Men's Sexual and Reproductive Health

Question 1

Outline

​

Answer 1

• The Basics: male GU anatomy, male reproductive physiology, erectile phsysiology
• The Clinic Visit: history taking, PE
• Common Diagnosis and Management
  
  • Male GU infections and inflammatory conditions including STIs
  • ED, other erectile and ejaculatory conditions
  • Testosterone deficiency
  • Infertility
• Prevention: male contraception
• When to refer

Question 2

Male GU Anatomy

• Production, maintenance, and transportation of ____ and semen
  
  • Sperm is stored where?
• Production and secretion of male sex _____

Answer 2

• sperm
  
  • epidydimis and travels through vas deferens
• hormones

Question 3

Male Reproductive Physiology

What axis (1) regulates the reproductive development and functioning?

1. (1) secretes (1) hormone which is directly transported to (1)
2. Which stimulates the production and release of (2) hormones
3. Anterior pituitary also produces (1) hormone, which plays several roles including increasing (1)

Answer 3

HPG Hypothalamic-Pituitary-Gonadal) Axis

1. Hypothalamus -> GnRH -> Anterior pituitary
2. FSH, LH
3. Prolactin, increases LH receptors on Leydig cells

Question 4

Male Reproductive Physiology

• LH
  
  • ​Target cells =
  • Stimulates production of =
    
    • Two compounds (2)
• FSH
  
  • Target cells =
  • Stimulates production of =
• Negative feedback loop to modulate ____ secretion
  
  • Testosterone -> ______
  • Estradiol -> ______

Answer 4

• LH
  
  • Leydig cells in testes
  • Testosterone (coverted from cholesterol)
    
    • DHT (Dihydrotestosterone) via alpha-reductase
    • Estradiol (via aromatase)
• FSH
  
  • Sertoli cells in testes
  • Spermatogenesis
• GnrH
  
  • hypothalamus
  • pituitary

Question 5

Erectile Physiology

Penile erection: a _____ event subject to _____ and _____ modulation

• Penile deep tissue has (3) erectile bodies
• Arterial blood flow starts from the common _____ artery -> ultimately to the common ____ artery, which bifurcates into dorsal penile artery (supplies ___ and ___) and deep penile artery (supplies ____ ____)
• Venous blood drainage/outflow via ____ vein

Answer 5

neurovascular, psychological, hormonal

• 2 corpora cavernosa, 1 corpus spongiosum
• iliac, penile, dorsal -> glans and skin, deep -> corpora covernosa
• dorsal

Question 6

Erectile Physiology

Erection involves filling and trapping blood in penile tissue

For an errection to occur

• Relaxation of cavernosal ___ ____ and _____
• This allows for maximal penile ___ and enlargement
• Blood volume pushed into penis results in pressure increase and maintains ______
• Most veins are _____/_____ between enlarged cavernosa and ____ albuginea, ____ outflow

Answer 6

• smooth muscle, arterioles
• inflow
• rigidity
• flattened/sandwhiched, tunica, minimizing

Question 7

Taking a Sexual History

• Setting a ___ environment for ___ discussion
• The 5 P’s: Pr____, Pa_____, P_____ prevention, Protection from ____, Past STI ______
• Questionnaires can be helpful to standardize/quantify symptoms and degree of bother (2)
• Evaluate for other conditions that impact sexual and reproductive health
  
  • _ _ risk factors (HTN, HLD, obesity, tobacco, physical inactivity)
  • D _
  • N_____ disorders (peripheral neuroapthy, spinal cord disease/trauma, parkinsons, MS, CVA)
  • ______ history (_____**)
  • S____ history
  • Ps_____ history

Answer 7

• safe, open
• Practices, Partners, Pregnancy, STIs, STI History
• IIEF, SHIM
  
  • CV
  • DM
  • Neurologic
  • Medication (Nitrates***)
  • Surgical
  • Psychosocial

Question 8

IIEF vs. SHIM

Acronyms stand for?

which one is preferred?

