Male Sexual Reproductive disorders Flashcards
What are some Differential Diagnosis for ED
- Erectile Dysfunction (ED):
Defined as the consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual satisfaction.
Can be differentiated from other conditions by assessing the frequency, severity, and timing of erectile difficulties, along with associated medical history, medications, lifestyle factors, and partner involvement. - Loss of Libido:
Characterized by a decrease in sexual desire or interest.
Can be temporary or long-term and may indicate androgen deficiency or depression.
Distinguished from ED by focusing on changes in sexual desire rather than erectile function. - Anejaculation:
Complete loss of seminal emission.
May result from various causes such as pelvic or retroperitoneal surgery, radiation, androgen deficiency, or sympathetic denervation due to spinal cord injury or diabetes mellitus.
Differentiated from ED by the absence of issues related to achieving or maintaining an erection. - Premature Ejaculation (PE):
Involves early involuntary climax leading to inadequate sexual satisfaction.
Can be primary (lifelong) or secondary (acquired) and is more common than ED in younger patients.
Distinguished from ED by focusing on the timing of ejaculation rather than erectile function. - Retrograde Ejaculation:
Occurs when semen enters the bladder instead of emerging through the penis during orgasm.
Can result from age-related prostate enlargement, mechanical disruption of the bladder neck, pelvic radiation, or certain medications.
Differentiated from ED by the presence of orgasm and ejaculation but with altered semen flow. - Peyronie Disease:
A fibrotic disorder of the tunica albuginea resulting in penile pain, curvature, or deformity.
Associated with varying degrees of sexual dysfunction due to physical changes in the penis.
Distinguished from ED by focusing on penile deformity, pain, or curvature as primary symptoms. - Priapism:
Prolonged penile erection in the absence of sexual stimulation.
Can result from various causes including improper dosing of medications or other therapies.
Differentiated from ED by the prolonged and often painful nature of the erection without sexual arousal. - Androgen Insensitivity Syndromes:
Genetic conditions where the body doesn’t respond properly to androgens (male hormones).
Can present with a range of symptoms including sexual development abnormalities.
Distinguished from ED by focusing on hormonal issues and primary sexual development concerns. - Gynecomastia:
Enlargement of breast tissue in males.
Can result from hormonal imbalances or medications.
Differentiated from ED by focusing on breast tissue changes rather than sexual function.
- Gynecomastia:
- Aging-related Changes in Male Reproductive Function:
Includes natural age-related declines in testosterone levels and sexual function.
Commonly involves gradual changes rather than sudden onset dysfunction.
Distinguished from specific sexual dysfunctions by the presence of age-related hormonal changes.
ED high LR’s
High LRs:
Hypogonadism (primary and secondary): LR not specified, but it’s mentioned as a significant factor in erectile dysfunction.
Diabetes: Accounts for about 5 – 24% of ED cases. Patients with diabetes are 3 times more likely to develop ED.
Associated Conditions:
Cardiovascular Disease (CVD): ED is associated with an increased risk of CVD, particularly in men with metabolic syndrome. It’s a strong predictor of coronary artery disease (CAD) and peripheral artery disease.
Metabolic Syndrome: Linked to an increased risk of ED. Elevated fasting blood glucose levels are associated with the highest risk.
Smoking: Significantly associated with ED. Current smoking increases the risk of developing ED.
Medications (antihypertensive, antidepressant, antipsychotic, opioid agents): Up to 25% of all cases of ED are thought to be due to prescription medications.
What are the Red Flags of ED
Rapid Onset of ED: Sudden onset of ED can suggest a psychogenic cause or drug-related issue.
Young Age with ED: ED in younger men, especially under 40, can be a red flag for underlying conditions like hypogonadism, hormonal imbalances, or vascular issues.
Presence of Other Health Conditions: Conditions such as diabetes mellitus, hypertension, hyperlipidemia, obesity, cardiovascular disease, and depression are red flags as they are strongly associated with ED.
Chronic Medication Use: Chronic use of medications like antihypertensives, antidepressants, antipsychotics, and opioids can lead to or exacerbate ED.
History of Pelvic or Spinal Trauma: Previous pelvic or spinal trauma, radiation, or surgery can be red flags for neurological causes of ED.
Family History of Genetic Disorders: A family history of genetic disorders related to sexual function or hormonal regulation may indicate a genetic component to ED.
Presence of Other Sexual Dysfunctions: Conditions such as decreased libido, premature ejaculation, delayed ejaculation, and Peyronie disease may coexist with or mimic ED, warranting further investigation.
Unexplained ED in Younger Men: Unexplained ED in younger men may signal an increased cardiovascular risk later in life.
Significant Impact on Quality of Life: ED that significantly impacts a patient’s quality of life, emotional well-being, or relationships should be thoroughly evaluated.
