Case 14 Flashcards
1
Q
What is the clinical relevance of the rectovesical pouch?
A
It is the most inferior portion of the pelvic cavity where fluid from trauma is most likely to collect in males.
2
Q
Describe the rectovesical pouch in males
A
It is a reflection of the pelvic peritoneum which dips behind the urinary bladder and rectum, and lines the back of the seminal vesicle and prostate.
3
Q
Describe the clinical relevance of the pouch of Douglas (rectouterine pouch)
A
In females it is where fluid is most likely to collect e.g. from trauma
4
Q
Describe the pelvic peritoneum in females
A
It starts from the superior border of pubic symphysis and continues over the urinary bladder, dips down into the vesicouterine recess and is reflected back up onto the funds and portion of the body of the uterus. It continues down the surface of the uterus to the posterior fornix. the pelvic basin of the rectouterine pouch, back onto the rectum and to the abdominal wall.
5
Q
Identify the 7 branches of the anterior division of the internal iliac artery
A
- Umbilical → Superior vesicle (bladder, urethra)
- Obturator → Towards obturator foramen
- Inferior vesicle (Male) / Vaginal (Female)
- Uterine → Uterus, cervix, vagina, uterine tubes
- Middle Rectal → Rectum
- Inferior Gluteal → Gluteal Region
- Internal Pudendal → Perineum (deep to levator ani)
6
Q
What arch attaches to and divides the obturator internus in 2?
A
The tendinous arch
7
Q
What is located in the urogenital hiatus in females?
A
Urethra and vagina
8
Q
What muscles make up the pelvic diapragm and pelvic floor?
A
Pelvic Diaphragm
Levator ani (iliococcygeus, pubococcygeous, puborectalis)
Ischiococcygeous
Pelvic wall
Piriformis
Obturator internus
9
Q
What is the puborectalis?
A
The puborectalis forms a sling around the rectal junction to create the anorectal junction, unless undergoing defecation.
10
Q
Describe the false greater pelvis
A
The false greater pelvis occurs from the iliac crest to the pelvic inlet and contains abdominal viscera, not pelvic.
11
Q
Describe the true lesser pelvis and pelvic inlet
A
The true lesser pelvis occurs from the pelvic inlet to the pelvic outlet and contains the true pelvic viscera.
The pelvic inlet is where the pelvic cavity begins.
12
Q
Describe the male pelvic viscera
A
Sperm travels into the pelvis from the testes through the ductus deferens along the bladder, underneath and into the prostate gland where it unites with the urethra. The male reproductive and urinary tracts merge, however in females they are completely separate.
The seminal vesicles sit behind the bladder and provide fluid for the sperm to travel within.
Main content – Distal Urinary, reproductive and digestive tracts
13
Q
Describe the female pelvic viscera
A
The fundus is in front of the uterine tube. The fallopian (uterine) tubes and the ovaries are not directly connected. Fimbriae (cilia) help to guide the eggs into the fallopian tube where fertilisation occurs, avoiding oocyte entry into the abdominal cavity.
14
Q
Describe the position of the uterus
A
The vaginal canal slopes posteriorly towards the rectum whilst the cervix and uterus curve anteriorly to sit over the bladder. The junction between the vagina and cervix is known as the angle of anteversion.
The junction between the cervix and uterus is known as the angle of anteflexion.
The opposite to anteflexed is retroflexed and the opposite to anteverted is retroverted. There is increased risk of prolapse with retroversion or retroflexion. Prolapse is where one or more of the organs in the pelvis slip down from their normal position ad bulge into the vagina.
15
Q
Describe the ligaments in females
A
Suspensory ligament - ovarian vessels to pelvic walls
ovarian ligament - ovary to uterus
Round ligament - passes through the inguinal canal and attaches to the external genitalia
16
Q
Describe the anal and urogenital triangle
A
The anal triangle and urogenital triangle are divided by an imaginary line between the ischial tuberosities.
The anal triangle contains the anal canal and external anal sphincter. It also contains a fat filled space with pudendal neurovasculature known as the ischio-anal fossae. It lies lateral to the anal canal.
The sacrotuberous ligament attaches the sacrum and the ischial tuberosities.
