Lecture 12 (GU)-Exam 4 Flashcards

Question 1

Q

What are the most common causes of male mortality (all ages)

Question 2

Q

Death in men:
* Do they die earlier or later in life than women? Why is that?
* What do men tend to do? (2)
* Age gap leading to death is what?
* Men are less likely to do what?
* men also largely define themselves by what?

Question 3

Q

Regulation of Testosterone & Sperm Production
* What does FSH stimulate?
* What does LH stimulate?
* What is LH close to? What do they contain?

Answer

A

FSH stimulates Sertoli cells to help spermatogenesis.
LH stimulates Leydig cells, which make testosterone. They are 5% of testicular volume.
* Close proximity to seminiferous tubules so local testosterone levels high
* They contain sertoli cells that support sperm production

Question 4

Q

Regulation of Testosterone & Sperm Production
* Testicular insults may show up when?
* What is the normal sperm count?

Answer

A

Testicular insults may not show up as reduced sperm levels for several months.
Normal sperm count 20-200 million sperm/ ml

Question 5

Q

Regulation of Testosterone & Sperm Production
* Testosterone is aromatized where?
* What changes testosterone to dihydrotestosterone?
* What does ^ this cause?
* Some circulating testosterone is bound what?
* What is finasteride?

Answer

A

Testosterone is aromatized in fat tissue, liver, etc., to estrogen.
5 alpha-reductases change testosterone to dihydrotestosterone .
The latter causes development of male external genitalia, prostate, seminal vesicles, and male hair pattern.
Some circulating testosterone is bound to albumin and other proteins
Finasteride targets 5 alpha-reductase in BPH treatment

DHTTN – have actual affect on the body

Question 6

Q

What are the phases of sexual life (plamsa testosterone) in males?

Question 7

Q

Phases of Male Sexual Life
* When does bioavailable testosterone cont. begin to decline?
* What is the total testosterone level in elderly?
* What also declines?

Answer

A

Beginning at about age 40, mean plasma bioavailable testosterone concentrations decline gradually;
Although statistically lower than levels in young men, concentrations of total testosterone usually remain within normal range, even in elderly men. (total includes the bound Testosterone)
In older men seminiferous tubule function & sperm production also usually decline.

Question 8

Q

Phases of Male Sexual Life
* What is often slight elevated?
* What plays a role in development of prostatic hyperplasia & in development of gynecomastia in aging men?

Answer

A

Plasma LH and FSH levels are often slightly elevated, consistent with a decline in gonadal function.
An increase in conversion of androgen to estrogen in peripheral tissues

Question 9

Q

Phases of Male Sexual Life
* What happens with erection?
* What happens with actual degree of erection?
* What happens with intensity of orgasm?
* What happens with Refractory period?

Answer

A

Time before an erection is achieved often increases for older men.
Actual degree of erection is often less, or full erection is achieved later during a sexual response, in older men.
Intensity of orgasm may decrease in older men.
Refractory period after orgasm typically increases as men age.

Question 10

Q

Androgen Deficiency
* What are come causes?
* Leads to the decrease of what?

Answer

A

Etiology
* Testicular Failure (Primary Hypogonadism)
* Hypothalamic-pituitary Defects (Secondary Hypogonadism)

Leads to decrease in one or both of the two major functions of the testes: sperm production or testosterone production

Question 11

Q

Primary or Hypergonadotrophic Hypogonadism
* What is low?
* What is high?
* What is more damaged?

Answer

A

Testosterone & sperm count low
High level of FSH & LH
Sperm count is more damaged than testosterone levels.

Pance Pearls: Decrease fucntion of leydig cells (decreased testosterone synthesis), seminiferous tubule dysfunction, alcoholic liver disease

Question 12

Q

Secondary or Hypogonadotrophic Hypogonadism
* What is low?
* What is low or normal?
* What is proportional?

Answer

A

Testosterone & sperm count low
Low or normal levels of FSH & LH
Sperm count level is proportional to testosterone levels

Disorder of the pituitary glnd or the hypothalamus (eg. pituitary adenoma, craniopharyngioma). Affects both spermatogenesis and leydig function

Question 13

Q

Clinical Findings of Androgen Deficiency
* What are general findings (4)?
* Public hair?
* What are testes and scrotum findings?

Answer

A

General
* Loss of libido
* High-pitched voice (if pre-pubertal)
* Smooth skin
* Decreased hair

Pubic hair
* Loss of pubic hair

Testes & scrotum
* Small & soft testes
* Small penis & scrotum
* Loss of erection & ejaculation
* Subfertility

Question 14

Q

Answer

A

Adolescents: Failure to undergo or complete puberty (decreased secondary male characteristics)
Adults: decreased libido, energy, body hair, muscle mass; osteoporosis, gynecomastia, infertility

Question 15

Q

Clinical Findings of Androgen Deficiency
* What can happen to skeletal and muscle?

Answer

A

Eunuchoid (if pre-pubertal or castrated) habitus (gynecomastia, excess growth distally in epiphyses that fuse later because of lack of sex steroid influence)
Decreased muscle bulk & power

Question 16

Q

What is the most common cause of primary hypogonadism?

Answer

A

Klinefelter’s Syndrome

Question 17

Q

Klinefelter’s Syndrome
* Due to the presence of what?
* What is present?
* What levels are low?
* What levels are high?
* Each extra X chromosome reduces what?

