CM- Male Reproductive System

Question 1

When doing a thorough examination of the penis, what 5 things are you on the lookout for?

Answer 1

1. developmental abnormalities
2. discharge
3. skin lesions
4. fibrosis
5. masses

Question 2

During a penile exam, you retract the forskin and examine the glans. The urethral meatus opens on the ventral surface of the penis. What is this called?

Answer 2

Hypospadias- the urethral meatus is on the ventral surface anywhere from the glans to the perineum.

Even if the meatus is very proximal, there will still be a blind-opening pit on the glans

Question 3

On PE, the foreskin and glans of the penis have a grey, thickened, fibrotic appearance.
What is this condition and what is it associated with?

Answer 3

It is lichen sclerosis [BXO] and can be associated with meatal stenosis and urethral stricture.

It can lead to phimosis and SCC.

Question 4

On PE, you notice thick fibrous plaques that are palpable deep to the base of the penile shaft. These plaques are characteristic of what disease?
What is the cause of the disease?

Answer 4

These plaques at the base of the penis are characteristic of Peyronie’s disease.

In Peyronie’s disease there is an inciting event [usually trauma during an erection] that causes the penis to become deformed and curved when erect.

Question 5

When examining the penis, it is important to look for skin lesions. What diagnosis is associated with the following lesions:

1. painless ulcers
2. grouped vesicles
3. painful ulcers
4. mucopurulent discharge

Answer 5

1. syphilitic chancre
2. Herpes virus
3. H. ducreyi [chancroid]
4. gonorrhea or chlamydial urethritis

Question 6

When you are doing a male genital exam, what are you examining during the scrotal portion of the exam?

Answer 6

1. testicular size and mass
2. epididymal masses and pain
3. other masses
4. hernias

Question 7

You are doing a male genital exam and note the absence of testes in the scrotum. What is the most likely problem and what are the implications?

Answer 7

Cryptorchidism [undescended testes].

This puts the patient at an increased risk for infertility and testicular cancer

Question 8

When doing an examination of the scrotum, what is the implication of:

1. painless firm masses of the testicular parenchyma
2. small atrophic testes

Answer 8

1. testicular cancer - grows rapidly and metastasizes but is still really treatable
2. oligospermia because volume of testis corresponds to the number of healthy seminiferous tubules

Question 9

A patient has sudden onset intense pain in his scrotum. He has abdominal pain, nausea and vomiting. What is the likely disorder? What is the pathology behind it and how is it treated?

Answer 9

It is testicular torsion where the spermatic cord is twisted making the testicle ischemic.

Detorsion and orchiopexy [where you tack the testicles in place] must be done within 8 hours to save the testicle and prevent subsequent contralateral torsion.

Question 10

While examining the male genitals, you palpate a painful mass of gradual onset originating from the ridge behind the testes. What is the likely problem?

Answer 10

Epididymitis

Question 11

When you are palpating the epididymis, how do you know when you have reached the lower pole that drains into the vas deferens?
What is likely if the vas deferens is absent?

Answer 11

It will feel like a firm toothpick.

If the vas deferens is absent, most likely there is renal agenesis because the testis and kidney share a common embroylogical origin, the mesonephric/wolffian duct in development.

Missing vas deferens is also associated with CF

Question 12

On male genital exam, you note a soft homogenous scrotal mass that transilluminates. What is the diagnosis?

Answer 12

Hydrocele

Question 13

On male genital exam, you palpate dilated, engorged testicular veins like a “bag of worms” in the spermatic cord on the left. The man discloses that he has been having trouble conceiving with his wife. What is the likely cause?

Answer 13

Varicocele- the leading cause of male factor infertility

Question 14

What are the 3 types of hernias assessed while examining the scrotum?
Where would you feel each?

Answer 14

1. direct inguinal- peritoneal cavity into the scrotum
2. indirect inguinal - circuitous route through patent inguinal canal
3. femoral - bulges below the inguinal ligament

To differentiate direct and indirect, place exam finger at the exit of the inguinal canal by following vas deferens proximally and then have the patient cough or bear down.
Direct = will press along the side of the exam finger
Indirect = will press at the tip of the exam finger

Question 15

When you do the DRE to check the prostate, what 3 features are you examining?

Answer 15

1. size
2. contour
3. tenderness

Size approx of volume “40g = a shot glass”
DRE estimate of prostate size tends to be an underestimate

Question 16

On DRE, the prostate is tender and there is excessive warmth.
The patient has fever and dysuria.
What is the likely problem?

Answer 16

acute bacterial prostatitis

Question 17

On DRE, you note irregular contour, firmness and nodules. What is the diagnosis?

Answer 17

Prostatic carcinoma

Question 18

On DRE, you note a symmetrically enlarged prostate. What is the diagnosis?

Answer 18

BPH

Question 19

How long does spermatogenesis take?
What takes place in the seminiferous tubules?
What cells are involved?

Answer 19

The production of sperm takes about 70 days.

Seminiferous tubules are lined by Sertoli cells which support the development of the germ cells undertaking meiotic division.
Gonocyte–> spermatogonia which migrates to periphery to divide mitotically–. spermocyte [pre-meiotic division]–> spermatid [post-meiotic differentiating cell] –> spermatozoa [MATURE]

Question 20

Where do the non-motile, mature spermatozoa go from the seminiferous tubules?