17
Q
Contents of the male deep pouch
A
Urethra urethra sphincter bulbourethral glands deep transverse perineal muscle perineal neurovasculature
18
Q
Contents of the female deep pouch
A
Urethra urethral sphincter vagina deep transverse perineal muscle perineal neurovasculature
19
Q
Muscles in the male and female superficial pouch
A
Bulbospongiosis muscle covers the (corpus spongiosum)
Ischiocavernosus muscle covers the corpus cavernous
Superficial transverse perineum
20
Q
Contents of the male superficial pouch
A
Penis - corpus spongiosusm contains the urethra
corpora cavernosa paired structures- crura attach to the ischiopbic rami
Scrotum containing the testes and spermatic cord (ductus deferens)
21
Q
Contents of the female superficial pouch
A
Clitoris -
corpus spongiosum attached to the perineal membrane
Corpora cavernosa paired structures - crura attach to the ischiopubic rami
main pubis, labia major and minor
22
Q
Describe the neurovasculature of the perineum
A
Pudendal nerve (S2-S4) - gives rise to the inferior rectal nerve and perineal nerve and its branches
23
Q
Describe the blood supply of the perineum
A
Internal pudendal artery which is a branch of the anterior division of the internal iliac artery
24
Q
Pelvic fistula and it’s causes
A
An abnormal connection via a tunnel-like hole between two epithelium-lined organs or vessels
Causes:
Obstructed/prolonged labour, severe inflammation due to infection, pelvic surgery, trauma
25
Prostate gland location and the 3 prostate glands
Superiorly - bladder
Inferiolaterally - levator ani
posteriorly - ampulla
anteriorly - pubic symphysis
1. Inner periurethral glands (opens directly into urethra)
2. Outer periurethral glands (ducts connect into urethra)
3. Main prostatic/external glands
Pale columnar epithelium and as you move towards the urethra they become more cuboidal and transitional like the urethra
Gland Secretions - acid phosphatase, citric acid and amylase
26
Arterial supply and innervation of the prostate gland
Arterial supply:
Inferior vesicle artery
middle rectal artery
internal pudendal
Innervation:
Sympathetic fibres originating T12-L3
Parasympathetic fibres originating S2-S3
27
Functions of Sertoli cells
Located in the seminiferous tubules
Respond to FSH to cause spermatogenesis
1. Attachment and reattachment of sperm to cells - guide towards lumen
2. Provide nutrients
3. Tight junctions between cells - provide safe, immunological environment
4. Fluid secretions - flush immotile sperm
5. Phagocytosis of dead sperm and residual cytoplasm
28
Steroidogenesis
Testosterone precursors are covered to testosterone or DHT via 5a reductase. They either bind to peripheral targets (active - 2%) or SHBG/albumin to act as a reservoir (inactive - 98%).
Testosterone or testosterone pre cursors are converted to oestrogen via aromatase
29
HPT Axis
The hypothalamus secretes GnRH which acts on the anterior pituitary gland. This the secretes FSH to act on Sertoli cells and LH to act on leydig cells. Sertoli cells cause spermatogenesis and produce inhibin which inhibits FSH via negative feedback.
Leydig cells release testosterone to act on the seminiferous tubules and peripheral targets.
30
Describe spermatogenesis
Spermatocytogenesis
Meiotic divisions - 4 haploid spermatids
Spermiogenesis
1. Golgi coalesce to form the acrosome
2. Mitochondria align and form the mid piece of the tail
3. Sertoli cells remove residual cytoplasm to form immature immotile spermatozoa.
Maturation at the epididymis
Closure of acrosomal binding sites to prevent hyperactivity
Sperm becomes motile
Storage at ductus deferens (approx 2-3 months)
31
Describe the composition of semen
60% seminal vesicle - thick alkaline fluid
20% prostate - thin milky fluid (citrate, zinc, PSA)
10% Bulbourethral gland - mucus
Semen enters the ampulla and then travels through to the ejaculatory duct, through the penile urethra and then deposited into the vagina.
32
Clinical Reasoning of breast lump
Fibroadenoma (Breast Mouse)
Highly mobile, smooth, painless, benign lump
Common in early 20s
Fibrocystic Changes
Multiple, tender, painful, benign lumps
Due to hormonal changes in week before menstruation
Breast Cyst
Fluid filled, painful lump
Common in pre-menopausal women (30s-50s)
Breast Abscess
Fluid filled painful lump - clinically indistinguishable from cysts due to infective symptoms - hot, swollen
Fat necrosis
Painless lump, erythema/bruising due to trauma
Lipoma
Several benign lumps - well circumscribed, soft, smooth, lobulated non tender. Found in breasts, abdomen, neck commonly
Breast Cancer
Lump with skin changes - tethering, nipple discharge, eczematous changes.