Answer

A

Due to presence of one or more X chromosomes (usually a 47 XXY karyotype)
Azoospermia present
Testosterone levels low
Gonadotropins ↑ (FSH > LH)
Each extra X chromosome reduces overall IQ by 15-16 points, with language most affected, particularly expressive skills.

Question 18

Q

Klinefelter’s Syndrome
* What are the variants?

Answer

A

Variants include 48XXYY, 48XXXY, 49XXXXY. These variants tend to have much lower IQ & other congenital abnormalities

Question 19

Q

Klinefelter’s Syndrome:
* What happens with fertility?
* What is common?
* What decreases?
* What type of pubic hair pattern?
* What happens to the limbs and hips?
* _ disabilities

Answer

A

Infertility
Gynecomastia common(20 x risk of breast cancer)
Decreased facial hair
Female-type pubic hair pattern
Eunuchoid habitus long arms & legs, wide hips
Learning disabilities

Question 20

Q

Klinefelter’s Syndrome
* They have small what?
* Increase risk for what? What screening should be done?

Answer

A

Testes small
Increased risk for testicular tumors: patient should have screening with beta-HCG and alpha-fetoprotein levels before age 25

Question 21

Q

Klinefelter’s Syndrome
* Hypogonadism can be treated with what?
* No increase in what preference?
* What is unlikely to improve?
* Successful fertility has been achieved with what?

Answer

A

Hypogonadism can be treated with testosterone
No increase in homosexual preference compared to peers
Hormone replacement unlikely to improve other abnormalities.
Successful fertility has been achieved with assisted reproductive technologies in some cases, but there are important genetic implications of these procedures.

Question 22

Q

Causes of Primary Hypogonadism
* What are the aquired primary testicular failure? (think infections, damage and systemic diseases?

Answer

A

Mumps orchitis: more common manifestation when occurs in adulthood than in childhood[median age-29]. Testicular involvement causes painful swelling of the testes followed by atrophy (seminiferous tubules, Leydig cells) OR return to normal function, unilateral-70%.

Question 23

Q

What are Other Acquired Causes of Primary Testicular Failure

Answer

A

Malnutrition
AIDS
Renal failure
Liver disease
Myotonic dystrophy
Paraplegias

Question 24

Q

What are toxin causes of Primary Testicular Failure

Answer

A

Alcohol
Marijuana
Heroin
Methadone
Lead
Antineoplastic & chemotherapeutic agents

Question 25

Q

Secondary Hypogonadism
* What levels are low?

Answer

A

Levels of both testosterone & gonadotropins (FSH/LH) are low
AKA Hypogonadotropic hypogonadism

Question 26

Q

Causes of Secondary Hypogonadism: Kallmann’s Syndrome
* Impairment of what?
* What are low levels?
* Associated with what?
* What type of loss?
* What type of blindness?
* Common cause of hypogonadism in who?

Answer

A

Impairment of synthesis & /or release of gonadotropin-releasing hormone(GnRH)
Low levels of LH & FSH
Associated with anosmia
Neurosensory hearing loss
Red-green color blindness
Common cause of Hypogonadism in females

Question 27

Q

Prader-Willi Syndrome:
* What is it?
* Stems from what?

Answer

A

Idiopathic hypogonadotrophic hypogonadism associated with mental retardation, obesity & short stature.
Stems from partial paternal chromosome 15 deletion

Question 28

Q

Pance pearls

Prader-Willi Syndrome
* What are the clinical manifestations in neotates, early childhood and later childhood/adolescence

Question 29

Q

What are other Causes of Secondary Hypogonadism

Answer

A

Cushing’s Syndrome
Congenital adrenal hyperplasia
Hemochromatosis
Hyperprolactinemia: Pituitary Adenoma & Drugs such as phenothiazines
Destruction of pituitary gland by tumors, infection, trauma or metastatic disease
* Causes disturbances in the production of other pituitary hormones

Question 30

Q

Hyperprolactinemia
* What can it be caused by? (2)

Answer

A

Pituitary Adenoma
Drugs such as phenothiazines

Question 31

Q

Clinical Features of Androgen Deficiency
* What are the features before onset of puberty?

Answer

A

Failure of sexual maturation
Eunuchoid proportions: arm span 2 cm greater than height suggests that androgen deficiency occurred before epiphyseal fusion
* Infantile amount & distribution of body hair
* Poor development of skeletal muscles

Question 32

Q

Clinical Features of Androgen Deficiency:
* What are the features after the onset of puberty?

Answer

A

Diminished libido, sexual function, general strength & energy level
Decreased rate of beard growth
Gynecomastia & small or soft testes
“Male Menopause”: ADAM syndrome (Androgen Deficiency in the Aging Male)

Question 33

Q

Metabolism of testosterone:
* Where does testosterone come from?
* What is testosterone converted into?

Answer

A

25% of Testosterone comes from ovaries/testes, 25% from adrenals, and 50% come from androstenedione produced by both above.
Testosterone is either converted into dihydrotestosterone (DHT) by the 5-alpha-reductase enzyme present in hair follicles
Or converted into estradiol by the aromatase enzyme present in adipose tissue.

Question 34

Q

Dx tests:
* What can help to figure out the difference between primary and secondary hypogonadism?

