Benign Andrology Flashcards
Definition of subfertility
-The failure of conception after 12 months of regular unprotected intercourse.
-The chance of normal couples conceiving ~90% at 1y
-1o infertility: failure to achieve a first pregnancy
-2o infertility: means failure to achieve a subsequent pregnancy
Incidence and sex/gender causes of male subfertility
-Incidence:
=10-25% of couples at 1y (or 1:7 couples)
-Sex/Gender causes:
=25% Female factor
=25% Female & Male factor
=25% Male factor
=25% Unexplained
Causes of male subfertility
-Varicocoele (40%)
-Idiopathic (25%)
-T: Trauma / UDT / Orchitis, Chlamydia, hot baths
-E: Endocrinopathy decrease (Kallman’s, Prader-Willi, Pit adenoma); increase Prl sec pit tumour, adrenal tumour (CAH), excess oestrogens
-S: Systemic: CKD, liver cirrhosis, CF
-T: Tumours: decrease Pit insuffic/adenoma; Pit radiation ; increase Pit (Prl), CAH
-I: Idiopathic: functional sperm disorders
-S: Steroids & Drugs: (anabolic) steroids, EtOH, Chemo Rx, marijuana, smoking, sulfasalazine
-Genetic: Klinefelter’s (47XXY), XX male, XYY synd
-Obstructive: Congen absence Vas, Agenesis Sem vesicles, Epidid obstruct/infection
History of male subfertility
-Sexual history: freq of intercourse, duration, sexual function, lubricants, prev birth control
-Developmental: UDT/orchidopexy, age at puberty, mumps orchitis,
-Female partner: Age, periods, previous pregnancies, ?assessed by Gynaecology
-Family history: hypogonadism, UDT, CF
-Surgical/Medical: vasectomy, orchidopexy, torsion, varicocoele, ing hernia repair, excision epididcyst ; STIs, mumps
-Drugs: (anabolic) steroids, EtOH, ChemoRx, marijuana, smoking, sulfasalazine
-Social: smoking; EtOH
Examination in male subfertility
-General appearance:
=2ry Sexual characteristics, Hypogonadism, Gynaecomastia
-Genital:
=Varicocoele,
=Testis volume & consistency (Prader orchidometer)
=Epididymis: tenderness, swelling
=Vas: present / absent
=DRE: prostate normal /abnormal
Further investigation of male subfertility
-All men:
=Hx, O/E
=Semen Analysis
=Hormones: LH, FSH, Testosterone
-Selective:
=Genetic studies: if azo/oligospermia, atrophic testes with increased FSH
=TRUS: Inx low ejac vols (obstrucn/agenesis Sem ves; ejec duct obstrucn)
=Scrotal USS: varicocoele, testic disorders
=Vasography: to investigate possible obstruction
=Testic Bx: to Inx azoospermia
Management of male subfertility
-Treat Reversible Causes:
=Lifestyle: limit EtOH, smoking,
=Rx Infection: STIs
=Vit E (improve sperm function & successful IVF)
=Zinc, Folic acid: may increase sperm concentrations
=Rx ED: PDE5i (sildenafil, tadalafil)
-Surgery:
=Varicocoele ligation, embolisation
=Micro-surgery to Vas, epididymis (vaso-vasosostomy)
=Sperm extraction: TESE, MESA
=Assisted Conception (MESA, TESE, ICSI & IVF)
Examples of male sexual dysfunction
-Erectile Dysfunction (ED)
-Premature Ejaculation
-Penile Deformity (Peyronie’s)
Male sexual function: Erection, Emission & ejaculation
-Innervation: Point and Shoot.
=Parasympathetic nerves (S2-4 – Onuf’s nucleus) stimulate Erection “Point”
=Sympathetic nerves (T11-L2) stimulate Ejaculation and Detumescence “Shoot”
=Sensory information from the penis: dorsal penile and pudendal nerves.
-Brain: the key areas for sexual function are the medial pre-optic area and the paraventricular nucleus.
