Male reproduction Flashcards
urethritis
can be 2/2 STD
chlamydia trachomatis
neisseria gonorroeae
or
mycoplasma
ureaplasma
H and P: dysuria urgency frequency purulent urethral discharge burning on urination
labs:
gram stain (pos diplococci with neisseria, neg with chlamydia)
DNA amplification testing to confirm g and c
treatment:
1x IM ceftriaxone
PO doxycylcine or azithromycin
treat partner
may need to report
Complications:
reinfection of partner
urethral strictures or scarring
narrowing of urethral lumen
Prostatitis causes, most likely by age
non-bacterial causes are more likely
Men35 or anal intercourse: enterobacteriaceae, gram neg infections
H and P: perineal pain dysuria frequency urgency fever, systemic sx when acute tender and boggy prostate
Treatment:
TMP-SMX
Fluoroquinolone
4-6 weeks
BPH
beginning around age 40, increases in prevalence as men get older
central prostate
not a/w prostate cancer which forms more in the peripheral zone
H and P: bladder outlet obstruction weak or intermittent stream straining to void urinary hesitancy dribbling
also, urinary frequency
urinary urgency
nocturia
urge incontinence
How is bph diagnosed?
clinical diagnosis
rule out other pathologies that may cause similar symptoms using history and the following tests:
-digital rectal exam to detect malignancy
-UA: hematuria indicating infection, calculi, prostatis
sCr: possible renal or prerenal disease
Other useful but optional tests:
- serum PSA
- postvoid residual
- maximum urinary flow rate
Treatment for BPH?
- behavior modification (no fluid before bed)
- alpha1-adrenergic antagonists
- relax smooth muscle of bladder neck, prostate capsule, and prostatic urethra, can cause ejaculatory dysfunction, and be careful if combinine with
- terazosin and doxazosin cause postural hypotension, so start these at bedtimephosphodiesterase inhibitors
- Tamsulosin, alfuzosin, silodosin are more uro-specific with less hypotensive effect - 5-alpha reductase inhibitors (finasteride, dutasteride)
- block conversion of testosterone to dihydrotestosterone, which grows the prostate
- decreases size of prostate
These drugs can be taken longterm, but symptoms return when the meds are stopped
side effects: erectile, ejaculatory dysfunction, decreased sex drive
decreases PSA by 50% in the first 3-6 months. If PSA doesn’t drop when you start these meds, then you should worry about prostate cancer
- Anticholinergics (oxybutynin, tolteridine, darifenacin)
- Phosphodiesterase inhibitors (tadalafil), improved urine flow rates after about 12 weeks
- Transurethral surgery if meds not tolerated (TURP)
Prostate cancer
peripheral zone of the prostate gland (DRE)
adenocarcinoma
mc non-derm ca in men
less aggressive than lung cancer
RF:
advancing age
family hx
high fat diet
H and P:
asx
weakened urinary stream, urinary retention
weight loss, back pain
mets to bones, osteoblastic
nodularity or irregular areas of induration
rectal exam may be normal
labs:
increased PSA
UA- hematuria, pyuria
increased alkaline phosphatase
diagnosis: tissue biopsy transrectal US bone scan CT scan CXR
Treatment:
surgery
radiation
hormonal therapy
if detected early, prognosis is good
active surveillance, regular evaluation of PSA
Side effects of surgical therapy, which is curative in younger men: erectile dysfunction (damage to cavernosal nerves) urinary incontinence (impacts sphincter mechanism) external beam radiation can treat localized prostate cancer but can lead to urgency, frequency urinary symptoms
Treatment for advanced/metastatic disease: -antiandrogen (hormonal therapy)
- surgical castration
- chemical castration (GNRH, leuprolide or goserelin, with continuous administration)
- flutamide (androgen receptor blocker), often used as an adjunt to GnRH therapy, seldom monotherapy
Screening:
digital rectal exam
PSA (around age 50)
Patient presents to ED with scrotal pain- ddx
torsion versus epididymitis
differentiate the 2 based on onset infection visual changes support cremasteric reflex ultrasound
Treat torsion with detorsion and b/l orchiopexy within 6 hours
Treat epididymitis with