- Lifestyle Factors: High-risk lifestyle factors such as smoking, excessive alcohol consumption, drug use, and sedentary lifestyle can contribute to ED and should be addressed.
What are differential diagnosis to Lower Urinary Tract Syndrome (LUTS)
1. Benign Prostatic Hyperplasia (BPH) vs. Urinary Tract Infections (UTIs):
- BPH: Primarily causes obstructive voiding symptoms (e.g., hesitancy, weak stream, prolonged micturition) due to prostate enlargement and urethral compression.
- UTIs: Present with irritative storage symptoms (e.g., frequency, urgency, dysuria) due to infection of the urinary tract.
2. Prostate Cancer vs. Prostatitis:
- Prostate Cancer: May present with similar voiding symptoms as BPH but also includes storage symptoms. DRE findings may reveal hard irregular nodules or dense induration.
- Prostatitis: Causes irritative symptoms such as dysuria, frequency, urgency, and pelvic pain. Acute bacterial prostatitis presents with systemic signs like fever and malaise.
3. Bladder Outlet Obstruction (BOO) vs. Detrusor Overactivity:
- BOO: Leads to obstructive voiding symptoms and postvoid symptoms (e.g., incomplete bladder emptying, dribbling) due to mechanical obstruction at the bladder neck or urethra.
- Detrusor Overactivity: Presents with irritative symptoms such as urgency, urge incontinence, and frequent urination due to involuntary detrusor contractions.
4. Urinary Tract Obstruction (Unilateral vs. Bilateral):
- Unilateral Obstruction: Often asymptomatic in patients with normal kidneys due to compensation by the unaffected kidney.
- Bilateral obstruction is required to cause acute kidney injury (AKI).
Bilateral Obstruction: Can lead to AKI and electrolyte imbalances due to impaired urine flow and tubular injury.
5. Different Types of Incontinence (e.g., Stress, Urge, Overflow):
- Stress Incontinence: Involuntary leakage due to increased intra-abdominal pressure, often associated with activities like coughing, sneezing, or lifting.
- Urge Incontinence: Involuntary leakage due to detrusor muscle overactivity and sudden urge to urinate.
- Overflow Incontinence: Involuntary leakage due to bladder overdistention and inability to empty properly, often associated with bladder outlet obstruction.
6.Functional Incontinence vs. Detrusor-Sphincter Dyssynergy:
- Functional Incontinence: Involuntary leakage despite a normally functioning bladder, often due to environmental or behavioral factors preventing timely access to a toilet.
- Detrusor-Sphincter Dyssynergy: Results from neurological conditions causing a lack of coordination between bladder contractions and sphincter release, leading to urinary retention and overflow incontinence.
What are the LRs for each of the differential diagnosis of LUTs
- Prostate Cancer:
High LR+ findings: Hard, irregular nodules or dense induration on digital rectal examination (DRE), elevated prostate-specific antigen (PSA) levels (especially in the context of age and risk factors), abnormal findings on transrectal ultrasound (TRUS) or MRI (e.g., suspicious lesions, increased vascularity). - Urinary Tract Infections (UTIs):
High LR+ findings: Presence of significant pyuria (elevated white blood cells in urine), positive urine culture with appropriate bacterial species and colony counts, characteristic symptoms such as dysuria, frequency, urgency, and cloudy/foul-smelling urine. - Bladder Outlet Obstruction (BOO):
High LR+ findings: Urodynamic studies showing elevated detrusor pressure during voiding, decreased urinary flow rate (Qmax) on uroflowmetry, post-void residual urine volume (PVR) >100-150 mL on ultrasound, abnormal findings on cystoscopy (e.g., bladder neck sclerosis, urethral stricture). - Detrusor Overactivity:
High LR+ findings: Urodynamic studies demonstrating involuntary detrusor contractions, absence of significant obstruction on uroflowmetry and cystoscopy, characteristic symptoms such as urgency, urge incontinence, and frequent urination. - Functional Incontinence:
High LR+ findings: Clinical assessment revealing environmental or behavioral factors contributing to urinary leakage (e.g., physical impairment hindering access to toilet facilities, cognitive impairment leading to delayed responses to urinary urges). - Detrusor-Sphincter Dyssynergy:
High LR+ findings: Neurological evaluation showing signs of spinal cord injury or neurological disease affecting bladder and sphincter coordination (e.g., upper motor neuron signs, detrusor-sphincter dyssynergy on urodynamic studies).
What are the common diagnosis of decreased bone mass density (BMD) and how is it diagnosed?
- Osteoporosis refers to decreased bone mineral density (BMD) below normal reference values, defined as a T-score less than -2.5 by the WHO.
-** Osteopenia **is a precursor to osteoporosis, indicating decreased BMD below normal but not meeting the osteoporosis criteria, defined as a T-score between -1 to -2.5 by the WHO.
