Male reproductive system pathologies Flashcards
Function of Bulbourethral gland?
Production of pre - ejaculate.
0 Neutralists urine that may be in urethra.
0 located in membranous Urethra
What is the ejaculatory duct made up of ?
Pathway of semen?
duct from seminal vesicles + vans deferens from prostate
Pathway of semen
Ejaculatory duct ——> prostatic urethra ——> Membranous U——> Penile / spongy U —– > glans penis (semen leaves through this )
- Semen - mixture of sperm and accessory fluid.
Where does the majority of blood go to in penis during an erection ?
Why?
90 % to corpus cavernosa
10% to corpus spongiosum
(majority goes to cavernosa so that only little goes to spongiosum - this contain male urethra. too much blood will cause too much pressure build up and occlude urethra.
Function of cremaster and dartos muscle.
0 located in scrotum , smooth muscle
0 contact to elevate the testes - bring closer to belly during cold weather to retain heat.
What is the spermatic cord ?
Cord containing testicular vein, arteries and nerves.
0 formed at opening of inguinal canal ——> enters scrotum via supercritical inguinal canal
What is the rete testis ?
Astamosing network of the seminiferous tubules in the testes - help with the transfer of sperm.
(seminiferous tubules join to form this network)
What are the possible cause of lump in testes ?
0 Hydrocele 0 indirect / scrotal hernia 0 Varicocele 0 Epididymitis 0 Epdidymal cyst 0 Tumour
What is a hydrocele ?
Painless swelling of scrotum
Common in newborns
collection of fluid between parietal and visceral layers of tunica vaginalis.
Can be : - non -communicating (isolated) - communicating (connects to abdominal cavity through potential hernia space - patent processus vaginalis )
hydrocele ofen get better on their own
surgical intervention 0 may be required for communicating hydroceles to close channel
What is epididymitis ?
inflammation of the epididymis
Characterised by :
unilateral scrotal pain
unilateral scrotal swelling
Causes
Bacterial epidymitis
0 <35 - most commonly sexually transmitted diseases (Neisseria gonorrhoeae or Chlamydia trachomatis) - can start as urethritis (infection of urethra).
0 > 35 - most commonly occur in urological abnormalities , indwelling catheters or recent urological procedures.
Other causes - rare except for in immunocompromised patients (HIV - infected patients )
Tuberculous epididymitis and syphilitic gummas
(bacteria infections )
Viral causes - Cytomegalovirus
Mycotic causes - (fungal causes )
What is an epididymal cyst ?
- Fluid filled sac - benign
0 Grows at top end of testicle (where spermatic cord is attached )
0 can be small or large - can grow to size of testes.
0 can be one or several on both testicles.
0 is felt separate from testicle (unlike testicular cancers)
SYMPTOMS
- pain free , lump at top of testicles , separate from testes.
- small cyst do not need treatment. Larger ones may need surgery or needle aspiration (not common)
- More common in men above 40
- spermatocele - can feel the same but is a cyst filled with sperm.
What is a varicocele ?
collection of varicose veins of the small vein near one or both testicles.
varicose
veins in
scrotum -
abnormal
dilation/
enlargement
of scrotal
venous
pampiniform
plexus -
drains from
each testicle.
0 Can happen above beside one or both testicles.
- Caused by weakening of valves so venous blood flow backwards
RARE CAUSES
0 Deep vein thrombosis
0 renal arteriovenous malformations
0 thrombosis of the pampiniform plexus.
- Can be felt as a bag of worms in scrotum.
- if man is over 40 and suddenly get varicocele - could be cancer (tumor in kidney adds back pressure - on smaller veins in scrotum.
What is testicular cancer ?
Cancerous
rare -not common but have to be on the look out.
- effect men between 15 and 49 most commonly.
SYMPTOMS
Felt as :
- painless swelling lump -usually 1
- Dull ache / sharp pain in testicles/ scrotum
- Heaviness in scrotum
- Testis loses normal shape - larger, irregular and bumpy.