Answer 8

International Index of Erectile Function vs. Sexual Health Inventory for Men

IIEF is more broad, “I prefer the SHIM” (less questions to ask)

Question 9

Physical Exam

• Blood _____*
• B _ _, ideally including waist circumference measurements (or assessment of obesity)
• General PE, with attention to ____ exam, peripheral ____, LE ____, r_____ - STIs
• Focused genital examination-inspect/palpate for
  
  • P____/s____ abnormalities - lesions, masses, plaques, etc
  • C_____? if uncircumcised is there phimosis (foreskin can’t retract), balanitis (inflammation of glands)
  • Varicocele =
  • Testicular v_____
  • Inguinal _____
  • (1) exam if appropriate

Answer 9

• Blood Pressure
• BMI
• oral, pulses, edema, rashes
  
  • Penile/scrotal
  • Circumcised
  • veins that run from testes and up enlarged (“bag of worms”, scrotal pain, problems with infertility)
  • volume
  • hernias
  • DRE

Question 10

How to Perform a Male GU Exam

GU Exam Pearls

• ______- ask permission, allow patients to decline and _____ if they do
• Explain ___ the exam is important
• Protect yourself too –ch______
• help patients prepare and feel comfortable
  
  • Say what you ___ do
  • Say what you are ____ to do
  • Say what you are ____ while you are doing it
  • ____ patients how to do testicular self exams-help them palpate normal findings
  • Let patients see your _____ hands
  • Let patients see you ___ your hands afterward
• Consider _____ sensitivities, h/o tr____ (especially relevant for DRE)

Answer 10

• CONSENT, document
• WHY
• chaperone
  
  • will
  • about
  • doing
  • Teach
  • gloved
  • wash
• cultural, traumas

Question 11

STI (Male Considerations) for Chlamydia

• Can be asymptomatic or symptomatic - more often will be _____ in males
• Possible symptoms: dys____, f_____, urethral discharge (cl___, cl___, or p___) urethr___/urethral i____, e____, p_____
• Screen ___ possible sites of ____ *importance of sexual history
• Typical Treatment (1) or (1) if allergic or low compliance

Answer 11

• symptomatic
• dysuria, frequency, (clear, cloudy, purulent), urethritis, itching, epididymitis, prostatis
• all sites of exposure
• Azithro 1g PO or Doxycycline 100mg BID x 7 days

Question 12

STI Male Consideration for Gonorrhea

• Can be asymptomatic or symptomatic - more often will be _____ in males
• More or less common in males?
• Possible symptoms: __uria, urethr___, signficant _____ urethral discharge
• Screen ___ possible sites of _____ - *importance of sexual history
• Typical Tx Rx?

Answer 12

• symptomatic
• more
• dysuria, urethritis, mucopurulent
• all, exposure (MSM: pharyngeal, rectal swab?)
• Ceftriaxone 250 mg IM x once (OR cefixine 400 PO x once not as effective tho) AND Azithro Ig PO (OR doxycylcline 100mg BID x 7 days if allergic to azithro)

Chlamydia: usually discharge will be more clear

Gonorrhea: discharge will be more pronounced, mucopurulent, discolored

Question 13

STI (Male Considerations) for Syphilis

• More common in what gender? especially in?
• Symptoms based on ____
  
  • Primary =
  • Secondary =
  • Tertiary =
• Typically screen with serum ___, with confirmatory ___ - ___ if RPR positive
• Treatment =
  
  • If PCN allergy =

Answer 13

• males, MSM and HIV+
• stage
  
  • painless chancre
  • maculopaular palmar rash
  • systemic irreversible damage (especially neurologic, CV, or derm)
• RPR, FTA - ABS
• Benzathine penicillin G 2.4 mil units IM x once (not cheap), if > 1 yr duration, penicillin G 2.4 mu IM once a week x 3 wks
  
  • Doxycycline 100mg BI x 14 days if PCN allergy

Serum RPR -> blood test, if positive will automatically check for abx

Most effectiv tx: Benzathine Penicillin IM injection

Question 14

Male GU Infections or Inflammations

(2)

Which is the MOST COMMON CAUSE OF ACUTE SCROTAL PAIN?