Peau d'orange - indicates secondary metastatic spread
Benign (smooth, regular borders, mobile)
DCIS - ductal lump, nipple discharge
LCIS - Abnormal cells in lobule - asymptomatic
Malignant (hard, irregular, fixed, skin/nipple changes)
Inflammatory carcinoma - red, hot, swollen breasts
Paget's disease - follicular, red, eczematous rash at nipple/areola with palpable nipple lump
Spread - direct to muscles, axillary spread, haematogenous
33
Breast Cancer modifiable and non-modifiable risk factors
```
Modifiable
Increasing age
large gap between menarche and menopause
Female
FH
Radiation
```
```
Non modifiable
Not breast feeding
nulliparous/first child over 30
COCP/HRT
obesity
sedentary lifestyle
```
34
Breast Cancer Triple Assessment
Specialist examination
Mammogram>40, ultrasound<40
Fine needle aspiration
35
Chemotherapy
2,3,4 weekly cycles combination drugs which target multiple signalling pathways to reduce resistance and attack heterogenous tumours
Adjuvant - after surgery to reduce relapse risk
Neo-adjuvant - before surgery to increase operability
Metastatic - palliative treatment only
Side effects:
Alopecia/rashes
GI disturbances - mucosal linings - diarrhoea/constipation/nausea
BM - reduced erythrocytes, platelet, leukocytes = reduced clotting = anaemia
36
Non-targeted anti cancer drugs
Alkylating agents - cyclophosphamide
cross link alkyl groups of guanine which stops DNA replication
Platinum agents - cisplatin
DNA inter and intra strand cross links stops DNA replication
Antimetabolites - methotrexate
inhibit DHFR enzyme - stops nucleotide synthesis
Anthracyclines - doxorubin
Inhibit topoisomerase II enzyme - stops DNA reannealing
inhibits DNA helicase
produces a reactive O2 radical species
Antimicrotubule agents
Vinca alkaloids - vincristine - stops mitotic spindle formation
Texans - docetaxel - inhibits mitotic spindle contraction
37
Targeted Cancer Drugs
Hormone antagonists - Tamoxifen (SERM)
Competitive inhibitor of ERs, forms a tamoxifen:ER dimer, binds to DNA - unstable complex
Protein Kinase Inhibitors - imatinib
Inhibit kinase domains which form the proliferative fusion protein that allows unregulated tumour division
38
Cancer Immunotherapy
1. Monoclonal antibodies
2. Cancer Vaccines - HPV
3. Immune checkpoint inhibitors - PD-1 antagonists - deactivate PD-1 receptors on T cells which tumours bind to to evade immune system
39
Ectocervix, Endocervix and cervical stroma microanatomy
Endocervix - columnar epithelium which is mucus secreting (low viscosity to allow sperm passage and ovulation) - connects uterine and vaginal cavities
Ectocervix -stratified sqaumous epithelium covers the ectocervix and projects into vaginal canal to vaginal fornices
Cervical stroma
lots of smooth muscle which decreases as you move distally down the cervix
very collagenous body for strength - pregnancy sphincter
40
Layers of the vagina
1. Stratified squamous epithelial mucosa (pale appearance as high in glycogen)
2. Lamina propria - elastic fibres and thin walled vessels
3. Fibromuscular layer - inner = circular fibres, outer - longitudinal
4. Adventita - fibrocollagenous tissue - thick elastic fibres, nerves and vessels
41
Describe the transformation zone of the cervix and vagina
change that occurs at puberty onset and during 1st pregnancy
replacement of the endocervical columnar epithelium to stratified squamous epithelium in vagina = squamous metaplasia
Squamocolumnar junction is located in the distal cervix at birth but with this change extends distally
3 cell types present
1. original squamous/columnar epithelium
2. metaplastic squamous cells
3. atypical epithelium - malignant potential (loss of regular stratified pattern/high nucleus to cytoplasmic ratio)
42
Carcinoma of the Cervix
Cervical intraepithelial neoplasia (CIN) = no invasions to basement membrane but malignant
Invasive cervical carcinoma - CIN breaches basement membrane - spread via blood and lymph vessels
43
Define Reproductive Cycle
The physiological changes that occur from conception to gestation through to partition
44
Define menstrual cycle
the cyclical changes in the ovaries where the ovum develops for ovulation and the uterus prepares for implantation, which results in either pregnancy or menstruation.