Most lumps or swellings in the scrotum are not in the testicle and are not a sign of cancer, but they should never be ignored
- men whose testes did not descend into the scrotum (cryptorchidism) by age 3 have a greater chance of developing testicular cancer.
0 Correcting cryptochidism can decrease risk of this cancer - but still higher than normal. - Metastic cancer - spread to other parts of the body causing other symptoms.
What is an scrotal hernia ?
Can also be called indirect hernia
Appears as a swelling / lump in groin or as enlarged scrotum.
Hernia - structure passes through a space or defect into an
abnormal location.
inguinal hernia - most common
0 protrusion of abdominal contents through acquired or congenital area of weakness /defect in abdominal wall just above inguinal ligament.
Symptoms
- visible bulge
- discomfort
- can be asymptomatic
findins - cannot rise above it affects spermatic cord.
Causes :
0 increased intra - abdominal
0 weakness in abdominal muscles
These can be caused by - chronic cough - constipation -obesity - heavy lifting advanced age.
Direct vs indirect hernia ?
Direct - abdominal contents passes through defect (abnormal opening) in posterior inguinal canal wall ——-> into inguinal canal (medial to deep ring )—–> out of superficial inguinal ring.
INDIRECT
Abdominal contents passes through deep ring —> inguinal canal —–> out via superficial
ring.
Clinical test to differentiate :
Indirect - press on deep ring (mid line of inguinal ligament) - you can control the indirect hernia which has been reduced
Direct - same thing is done, but hernia still protrudes indicates it is merging through posterior inguinal wall defect.
Meaning of these terms relating to hernias.
- reducible
- incarcerated
- obstructed
- strangulated
Reducible - hernia contents can be manipulated back into original position (returned to it original compartment through defect that it emerged through. ) - can provide symptom relief
Incarcerated / irreducible - Cannot be pushed back into original position / compartment,- due to compression of hernia by defect.
Obstructed - relates mainly to hernias containing bowel - hernia containing bowel compressed so bowel obstruction occurs
bowel lumen not patent (open - unobstructed )
Strangulated - lack of blood flow to hernia contents due to compression around the hernia - causes ischemia and pain.
Management of suspected inguinal hernia
- Exclude strangulated or obstructed hernias.
0 If present admit to hospital immediately .0 if not
present :
- Infant / young boy - refer urgently to paediatric surgeon .
- men /
older boys
-urgent referral for
surgical repair - if irreducible or partially reducible
Refer all others routinely for surgical repair, unless they have :
0 minimally symptomatic inguinal hernias \+ 0 significant comorbidity \+ 0 do not want to have surgery.
Treatment of inguinal hernia ?
Inguinal hernia repair
Laparoscopic surgery /keyhole
-0 3 small incision made allowing various instrument to enter through one hole and repair hernia
(includes laparoscope - light & camera inserted through incision - through the other holes)
Open surgery - Cut made to allow surgery to push lump back into abdomen . Mesh is used to reinforce area of weakness where hernia came through
- if area of bowel is strangulated - needs to removed and healthy 2 ends joined.
primary single sided hernia - open surgery recommended .
recurrent or bilateral hernias - keyhole surgery recommended.
What are the 2 types of Keyhole surgery ?
Transabdominal preperitoneal (TAPP)
- insertion of instruments through abdominal wall & peritoneum (lining covering organs)
- Flap of peritoneum then pulled over hernia and reinforced with mesh.
Totally extraperitoneal (TEP)
- repair of hernia without entering peritoneal cavity. incisions stitched or sealed with surgical glue.
These procedures should only be performed by surgeons who regularly carry out procedure.
Management of Testicular cancer ?
Refer urgently to urologist, to be seen within 2 weeks.
Consider measuring tumour markers whilst waiting :
0 Human chorionic gonadotrophin (hCG) levels.
0 AFP - Alpha fetoprotein levels
What AFP ?