Diagnosis:
Dual-energy x-ray absorptiometry (DXA or DEXA) scans are the gold standard for assessing BMD and diagnosing osteoporosis or osteopenia.
T-scores are used to categorize bone health: normal (T-score between +2.5 and -1), osteopenia (T-score between -1 and -2.5), and osteoporosis (T-score at or below -2.5).
What are LRs and risk factors for Fracture and other bone diseases
The LRs
1. Accuracy of Physical Exam Findings for Diagnosis of Osteoporosis:
Weight less than 51kg: LR+ 7.3, LR- 0.8
Tooth count less than 20: LR+ 3.4, LR- 0.8
Self-reported humped back: LR+ 3.0, LR- 0.85
2. Accuracy of Physical Exam Findings for Diagnosis of Spinal Fracture:
Wall-occiput distance greater than 0 cm:
* Sensitivity 60%, specificity 87%, LR+ 4.6 (2.9-7.3), LR- 0.5 (0.3-0.6)
Rib-pelvis distance less than 2 finger breadths: * Sensitivity 88%, specificity 46%, LR+ 3.8 (2.9-5.1), LR- 0.6 (0.5-0.7)
Armspan-height difference greater than 5 cm: * Sensitivity 39%, specificity 76%, LR+ 1.6 (1.1-2.5), LR- 0.8 (0.6-1.0)
3. FRAX tool for identifying osteoporosis:
Sensitivity 33.3%, specificity 86.4%, LR+ 2.4, LR- 0.77
4. Osteoporosis Self-Assessment Tool (OST) for identifying osteoporosis:
Sensitivity 79.3%, specificity 70.1%, LR+ 2.4, LR- 0.29. This tool has a higher sensitivity for identifying low BMD.
=======Risk Factors======
1. Risk Factors for Fracture:
Age ≥ 65 years: LR+ not specified, but advanced age is a major risk factor for osteoporotic fractures.
Low bone mineral density (BMD): LR+ not specified, but low BMD is a strong predictor of fracture risk.
2. Clinical Risk Factors:
Parental hip fracture: Increases the risk of fracture; exact LR not provided.
Osteopenia identified on x-ray: Indicates decreased BMD and increased fracture risk; specific LR not mentioned.
3. DXA/DEXA Scans:
T-score at or below -2.5 (osteoporosis diagnosis): LR+ not given, but this T-score indicates a significantly increased risk of fractures.
Z-score below -1.5 (warrants secondary osteoporosis workup): Indicates lower than expected BMD for age-matched controls; specific LR not provided.
4. Bone Strength and Fracture Risk:
Relative risk of hip fracture is 2.5 for each decrease of 1 SD in bone density at the femoral neck: Indicates a strong association between low BMD and hip fracture risk.
5. FRAX Tool:
FRAX tool for identifying osteoporosis (defined as T-score ≤ -2.5): Sensitivity 33.3%, specificity 86.4%, LR+ 2.4, LR- 0.77. While LR+ is modest, the specificity indicates its utility in ruling in osteoporosis.
What are differential diagnosis for dizziness?
1. Benign Paroxysmal Positional Vertigo (BPPV)
Differentiating Factors:
- Episodic vertigo triggered by head movements or positional changes.
- Positive Dix-Hallpike or Roll test.
- Nystagmus usually lasts less than one minute.
2. Vestibular Neuritis/Neuronitis
Differentiating Factors:
- Severe episodic vertigo without triggers.
- Accompanied by nausea/vomiting, oscillopsia, and unsteady gait.
- Spontaneous horizontal (and torsional) nystagmus.
3. Ménière’s Disease
Differentiating Factors:
- Unilateral sensorineural hearing loss.
- Episodic attacks of vertigo with nausea, vomiting, and balance issues.
- Unidirectional, horizontal-torsional nystagmus during vertigo episodes.
4. Vestibular Migraines
Differentiating Factors:
- Associated with migraine features like unilateral headache, photophobia, phonophobia, and visual auras.
- Episodic vertigo with moderate or severe intensity.
- No other cause of vestibular symptoms.
Psychogenic Dizziness
Differentiating Factors:
- Often secondary to psychiatric disorders.
- Long-duration dizziness with poorly defined symptoms.
- Associated symptoms like chest pain, shortness of breath, and perioral paresthesias.
6. Orthostatic Hypotension
Differentiating Factors:
- Dizziness or presyncope upon standing.
- Drop in blood pressure within 3 minutes of standing.
- Prevalent in elderly or due to medications causing hypotension.
7. Acute Labyrinthitis
Differentiating Factors:
- Inflammation from viral infections affecting both vestibular and auditory systems.
- Acute onset of severe vertigo with hearing loss and tinnitus.
- Gradual improvement over weeks with possible permanent hearing impairment.