45
Define ovarian cycle
The cycle of follicle growth resulting in ovulation and corpus luteum formation.
46
Oestrogen and Progesterone production and roles
LH binds to theca cell LH receptors causes the conversion of cholesterol to progesterone to testosterone.
Testosterone diffuses to granulosa cells and is converted to oestrogen via aromatase.
Oestrogen
Increases endometrial and follicular growth and increases fallopian tube transport
Inhibits milk let down
Causes breast duct growth
Development of secondary sexual characteristics (breast and external genitalia)
Progesterone
Reduces endometrial growth, follicular growth and fallopian tube motility
Increases breast alveolar/lobular growth and milk secreion
PMS (progesterone withdrawal)
47
Follicular cycle of growth
1. Low oestrogen stimulates the hypothalamus to release GnRH and the APG to release FSH
2. Increased FSH causes follicular development
3. Increased oestrogen for 48 hours causes the LH surge
4. LH surge = ovulation - corpus luteum formation
5. CL releases progesterone and oestrogen until placenta can produce enough
6. If not pregnant, CL regresses and oestrogen and progesterone decreases
48
HPO axis
1. GnRh released by the hypothalamus
2. Acts on APG to release FSH and LH
3. Acts on the ovaries to release oestrogen or progesterone
49
Menstrual Cycle Frequency disorders
Primary Amenorrhea - absence of menses and SSC at 14
OR absence of menses with SSC at 16
Secondary Amenorrhea - absence of menses for 3-6 consecutive months
Polyamenorrhea = less than 24 days
Regular - 24-32 days
Oligomenorrhea - over 32 days
Amenorrhea - absent
50
Uterine Bleeding disorders
Menorrhagia - (>80ml) - measured by increased changing of tampons and pads
Metrorrhagia - Post-coital/intermenstrual/post menopausal bleeding
51
Dysmenorrhea
Normal to have headaches, diarrhoea nausea, cramps (due to imbalance of prostaglandins and leukotrienes - SM contractions and vasoconstriction). (more common in younger women who recently started menses)
```
Primary = no pelvic pathology
Secondary = underlying pelvic pathology
```
52
Investigations of menstrual disorders
```
Prolactin (high = APT)
FSH (high = ovarian failure)
Testosterone (high = PCOS)
TFT
Clotting factors (reduced = excess bleeding)
```
Further investigations - Ultrasound, Hysteroscopy, laparoscopy
53
Hormonal Changes during menstrual cycle
1. Menses (0-5) = Progesterone withdrawal
Endometrial shedding of functional zone (Stratum Compactum and Spongiosium)
2. Proliferative Phase (5-14) - Increase in oestrogen
Increased functional zone regeneration via basal layer, thin watery electrolyte rich secretion with high spinbarkeit for sperm passage, increased embryo transport speed in FT
3. Secretory Phase (14-28) = high in progesterone and oestrogen
reduced differentiation of epithelium to prepare for decidualisation
reduce endometrial growth
reduce FT transport speed
thick viscid secretions with low spinbarkeit to prevent sperm passage
54
Eating disorders impact on reproductive hormones
Low BMI - anorexia
stops GnRH secretions which disrupts HPO axis , reduces FSH/LH, reduces oestrogen and progesterone and stops endometrial thickening = no menstruation
High BMI - obesity
Increased basal oestrogen levels - no oestrogen decrease for FSH increase = low oestrogen levels = no FSH increase and follicular development = no endometrial thickening
55
PCOS impact on reproductive hormones
Increased LH on theca cells = increased testosterone levels, reduced FSH means no conversion to progesterone (reduced levels)
```
Diagnostic criteria:
1. Hyper-androgenism
2. Cystic Ovaries (caused by low progesterone)
3. Oligo/Anovulation
Linked to obesity in 50% of cases
```
56
Thyroid Disorders impact on reproductive hormones
Hyperthyroidism (High T3/4, low TSH)
Increased SHBG and LH - No significant LH surge - light, infrequent periods (oligo-ovulation)
Hypothyroidism (Low T3/$, high TSH)
ineffective blood clotting = irregular periods and menorrhagia
57
MofA, Advantages and Disadvantages of Male condoms
Male Condoms
Barrier method to ejaculate or pre-ejaculate preventing sperm meeting the ovum.