Answer 14

Nongonococcal Urethritis (NGU)

Epididymitis/Orchitis

Epididymitis MOST COMMON CAUSE OF SCROTAL PAIN

Question 15

Nongonococcal Urethritis (NGU)

• Urethral symptoms caused by ____ or possible _____
• Most commonly caused by _____, but other causitive organisms include mycoplasma genitalium, ureaplasma, trichomonas vaginalis, or HSV
• 50% of cases there is __ causitive organism found
• Symptoms include urethral _____*, dysuria, urethral discharge, or pain
• Consider treating with _____ 1g PO x once, or _____ 100mg BID x 7 days, but treatment recommendations can vary

Answer 15

• inflammation, infection
• Chlamydia
• no
• itching
• azithro, doxy

Question 16

Epididymitis/Orchitis

Epidiymitis =

Orchitis =

• Combination - Epididymo-orchitis

C/O: ______ testicular pain and swelling, possibly ____ or dysuria

PE

• S_____ and t_____ of epididymis, testicle or both. May be hard to distinguish during acute infection
• May be able to palpate _____ spermatic cord
• Possible scrotal ____ and ____ on affected side. Could also develop a reactive hydrocele.

Answer 16

Inflammation of epididymis

Inflammation of testicle

unilateral, fever

• Swelling, tenderness
• thickened
• erythema, edema

Question 17

Epididymitis/Orchitis

Treatment Options

• In men <35: most common causes are ____ (N. gonorrhoeae and C. trachomatis)
  
  • ​_______ 250 mg IM x 1 AND ______ PO BID x __* days (or azithromycin 1g PO x 1)
• In men >35: most cause is non-sexually transmitted _____ infection most commonly _____
  
  • ​Treat for most likely cause, ex. _______ (ie levofloxacin 500mg x __ days) or other
  • Unless STI is suspected, then treat for STI
• In men who practice insertive anal sex, generally cover for __/__ AND ____ organisms with ______ IM and _____ PO
• PO alternative to ceftriaxone (1)
• Non rx (3)**

Answer 17

• STIs
  
  • Ceftriaxone, Doxycycline 10 days - bc takes time for abxto work down near testes
• Bacterial, E.Coli
  
  • ​Fluoroquinolones, 10 days
• GC/CT, enteric, ceftriaxone, levofloxacin
• cefixime
• NSAIDS, scrotal elevation/support, ice

Fluoroquinolones a bit outdated bc black box warning but effective

Nonrx treatments very effective - scrotal elevation helps minimize swelling, keeping area supported limits pain from movement

Question 18

Erectile Dysfunction

Difficulty either _____ or _____ (or both) an erection firm enough for intercouse

• 5 main categories of causes of ED: p___genic, n___genic, h____, v____genic, and ____-induced
• Impotence = erectile ____ more than __% of the time

Answer 18

achieving, maintaining

• psychogenic, neurogenic, hormonal, vasculogenic, medication
• failure, 75%

Question 19

Erectile Dysfunction

Many potential medication causes and comorbid conditions that could cause/worsen ED

• Conditions such as?
• Medication SE such as?

Answer 19

• DM (decreased blood flow), psychologic, hypertension, neurologic (stroke, spinal cord injury), obesity, tobbaco, alcohol
• diuretics, antihypertensives, antihistamines, antidepressants, parkinsons drugs, tranquilizers, muscle relaxants, NSAIDS, hormons/prostate cancer drugs, chemotherapies, anti-seizure meds

psychological component can play a huge role especially in younger patients

Question 20

Erectile Dysfunction Evaluation

1. Especially important is ____ does the problem occur?
2. Any ______ to treatment options?
3. Is labwork required to initiate tx?
   
   1. Could consider an ___ testosterole lvl, PSA, LH, FSH, estradiol, prolaction (if low T and low LH)
   2. Evaluate for other non-____ causes: Hgb ___/ B_ _, l____ panel, T_ _
4. In urology: consider penile doppler ___ to assess for adequate blood flow
5. Could do noctural penile tumescence (NPT) testing, but no only used in rare cases, what is it?