Answer

A

Levels of LH & FSH can be used to differentiate between primary (increased LH, FSH) & secondary hypogonadism (decreased gonadotropins); testosterone level should also be drawn to aid in differentiation.

Question 35

Q

Diagnostic Tests
* Males without true androgen deficiency may have what?

Answer

A

may have isolated testosterone levels that are below normal range during day, particularly in afternoon; hence you also need to draw the testosterone level.

Question 36

Q

Treatment of Androgen Deficiency
* What do you need to replace?
* What does it restore? (3)

Question 37

Q

Treatment of Androgen Deficiency
* What do you do for disorders in which hypogonadism occurred prior to puberty?
* What is the principal goal?
* Testosterone is what?

Answer

A

Increasing doses of testosterone for disorders in which hypogonadism occurred prior to puberty
Restore testosteron level to normal range (300-1000)
Testosterone is a controlled substance (schedule III) due to abuse potential

Question 38

Q

Testosterone:
* What is the parenteral administration?
* What is the principal goal?
* What are the daily application options?

Answer

A

Parenteral administration of a long-acting testosterone ester(100-200 mg testosterone inundate at 1-to 3- week intervals)
Principal goal: restore testosterone level to normal range (300-1000 ng/dL)
Daily application of transdermal testosterone patches or gel

Question 39

Q

Question 40

Q

Side Effects of Androgens
* At physiologic replacement doses, testosterone esters have few what? What should you always discuss though?
* What happens when supraphysiologic doses (Abuse)?

Answer

A

At physiologic replacement doses, testosterone esters have few toxic effects in mature men.
* Should always discuss Hypercoagulability with patient

Supraphysiologic doses - abuse
* Gonadotropin secretion inhibited (negative feedback loop effect)
* Testes shrink
* Sperm count falls
* Infertility

Question 41

Q

Anabolic Steroid Abuse- Male
* What are other sxs?

Answer

A

Acne
Aggressive behavior
Fits of rage
“Body builder physique”
Abnormal LFT’s
High levels of LDL & low levels of HDL
Small testicles

Question 42

Q

Side Effects of Androgens
* What are sxs that can happen in older men? (5)

Answer

A

Polycythemia (hematocrit >52%)->Hypercoagulability (PE)
Initiate or worsen symptoms sleep apnea
Should be screened for prostate cancer before initiating androgen replacement
May lead to edema in patients with underlying heart disease or renal failure
May promote growth of & intensify pain from carcinomas of prostate & breast in men

Androgens make cancer grow.

Question 43

Q

Hypogonadism in Females:
* What are common causes of primary hypogonadism?
* What are some common causes of secondary hypogonadism?

Answer

A

Turner Syndrome are common causes of primary hypogonadism
Hyperprolactinemia or Anorexia Nervosa or Kallman Syndrome are common causes of secondary hypogonadism

Question 44

Q

Hypogonadism in Females
* Hyperprolactinemia can be what?
* Hyperprolactinemia and anorexia can be treated with what?
* What does kallman respond to?

Answer

A

Hyperprolactinemia can be physiologic (pregnancy or stress) or pathologic (HPA axis disease or pituitary adenomas
Hyperprolactinemia and anorexia can be treated with Dopamine agonists such as carbergoline (Dostinex) or bromocriptine (Parlodel)
Kallman responds to hormone replacement therapy

Question 45

Q

Turner Syndrome
* What type of disease is this? Occurs only in who?
* What does it lead to?
* What is a common clinical sign?

Answer

A

Autosomal Dominant (45X) and only occurs in females
Hypergonadotrophic hypogonadism
* Gonadal Dysgenesis leading to absence of ovarian oocytes and follicles
Webbed neck is a common clinical sign

Question 46

Q

Turner syndrome
* What are the hypogonadism issues?
* What does the physical exam show?
* What does the cardiovascular exam show?

Question 47

Q

Male Infertility
* Not an what?
* Inability to do what?
* Common problem or not?
* Couple is considered to be infertile if there has been no pregnancy after how long?
* Estimated 30% of all fertility is due what?

Answer

A

NOT an impotence
Inability to conceive or to cause pregnancy
Common problems in as many as 10% of all marriages
Couple is considered to be infertile if there has been no pregnancy after 1 to 1½ years of unprotected sexual intercourse (intercourse occurring no less than 3 times a week)
Estimated 30% of all fertility is due to “male” factor

Question 48

Q

Etiologies of Male Infertility
* Scondary impairment of spermatogenosis by what?
* How does spermatogenic tubule dysfunction cause infertility?
* Immotile what?

Question 49

Q

Etiologies of Male Infertility: ejaculatory obstruction
* What are the congenital and acquired causes?

Answer

A

Congenital
* Cystic fibrosis
* In utero DES exposure
* Idiopathic

Acquired
* Previous surgery: inguinal, scrotal, retroperitoneal, bladder neck, vasectomy
* TB
* Leprosy
* GC

Question 50

Q

Other Etiologies of Male Infertility
* Hx of what?
* Defects of what?
* Disorders of what?
* What type of toxins?
* Abusing what?
* What type of systemic illness?

