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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

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

25
Causes of Priapism
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
Mx of low flow priapism
**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
How to give phenylephrine in priapism
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
Types of shunt
Winter's Shunt (Biopsy needle) Ebbehej (No 11 scalpel) T Shunt (No 10 scalpel then twist ) Tunnelled T Shunt
29
Other considerations in ischaemic priapism: i) Other investigations
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
High Flow Priapism i) Patho ii) Mx
i) Lacerated cavernosal artery, Pernieal/genital trauma, Intravernosal Injections, ii) Spontanoues resolution, Conservative Mx (Ice packs + Compression), Embolisation
31
Stuttering Priapism: Ix/Dx
Can herald impending full priapism Related to - SCD, Drugs, Idiopathic Need - Haematological, vasculitis, biochemical assessment. CTCAP to exclude malignancy.
32
**Penile Fracture** i) Classic history ii)Examination findings iii) associated history iv) When do you image
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
Penile Fracture Repair i) incision ii) choice of suture material iii) Timing of intervention/ Intervention vs conservative
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
**Erectile Dysfunction** i) RFs ii) Drug Causes iii) Assessment + Ix
i) Cardiovascular risk factors -> Atherosclerosis. ED Preced CAD symptoms by 3 years.
35
How does CVD manifest in ED
Endothelial Dysfunction in atherosclerosis -> Prevents Vasodilation during sexual stimulation preventing erections.
36
**erectile dysfunction** Drug Causes
Diuretics Anti HTN Psychiatric H2 Antag Hormones (Finasteride) Cytotoxics.
37
Erectile Dysfunction Assessment
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
Further ED Investigation: Indications Indication Modality
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
What is NPT?
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
ED Mx
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
i)Side effects of PDE5i ii) MOA PDE5i iii) PDE5i CI
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
Caverject? Efficacy? MOA?
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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