AFP levels - tumour marker for cancer of testis
Normal adult ranges - 0 to 10 IU/ml
Alpha-fetoprotein (AFP) levels. 0 ( protein produced by liver in developing baby - high but fall by age 1. healthy adults adults - low levels.
0 AFP - made by cancer cells or by normal cells in response to cancer.
- High level suggest possible cancer but not always
high level don’t always mean cancer , normal levels don’t exclude cancer. Used in conjunction with other methods t screen for cancer.
*can be used to check effectiveness of treatment.
(Go higher - cancer spreading
Go lower - treatment working.
What is hCG?
Human chorionic gonadotropin - beta subunit HCG
- used a tumour marker
- Not present in normal men
- presence indicates cancer.
- can be used to determine the effectiveness of cancer therapy.
Treatment of testicular cancer ?
orchidectomy - removal of a testicle(plus attached Blood vessels)
(some cases only a part is removed)
(orchido - testicles )
(ectomy - removal )
- Artificial one out of silicone inserted for appearance.
Higher chance of recovery - ability to father children and sex life not affected.
0 bilateral orchidectomy removal of both testes - infertile. (can bank sperm if plan to have children in future)
- may be only treatment needed if cancer found early)
- Lymph node and lung surgery - if cancer spread lymph nodes need to be removed - most likely tummy ones.
- damage to nerves around lymph node can lead to retrograde ejaculation.
What is retrograde ejaculation?
Semen travels backwards to bladder instead of through urethra.
CAUSES
damage to nerves and muscles around bladder.
Muscles usually tightly closer around bladder neck at time of orgasm. Damage means this does not happen.
SYMPTOMS
0 produce no semen
0 Cloudy urine - semen in it when you fist go to toilet after having sex.
TREATMENT
0 Usually no treatment required - still have a healthy sex life and lack of adverse health effects.
0 pseudoephedrine (commonly used as a decongestant) - for retrograde ejaculation caused by surgery of diabetes
0 can be caused by prescribed medicine - stopping will stop problem.
0 extensive - treatment may not be possible
What are the ejaculation issues ?
0 premature ejaculation - ejaculate too quickly during intercourse.
CAUSES
many :
physical - prostate , thyroid problems and recreational drug use.
Physchological - depression , stress, anxiety aboiut sex etc.
Treatment - does need to if couple happy with it. but can seek treatment :
SSRI - Selective serotonin inhibitors - treat depression but delay ejaculation also.
0 paroxetine
0 sertraline
0 fluoxetine
0 * Daproxetine - specially made SSRI to treat premature ejaculation. -
0 Delayed ejaculation
0 Retrograde ejaculation
What is delayed ejaculation?
classed as either:
0 experiencing a significant delay before ejaculation
0 being unable to ejaculate at all, erection is normal and they want too.
May have it if :
0 experience a repeated , unwanted delay before ejaculation lasting for 30 to 60 minutes
0 you’re unable to ejaculate at least half the times you have sex.
CAUSES
Physical :
0 diabetes (usually only type 1 diabetes)
0 spinal cord injuries
0 multiple sclerosis
0 surgery to the bladder or prostate gland
0
increasing age
Medicines that cause delayed ejaculation ]]
0 antidepressants, particularly (SSRIs)
0 blood pressure medication - beta-blockers (especially)
0 antipsychotics, used to treat episodes of psychosis
muscle relaxants such as baclofen, which is widely used to treat motor neurone disease and multiple sclerosis
0 powerful painkillers,
e.g. methadone (which is also widely used to treat people addicted to heroin)
TREATMENT
Sex therapy
change medication e.g from SSRI
can use this to block effects of SSRI:
amantadine – originally designed to treat viral infections
buproprion – usually prescribed to help people quit smoking
yohimbine – originally designed to treat erectile dysfunction
- get help for alcohol and drug use.
Pseudoephedrine - prescribe off label
Variocele - NICE GUIDELINES.
left sided varioceles are more common because of left tesicular vein drainage route. (renal vein)
REFFERAL
- Solitary right sided V - more abnormal - refer to secondary care ( may be suggestive of underlying abdominal abnormality e.g blockage - blood clot , tumours ,
- Uncertain (any)
- Causing pain & discomfort
- Appear suddenly - especially in aged over 40 & and remains tense lying down.