Answer

A

History of mumps, testicular injury, VD, exposure to x-rays or any urological surgical procedure
Defects of androgen receptor
Disorders of sperm transport
Radiation, chemotherapeutic agents & environmental toxins
Androgen abuse can lead to testicular atrophy & a low sperm count
Systemic illness especially chronic hepatic & renal disease

Question 51

Q

Clinical features: Male infertility
* Evidence of what?
* What can be abnormal? What can be present?
* When seminiferous tubules are damaged prior to puberty, what can happen?
* Postpubertal damage causes what?
* Hx of what?

Answer

A

Evidence of hypogonadism
Testicular size & consistency may be abnormal, Varicocele may be present
When seminiferous tubules are damaged prior to puberty, testes are small & firm
Postpubertal damage causes testes to be soft
History of Varicoceles or cryptorchidism?

Question 52

Q

Clinical Features: male infert
* What is the key dx test?
* What are the normal findings of sperm count, motility, sperm morpholgy?

Answer

A

Key diagnostic test is a semen analysis

Normal Findings
* Sperm count: 20-200 million/ml
* Sperm motility: 60%-80% actively mobile
* Sperm morphology: 70%-90% normal shape

Question 53

Q

Clinical Features
* Sample should be collected when?
* What is stress pattern?
* What is oligospermia? What motility percentage associated with infertility?
* Testosterone levels should be measured when?

Answer

A

Sample should be collected after 2-3 days of sexual abstinence
“Stress pattern”: > 20% have abnormal appearance & sperm count low. May indicate presence of varicocele or recent febrile illness
Sperm counts of < 20 million/ml (oligospermia), with a motility of < 40% are associated with infertility
Testosterone levels should be measured if sperm count is low on repeated exam or clinical evidence of hypogonadism

Question 54

Q

Cryptorchidism
* What is the definition?
* What can be one cause?
* If one testis is undescended-sperm count will be what?
* If both testes are undescended, sperm count will be what?
* Increased risk of what?

Answer

A

Definition: Incomplete descent of testis from abdominal cavity into scrotum by age of 1 year
Etiology unknown but gonadotropin deficiency in utero appears to be one cause.
If one testis is undescended-sperm count will be subnormal in 25-33%.
If both testes are undescended, sperm count will be severely subnormal & serum testosterone may be reduced.
Increased risk of testicular cancer

Question 55

Q

txt of male infert
* Men with primary hypogonadism may respond to what?
* Men with 2nd hypogonadism require what?
* In vitro fertilization option for who?

Answer

A

Men with primary hypogonadism may respond to androgen therapy if there is minimal damage to seminiferous tubules
Men with 2nd hypogonadism require gonadotropin therapy to achieve fertility
In vitro fertilization option for men with mild to moderate defects in sperm quality

Question 56

Q

Clinical Features in Men with Sexual Dysfunction
* What are the sxs?

Answer

A

Loss of libido
Erectile Dysfunction(Inability to initiate or maintain an erection)
Ejaculatory failure – common with cocaine use
Premature ejaculation

Question 57

Q

Clinical Features in Men with Sexual Dysfunction: Evaluation
* What exam do you need to do?
* What do you need to note?
* Check for what?

Answer

A

General as well as genital Exam
Note penile abnormalities, testicular size, & gynecomastia
Check for peripheral pulses & bruits

Question 58

Q

Clinical Features in Men with Sexual Dysfunction: Evaluation
* Neuro exam to assess what?
* What levels?
* What imaging can be done?

Answer

A

Neuro exam to assess anal sphincter tone, perineal sensation, & bulbocavernous reflex
Serum testosterone & prolactin levels
Penile arteriography, electromyography, or penile Doppler US occasionally performed

Question 59

Q

Erectile Dysfunction (ED)
* What is it?
* Affects how many people?
* Can be what?

Answer

A

Persistent inability to attain or maintain penile erection sufficient for sexual intercourse
Affects 10-25% of middle-aged & elderly men; 10-20 million American men
Can be psychogenic but often has an organic component: most commonly vascular disease that decreases blood flow into penis

1992 Consensus Development Conferences recommends use of the term ED rather than “impotence”.

Question 60

Q

Psychogenic ED
* What are the causes? (8)

Answer

A

Performance anxiety
Depression
Relationship conflict
Loss of attraction
Sexual inhibition
Conflicts over sexual preference
Sexual abuse in childhood
Fear of pregnancy or sexually transmitted disease.

Question 61

Q

Almost all patients with ED, even when it has a clear-cut organic basis, develop what?

Answer

A

develop a psychogenic component as a reaction to ED.

Question 62

Q

ED:
* What are 3 important questions to ask? What happens if they are yes?

Answer

A

Important questions to ask
* “Do you have early morning erection or nighttime emissions?”
* “Do any individuals other than your partner arouse you?”
* “Are you able to masturbate to an erection or climax?”

Positive answer to these questions usually indicates that ED is
psychological/psychogenic in origin

Allowing pt to discuss his problems may serve to vent some of his anxieties

Question 63

Q

Organic Causes of ED in Men
* What are endocrine causes?
* What are antiandrogens drugs that cause ED?

