Male Reproductive Flashcards
1
Q
Erectile Dysfunction: Definition, Types, & Risks
A
-
Definition:
- inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance
-
Types:
- vascular = MC
- arteriogenic, veno-occlusive), neurogenic, hormonal, anatomic, drug-induced, psychogenic
-
Risks:
- DM, HTN, CAD, dyslipidemia, EtOH, smoking, obesity, anxiety, depression, PTSD, neurological disease, pelvic or vascular surgery, meds (anti-HTN, antidepressants), endocrine disorders, urologic disorders
2
Q
Organic vs Psychogenic Erectile Dysfunction
A
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Organic:
- **Gradual Onset
- -lack of tumescence (to become swollen as a response to sexual arousal)
- normal ejaculation & libido
- medical risk factors
- medications, smoking, EtOH, recreational drug use
-
Psychogenic:
- **Sudden onset
- easy loss of erection
- Better quality with self-stimulation
- premature ejaculation
- relationship or psychological problems major life events
3
Q
Erectile Dysfunction: Dx & Tx
A
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Dx:
- clinical dx
- labs to order:
- fasting plasma glucose to assess for DM
- lipid profile
- BUN, Cr
- AST/ALT (serum transaminases)
- TSH
- Serum total testosterone
-
Tx:
- *Drugs MOA: nitric oxide (PGE1) → increase in cGMP → reduced calcium influx into vascular smooth muscle → increase in cavernosal blood flow
-
Phosphodiesterase-5 inhibitors (Sildenafil, vardenafil, Tadalafil, avanafil;
- do NOT use with nitrates (hypotension), use with caution with alpha-adrenergic blockers; SEs: HA, GI, visual changes
- Prostaglandin E1: alprostadil, transurethral, used in men with contraindication or failed PDE-5 inhibitors
4
Q
Male Hypogonadism: definition, etiology, S/sxs
A
-
Definition:
- decrease in either or both of the primary fnx of the testes (testosterone & sperm production)
-
Etiology:
-
Primary:
- decreased function of Leydig cells → decreased testosterone; aging, obesity, meds, anorchia, cryptorchidism, Klinefelter’s, trauma
-
Secondary:
- disorder of the pituitary gland or hypothalamus; cirrhosis, feedback inhibition by high estrogen, hypothyroid, hyperprolactin, opiates, THC, Crohn’s, arthritis
-
Primary:
-
S/sxs:
- Decreased muscle mass & increased fat mass
- decreased bone mass and increased risk of fracture
- depression, loss of motivation, fatigue, decreased labido
- erectile dysfunction
- Adolescents: failure to undergo puberty
5
Q
Male Hypogonadism: PE, Dx, & Tx
A
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PE:
- Evidence of hypothyroid or cortisol excess: dry skin, hair loss, moon face, flushing
- Jaundice (d/t liver failure, hepatitis)
- Rash or oral lesions (HIV)
- BMI, Waistline > 40in (HTN, CVD, DM II)
- obesity, striae, bruits of the abd
- testicular problems with size, volume, consistency
-
Dx:
- Morning total serum testosterone: initial screen, decreased (<300 ng/dL)
- *If decreased → then run total testosterone panel: total, free (2%), sex steroid hormone binding globulin (68%)
- Then run LH: to determine primary vs. secondary
- Then run Prolactin: if T < 140 ng/dL
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Tx:
- Testosterone Supplements: IM injections, subdermal pellets, dermal patches, axillary liquid, nasal gel (oral formulations not recommended)
- Smoking cessation, diet, exercise
6
Q
Complications Associated with Low Testosterone
A
increased risk of MI or stroke, obesity, DM, metabolic syndrome, OSA
7
Q
Risks of Testosterone Replacement & Monitoring
A
elevated LFTs, altered HDL/LDL ratio, increased hematocrit, progressive OSA, promotion of prostate cancer, increased aggressiveness, dependency → monitor LFTs, hematocrit, lipid panel, PSA, total testosterone
8
Q
Nerves involved in the sexual response in Men
A