Answer 20

1. when
2. CI’s
3. no
   
   1. AM*
   2. nonurologic, A1C, BMP, lipid, TSH
4. US
5. erection over night rips paper

Question 21

ED Treatments (Meds)

• First Line (1) ​
  
  • oral meds: _____ (viagra), tadalafil (cialis), vardenafil (levitra), vardenafil dissolving tablets (staxyn), avanafil (stendra)
  • Sig: on ____ use (viagra) vs. low dose ____ use (cialis)- numerous combos
• CONTRAINDICATION with (1)
• SE: (1) in all, pr____ (all), dyspepsia (all), nasal congestion/flushing/headaches (viagra/levitra), ___ spots (viagra), leg and back ____ (cialis)

Answer 21

• PDE5 Inhibitors
  
  • ​Sildenafil
  • demand, daily
• Nitrates
• Hypotension, priaprism, blue spots in viagra, leg and black pain in cialis

Question 22

ED Treatments (Cont)

• V____ erection device (VED)
• Penile constriction r___
• Alprostadil
  
  • urethral _____ -Muse
  • Intra______ injection system - Caverject, Edex
• Medication combinations for intracavernosal injections (ICI) - Bi, Tri, and Quad___ (all end this way)
• Supplements - usually to try to promote vaso____/blood flow (Edox, L-arginine, ginseng, gingko biloba, maca)
• Experimental newer therapies - little data yet, some may be commercially available but expensive
  
  • S____ cell therapy, _____-rich plasma (PRP), h_____ oxygen
  • Low intensity _____ therapy (LIST)
• Penile ____ - inflatable penile prosthesis (IPP)

Answer 22

• Vacuum
• ring
  
  • suppository
  • cavernosal injection (small insulin needle to deliver med directly and effective for men who can’t take PO, esp after prostatectomy, chemo (decreases nerve sensitivity)
• Bi, Tri, Quadmix
• vasodilation supplements
• Experimental therapies
  
  • Stem cell, Platelet rich plasma, Hyperbaric
  • Shockwave

Question 23

Priaprism

Persistent penile erection, hours beyond or unrelated to, sexual stimulation lasts greater than __ hrs duration

• What should you tell the pt to do?
• Managment Goals
  
  • D______ - ph______ injections, corporal as_____ with or without irrigation
  • Preservation of erectile _____
  • P_____ of further episodes
• Longer duration = increased rate of erectile ______
  
  • Intervention < ___ hrs - ED may occur in up to 50% cases
  • If present __-__-ED will develop in 65-90% of cases
  • If present >___ hrs -almost 100% men will develop severe ED

Answer 23

>4 hrs erection

• SEND TO ER*!​
• Management Goals
  
  • Detumescence - phenylephrine, aspiration
  • function
  • prevention
• dysfunction
  
  • <12h
  • 24-36
  • >36

Question 24

Peyronie’s Disease

Dense fibrous _____ that forms on penile ____ causing penile _____ and often p_____/poor erections

• Typically not painful when ____
• Often cause is _____, however microscopically is c/w severe vasculitis
• Possible association with ______ contracture of tendons in hand
• May develop as a SE of (1) given for ED
• 50% ______ resolve
• Options for tx often with _____ success
  
  • ​Oral pentoxifylline, intralesional v_____, intralesional collagenase + modeling
  • Ex_____ of plaque/skin graft and penile prosthesis have been more successful

Answer 24

plaque, shaft, curvature, painful

• flaccid
• unclear
• Dupuytren’s contracture
• intracavernosal injections
• spontaneously
• poor
  
  • ​verapamil
  • Excision is better

Question 25

Ejaculatory Issues ## Footnote Ejaculatory issues *usually NOT* related to erectile \_\_\_\_, unless there is concomitant ED * Premature ejaculation - ejaculatory latency time (ELT) of? * 20-30% of men * Management with what type of medication? **(1)** * ______ ejaculation - frequently r/t BPH med SE * _____ ejaculation - could be prostatitis * Hematospermia (blood in semen) - is it concerning? Also ask - is the issue related to ejaculation or \_\_\_\_? may approach differently

