Men's Sexual and Reproductive Health Flashcards
Outline
- 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
Male GU Anatomy
- Production, maintenance, and transportation of ____ and semen
- Sperm is stored where?
- Production and secretion of male sex _____
- sperm
- epidydimis and travels through vas deferens
- hormones
Male Reproductive Physiology
What axis (1) regulates the reproductive development and functioning?
- (1) secretes (1) hormone which is directly transported to (1)
- Which stimulates the production and release of (2) hormones
- Anterior pituitary also produces (1) hormone, which plays several roles including increasing (1)
HPG Hypothalamic-Pituitary-Gonadal) Axis
- Hypothalamus -> GnRH -> Anterior pituitary
- FSH, LH
- Prolactin, increases LH receptors on Leydig cells
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 -> ______
- 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
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
neurovascular, psychological, hormonal
- 2 corpora cavernosa, 1 corpus spongiosum
- iliac, penile, dorsal -> glans and skin, deep -> corpora covernosa
- dorsal
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
- smooth muscle, arterioles
- inflow
- rigidity
- flattened/sandwhiched, tunica, minimizing
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
- safe, open
- Practices, Partners, Pregnancy, STIs, STI History
- IIEF, SHIM
- CV
- DM
- Neurologic
- Medication (Nitrates***)
- Surgical
- Psychosocial
IIEF vs. SHIM
Acronyms stand for?
which one is preferred?
International Index of Erectile Function vs. Sexual Health Inventory for Men
IIEF is more broad, “I prefer the SHIM” (less questions to ask)
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
- 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
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)
- CONSENT, document
- WHY
- chaperone
- will
- about
- doing
- Teach
- gloved
- wash
- cultural, traumas
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
- symptomatic
- dysuria, frequency, (clear, cloudy, purulent), urethritis, itching, epididymitis, prostatis
- all sites of exposure
- Azithro 1g PO or Doxycycline 100mg BID x 7 days
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?
- 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
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 =
- 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
Male GU Infections or Inflammations
(2)
Which is the MOST COMMON CAUSE OF ACUTE SCROTAL PAIN?
Nongonococcal Urethritis (NGU)
Epididymitis/Orchitis
Epididymitis MOST COMMON CAUSE OF SCROTAL PAIN
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
- inflammation, infection
- Chlamydia
- no
- itching
- azithro, doxy
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.
Inflammation of epididymis
Inflammation of testicle
unilateral, fever
- Swelling, tenderness
- thickened
- erythema, edema
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)**
- 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
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
achieving, maintaining
- psychogenic, neurogenic, hormonal, vasculogenic, medication
- failure, 75%
Erectile Dysfunction
Many potential medication causes and comorbid conditions that could cause/worsen ED
- Conditions such as?
- Medication SE such as?
- 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
Erectile Dysfunction Evaluation
- Especially important is ____ does the problem occur?
- Any ______ to treatment options?
- Is labwork required to initiate tx?
- Could consider an ___ testosterole lvl, PSA, LH, FSH, estradiol, prolaction (if low T and low LH)
- Evaluate for other non-____ causes: Hgb ___/ B_ _, l____ panel, T_ _
- In urology: consider penile doppler ___ to assess for adequate blood flow
- Could do noctural penile tumescence (NPT) testing, but no only used in rare cases, what is it?
- when
- CI’s
- no
- AM*
- nonurologic, A1C, BMP, lipid, TSH
- US
- erection over night rips paper
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)
-
PDE5 Inhibitors
- Sildenafil
- demand, daily
- Nitrates
- Hypotension, priaprism, blue spots in viagra, leg and black pain in cialis
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)
- 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
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
>4 hrs erection
- SEND TO ER*!
- Management Goals
- Detumescence - phenylephrine, aspiration
- function
- prevention
- dysfunction
- <12h
- 24-36
- >36
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
plaque, shaft, curvature, painful
- flaccid
- unclear
- Dupuytren’s contracture
- intracavernosal injections
- spontaneously
-
poor
- verapamil
- Excision is better