pelvic sympathetic & parasympathetic nerves merge to form the cavernous nerves which regulate blood flow through sexual response; pudendal nerve provides somatic sensation contract/relax muscles around penis
9
Q
Effects of Testosterone & it’s metabolites in men
A
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Testosterone:
- muscle mass, skeletal growth, spermatogenesis, sexual fnx
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Dihydrotestosterone (DHT):
- facial & body hair, acne, scalp hair loss, prostate growth
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Estradiol:
- bone formation, breast tissue, libido
10
Q
Cryptorchidism
A
- when the testes do not descend aka undescended testicle
-
Risk factors:
- premature infants (30%) vs full term infants (5%)
- most common in R testicle
- increases risk of cancer and infertility
-
Dx:
- referral made to urology if testicles have not descended by 3 months of age
- surgery between 6months - 1 year of age (orchiopexy)
*
- surgery between 6months - 1 year of age (orchiopexy)
- referral made to urology if testicles have not descended by 3 months of age
11
Q
Peyronie Disease Etiology, S/sxs, Dx, & Tx
A
buildup of fibrous hardened tissue in the corpus cavernosum → often caused by repeated injury (sex, physical activity) and genetic susceptibility is involved
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S/sxs:
- penile pain worsened with erection
- curvature of penis on erection
- interference with sexual function
- thick circumferential plaque at the coronal sulcus
-
Dx:
- hx and penile exam
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Tx:
- stable, mild curvature (≤ 30 degrees) with satisfactory sexual function:
- observation = okay
- worsening curvature or sexual dysfunction:
- pentoxifylline (vasodilator & anti-inflammatory) = best if initial tx within 3 months of onset
- > 3 months of deformity?
- intralesional injection with collagenase
- >12 months and wont respond to other txs?
-
surgical management
*
-
surgical management
- stable, mild curvature (≤ 30 degrees) with satisfactory sexual function:
12
Q
Epididymitis S/sxs, PE, Dx, and Tx
A
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Pathogens:
- Men < 35 = chlamydia and gonorrhea
- Men ≥ 35 = E.coli
-
S/sxs:
- dull, aching scrotal pain that gradually increases
- dysuria, unilateral scrotal pain & swelling
-
PE:
- (+) Phren’s sign → relief of sxs with elevation = Classic Sign
- tender scrotum on posterior
-
Dx:
- important to r/o testicular torsion → Rapid onset, higher testis → u/s with doppler
- urinalysis & cx + GCCT → pyuria (WBCs in urine) and bacteriuria
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Tx:
- <35 or suspected STD: ceftriaxone IM + doxycycline
- ≥ 35 with suspected enteric organism:
- levofloxacin or double strength Trimethoprim-Sulfamethoxazole (Bactrim)
13
Q
Orchitis s/sxs, PE, Dx, & Tx
A
- Mumps = most common cuase in kids
- orchitis without epididymitis = very uncommon in adults
- S/sxs: unilateral scrotal pain
-
PE:
- tender, swollen testicle
- shininess of the overlying skin
- scrotal edema with erythema
- tender, swollen testicle
-
Dx:
- r/o testicular torsion with u/s with doppler
- urinalysis with cxs: pyuria and bacteriuria with cxs positive for suspected organisms
-
Tx:
- rest, NSAIDS, scrotal support, ice, and abx (if bacterial)
- Age <35 or sexuallya ctive post-pubertal males → tx like epididymitis
- → ceftriaxone IM + doxycycline
- Age ≥ 35 (STI not suspected) →levofloxacin
14
Q
Acute Bacterial Prostatitis S/sxs, PE, Dx, & Tx
A
- Men < 35: chlamydia & gonorrhea
- Men ≥ 35: E.coli
- most common in younger men and more serious
-
S/sxs:
- fever, chills, malaise
- dysuria (pain with urination), urgency, frequency
- perineal and low back pain
-
PE:
- DRE (digital rectal exam):
- boggy, warm, tender, enlarged prostate
- if you suspect prostatitis DO NOT MASSAGE THE PROSTATE → can lead to SEPSIS
- DRE (digital rectal exam):
