Problems of male reproductive system

Question 1

Describe the 3 glandular regions of the prostate, and the pathologies that are common to each one.

Answer 1

1. Peripheral zone
   - 70% of prostate
   - surrounds urethra
   Focal atrophy is quite common
   Chronic inflammation, high grade prostatic intraepithelial neoplasia + carcinoma are also common
2. Central zone
   - 25% of prostate
   - surrounds ejaculatory ducts
   not many issues are common to this area
3. Transition zone
   - 5%
   - surrounds proximal urethra
   BPH is very common
   Focal atrophy + chronic inflammation are also common

Question 2

How do you tell the difference between benign prostatic enlargement/hyperplasia and prostate cancer?

Answer 2

BPE = bigger than normal, but still has a smooth surface

Prostate cancer = feels like a craggy surface

Question 3

Describe the different stages of BPE.

Answer 3

Early = no real change occurs
Intermediate = narrowing of prostatic urethra
Late = severe narrowing of the urethra

Question 4

Why are older men more likely to have BPE?

Answer 4

Enlargement of prostate cause by increased cell proliferation and reduced apoptosis

Question 5

How is testosterone metabolised/used in the stromal and epithelial cells; how can this contribute to BPE?

Answer 5

Stromal cells –> testosterone is converted to estradiol = stromal cell proliferation

Epithelial cells –> testosterone converted to DHT and binds to AR = antagonises epithelial cell apoptosis

(estradiol = apoptosis of epithelial cells)

Question 6

What are the signs + symptoms of BPE?

Answer 6

SHITE:
Slow stream 
Hesitancy 
Intermittent flow 
Terminal dribbling 
Emptying not complete

FUN:
Frequency
Urgency
Nocturia

Question 7

How is BPE diagnosed?

Answer 7

History
DRE
Ultrasound (biopsy)
Blood test - PSA

Question 8

What are the normal values for PSA for men 40+ y/o?

Answer 8

40-49 = 0-2.5 ng/ml
50-59 = 0-3 ng/ml
60-69 = 0-4 ng/ml
>70 = 0-5 ng/dl 

**if the value is abnormal but <10 then it is probably due to BPE/BPH

Question 9

What drugs can be used to treat BPE? How do they work?

Answer 9

alpha-1-adrenergic blockers = relaxes smooth muscle in bladder neck and prostate - improves flow rate

5alpha-reductase inhibitors = 2 isoforms: type I + II (type II is the predominant prostatic reductase)
it prevents testosterone –> DHT which prevents epithelial cell apoptosis
(examples include dutasteride and finasteride)

Question 10

What surgical options are available for BPE?

Answer 10

Transurethral resection = loop of wire passed along urethra, heated and cut away part of prostate causing the symptoms

Open prostatectomy = inner core of the prostate is ‘shelled out’, leaving the peripheral zone

Laser ablation
Transurethral microwave
High energy US therapy

Question 11

How many stages are there of prostate cancer? What is the general difference between each stage?

Answer 11

4 stages

There is increased cancerous cell volume with each stage and lymph node involvement in stage 4

Question 12

What type of hernia, direct or indirect, enters the deep inguinal canal?

Answer 12

Indirect

Question 13

What type of hernia, direct or indirect, is more common?

Answer 13

Indirect (85%)

Question 14

What are the predisposing factors for direct hernia?

Answer 14

Weakness of anterior abdominal wall in inguinal triangle

Question 15

Where does a direct hernia usually exit from the abdominal cavity?

Answer 15

Peritoneum plus transversals fascia (lies outside inner core or two fascial coverings of cord)

Question 16

What is the normal course of a direct hernia?

Answer 16

Passes through/around inguinal canal, usually traversing only medial third of canal, external and parallel to vestige of processes vaginalis

Question 17

Where does a direct hernia exit from the anterior abdominal wall?

Answer 17

Via superficial ring, lateral to cord

rarely enters scrotum

Question 18

What are the predisposing factors for indirect hernia?

Answer 18

latency of processus vaginalis (complete or at least superior part)

Question 19

Where does an indirect hernia usually exit from the abdominal cavity?

Answer 19

peritoneum of persistent processus vaginalis plus all 3 fascial coverings of cord/round ligament

Question 20

What is the normal course of an indirect hernia?

Answer 20

traverses inguinal canal (entire canal if it is of sufficient size) within processus vaginalis

Question 21

Where does an indirect hernia exit from the anterior abdominal wall?

Answer 21

via superficial ring inside cord, commonly passing into scrotum/labium majus

Question 22

What role does nitric oxide play in erections?

Answer 22

nerves and vascular endothelium release nitric oxide in response to sexual arousal
this activates cytoplasmic guanylate cyclase (GTP –> cGMP)
increased cGMP results in cavernosal smooth muscle relaxation, dilatation of cavernous and helicon arteries and engorgement of lacunar spaces
expanding lacunar spaces compress the subtunical venous plexus against the tunica albuginea
results in reduced cavernosal venous outflow and therefore increases intracavernosal pressure

Question 23

What is Peyronic’s disease? What complications/issues can it cause? What are the treatment options?

Answer 23

When scar tissue forms in the shaft of the penis
This causes bending
Results in painful erections and difficulties with sex

Treatment:
Non-surgical: stretching, para-aminobenzoate (increases action of MAO, which breaks down fibrous tissue)
Surgery

Question 24

What is variocele? What issues can it cause? What are the treatment options?

Answer 24

= varicose veins of the scrotum (pampiniform venous plexus)
There is a 2 degrees increase in temperature
Usually harmless but can cause infertility

Treatment:
Varicocelectomy