- Is associated with fertility problems - but 2/3rds of patients can have children.
GRADES
According to size.
0 Sub-clinical — detected only by Doppler ultrasound.
0 Grade I (small) — palpable only with Valsalva manoeuvre.
0 Grade II (moderate) — palpable without Valsalva manoeuvre.
0 Grade III (large) — visible through the scrotal skin.
DIAGNOSIS
- Clinica exam - presence of swelling in scrotom - can present as a bag of worms with spermatic cord.
TO CONSIDER
- COLOUR FLOW DOPPLER IIMAGING (with ultrasound)
Treatment of Varicole ?
SUB CLINICAL OR GRADE ONE :
1st line - observation + reassurance
(adolescent version - only reassurance)
GRADE 2 & 3 - Asymptomatic + normal semen parameters - Observation
(adolescent version - less than 20 % size difference vs other testes or testes look symmetrical - Observation)
GRADE 2 & 3 - symptomatic or / with abnormal semen parameters.
1st line - Surgery
(open / laproscopic ) or
percutaneous embolisation ( catheter used to lace coils and / or liquid substance to divert blood flow away from varicocele.
(adolescent version - GRADE 2 & 3 - surgery - testes asymmetrical , or more than 20 % difference)
What is benign prostate hyperplasia?
Enlargement of the prostate without malignancy being present.
CAUSES
Failure of apoptosis (programmed cell death), so benign increase in prostatic tissue
Or prostatic smooth muscle tone is increased mediated by alpha-adrenergic receptors.
( CAUSES BLADDER OUTLET OBSTRUCTION)
CONSQUENCES
enlargement compresses the urethra located in the prostate blocking urine flow.
SIGNS AND SYMPTOMS
0 Lower urinary tarct symptoms :
(Storage problems )
- Increased frequency of urination
- increased frequency urge to urinate
- Nocturia
- Incontince
( Voiding problems )
- Weak /interrupted urine stream
- Straining on urination
- dysuria
- dribbling
ETC.
( can have urinary retention ( acute complication )
- Fever & dysuria - indicates urinary tract infections
RISK FACTORS
- Age - over 50 yrs
- fx history
- non - asian race
- cigarrette smoking
Causes of nocturnal polyuria?
Diabetes mellitus
Diabetes inspidius
Adrenal insufficiency
Liver failure - (cant process waste , reduced blood flow to kidneys )
polyuric renal failure (excessive urination - stage in AKI - can indicate recovering kidney function)
Chronic heart failure
onstructive apnoea
pyelonenephritis
Hypercalcemia - high CA affect ADH levels
pregnancy
Cushings syndrome ( High cortisol levels affects ADH)
Medication causes of nocturnal polyuria ?
CAB - increase urine
Diuretics
SSRI - stop production of ADH
Lithum - can cause kidney damage
Causes of nocturnal polyuria?
Diabetes mellitus
Diabetes inspidius
Adrenal insufficiency
Liver failure - (cant process waste , reduced blood flow to kidneys )
polyuric renal failure (excessive urination - stage in AKI - can indicate recovering kidney function)
Chronic heart failure
onstructive apnoea
pyelonenephritis
Hypercalcemia - high CA affect ADH levels
pregnancy
Cushings syndrome ( High cortisol levels affects ADH)
Treatment of LUTS ? - not caused by BPH
Storage symptoms - conservative management e.g. containment , pads, collecting devices , bladder training , advcie on fluid intake
Medical management
1ST LINE
Alpha blocker (zosins)
can use antichlonergics in combination (look at examples online )
- (If they have noctural polyria )
- offer late afternoon loop diuretic
- consider oral desmopressin if other medical causes excluded & other treatments not worked
SURGERY - if these dont work.