-
Dx:
- urinalysis: pyuria +/- hematuria
- urine cx: positive
- prostatic fluid/secretions: may show leukocytosis with a cx → typically positive for E.coli
- U/S CT scan Cystoscopy for men with significant voiding issues
-
Blood Tests: CBC, blood cx if clinical findings suggestive of bacteremia → BUN, creatinine levels for pts with urinary retention/obstruction
- → serum PSA may be elevated
-
Tx:
- Men < 35: ceftriaxone + doxy
- Men ≥ 35: fluoroquinolones or Bactrim for 3-6 weels
- URETHRAL CATHETERIZATION IS CONTRAINDICATED IN THESE PATIENTS
15
Q
Chronic Prostatitis S/sxs, PE, Dx, & Tx
A
- usually men age 40-70
- can be bacterial/abacterial; chronic bacterial = most common form of prostatitis
-
S/sxs:
- can be asymptomatic
- hx of recurrent UTIs
- perineal/low back pain; suprapubic discomfrot
- PE: DRE → enlarged, non-tender prostate
- Tx: fluoroquinolones or Bactrim x 6-12 weeks
16
Q
Urethritis Etiology, S/sxs, Dx, & Tx
A
infx of the urethra
- Etiology: STIs: chlamydia, N. gonorrhoeae, trichomonas vaginalis & HSV = common cause in both sexes
-
Sxs: dysuria
- in men: urethral discharge → can be purulent, whitish, or mucoid
-
Dx; first void or first-catch urine sometimes with cx
-
positive leukocyte esterase on urine dipstick
- or ≥ 10WBCs/HPF
- nucleic acid amplification test = allows for identification of N. gonorrhoeae, C. trachomatis
-
positive leukocyte esterase on urine dipstick
- Tx: should treat empirically for STDs in sexually active pts pending test results
- →ceftriaxone 500mg IM + doxycycline 100mg PO BID x7 days
- → can consider replacing doxy with azithromycin 1g PO if compliance in question or pregnancy
17
Q
Penile Cancer Etiology, Risks PE, Dx, Tx & Prevention
A
squamous cell carcinoma = most common type
- mean age of diagnosis = 60 years old
- Etiology: HSV & HPV 18
- Risk factors: uncircumcised, poor hygiene
-
PE: mass or blister that can become wart-like growth that discharges blood or foul-smelling fluid
- penile mass or ulcer, especially those who have not been circumcised
- Dx: biopsy
-
Tx: surgery = most common
- radiation & chemo = also options
-
Prevention:
- condom use and HPV vaccine
18
Q
Prostate Cancer Etiology, S/sxs, PE, Dx, Tx
A
- most are adenocarcinomas
- associated with the BRCA1 gene
- Risk factors: african american, old age, family hx
-
S/sxs: urinary retention (more likely sign of BPH), decrease in urine stream strength
- back pain (metastatic disease)
- painful ejaculation
- PE: DRE: hard, nodular, enlarged, and asymmetrical prostate
-
Dx:
- indications for transrectal biopsy with normal rectal exam → PSA > 10 or abnormal transrectal U/S
- PSA > 4: U/s with needle biopsy
- PSA >10: bone scan to r/o metastases
-
Tx;
- radical prostatectomy → complication = erectile dysfunction & urinary incontinence
- with metastases: need androgen deprivation therapy (leuprolide) → type of medical castration, but can be reversible
*
19
Q
Testicular Cancer Etiology, PE, Dx, & Tx
A
- Most common solid tumor in young men ages 15-40 (avg 42 yo)
- 5 year survival =90%
- most common type =germ cell tumor
- 2 types: seminomas
- nonseminomatous germ cell tumor (NSGCT)
- Seminomas:
- classic seminoma (95%)
- spermatocytic seminoma
- NSGCTs
- emrbyonal carcinoma
- yolk sac carcinoma
- choriocarcinoma
- 2 types: seminomas
-
PE:
- firm, painless, nontender, fixed mass on testicle
-
Dx: Scrotal U/x
- radiologic studies to search for metastases → most commonly in brain, belly, lungs
-
tumor markers: alpha-fetoprotein (AFP) → + in NSGCT, not seminomas
- human chorionic gonadotropin + in both NSGCT and seminomas
- lactate dehydrogenase (LDH)
-
Tx:
- orchiectomy +/- chemo and radiation depending on cell type
- NSGCT = radioresistant
- Seminomatous tumors = radiosensitive and can be treated with radiation therapy
20
Q
Hypospadias/Epispadias Dx and Tx
A
-