```
Advantages:
Easy to use
Effective
No side effects (latex allergy)
Some STI Protection
```
Disadvantages
Sensitivity loss
Interruption of Sex
Can break or slip off
58
MofA, advantages and disadvantages of caps and diaphragms
(Barrier) Dome-shaped rubber ring which fits into vagina between posterior fornix and behind the pubic symphysis to cover cervix. Spermicide is applied and must be left in 6 hours after having sex.
```
Advantages
Effective
No side effects
Direct control by women
Can be put in convenient time before sex
```
```
Disadvantages
Increase in UTI or cystitis rate
Not suitable if TSS history
Must be used with spermicides
Must be comfortable with self examination
```
59
MofA, advantages and disadvantages of female condoms
(Barrier)Loose sheath with inner ring with closed end in the vagina. Ring sits on the vulva and acts as a barrier to sperm.
```
Advantages
Some STI protection
No side effects
No spermicide need
Direct control by women
```
Disadvantages
Requires careful insertion
Can be noisy
Can interrupt sex
60
MofA, advantages and disadvantages of withdrawal method
Withdrawing penis before ejaculation
Advantages
Slight reduced risk of fertilisation
Use of spermicide increases reliability
Disadvantages
Very unreliable as pre ejaculate contains some motile sperm
61
MofA, advantages and disadvantages of spermicide
(Nonoxynol-9)
Inserted into the vagina prior to intercourse to alter vaginal pH and integrity of the sperm cell membranes.
```
Advantages
No side effects
Easy and simple to use
Provides lubrication
Enhances efficacy of barrier methods
```
Disadvantages
Increased risk of vaginal and urinary infections
Possible sensitivity, irritation, or allergy
Should not be used as sole contraceptive
62
MofA, advantages and disadvantages of LAM (lactational amenorrheic method)
Suckling infant reduces the release of gonadotrophins, which suppress ovulation but as suckling reduces, ovulation returns.
Advantages
Over 98% effective if:
Less than six months postpartum.
Amenorrhoeic- no vaginal bleeding after the first 56 days postpartum.
Fully breast-feeding day (at least four-hourly feeds) and night (at least six-hourly feeds).
```
Disadvantages
Less effective if:
Breast-feeding decreases e.g. fewer night feeds, use of formula
Menstruation resumes
More than six months postpartum.
```
63
MofA, advantages and disadvantages of Female Sterilisation
Tying or removal of tubes, sealing using diathermy to prevent re-joining of cut tubes.
Laparoscopy = abdominal access
Hysterectomy = vaginal access
```
Advantages
Highly effective
Permanent
No weight gain
No heavy periods – potential amenorrhea.
```
```
Disadvantages
Irreversible
Surgical procedure – local anaesthetic
No STI protection
Potential complications
```
64
MofA, advantages and disadvantages of Intra-uterine Devices
Prevents fertilisation primarily but also may prevent implantation and be spermicidal.
Nearly 100% effective
65
Natural Family Planning as a non-hormonal contraception method
Women abstain from sexual intercourse during their ovulary period and fertile window (5 days) - but sperm can live in the cervix for up to 9 days.
```
Detection of ovulation:
Increase in basal temperature (0.2C)
Sensitive breasts
Mood changes
Change to cervical mucus
Cycle length
Mid cycle ovulation pain, discharge, and bleeding
```
66
MofA, advanatages and disadvantages of Progesterone only hormonal contraceptives
(POP, Injectables, Implant)
Contains a third of progesterone as in COCP.
Affects ovulation via thickening of cervical mucus, thinning of endometrium and reducing fallopian motility.
```
Advantages
Very effective and safe - 12 hour window of protection
No oestrogen
Decreased risk of endometrial cancer
May relieve dysmenorrhoea or menorrhagia
Suitable for:
-Older women (up to 55yo)
-Smokers
-Diabetes / obesity
-Hypertension
-Migraine
```
```
Disadvantages
12 hour window of protection
Menstural disturbance
Breast tenderness
Worse acne
Mood changes
Headaches
Surgical procedure with implants
No STI Protection
```
Injectables:
Weight gain
Cant be removed
Delay to return to fertility (1 year)
67
MofA, advantages and disadvantages of combined oral contraceptives
(COCP, Ring, Patch)
Prevents ovulation by suppressing GnRH release by hypothalamus and pituitary glands, inhibiting sperm transport, thickening cervical mucus, thinning endometrium lining and reducing fallopian motility.