under 35yo- GC/chlamydia- IM ceftriaxone and then doxycycline for 10 days
over 35yo or ho anal intercourse consider enterobacteriaceae terat with fluoroquinolone 10-14 days
Testicular cancer
95% germ cell
- seminoma
- nonseminoma
5% stromal
- leydig
- sertoli
- granulosa
RF:
undescended testicle
history of testicular cancer
family history of testicular cancer
H and P: painless, firm, testicular mass gynecomastia lower abdominal pain GI symptoms Pulmonary symptoms
Lab tests and imaging to test for testicular cancer
- beta-hCG elevated in
choriocarcinoma
seminoma - alpha-fetoprotein
produced by yolk sac elements of nonseminomatous tumors
if elevated, you may have several types of germ cell tumors mixed together
- estrogen increased in stromal cell tumors
- scrotal ultrasound
- solid testicular mass on affected sied
- confirm normal testis on other side
*CT scan of abdomen/pelvis and CXR to evaluate for nodal metastases
rarely do a biopsy, as biopsy alters lymphatic flow, thereby increasing risk of mets
radical orchiectomy is preferred to bx
Treatment: early stage seminoma
chemotherapy or radiation to retroperitoneum
high cure rates
observation protocols with strict surveillance
Treatment: nonseminoma
retroperitoneal LN dissection or chemotherapy after radical orchiectomy for micromets
observation protocol if no sign of metastasis
high cure rates, with a slightly lower cure rate than seminomatous tumors
retroperitoneal LN dissection can result in ejaculatory dysfunction, which results from sympathetic nerves during dissection
male infertility
unable to conceive after 1 year
H and P: testicular trauma surgery chemotherapy undescended testes
Labs:
semen analysis (morphology and motility of sperm)
serum hormone levels (FSH if elevated, then the testical has primary failure unable to respond)
Treatment:
DO NOT treat with exogenous testosterone which would inhibit endogenous release of gonadotropin
treat underlying condition
surgical correction of anatomical defects
hormone therapy
in vitro fertilization
Varicocele
dilation of veins of pampiniform plexus
the valves become incompetent, and you get a backflow of blood toward the testicle, which dilates the veins
often seen on routine exam
dull, aching scrotal pain usually on the left (left-sided varicoceles are 10 times more common than right- sided)
A solitary right- sided varicocele, suspect RCC (these are very uncommon)
Testicular atrophy on the affected side
infertility is common; varicoceles are present in 25% of infertile men vs. only 11% of fertile men
Color Doppler US showed retrograde flow to the scrotum
Treatment: surgery. Tie off incompetent veins
Erectile dysfunction
inability to achieve or maintain an erection during sexual activity
causes: neurogenic, or prior surgery on prostate or retroperitoneum, diabetic neuropathy, vasculogenic
RF: htn, hypercholesterol, smoking
hypogonadism, hypothyroid
drug abuse, heavy alcohol use
psych
history:
- discuss onset, duration
- symptoms of depression
- medications and drug use
- psychological stressors and interpersonal conflict
- if dysfunction is situational (only with one particular partner)
- presence of nocturnal or early- morning erections (absent if organic cause, present if psychogenic)
On physical exam:
- anal tone (neuro dysfunction)
- lower extremity sensation (neuro dysfunction)
- cremasteric reflect (neuro dysfunction)
- femoral and peripheral pulses (vasculogenic cause)
- penis (Peyronie disease)
- testes (hypogonadism)
- secondary sexual characteristics (hypogonadism)
- visual fields (pituitary tumor)
- gynecomastia (prolactinoma)
serum lab tests:
- total testosterone
- prolactin
- TSH
- PSA to establish baseline
if vasculogenic- cardiac stress test to assess for cardiac endothelial damage as well
MRI head if you suspect pituitary mass
What medications are known for causing erectile dysfunction?
Most antidepressants, esp SSRIs
Spironolactone
Sympathetic blockers: clonidine, guanethidine, methyldopa
Thiazide diuretics, beta blockers
Ketoconazole
Cimetadine (not ranitidine or famotidine)
Antipsychotics