Answer

A

Endocrine causes
* Testicular failure (primary or secondary)
* Hyperprolactinemia

Antiandrogens
* Spironolactone
* Ketoconazole – fungal infection
* H2 blockers (cimetidine)
* Finasteride

Question 64

Q

Organic Causes of ED in Men
* What are the antihyperstive meds that cause ED?
* What are some other classes of meds? (3)

Answer

A

Antihypertensives
* Centrally-acting sympatholytics(clonidine & methyldopa)
* Peripheral acting sympatholytics (guanadrel)
* Beta blockers
* Thiazides

Anticholinergics

Antidepressents -SSRI

Antipsychotics

Answer 57

A

A. Aortic occlusion (Leriche syndrome)
B. Atherosclerotic occlusion or stenosis of pudendal &/or cavernosal arteries
C. Venous leak
D. Disease of the sinusoidal spaces
E. Arterial damage from pelvic radiation

Answer 58

A

Definition: Persistent or recurrent delay in or an absence of orgasm after normal sexual arousal

Mitigating factors
* Age
* Adequacy of the stimulation: Focus, intensity, and duration

Answer 59

A

Physical disorders
Chemical exposure
Use of a substance(e.g., alcohol, opioids, cocaine, antihypertensives, antidepressants, antipsychotics)
Depression: common cause of orgasmic difficulty as well as decreased desire and arousal

Answer 60

A

Problems with achieving orgasm are usually linked to difficulty in developing sufficient arousal
Emotional state (e.g., anger, anxiety, guilt, boredom) can inhibit arousal & orgasm
Arousal may be sufficient to achieve partial or full erection but not to produce orgasm
Erectile failure (Impotence) may cause more distress than orgasmic difficulty

Answer 61

A

Occurs in 35 to 75% of men with DM
Pathologic mechanisms are primarily related to diabetes-associated vascular & neurologic complications.
Diabetic macrovascular complications are mainly related to age, whereas microvascular complications correlate with duration of diabetes & degree of glycemic control

Answer 62

A

Testosterone: If patient hypogonadal & has low testosterone levels

Correction of underlying disorders or discontinuation of responsible medications

Selective cGMP-specific phosphodiesterase type 5 (PDE5) inhibitors
* Sildenafil (Viagra)
* Vardenafil (Levitra)
* Tadalafil (Cialis)

Answer 63

A

Contraindicated in men receiving any form of nitrate therapy & should be avoided in CHF

Answer 64

A

Sexual stimulation causes the release of nitric oxide (NO) by the cavernous nerve into the neuromuscular junction
Current med therapy based on inhibition of PDE-5

Answer 65

A

MUSE (Medicated Urethral System for Erections): small suppository placed into urethra
* Noninvasive

Answer 66

A

Vacuum constriction devices (with constricting ring at base of penis)

Answer 67

A

Injection of alprostadil into corpora cavernosa or urethra (Caverject)
* Comes in suppository too

Injection of papaverine, phentolamine, and prostaglandinE1 (TriMix)

Answer 68

A

SE: Pain & burning. Priapism 4%. Scarring (Peyronie’s disease) 8% after 1 year
Only for patients that failed oral meds and other modalities like MUSE

Answer 69

A

Noninflatable semi-rigid rods or cylinders implanted in corpora cavernosa
Inflatable devices surgically implanted that can be expanded using pressurized fluid.
Tubes connect cylinders to a fluid reservoir implanted in abdomen and subcutaneous pump implanted in scrotum. User inflates cylinders by pressing on small pump.

Answer 70

A

Orgasm & ejaculation with minimal sexual stimulation
Persistently or recurrently occurs before, during, or shortly after penetration & before person desires

Answer 71

A

Usually related to anxiety or a learned behavior
May be partner related
Most men can delay orgasm during masturbation for much longer than they can during coitus

3-5min is the avg time

Answer 72

A

Amenable to behavioral therapy (sex therapy)

Treatment with medications such as selective serotonin reuptake inhibitors (SSRIs)-Prozac, Zoloft, Celexa & Paxil
* Drug is taken either daily or 1 to 2 h before a sexual encounter

Answer 73

A

Ejaculation into bladder
* Results when internal urethral sphincter does not close

Consider this when persistently see semen on UA

Answer 74

A

Breast enlargement (gynecomastia) is most consistent feature of feminizing states in men
Gynecomastia is due to an increase in both glandular & adipose tissue

Answer 75

A

Neonatal (due to mother’s estrogen)
Puberty: 13-14, uncommon after 17 (usually lasts 6m-2years)
Older men

Answer 76

A

Elevations in estrogen production & estrogen plasma levels
* Increase in plasma precursors (liver or adrenal disease) especially in cirrhosis
* Increased extraglandular aromatization (obesity)
* Increased production by testes (testicular tumors, androgen resistance, gonadotropin stimulation).

Answer 77

A

Most of estradiol and all of estrone produced in normal men is formed by extraglandular aromatization of circulating androgens.
* Estradiol usually is <180 pmol/L (50 pg/mL) in normal men
* Estrone level is somewhat higher but usually is <300 pmol/L (80 pg/mL).

Answer 78

A

Calcium channel blockers
Digitalis
Estrogens
Griseofulvin
INH
Methyldopa
Phenytoin
Spironolactone
Testosterone

Answer 79

A

Cirrhosis
Chronic renal failure
Hypogonadism
Hyperthyroidism
Idiopathic

Answer 80

A

It is usually painful & may be unilateral or bilateral.
Gradually appears & gradually disappears within 1 year of onset.
Pubertal changes that occur during Tanner stages 2&3 include growth spurt, growth of testes & penis, spermarche, acne, axillary perspiration, & appearance of pubic hair.

