

i) Headache, Flushing, Dyspepsia, Nasal Congestion, Back Pain, Myalgia Dizziness,

Those in bold are worse with Tadalafil

ii) Works by potentiating NOS pathway -> preventing breakdown of cGMP to GMP (usually mediated by PDE5). cGMP is responsible for SM relaxation -> Vasodilation -> erection

iii) Nitrates - absolutely not, alpha blockers (hypotension if taken within 4o of PDE5i),

42
Q

Caverject?
Efficacy?
MOA?

A

i)Intracavernosal Alprostadil (PGE1)
Dose - 5-40 micrograms

ii) >70% response rate
Can also be given urethrally

iii) Bypasses NOS pathway and directly activated edenylate cyclase in SM -> Converting AMP to cAMP -> Decreases intraceullar calcium and causing SM relaxation -> vasodilation
Doesn’t require sexual stimulation

Urology NTN (14 decks)

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