Male Reproductive

Question 1

Erectile Dysfunction: Definition, Types, & Risks

Answer 1

• 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

Question 2

Organic vs Psychogenic Erectile Dysfunction

Answer 2

• 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

Question 3

Erectile Dysfunction: Dx & Tx

Answer 3

• 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

Question 4

Male Hypogonadism: definition, etiology, S/sxs

Answer 4

• 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
• 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

Question 5

Male Hypogonadism: PE, Dx, & Tx

Answer 5

• 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
• Tx:
  
  • Testosterone Supplements: IM injections, subdermal pellets, dermal patches, axillary liquid, nasal gel (oral formulations not recommended)
  • Smoking cessation, diet, exercise

Question 6

Complications Associated with Low Testosterone

Answer 6

increased risk of MI or stroke, obesity, DM, metabolic syndrome, OSA

Question 7

Risks of Testosterone Replacement & Monitoring

Answer 7

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

Question 8

Nerves involved in the sexual response in Men

Answer 8

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

Question 9

Effects of Testosterone & it’s metabolites in men

Answer 9

• Testosterone:
  
  • muscle mass, skeletal growth, spermatogenesis, sexual fnx
• Dihydrotestosterone (DHT):
  
  • facial & body hair, acne, scalp hair loss, prostate growth
• Estradiol:
  
  • bone formation, breast tissue, libido

Question 10

Cryptorchidism

Answer 10

• 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)
      *

Question 11

Peyronie Disease Etiology, S/sxs, Dx, & Tx

Answer 11

buildup of fibrous hardened tissue in the corpus cavernosum → often caused by repeated injury (sex, physical activity) and genetic susceptibility is involved

• 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
• 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
        *

Question 12

Epididymitis S/sxs, PE, Dx, and Tx

Answer 12

• 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
• Tx:
  
  • <35 or suspected STD: ceftriaxone IM + doxycycline
  • ≥ 35 with suspected enteric organism:
    
    • levofloxacin or double strength Trimethoprim-Sulfamethoxazole (Bactrim)

Question 13

Orchitis s/sxs, PE, Dx, & Tx

Answer 13

• 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
• 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

Question 14

Acute Bacterial Prostatitis S/sxs, PE, Dx, & Tx

Answer 14

• 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
• 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

Question 15

Chronic Prostatitis S/sxs, PE, Dx, & Tx

Answer 15

• 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

Question 16

Urethritis Etiology, S/sxs, Dx, & Tx

Answer 16

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
• 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

Question 17

Penile Cancer Etiology, Risks PE, Dx, Tx & Prevention

Answer 17

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

Question 18

Prostate Cancer Etiology, S/sxs, PE, Dx, Tx

Answer 18

• 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
    *

Question 19

Testicular Cancer Etiology, PE, Dx, & Tx

Answer 19

• 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
• 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

Question 20

Hypospadias/Epispadias Dx and Tx

Answer 20

• 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

Question 21

Paraphimosis Dx & Tx

Answer 21

• 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

Question 22

Phimosis Dx and Tx

Answer 22

• 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

Question 23

When to screen for PSA

Answer 23

DISCUSS WITH PATIENT

• men age 55-69 yo
• 50 years old if first degree family hx
• 45-50 if african american

Question 24

BPH S/sxs, PE, Dx, & Tx

Answer 24

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)

Question 25

Hydrocele PE, Dx, & Tx

Answer 25

• 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

Question 26

Varicocele PE, Dx & Tx

Answer 26

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

Question 27

Testicular Torsion S/sxs, PE, Dx, & Tx

Answer 27

• 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)

Question 28

Priapism

Answer 28

• 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

Question 29

Premature Ejaculation

Answer 29

• 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

Question 30

Retrograde Ejaculation

Answer 30

• 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

Question 31

Decreased Libido

Answer 31

• 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

Question 32

Male Hypogonadism

Answer 32

• 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
• 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

Question 33

Low Testosterone Complications

Answer 33

increased risk of MI or stroke, obesity, DM, metabolic syndrome, OSA

Question 34

Testosterone Replacement Risks

Answer 34

• 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