Answer 81

A

Phimosis: orifice of prepuce so small that foreskin cannot be retracted from glans
Paraphimosis: Tight foreskin, once retracted, may become edematous, so that it cannot resume its normal position over glans

Pic from smarty pants

Answer 82

A

Distal Scarred down foreskin (after trauma, inflammation or infection) which cannot be retracted over head of penis

Tx:
* Proper hygiene and streching excises of foreskin (pance pearl)
* Topical corticosteroid (betamethasone) if able to urinate
* Circumcision if unable

Answer 83

A

Inflammation of the glans occurs only in uncircumcised individuals and is often associated with phimosis
Dark field and serologic tests are negative

Answer 84

A

Inflammation of the opposing surfaces of the glans penis (balanitis) & prepuce (posthitis) & occurs most commonly in uncircumcised diabetic males.
Usually caused by Candida albicans and group B beta-hemolytic Streptococcus.
Treatment: based on cause

Answer 85

A

Prolonged painful penile erection, unaccompanied by sexual desire or excitation
Mechanisms are poorly understood but probably involve complex vascular & neurologic abnormalities
Appears to result from a blockage of venous drainage from penis, while arteries remain patent

Answer 86

A

Prolonged sexual activity
Hemoglobinopathies such as Sickle cell disease or trait (MCC)
Leukemia or other blood dyscrasias
Pelvic hematoma or neoplasm
Genital infection & inflammation, especially if complicated by a bladder calculus
Spinal cord injuries, tumor or neurosyphillis

Pearl: Trazodone (medication that can cause it)

Answer 87

A

Phenylephrine injection (FIRST LINE and under 4 hours)
* 100–500 μg/ml injected intracavernously every 5 minutes
* Generally should reach out to specialist if 2-3 doses have not worked.

Blood extraction with syringe and/or scalpel (over 4 hours)

In those with Sickle cell and recurrent priapism, consider hydroxyurea to reduce vaso-occlusive complications

Answer 88

A

Clinical
Cavernosal blood gas: high flow results similar to ABG and normal glucose but low flow shows hypoglycemia, hypoxemia, hypercarbia and acidemia

Answer 89

A

Disease of unknown cause it is characterized by a fibrous band in corpus cavernosum
It is generally unilateral & results in deviation of penis during erection
Affects 1% of population, age 40-70

Answer 90

A

Lump in penis
Pain, especially during erection
Bending or deformity of erect organ
Difficulty in vaginal penetration

Answer 91

A

Depending on extent of fibrous band, condition may make erection painful & intromission impossible
Oral pentoxifylline-increases blood flow to the affected microcirculation (if curve over 30 degrees or associated with sexual dysfunction and within 3 months of onset)
Occasionally surgery is required to remove fibrous band

Answer 92

A

A 29-year-old man complained of sudden-onset groin pain during intercourse when he heard an audible “crack.“
Examination revealed a large deformity & angulation of midshaft of his penis with meatal blood.
Is a true emergency:Tunica Albugenia has to be sewn back together

Answer 93

A

Bloody Semen
Most patients have recurrent hematospermia, although some experience it just once

Answer 94

A

Usually idiopathic
Seminal vesiculopathy due to unidentified infection or vascular congestion
May be associated with prolonged sexual abstinence or frequent or interrupted coitus
Bleeding disorder

Answer 95

A

Inflammation of seminal vesicles
May cause painless, bloody ejaculate
Difficult to diagnose by culture technique
Transrectal US allows aspiration, which confirms seminal vesicles as source of blood in ejaculate

Answer 96

A

Workup
* Disorder usually benign & rarely associated with malignancy or serious infection
* Patients should be evaluated for prostatic infection or urethral strictures

Treatment
* Empiric unless a cause is found
* Some urologists advocate 5-7 day trial of tetracycline 250 mg qid followed by gentile prostatic message

Answer 97

A

Continuous or intermittent flow of fluid from urethra
Bloody: associated with ulcerations, neoplasms, and/or urethritis
Purulent discharges - thick & yellowish-green are associated with GC urethritis or chronic prostatitis

Must ask about exposure to STI’s, sexual partners & whether partners have any known illnesses

Answer 98

A

Most common cause of urethritis worldwide
Purulent urethral discharge produces severe dysuria.
PE Findings:Yellow-green discharge; spontaneous or copious amounts with stripping of penis

Answer 99

A

Collect specimens at least 1 hour, preferably 4 hours after last voiding
Gram stain, culture-R: intracellular gram-negative diplococci of Neisseria gonorrhoeae on urethral smear.

Answer 100

A

Typically caused by Chlamydia trachomatis or Mycoplasma genitalium

Answer 101

A

Unprotected sexual activity
Longer incubation period 1-5 weeks
Meatal itching or irritation
Scant mucoid-like discharge > 1 week , if present before first voiding of the day; may be present only with urethral massage
Symptoms vary and range in severity for urgency, frequency,& dysuria

Answer 102

A

Thin mucoid discharge may be absent or minimal while penile milking or stripping
Chlamydia trachomatis causes various sexually transmitted diseases, transmitted by oral, vaginal or anal sex.
Common cause of Infertility in females

Answer 103

A

Diagnostic Studies
* Gram stain; culture
* DNA probe for Chlamydia
* Urine screen for DNA; Chlamydia particles
* DNA/NAAT amplification test can detect genetic material in secretions within 24 hours.