8. Herpes Zoster Oticus (Ramsay Hunt Syndrome)
Differentiating Factors:
- Inflammation of the vestibulocochlear nerve due to reactivated Varicella-zoster virus.
- Can involve facial nerve leading to facial paralysis.
- Presents with vertigo, hearing loss, and possible facial symptoms.
9. Vertebrobasilar Insufficiency (VBI) or Vertebrobasilar Ischemia
Differentiating Factors:
- Inadequate blood flow in the posterior circulation leading to vertigo.
- Initial symptom in nearly half of patients with associated neurological findings.
- Can progress to transient ischemic attack (TIA) or stroke.
What are the red flags for dizziness/vertigo?
1. Neurological Deficits: Look for signs of neurological deficits, such as diplopia (double vision), dysarthria (difficulty speaking), dysphagia (difficulty swallowing), dysphonia (changes in voice), sensory or motor impairment, and cerebellar dysfunction like ataxia (loss of coordination) or dysequilibrium (impaired walking due to balance difficulties). These deficits may suggest central causes of dizziness/vertigo that could be progressive or life-threatening.
2. Cerebrovascular Accidents: Central lesions such as vertebrobasilar insufficiency (VBI), transient ischemic attack (TIA), or stroke can present with vertigo as an initial symptom in some cases. These conditions are serious and require immediate medical attention.
3. Neoplasms/Tumors: Consider the possibility of tumors arising from the cerebellopontine angle, such as brainstem glioma, medulloblastoma, or vestibular schwannoma. Metastases should also be considered, especially in patients with known primary neoplasia or multiple brain lesions. Symptoms may include sensorineural hearing loss and vertigo.
4. Progressive Symptoms: Be cautious if the symptoms are progressive or if there are associated signs of increased intracranial pressure, such as headache, nausea, vomiting, or altered mental status.
5. Risk Factors for Stroke: Patients with risk factors for stroke, such as hypertension, diabetes, smoking, or a history of cardiovascular disease, should be evaluated carefully for dizziness/vertigo, as these conditions can sometimes be related to cerebrovascular events.
What is the neuroimage in central lesion is suspected in particular to dizziness/vertigo?
- Risk factors for stroke, associated focal neurological deficits, a new headache, physical exam is not entirely consistent with peripheral lesion
- Modality of choice: magnetic resonance imaging (MRI) and magnetic resonance
angiography (MRA) - CT scan (with thin cuts through the brainstem and cerebellum) is less sensitive for detection of central lesions but may be used if MRI is unavailable/contraindicated
What are differential diagnosis for Vaginitis?
Bacterial Vaginosis (BV):
Characterized by a fishy odor, thin, homogeneous discharge, and absence of inflammation.
Risk factors include low estrogen, new or multiple sex partners, frequent douching, intrauterine contraceptive devices, and pregnancy.
Diagnosis involves Amsel’s criteria (thin, white, homogeneous discharge; pH > 4.5; positive amine whiff test; presence of clue cells on microscopic examination).
Vulvovaginal Candidiasis (VVC):
Causes white, thick, cheesy, or curdy discharge, along with vulvar itching or burning.
Risk factors include recent antibiotic use, heat, moisture, estrogen therapy, pregnancy, uncontrolled diabetes, AIDS, corticosteroid use, and immunosuppression.
Diagnosis includes wet prep examination (budding yeasts, pseudohyphae, large numbers of white blood cells, lactobacilli, and clumps of epithelial cells), pH testing (< 4.5), and negative amine whiff test.
3. Trichomoniasis:
Presents with green or yellow, frothy discharge, foul odor, vaginal pain or soreness, and inflammation (strawberry cervix).
Associated with increased risk of HIV infection, preterm labor, and other sexually transmitted infections.
Diagnosis involves wet prep examination (elevated pH, positive amine test), culture with Diamond’s medium, or PCR testing for rapid and accurate diagnosis.
4. Atrophic Vaginitis/Genitourinary Syndrome of Menopause (GSM):
Due to estrogen deficiency, leading to thin, clear discharge, vaginal dryness, dyspareunia, itching, and inflammation.
Diagnosis includes wet mount examination (large numbers of white blood cells, decreased lactobacilli, increased gram-positive cocci and gram-negative rods) and may require vaginal estrogen therapy.
5. Irritant/Allergic Vaginitis:
Caused by contact irritation or allergic reactions to substances like soaps, tampons, contraceptive devices, sex toys, topical products, douching, medications, and clothing.
Risk factors include a history of irritant exposure or allergies.
Diagnosis involves identifying the specific irritant or allergen through history and examination.
6. Inflammatory Vaginitis:
Possibly autoimmune in nature, leading to purulent vaginal discharge, burning, and dyspareunia.
Diagnosis is challenging and often requires ruling out infectious causes and other inflammatory conditions.