Answer 25

NOT related to erectile FUNCTION * **\<1-2 min** * **​****SSRI's**(low daily dose or PRN),**possibly PDE5i**(either alone or with SSRI) - tends to be more effective if also has ED), topical anesthetic cream or spray, behavioral/psychologic therapies, possibly short course**Tramadol (3rd line)** * Retrograde * Painfual * Majority benign etiology orgasm

Question 26

Testosterone Deficiency ## Footnote Historical diagnosis: hypo\_\_\_\_ * **Dx = (1) + (1)** * **How to take testosterone lvls?** * Also check hormones involved in _ \_ _ axis * **Most common symptom (1)** **​** * Other sx can include?

Answer 26

hypogonadism * **Low serum testosterone AND symptoms of low testosterone** * **​****2 separate AM testosterone** values of \<300ng/dL * HPG (LH, FSH, estradiol, prolactin) * **Low Libido** * **​**ED, infertility, fatigue, altered masculine features (gynecomastia, decreased facial and body hair, reduced muscle mass), increased body fat, decreased bone mineral density, mood disturbances

Question 27

Testosterone replacement ## Footnote * When considering testosterone replacement goal should be improvement of ____ with therapeutic target serum AM testosterone in \_\_\_-\_\_\_\_ normal range (don't want to over do it) * **Considerations to discuss? (1)** * Monitoring during testosterone replacement = * Testosterone is considered a?

Answer 27

* improve symptoms + low-mid lvl range am lvls * **long term impact of exogenous testosterone** on spermatogenesis, CV risk , myths that may need debunking/clarification * **Close monitoring - labs and follow up visits Q3 months** (eventually Q6mos if stable) * CONTROLLED SUBSTANCE

Question 28

Contraindications to Testosterone Replacement ## Footnote * Prostate or Breast \_\_\_\_\_ * Abnormal ___ \_\_\_ exam * _____ \> 3ng/ml that has not yet been evaluated * Untreated _ \_ \_ * Severe _____ failure * E\_\_\_\_\_\_\_ (Hct \>50%)

Answer 28

* CA * DRE * PSA * OSA * Heart failure * Erythrocytosis

Question 29

Testosterone Deficiency ## Footnote **Primary Hypogonadism =** **Secondary Hypogonadism =**

Answer 29

**Testicular Failure (Low T, Elevated LH)** **Hypothalmic pituitary disruption (normal tests) (Low T, normal or Low LH)**

Question 30

Testosterone Deficiency ## Footnote **Other clinical conditions that can have some degree of impact on HPG axis?**

Answer 30

* Obesity (increased adipose tissue) dt increased aromatization of testosterone in adipose tissue -\> increased estradiol * DM * Opioid induced androgen deficiency (OPIAD) * Nonsurgical cancer tx * HIV (multifactorial: AIDS wasting syndrome, testicular atrophy 2/2 opportunistic infeciton, anti-mitotic medications) * HCV * Osteoporosis/osteopenia

Question 31

Alternatives to Testosterone (3)

Answer 31

1. **SERMS** * **​​**Clomiphene, tamoxifen - increases LH and FSH via negative feedback loop (reduces negative feedback) 2. **Aromatase Inhibitors** * **​**​Anastrozole - inhibits conversion of testosterone into estradiol 3. **Human Chorionic Gonadotropin** * ​​same activity as LH

Question 32

Male Infertility ## Footnote * **Consider infertility evaluation if ______ fails to occur within ___ y of regular unprotected intercouse (or prior to that if known risk factors)** * Male partner/factor infertility is solely responsible in 20% of cases, and contributory in another 30-40% of cases * Almost always defined by the finding of an **abnormal _____ analysis** * Refer to _____ (+/- endocrine) for evaluation * **Oligospermia =** * **Azoospermia =**

Answer 32

* **pregnancy, 1year** * **semen** * urology * low sperm count * complete absence of sperm