Advantages
Reliable and reversible
Relives dysmenorrhea and menorrhagia by 60%
Improves acne
Reduces risk of cysts, ovaria and cervical cancers, PID
Treatment of endometriosis
Relieves PMS
```
Disadvantages
Not suitable if:
Migraine with aura
Breast cancer
BMI >35 kg/m2
Hypertension
Multiple risk factors for CVD
Diabetes
No STI protection
```
68
Describe the types, MofA, advantages and disadvantages of emergency contraception
Prevention or delay of ovulation for 5-7 days if taken prior to the LH surge. Progesterone only which can be use dafter UPSI
Levonorgestrel (LNG) eg Levonelle
Taken as a Single dose
Within 72 hours. Available with a prescription or to buy.
Ulipristal acetate eg EllaOne
-Single dose which can be taken up to 120 hours after unprotected sex, but is only available with a prescription
Advantages
97-99% effective
Disadvantages
Side effect - nausea, vomiting, irregular short term cycle
Contraindication if current or suspected pregnancy
All women should take a pregnancy test
69
MofA, advantages and disadvantages of IU copper devices
Prevents implantation by thinning endometrium lining. Can be used as emergency contraception up to 5 days after UPSI.
Advantages
Almost 100% effective
Disadvantages
Contraindication in suspected pregnancy or acute pelvic infections.
70
Describe a vasectomy and its advantages and disadvantages
A small incision is made along the midline of the scrotum to remove/cut/tie part of the vas deferens (cute tubes should be sealed by cautery to stop rejoining). This means no sperm will enter the ejaculate - semen only.
Vasectomy success should be confirmed by doing via some analysis for azoospermia.
Advantages:
Effective and permanent
Minor, easy operation done at GP
no increased risk of CVD, Testicular or prostate cancer
```
Disadvantages:
Not easily reversible
Not immediately effective
Surgical procedure - potential complications
No STI protection
```
71
Stages of Sexual Response in females and males
Male
Arousal - Plateau - Orgasm - Refractory period and resolution (can go on to have second orgasm after refractory period).
```
Female
Less definitive sexual response
No refractory period
Can have long plateau but no orgasm
Can have multiple orgasms
Can have no plateau - straight to orgasm
```
72
Female Sexual Dysfunction definition and causes
Subjective dissatisfaction with the level or nature of sexual activity, involving one or more of the following:
Sexual interest/arousal disorder
Orgasmic disorder
Genitopelvic pain/penetration disorder
```
Causes:
Dyspareunia
- Arousal pain
- Sensitive external genitalia
- PID/Upper reproductive tract infection
-Endometriosis
- Vaginismus (invol.contractions)
```
Reduced desire
- psychological
- hormonal* (reduced androgens = reduced libido)
Reduced arousal
- vascular (reduced blood supply = clitoral erectile dysfunction)
- CNS/PNS damage
- Hormonal*
```
Additional:
medication
chronic pain/illness
pregnancy
post partum
```
73
Management of Female sexual dysfunction
Non-pharmacological:
- CBT - physiological cause
- Lifestyle changes - reducing obesity, alcohol and smoking
- Pelvic floor exercises
- Medical devices - vaginal dilators
Pharmacological:
- Androgens
- Oestrogen
- Sildenafil (PDE-5 inhibitor)
74
Penile Erection and Ejaculation physiology
Erection
1. NO binds to guanyl cyclase (GTP to cGMP)
2. increased cGMP = decreased intracellular Ca = SM relaxation
3. Blood fills spaces - dialled pudendal arteries = increased BP of corpus cavernosum which causes veins to collapse = trapping of blood
4. Blood trapping limits tunica expansion - increases SBP - erection
Ejaculation - sperm deposition (not the same as orgasm = rhythmic contractions, increased HR and RR associated with ejaculation)
1. Emission
Sperm flow from distal epididymis - ductus deferens - ejaculatory duct (seminal fluid secreted here)
Internal urinary sphincter closes at neck of bladder to prevent sperm entry
2. Expulsion
external urinary sphincter relaxes in deep perineal pouch
striated muscles contract to expel ejaculate
(innervation - somatic pudendal nerve S2-4)
75
Male sexual dysfunction definition and causes
The persistent inability to initiate or sustain penile erection for sufficient sexual activity
Causes
- Psychogenic - young men with poor relationship/sexual experiences
- Vasculogenic - penile artery atherosclerosis
- Neuro - CNS/PNS damage, spinal cord injury
- endocrine - reduced testosterone = primary/secondary hypogonadism
increased prolactin = hyperprolactinaemia
- iatrogenic - antihypertensive drugs prevents increased BP for erection, recreational drugs (cannabis) reduce NO, alcohol/opiates reduce testosterone
76
Male sexual dysfunction management
Non-pharmacological
- CBT - psycho
- Lifestyle changes (reduced alcohol, obesity, smoking, drug use)
- Associated disease screening
Pharmacological
- Sildenafil - PDE-5 inhibitor (Viagra) - increases cGMP = increased SM relaxation