Hypospadias: when the urethral meatus open onto the ventral (bottom/underside) of the penile shaft
- genetic heritability
- IVF has been associated with increased risk of hypospadias
- Epispadias: when the urethral meatus opens onto the dorsal (topside) of the penile shaft
- Dx: usually made during the newborn exam but imaging studies (excretory urogram) can be helpful
-
Tx: surgical repair before 1-2 years of age
- DO NOT CIRCUMCISE → may use foreskin in surgical repair
21
Q
Paraphimosis Dx & Tx
A
- entrapment of the foreskin in the retracted position → Medical Emergency
- Paraphimosis needs a Paramedic
- ***always remember to reduce the foreskin after urethral catheterization***
- Dx: clinical
-
Tx: firm circumferential compression of the glans with the hand may reduce the edema enough to allow the foreskin back to its normal position
- → if not successful, dorsal slit using local anesthetic temporarily relieves the problem → CIRCUMCISION after edema is resolved
22
Q
Phimosis Dx and Tx
A
- foreskin in normal position and cannot be retracted
- adult phimosis often caused from scarring after trauma, infx (such as balanitis) or prolonged irritation
- Dx: clinical
-
Tx: in children, will normally resolve by age 5
- tx not usually required in absence of other issues such as balanitis, UTIs, urinary obstruction
- betamethasone cream 0.05% BID-TID
- gently stretch the foreskin
23
Q
When to screen for PSA
A
DISCUSS WITH PATIENT
- men age 55-69 yo
- 50 years old if first degree family hx
- 45-50 if african american
24
Q
BPH S/sxs, PE, Dx, & Tx
A
Benign Prostatic Hyperplasia
- 50% of men have BPH by age 60, >90% by age 85
-
S/sxs: difficulty starting stream, post-void dribbling, hesitancy (start and stop)
- nocturia
- weak urinary stream
- PE: digital rectal exam → uniformly enlarged firm and rubber prostate
-
Dx:
- DRE +PSA
- PSA < 4 = normal
- PSA > 4 → BPH, prostate cancer, prostatitis
- UA to r/o other causes
-
Tx:
- if mild → watchful waiting
-
alpha blockers can provide the most rapid relief (smooth muscle relaxation of prostate and bladder neck
- tamsulosin, prazosin, terazosin (shrink size of prostate)
- TURP (transurethral resection of the prostate) if unresponsive to meds
-
5-alpha reductase inhibitors
- finasteride & dutasteride (Prevent conversion of testosterone → DHT (active form)
25
Q
Hydrocele PE, Dx, & Tx
A
- mass of fluid-filled congenital remnants of the tunica vaginalis
- infants: will usually close within the 1st year of life
-
PE:
- painless scrotal swelling (most common cause of this)
- + transillumination vs tumor or varicocele which both do not transilluminate
- Dx: Scrotal U/S
-
Tx: in infants → will usually close in the 1st year of life, but may require surgery if clinically indicated
- have parents practice watchful waiting for 1 year
26
Q
Varicocele PE, Dx & Tx
A
venous varicosity within the spermatic vein
-
PE: feels like a “bag of worms’ superior to the testicles
- dilation worse when the pt is upright or with valsalva → decrease in size with elevation of the scrotum or supine position
- negative transillumination → chronic non-tender mass that does not transilluminate
- Dx: Scrotal U/s
- Tx: surgical repair if varicocele is painful or appears to be cause of infertility
27
Q
Testicular Torsion S/sxs, PE, Dx, & Tx
A
-
Risk Factors: after vigorous activity or minor trauma
- usually post-pubertal boys (65% in boys age 10-20)
- more common in pts with a hx of cryptorchidism
-
S/sxs:
- severe, acute onset lower abdominal pain, sharp pain that may radiate into thigh
- vomiting
-
PE: negative phren’s sign
- loss of cremasteric reflex ( elevation of the testes in response to stroking of the inner thigh)
- Blue dot sign: tender nodule 2-3mm in diameter of the upper pole of the testicle
-
Dx: U/s with doppler = best initial test
- Radionuclide scan demonstrates decreased uptake in the affected testes → GOLD STANDARD