Answer 104

A

Azithromycin, Doxycycline, Erythromycin, Ofloxacin

Answer 105

A

History
* Joint and tendon involvement
* Urethritis (Chlamydia)
* Can occur from Salmonella, Shigella, Campylobacter GI infection

Physical findings
* Joint and tendon involvement
* Decreased range of motion
* Skin and mucous lesions
* Conjunctivitis

Answer 106

A

Blood, synovial fluid for NAAT;
HLA-B 27 antigen
X-Rays

Answer 107

A

Chlamydiae Trachomatis
Occurs rarely in US
Can start with small genital ulcer which resolves before lymphadenopathy (usually painless, so confused with syphilis)
Diagnose with compliment fixations titers > 1 :64
Buboes
Increase in US with MSM proctitis

Answer 108

A

Lymphadenopathy is usually unilateral, with a matted, fluctuant appearance, and frequently goes on to become suppurative.
Groups of swollen nodes are termed “buboes“& may be confused with syphilitic buboes or adenopathy associated with chancroid or genital herpes.

Answer 109

A

Standard treatment regimens for Chlamydia trachomatis with exception that treatment must be continued for at least three weeks.
* Doxycycline 100 mg p.o. BID x 3 weeks
* Pregnant patients may be treated with erythromycin 500 mg p.o. QID x 3 weeks
* Another alternative is sulfisoxazole 500 mg p.o. QID 8 3 weeks

Patients with rectal LGV may require more prolonged courses of treatment. Compliance with a three-week course of therapy is often a problem in this patient population, making careful follow-up mandatory.

Answer 110

A

Incision and Drainage of the buboes
* Contraindicated as it does not shorten course of disease & may in fact promote development of chronic cutaneous fistulas

Answer 111

A

HSV-2 usually transmitted venereally.
Incubation 2-21 days.
Rapidly develop into vesicles & later ulcers covered with grayish exudate.
Treatment: acyclovir, famciclovir, valacyclovir

Answer 112

A

Primary: Painless sore (chancre) may go undetected. Infectious. Eventually heals as infection progresses
Secondary: Rash appears (usually palms of hands & soles of feet). May be accompanied by flu-like symptoms. Condyloma lata: moist flat confluent patches

Answer 113

A

Latent: Infected persons may not show any symptoms while bacteria multiples

Tertiary:
* From 3 to 40 years later. Heart failure, aortic regurgitation and aneurysm, paralysis, blindness, liver damage, mental disturbance & death
* Gummas are nodular lesions with granulomatous inflammation

Answer 114

A

Primary syphilis produces a painless ulcer (chancre) within 10 days to 3 months after exposure, but usually within 2-6 weeks
Ulcer heals (unlike in chancroid or cancer)

Answer 115

A

Typical eruption of red flat lesions over whole body but especially palms of hands & soles of feet.
Active bacteria are presents in sores and can be transmitted from broken skin of infected person
Rash is Very contagious

Answer 116

A

Benzathine penicillin G IM
* Primary and early latent: 2.4 million units
* Secondary: 2.4 million units
* Tertiary and late latent: 7.2 million units total, 2.4 million units/ week x 3
* Recent push for Amoxicillin instead of PCN G, with or without Probenecid, in HIV coinfection

Answer 117

A

Jarisch-Herxheimer Reaction: fever, headache, myalgias occur within 24 hours of treatment (Sepsis like)
Penicillin allergic patients need desensitization
Treat partners within 90 days of exposure even if seronegative
In HIV patients - amoxicillin 3g daily with probenecid 750mg for 2 weeks

Answer 118

A

Caused by a small gram-negative bacterium Haemophilus ducreyi. Incidence in U.S. has declined.
Soft chancre, accompanied by painful lymphadenopathy.
Lymph glands in groin may swell, creating a pus-filled bulge (bubo) enlarge until they burst through skin.

Answer 119

A

Painful, irregularly shaped sores with “ragged edges” that can vary from 1-2 mm to 1-2 cm. Unlike chancre of syphilis, chancroid ulcer edge is soft, changes shape when squeezed
“Railroad tracks” can be seen on gram stain

Answer 120

A

Azithromycin 1 G x 1
Ceftriaxone 500 mg IM x 1
Ciprofloxacin 500 MG PO BID x 3 days (contraindicated in pregnant or lactating females)
Erythromycin 500 mg TID x 7 days

Pance pearl said: Azithromycin 1 G x 1 and Ceftriaxone 500 mg IM x 1 as first line

Answer 121

A

STD caused by a poxvirus
Lesions are pearly white, often umbilicated, smooth & dome shaped with discrete margins
Occur most commonly on glans penis
No treatment usually required (self-limited)

Answer 122

A

Are benign, not related to HPV
Also known ashirsutoid papillomas
Small, skin-colored bumps that form around the head of the penis
Tend to fade with advancing age
Cosmetic cryosurgery or laser therapy can be done electively

Answer 123

A

Yeast infection is not usually transmitted sexually.
Produces a rash and balanitis (red patches & blisters). It is also a cause of intertrigo: painful inflamed skin in skin folds of obese patients.

Answer 124

A

Caused by Human Papillomavirus and spread by sexual contact. Involve scrotum, penis, anus.
Cauliflower-like painless growths.