(NOT for use if CVD, diabetes or any nitrate meds)
- Prostaglandin E injection - increases SM relaxation
- Penile implant
- Vacuum erection device
77
Transmission of Chlamydia Trachomatis, Neisseria gonorrhoea and treponema palladium
Unprotected sexual intercourse
Sharing sex toys
Mother to fetus
78
Methods to reduce STI spread
regular HIV testing
increased education
Correct and regular condom use
Annual/new partner (<25) chlamydia testing
79
Chlamydia trachomatis clinical features and treatment
Most prevalent = M -19-24, W = 16-19
```
Clinical Features:
Asymptomatic (50% Men, 70% women)
Penile/vaginal discharge (cottage cheese)
Dyspareunia
Dysuria
Metrorrhagia
Testicular pain
Epididymitis/Proctitis/salpingitis/cervicitis
```
Mother - fetus = neonatal opthalmia
Repeated infections can cause infertility and rarely in homosexual men lymphogranuloma venereum infection
Treatment
5-7 day course oral doxycycline
80
Neisseria gonorrhoea clinical features and treatment
Most prevalent - 15-24yo
Clinical Features
Males - Urethritis (Penile discharge), dysuria
Females - Endocervical infection (Abnormal vaginal discharge), PID
Mother- fetus = neonatal opthalmia
Treatment
IM ceftriaxone and azithromycin
81
Treponema Palladium clinical features and treatment
Primary Syphilis - lesion at inoculation site around 3 wks after exposure which heals within 2-6 weeks
Secondary Syphilis - 6 weeks later red, eczematous rash on rest of body
80% latency, 20% tertiary syphilis - dementia (irrational, wild proclamations), gummata - inflammatory nodules which are locally destructive around the body)
Treatment
IM benzathene benzylpenecillin
82
Pappilomavirus infections
HPV - ds non-enveloped ds DNA virus, sexual transmission
HPV 6,11 responsible for anogenital warts (condylomata acumiate) in genital, perineal, perianal and anal regions.
HPV 16, 18 - responsible for genital, anal, mouth and throat cancers
Gardasil vaccine - HPV vaccine given to all 12-13 year olds to reduce incidence of anogenital warts and genital, anal, mouth and throat cancers
83
Step by Step Process of Fertilisation including polyspermy blocks
1) Capacitation (when sperm enters the female reproductive tract)
Uterine wall secretions remove glycoproteins and sterol groups from membrane to cause sperm hyperactivity and increased flagella action
2) Penetration of corona radiata
3) Attachment to zona pellucida
4) Activation - Acrosome reaction
In oocyte vicinity, release of hydrolytic enzymes
Acrosome binds to zona pellucida allowing sperm to penetrate ovum
5) Plasma membrane binding and sperm entry
6) Polyspermy blocks
Block 1 = only 200-300 sperm make it to the ampulla of the uterine tubes out of the 1x10(9) sperm in the ejaculate
Fast block - 2-3 seconds after fertilisation
Na channel opening = depolarisation of membrane to prevent sperm binding
Slow block - 10-60 seconds after fertilisation
Cortical reaction - release of lysozyme from the cortical granules prevents sperm dining to plasma membrane
Zona reaction - structural changes make ovum impenetrable
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Results of fertilisation
1) First meiotic division occurs prior to fertilisation (one polar body)
2) second meiotic division occurs after fertilisation resulting in 3 polar bodies (one is reabsorbed)
3) Male and female pro nuclei form
4) Pronuclei dissolve releasing genetic material
5) First cleavage division
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Male and female causes of sub-fertility
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Female
Ovulatory disorders (25%)
Tubal damage (20%) - non-latency, sterilisation
Uterine/peritoneal disorders (10%) - endometriosis, PID< fibroids
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Male
Pre-testicular - HPT axis, genetics
Testicular = impaired spermatogenesis - congenital (undescended testes), acquired (variocoele)
Post testicular - Ejaculatory/Erectile dysfunction, obstructive azoospermia
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Sub-fertility Initial Investigations
Investigate any couple who are having regular UPSI (2-3 times a week) for one year and have failed to conceive
Investigate earlier if known underlying issues, or if women under 35 with amenorrhea
Female
Mid luteal phase progesterone to check ovulation
Measure weekly serum FSH and progesterone if irregular cycles
Measure TFT if indicative of thyroid issues
Measure prolactin if symptoms
Male
Semen analysis - repeated 3 months later
Both
Full medical examination
Full medical, social and sexual history
Chlamydia screening
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Sub fertility Secondary Investigations
Female
Tubal patency tests
Hysterosalpingography/hysterosalpingo-contrast ultrasonography
Male
Any sperm abnormalities do, testicular biopsy, sperm culture, urogenital imaging, endocrine tests, microbiological tests.