-
Tx:
- need to de-torse the testicles in < 6 hours (90% salvage rate)
- >24 hours? <10% salvage
- orchiopexy (permanent fixation of the testicle)
28
Q
Priapism
A
- Definition: a prolonged (>4 hours), painful erection
-
Etiology:
- medications: PDE-5 inhibitors, PGE-1, phentolamine, papaverine, bupropion,
- Blood disorders: sickle cell anemia, leukemia
- Alcohol, marijuana, cocaine
-
Complications:
- may result in severe ischemia, fibrosis & impotence after 12 hours
-
tx:
- ice packs
- decongestants: phenylephrine
- Procedures: injections, needle aspiration, surgery
29
Q
Premature Ejaculation
A
- Definition: an orgasm before intercourse or less than one minute after starting
-
Causes:
- unclear – psychogenic, penile hypersensitivity, cultural basis
-
Epidemiology:
- ~30% of men worldwide
-
s/sxs:
- loss of control
- significant distress to man or partner
-
Tx:
- SSRI: paroxetine (PRN vs continuous)
- -TCA: clomipramine
- -Topical lidocaine/prilocaine
- -Psychological: sex therapy
- -Behavioral: distraction techniques, prolonged arousal time, sex holidays
30
Q
Retrograde Ejaculation
A
-
Definition:
- semen enters the bladder instead of emerging through the penis during orgasm
-
Causes:
- longstanding DM, relaxation of the urethral sphincter by meds (alpha adrenergic antagonists), prostate surgery
-
S/sxs:
- little to no semen during orgasm
-
Tx:
- trial of Pseudoephedrine
31
Q
Decreased Libido
A
-
Definition:
- decrease in sexual interest, initiative, frequency and intensity of responses to internal or external erotic stimuli
-
Causes:
- psychogenic, neurologic disorders, androgen deficiency, meds (Thiazides, spironolacton, SSRI, TCA, opiates), alcoholism, depression, fatigue, drugs, relationship problems, sexual dysfunction, systemic illness
-
Dx:
- metabolic & hormonal eval (testosterone): for s/sxs of hypogonadism
-
Tx:
- address underlying cause
- change class of meds
32
Q
Male Hypogonadism
A
-
Definition:
- decrease in either or both of the primary function of the testes (testosterone & sperm production)
-
Etiology:
- Primary: decreased function of Leydig cells → decreased testosterone; aging, obesity, meds, anorchia, cryptorchidism, Klinefelter’s, trauma
- Secondary: disorder of the pituitary gland or hypothalamus; cirrhosis, feedback inhibition by high estrogen, hypothyroid, hyperprolactin, opiates, THC, Crohn’s, arthritis
-
S/sxs:
- decreased muscle mass & increased fat
- decreased bone mass and increased risk of fracture
- depression, loss of motivation, fatigue
- decreased labido, erectile dysfunction
- adolescents: failure to undergo puberty
-
PE:
- Evidence of hypothyroid or cortisol excess: dry skin, hair loss, moon face, flushing
- Jaundice (d/t liver failure, hepatitis)
- Rash or oral lesions (HIV)
- BMI, waistline > 40in (HTN, CVD, DM II)
- obesity, striae, bruits of the abd
- testicular problems with size, volume, consistency
-
Dx:
-
Morning total serum testosterone: initial screen: decreased (<300 ng/dL)
- *If decreased → then run total testosterone panel: total, free (2%), sex steroid hormone binding globulin (68%)
- Then run LH: to determine primary vs. secondary
- -Then run Prolactin: if T < 140 ng/dL
-
Morning total serum testosterone: initial screen: decreased (<300 ng/dL)
-
Tx:
- Testosterone Supplements: IM injections, subdermal pellets, dermal patches, axillary liquid, nasal gel (oral formulations not recommended)
- Smoking cessation, diet, exercise
- No evidence supports natural testosterone boosters
33
Q
Low Testosterone Complications
A
increased risk of MI or stroke, obesity, DM, metabolic syndrome, OSA
34
Q
Testosterone Replacement Risks
A
- elevated LFTs, altered HDL/LDL ratio, increased hematocrit, progressive OSA, promotion of prostate cancer, increased aggressiveness, dependency → monitor LFTs, hematocrit, lipid panel, PSA, total testosterone