Question 33

Goals of Male Infertility Evaluation are to Identify ## Footnote * Potentially c\_\_\_\_\_\_ conditions * Irreversible conditions that are amenable to (1) type of therapy using the sperm of the male parter * Irreversible conditions that are NOT amenable to above, so one of (2) types of therapies may be recommended * Life or health ______ underlying conditions * ______ abnormalities that may affect the health of the offspring if ART utilized

Answer 33

* correctable * Assisted Reproductive Techniques (ART) * Donor insemination OR Adoption * threatening * Genetic

Question 34

Male Infertility: Contributing Factor Typically divided into 3 categories ## Footnote What category do these describe? 1. Antisperm antibodies, ED, vasectomy, failed vasectomy reversal, inguinal hernia repair, RGE 2. Anabolic steroid use, idiopathic hypogonadism, DM, Kallmann syndrome (delayed or absent puberty), obesity, pituitary or hypothalmic dysfunction, spinal cord injury, medications 3. Cryptorchidism, mumps, orchitis, Klinefelter syndrome (XXY-extra X chromosome), previous chemotherapy or radiation, varicocele

Answer 34

1. **Post-testicular** 2. **Pre-testicular** 3. **​Testicular** Knowing what category gives us a hint on if we should even get a semen analysis

Question 35

Male Infertility Evaluation (in addition to H/P) ## Footnote 1. **Semen Analysis x \_\_****​** * **​​**\_\_\_\_\_ for 2-5 days prior to semen analysis * Semen analyses should be at least how long apart? 2. **Hormone Lab Work** * **​​**Similar to evaluation for ______ deficiency -\> what labs? 3. **Estimation of Testicular size/volume** * **​​**Often scrotal __ is helpful here, also helps with anatomic evaluation for v\_\_\_\_\_ 4. **Genetic Testing** * **​​**Karyotype analysis (any missing or extra chromosomes - _____ syndrome) * \_\_-chromosome microdeletion (missing some genes) * CFTR gene mutation if absent (1) on exam (cystic fibrosis)

Answer 35

1. **Semen Analysis X2** 1. **​****Abstain** 2. **1 month apart** 2. **Hormones** 1. **​**Similar to testosterone deficiency: AM testosterone, LH, FSH, prolactin, estradiol 3. **Estimation of testicular size/volume** 1. **​**US, varicocele (often found in male infertility, doesn't mean man is infertile, could just be contributing to infertility) 4. **Genetic Testing** 1. **​**Klinefelter 2. Y 3. vas deferens absent

Question 36

Male Contraception ## Footnote 1. A\_\_\_\_\_\_ 2. Coitus interruptus (\_\_\_\_\_\_\_) 3. Male c\_\_\_\_\_ (also could include dental dams 4. **V\_\_\_\_\_\_\_****​​**

Answer 36

1. Abstainence 2. Withdrawal 3. condoms 4. **Vasectomy**

Question 37

Vasectomy ## Footnote **Definition =** **What do Vasectomies NOT do?** **Are they reversible?** * Efficacy? * Is the procedure done inpatient or outpatient? * Complication risk? * When do you typically check first post-vasectomy semen analysis? If not yet azoospermic then just \_\_\_\_

Answer 37

**Cuts and occludes the vas deferens bilaterally** **DOES NOT stop sperm production, just prevents sperm from entering ejaculate** **YES** but success depends on type of vasectomy done, time passed, etc * Very effective (0.15% preg rate in first year after) * outpatient, usually done in office with local anesthesia * Relatively low (~2% hematoma, infection, scrotal pain) * **8-16 weeks post,** recheck until azoospermia *Just cutting off the road - still residual sperm so takes time to be azoospermic*

Question 38

**What to do when conditions like below?** * Testicular mass/concern for testicular cancer * erectile dysfunction - initial or further eval * Sx r/t ejaculation and orgasm * Testosterone deficiency * Male infertility * Vasectomy consult * Scrotal conditions, possible prostatitis, recurrent UTIs * Nonsexual/nonreproductive issues: concern for any GU malignancy, elevated PSA, hematuria (gross or microscopic), kidney/bladder stones, voiding issue

Answer 38

**REFER TO UROLOGY**