Answer 20

The non-motile sperm empty into the epididymis for storage and maturation [20 more days].
This is where the sperm gain motility and fertility.

Question 21

Where in the testes is testosterone made? What triggers the release?

Answer 21

Testosterone is made and secreted by the interstitial Leydig cells adjacent to the seminiferous tubules of the testes.

Hypothalamus releases GnRH which stimulates pituitary to secrete LH which acts on Leydig cells to make testosterone

Question 22

The hypothalamus produces _______ which stimulates the pituitary to release _____ which acts on the Leydig cells to secrete testosterone and ____________ which acts on the seminiferous tubules/Sertoli cells to produce sperm.

Answer 22

GnRH releases:

LH–> Leydig –> testosterone

FSH–> Sertoli/seminiferous vesicles–> sperm

Question 23

What all does FSH stimulate the Sertoli cells to produce?

Answer 23

1. AMH
2. inhibin
3. androgen binding protein
4. stimulate spermatogenesis

Question 24

What is ED?

Answer 24

The consistent inability to achieve or maintain an erection sufficient for satisfactory sexual activity
52% of men btw 40-70 with the incidence increasing with age

Question 25

A patient presents with a swollen “eggplant deformity”. He was having sex with the female on top, heard a pop and immediately lost his erection. What is the physiology of what happened?

Answer 25

This occurs when the penis fractures and the dense tunica albuginea around the paired/communicating corpus cavernosum ruptures. This produces swelling and detumescence.

Question 26

What are the 3 cylinders of the penis?

What does each protect/contain?

Answer 26

There are 2 corpus carvernosum which run the length of the penis and are surrounded by tunica albuginea.
They contain a lattice of blood sinusoids surrounded by trabeculae of smooth muscle which control the blood capacity of the sinusoids.

There is 1 corpus spongiosum that contains the urethra and extends distally to form the glans.

Question 27

Where is the blood that enters the penis derived from? What are the arteries and veins involved?

What nerves allow erection? What allows ejaculation?

What vessels are contracted in the erect state? Which are relaxed?

Answer 27

Internal iliac arteries–> internal pudendal arteries–> carvernosal arteries through the center of the corpora–> dorsal arteries.

Venous blood is collected from the sinusoids and exits through the tunica albuginea as emissary veins to form the deep dorsal vein of the penis.

Parasympathetic S2-4 cause erection
Sympathetic T11-L2 control ejaculation and tumescence

In the flaccid state, arterioles and sinusoids are contracted and the vein is relaxed. During erections, sinusoids and arterioles relax and the venules are compressed under the tunica albuginea preventing outflow

Question 28

Describe the neurotransmitters that modulate erection.

Answer 28

The key modulator is the tone of smooth muscle walls of the arterioles and trabecular spaces.

NO converts GTP to cGMP which relaxes vascular smooth muscle of the arterioles allowing for erection.

PDE5 cleaves cGMP to GMP contracting the vascular muscle, blood is no longer trapped in the sinusoid, and the veins are no longer compressed ending the erection

Question 29

A man complains of ED that is sudden onset and situational. He has been having trouble with his wife recently. When asked, he states that he still gets nocturnal erection. What is likely precipitating the ED?

Answer 29

Psychogenic causes:

• anxiety
• loss of attraction
• stress
• relationship problems

Question 30

A man has been severely depressed recently but has not taken any medications. What is the likely cause of the ED?

He starts taking antidepressents and he continues to have ED, but he feels emotionally better! What is the continued cause of ED?

Answer 30

psychiatric

ED can be caused by anti-depressants, anti-hypertensives, and hormones

Question 31

What are the neurogenic causes of ED?

Answer 31

1. Trauma
2. MS
3. DM
4. myelodysplasia
5. alcohol
6. pelvic surgery

Question 32

What are the endocrine causes of ED?

Answer 32

Hypogonadism [primary or secondary]

Hyperprolactinemia

Question 33

Whart are the arteriogenic causes of ED?

What are the venous causes?

Answer 33

Arteriogenic:

1. hypertension
2. smoking
3. diabetes
4. hypercholesterolemia
5. PVD

Venous:
Impairment of venous occlusive mechanism
Peyronie’s disease

Question 34

A man present with ED that was gradual onset and progressive. There is reduced nocturnal and early morning erections. Normal libido and sexual development in puberty. What is the cause of ED?

Answer 34

Organic/ idiopathic

Question 35

What are the effects of antidepressants and alpha blockers [tamsulosin] on sex?

Answer 35

Antidepressants cause delayed ejaculation

A-blockers cause retrograde ejaculation

Question 36

What labs should be ordered for men with ED?

Answer 36

It should be done on an individual basis, but some to consider are:

1. serum glucose –>diabetes
2. serum testosterone
3. prolactin
4. thyroid hormone panel
5. lipid profile
6. PSA

Question 37

The most common treatment for ED is the PDE5 inhibitors [sildenifil, tadalafil]. How do they work?
What are the contraindications?

Answer 37

They block PDE5 from breaking down cGMP to GMP so the erection can last longer.
The patients still need parasympathetic stimulation to get it up, but viagra can keep it up.

Contraindications:

1. nitrates
2. unstable angina
3. recent MI

Question 38

What is priapism?

Answer 38

painful, unwanted and persistent erection that can produce ischemic damage to the corpus carversnosa if untreated for 6 hrs.