(DESMOPRESSIN - FORM OF VASOPRESSIN - reabsorbs water)
- ( if they have overactive bladder )
- anticholengerics e.g. Mirabegron
Treatment of BPH ?
same as treatment for LUTS caused by BPH
NON BOTHERSOME SYMPTOMS
1ST LINE
Watchful waiting + behavioural management programme (methods to reduce symptoms e.g. urethral milking , bladder training etc)
BOTHERSOME SYMPTOMS
if voiding symptoms ( retention , ) - offer intermittent bladder catheterisation (indwelling urethral or suprapubic)
* long term indwelling urethral catheter may be offered to those whose medical management has failed and surgery not an option, intermittent not tolerated , skin wounds & pressure ulcers that could be contaminated
Medical management - is only for bothersome symptoms where conservative measures have not worked
1ST LINE
prostate larger than 30g or PSA > 1.4ng/ml who are at risk of worsening symptos/ condition (older men)
0 5 - alpha reductase inhibitor (Finasteride , dutasteride)
0 Alpha blocker (moderate to severe LUTS (lower urinary tract symptoms )
- terazosin
- doxazosin
- alfuzosin
- tamsulosin
- silodosin
0 Can gie 5 alpha reductase inhibitors + alpha blockers.
2ND LINE - if conseravtive measure and medical management does not work - SURGERY.
Investigations of benign prostate hyperplasia ?
0 Digital rectal exam - essential to diagnosis (distingush from prostate cancer ) —————> International prostate symptoms score is part of assessment .
0 International prostate symptoms score is part of assessment
- 7 questions ( each with scale of 0 to 5 0 - total score added up. ( scale - 0 to 35)
- Mild - 0 to 7
- Moderate - 8 to 19
- Severe - 20 to 35
0 Urinalysis
- normal in uncomplicated BPH
- Pyuria (WBC ) - infection (UTI)
- Haematuria (may indicate cancer )
0 PSA - prostate- specific antigen - elevated
- when take history of urinary symptoms - questions to ask ? - same as international prostate symptoms score.
( When you urinate does you bladder feel empty after you have finished ? - If no ( Incomplete emptying )
(Check for frquency - how many times do you go to the toilet a day - is this normal for you )
( Do you stop and start when urinating several times ? - intermittency )
( Can you postpone urination ( urgency ))
(Do you strain when urinating ?)
(Urination during the night (nocturia ))
( Ask about how it affects them (how does it bother them - could they deal with it ?)
Consider
Ultrasound, / CT pelvis/ abdomen, - recommended in chronic retention. if signs of urolithasis , renal insufficiency , diabetes (preffered in those with RI or diablites ), Hx of urinary tract surgery , recurrent UTI , haematuria .
( LOOKING FOR HYDRONEPHROSIS , MASS , UROLITHIASIS , POST - VOID RESIDUAL)
Causes of nocturnal polyuria?
Diabetes mellitus
Diabetes inspidius
Adrenal insufficiency
Liver failure - (cant process waste , reduced blood flow to kidneys )
polyuric renal failure (excessive urination - stage in AKI - can indicate recovering kidney function)
Chronic heart failure
onstructive apnoea
pyelonenephritis
Hypercalcemia - high CA affect ADH levels
pregnancy
Cushings syndrome ( High cortisol levels affects ADH)
Differentials of BPH ?
Overactive bladder
Prostatitis
(Fever ,tender , enlarged prostate on rectal examination , supra pubic or lower back pain )
Prostate cancer
(abnormal digital rectal exam e.g. prostate nodules , asytmmetry)
UTI - fever , dysuria , suprapubic or low back pain (URINEANALYSIS - WBC - infection)
Bladder cancer - haemutria , suprapubic pain , bladder spasms, abnormal voiding , hx of smoking etc.
(URINE ANALYSIS - BLOOD, abnormal cystoscopy )
urethral strciture - prior urological surgery , straddle injury.
Neurogenic bladder ( problems with nervous system affect the bladder e.g. stroke , parkinstons , MS, neurpathy (diabetes )