Answer 125

A

0.5% podofilox solution
Burning with trichloracetic acid
Blistering agent (20% podophyllin solution);
5% 5-fluorouracil cream
Aldara (Imiquimod) cream (immune response modifier also used for AK 7 BCC
Condylox (podofilox)

Answer 126

A

Generally squamous
Tends to occur in uncircumcised men who practice poor hygiene
Often appears as a painless ulceration that, unlike a syphilitic chancre, fails to heal
Majority arise on glans
30-60% have inguinal LAD

Answer 127

A

Lesions are often extensive by time help is sought, either because of fear or because lesion is unnoticed under foreskin
Typically managed by Moh’s or penectomy

Answer 128

A

Testicular or epididymal Tumor
Hernia: soft fullness, often intermittent, revealed during Valsalva maneuver
Varicocele: feels like bunch of worms; collapses when patient lies down, worse with Valsalva
Spermatocele: scrotal mass that contains sperm that is greater than 2 cm
Hydrocele: tense, fluid-filled mass; transilluminate
Epididymal cyst: smooth, lobulated mass on epididymis, separate from testicle

Answer 129

A

Epididymitis/Orchitis: Acute inflammation of epididymis or testis
and Epididymal hypertension
Torsion of spermatic cord: Acute onset, swollen, tender mass, younger age (10yo-20yo)
Strangulated hernia

Answer 130

A

“When did you first notice the enlargement?”
“Is it painful?”
Have you sustained any injury to your groin?”
“Does the enlargement change in size?”
“Have you ever had it before?”
“Have you ever had a hernia?”
“Have you had any problems with fertility?”

Answer 131

A

Hernia (most common cause)
Adenopathy from any infection of external genitalia
Carcinoma of the testis if scrotal skin is involved

Answer 132

A

“When did you first notice it?”
“Is the mass painful?”
“Does it change in size with different positions?”
Have you had any venereal disease”

Answer 133

A

Abnormal collection of clear fluid in parietal and visceral layers of the tunica vaginalis which directly surrounds the testis and the spermatic cord
It transilluminates and the examining fingers can get above the mass within the scrotum
Testicle is contained within the cystic mass preventing actual palpation of testis itself

Answer 134

A

Com: peritoneal/abdominal fluid enters the scrotum via a patent processus vaginalis that failed to close
Noncom: Derived from fluid from the mesothelial lining of the tunica vaginalis (no connection to the peritoneum)

Answer 135

A

Picture on left shows hydrocele with collection of fluid in space around testis. The fluid allows passage of light (transillumination) seen in picture on the right.

Answer 136

A

Testicular US is uded to r/o associated testicular tumor, other masses or inflammatory scrotal conditions

Answer 137

A

Most hydroceles do not require intervention. Treatment is only indicated in patients who are symptomatic with pain or a pressure sensation or when the scrotal skin integrity is compromised from chronic irritation. For asymptomatic patients with hydroceles, there is no need for routine follow-up.
The most common surgical procedure is excision of the hydrocele sac. Simple aspiration is generally unsuccessful because of the rapid reaccumulation of fluid but may be effective if combined with instillation of a sclerosing agent (tetracycline, alcohol) into the sac

Answer 138

A

Enlargement of the spermatic cord due to dilatation of the pampiniform plexus
These varicosities are usually on the left side
Impression on palpation has been likened to that of feeling a bag of worms
Usually gravity dependent and only visible while the pt is standing or straining

Occur in 25-40% of men with unexplained infertility

Answer 139

A

These varicosities are usually on L side Impression on palpation has been likened to that of feeling a bag of worms
* Increased blood flow, raises testicular temperature & thereby Causes damage to seminiferous tubules (infertility)

Answer 140

A

Usually gravity dependent & only visible while pt is standing or straining
Pt is asked to turn his head and cough while spermatic cords are held
A sudden pulsation confirms the diagnosis (pance pearls said you can use US as first test)
Treatment: Ligation

Answer 141

A

Pea-sized nontender mass that contains spermatozoa usually attached to the upper pole of epididymis

Answer 142

A

Twisting of spermatic cord upon itself that results in obstruction of blood vessels supplying testis & epididymis.
Usually result of anomalous suspension of testes within scrotum (Bell Clapper testes).
More common in children, but accounts for 20% of acute scrotal pathology in post-pubertal males

Answer 143

A

Testicular torsion & acute epididymitis or epididymo-orchitis are most common causes of an acute scrotal pain.
Differentiating between the entities that cause acute scrotal pain is often difficult on PE

Answer 144

A

Cause by torsion resulting in ischemia of epididymis
Present early in torsion

Ischemia of epididymis or testicle. Can also be testicular appendage.

Answer 145

A

Diminished flow in right testicle (arrow) & increased flow in scrotal wall.
Left testicle & epididymis are normal.
Cremasteric reflex is absent

Answer 146

A

Differentiating Acute Torsion vs. Epididymitis
Decreased or absent blood flow within the testicle on doppler examination indicates acute torsion
Increased blood flow indicates epididymitis or orchitis
Prehn’s (negative in testicular torsion) and Cremasteric (negative in testicular torsion) signs are both insensitive and nondiagnostic

Answer 147

A

Delayed treatment results in a much lower salvage rate.