-These nervous signals activate the veno-occlusive mechanism of the corpura cavernosa.
-This increases arterial blood flow to the sinusoidal spaces, relaxation of the cavernosal smooth muscle and opening of the vascular space. The increase in the sinusoidal spaces presses on the tunica albuginea which reduces venous outflow.
-The rising intracavernosal pressure and contraction of ischiocavernosus muscles produce a rigid erection.
-After ejaculation art vasoconstriction (due to increased sympathetic activity) > detumescence
Erection requires an intact parasympathetic reflex at S2 and S3. Ejaculation requires an intact sympathetic L1 root.
Causes of erectile dysfunction
-Definition: Inability to attain/maintain erection sufficient for penetrative intercourse/ satisfactory sexual performance
-Incidence: 40% at 40y, 70% at 70y (incl mild-complete)
-Causes ED (Erectile Dysfunction):
=I: Inflammatory– Prostatitis
=M: Mechanical– Peyronie’s (penile curvature)
=P: Psychological– Depression, Anxiety, Stress
=O: Occlusive Vasc Factors– Art (HTN, smoking, DM, Hyperlipidaemia, PVD, IHD); Ven (impair veno-occl mech)
=T: Trauma– Pelvic fracture, Sp cord injury, penile trauma
=E: Extra factors– Surgery (prostatectomy, pelvic surgery)
=N: Neurogenic– CNS (MS, Parkinsons, Tumour, stroke); Sp cord (MS, spina bifida, tumour); PNS (pelvic surgery, EBRT, DM/EtOH Npathy)
=C: Chemical/Drugs– Antihypertensives, Antidepressants, Anxiolytics, Anti-androgens, Anti-Parkinsons, Statins, EtOH
=E: Endocrine– DM, Hypogonadism, HyperPrl, Hypo-/Hyper-thyroidism
Factors of ED favouring organic cause
-Lack of tumescence
-Normal libido
-Gradual, insidious onset with progressive worsening until no erection is obtained
present in all situations e.g. - during attempted intercourse with his regular or another partner, masturbation or in response to erotic stimuli
-Markedly diminished nocturnal erections and absence of morning erections
-Risk factor in medical history (cardiovascular, endocrine or neurological)
operations, radiotherapy, or trauma to the pelvis or scrotum
-Use of drugs associated with erectile dysfunction
-Cigarette smoking, a sedentary lifestyle, recreational drugs
Factors of ED favouring psychogenic cause
-Sudden onset of symptoms
-Decreased libido
-Good quality spontaneous or self-stimulated erections
-Major life events
-Problems or changes in a relationship
-Previous psychological problems
-History of premature ejaculation
-History of sexual abuse, marital or relationship stress
-Performance anxiety
Risk factors for ED
-Age
-Cardiovascular disease: obesity, DM, dyslipidaemia, metabolic syndrome, HTN, smoking
-Alcohol
-SSRIs, beta-blockers
History of erectile dysfunction
-Sexual: onset (sudden/gradual), duration of problem, Early morning tumescence, lossof libido, frequency of intercourse
-IIEF Questionnaire
-Medical: Vasc (DM, HTN, IHD, PVD, smoking), Neur (MS, Parkinsons, sp bifida);Depression etc
-Surgical (prostatectomy, pelvic surgery); Trauma (EBRT, penile trauma)
-Psychosocial: smoking, EtOH, stressors (work, relationships)
-Drugs: Antihypertensives, Antidepressants, Anxiolytics, Anti-androgens, Anti-Parkinsons, Statins, EtOH
Examination of erectile dysfunction
-CVS: BP, pp
-Abd: masses, AAA,
-Neuro: sensory, motor
-DRE: anal tone (S2-4), prostate in the presence of genito-urinary or protracted secondary ejaculatory symptoms
-Genitalia:
=Penis: phimosis, hypospadias, Peyronie’s plaques
=Testes: size, locus