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Emotional issues of assisted conception
Guilt/blame - pushes couple apart
Shared trauma/hope - brings couple together
Depression
Social family and friend relationships breakdown - jealousy of children etc
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Ethical and legal issues of assisted reproduction and use of embryos
Sperm donation
Donors must be between 18 and 41
Samples must be kept fresh/frozen for 180 days before use
All donors must be screened for serious infectious diseases
Donors are not paid for their contribution, only given loss of earnings
Egg Donations
Donors must be between 18 and 35
Can only be given loss of earnings
Donors whose eggs have been used for research and surrogacy can receive discounted IVF
Surrogacy - have legal parentage of the child which can be changed through court or adoption.
Sex selection - prohibited unless it is to avoid a serious gender related condition
Embryo research - all embryos must not be kept past the primitive streak appearing, and researchmust be involved in:
a) finding more effective contraception
b) infertility treatment advances
c) congenital disease causes
d) miscarriage causes
e) detecting chromosomal abnormalities before embryo implantation
Ethical Issues
Playing god
Non-malificience - destroying life
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Define pre-embryo, embryo and fetus
pre-embryo = Conceptus prior to implantation into uterine wall (day 0-12)
embryo - conceptus after complete implantation - most susceptible to teratogens
fetus - growth period between week 9 to birth
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Pre implantation stages
Day 1-2 = Cleavage (2-8 totipotent cells)
Day 3 - Morulla - 16 pluripotent cells
Day 4 - Blastocyst formation - embryoblast, trophoblast, blastocoele
Day 5 - implantation
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Implantation process
Day 5-6 = attachment and invasion
Trophoblast differentiates into cyto- and synctiotrophoblast
Embryoblast differentiates into epi- (embryo) and hypoblast (supportive roles)
Day 7-8 = incomplete implantation
Pre-embryo sheds zona pellucida and begins attachment to endometrium of uterine wall
Day 9-10 = approaching complete implantation
decidual reaction - endometrium prepares for nutritional support and reducing immune attack
Day 11-12 = interstitial implantation
uterine lining repair, complete implantation and lacunae formation
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Abnormal implantation sites and ectopic pregnancy
Occurs in less than 1% of pregancies - Increased risk with pID, previous surgery, fertility treatment, increasing age, past ectopic surgery, PID
Tubal pregnancy - associated with PID, endometriosis
Ampullary-54%, Isthmic - 25%, Fimbrial - 17%, Ovarian - 0.5%
Interstitial - 2%, Cervical, 0.3%
Abdominal - intestinal, rectouterine pouch
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Describe intrauterine insemination
1) follicles are monitored by USS - ovulation is induced
2) Fresh/frozen sperm sample inserted directly into uterine activity
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NICE Guidelines for usage
Requires patent tubes
1)Use of common donor (heterosexual relationships)
2)Vaginal intercourse difficulties
3) Must have reasonable sperm quality
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Descrive IVF
2-3 month cycles costing £5-10,000 each
1. Down regulation of the natural cycle occurs using a GnRH agonist or antagonist for 2-3 months
2. Daily injections of an FSH analogue for 10-13 days cause super ovulation. This is monitored via USS and medication is taken to trigger maturation.
3. The oocyte is retrieved using a US guided needle collection under sedation.
4. If using IVF, thousands of prepared sperm are added to the oocyte, if using ICSI (IVF but injected sperm not in vitro) one motile sperm is added.
5. Fertilisation takes around 18 hours to complete. The female is given hormones to prepare the uterus for implantation.
6. The embryos develop with its growth carefully monitored.
7. At day 5 the 2 best embryos are transferred (only 2 to reduce risk of multiple births). No sedation is required.
8. After 2 weeks a pregnancy test is completed.
