Problems of the Male Reproductive System

Question 1

What is the function of the prostate?

Answer 1

Makes up alkaline seminal fluid which contains anticoagulant (PSA) so sperm can swim and survive in female vagina acidic environment

Question 2

What are the anatomical relations of the prostate?

Answer 2

Base - neck of bladder
Apex - fascia on superior aspect of urethral sphincter
Posterior - ampulla of rectum
Anterior - muscular surface
Inferolateral - levator ani

Question 3

What are the 3 regions of the prostate?

Answer 3

Peripheral Zone
Central Zone
Transition Zone

Question 4

What are the properties of the peripheral zone?

Answer 4

• around periphery of gland
• surrounds urethra at lower end
• large glandular tissue (contains seminal fluid)
• site of prostate cancer

Question 5

What are the properties of the central zone?

Answer 5

Surrounds ejaculatory ducts

Question 6

What are the properties of the transition zone?

Answer 6

Surrounds proximal part of urethra as exits bladder

• transition from CT in central zone to glandular tissue in peripheral
• benign prostate enlargement

Question 7

What is benign prostatic hyperplasia?

Answer 7

Hyperplasia of epithelial and stromal cells

• thickening of CT around glandular tissue and fibroblast proliferation
• nodule form but not felt (deep within prostate)

Question 8

What is BPH associated with?

Answer 8

• advanced age = increased cell proliferation/decreased apoptosis
• testicular androgens (lifelong exposure to testosterone and oestrogen = proliferation)
• neurotransmitters from gland
• prostatic stromal and epithelial interactions

Question 9

What are the signs and symptoms of BPH?

Answer 9

• weak/interrupted urine flow
• nocturia
• trouble urinating
• pain/burning during urination
• blood in urine/semen

SHITE = slow stream, hesitancy, intermittent flow, terminal dribbling, emptying incomplete

FUN = frequency, urgency, nocturia

Question 10

What may some men over 40 develop when they have BPH?

Answer 10

• enlarged prostate

- Bladder outlet obstruction

Question 11

How do you diagnose BPH?

Answer 11

History
DRE
Ultrasound (biopsy) = estimate of weight/height/length of prostate
- blood test PSA

Question 12

What drugs are used to treat BPH?

Answer 12

• alpha-1-adrenergic blockers (relax SM in bladder and prostate)
• 5-alpha reductase inhibitors (block conversion of testosterone to active form dihydrotestosterone which binds to androgen receptor causing cell proliferation)

Question 13

What is an example of a alpha-1 adrenergic blocker?

Answer 13

Tamulosin

Question 14

What are some examples of 5 alpha reductase inhibitors?

Answer 14

Dutasteride and finasteride

Question 15

What surgical options are there for BPH?

Answer 15

• transurethral resection of prostate
• open prostatectomy (large prostates)
• laser ablation/transurethral microwave/high energy US therapy (kills transitional zone)
• urolift (urethra opening)

Question 16

When would transurethral resection of the prostate occur?

Answer 16

• UTI
• recurrent gross haematuria
• failed voiding trials
• renal insufficiency secondary to obstruction

Question 17

What is transurethral resection of the prostate

Answer 17

• cuts out transitional zone leaving PZ

Question 18

How does prostate cancer present?

Answer 18

• BHP symptoms

- if PSA raised higher than in BPH

Question 19

What are the features of a direct inguinal hernia?

Answer 19

• less common than indirect
• old age
• does not enter deep inguinal ring
• does not extend beyond superficial inguinal ring
• neck medial to IEA
• ring test negative

Question 20

What are the features of an indirect inguinal hernia?

Answer 20

• more common
• young
• enters deep inguinal ring
• reaches scrotum (labius majus)
• neck lateral to IEA
• ring test positive

Question 21

How is a 3 finger test done?

Answer 21

• index finger on DIR
• middle finger on SIR
• ring finger on saphenous opening
• ask patient to cough
• indirect = DIR
• direct = SIR
• femoral = saphenous

Question 22

How do you treat direct inguinal hernia?

Answer 22

Reducible through truss or surgery

Question 23

How do you treat indirect hernia?

Answer 23

Always requires surgery

Question 24

What is the mechanism of BPH?

Answer 24

• stromal cells proliferation converting testosterone into estradiol
• epithelial cells convert testosterone to DHT preventing apoptosis
• estradiol leaks across causing apoptosis of epithelial cells but in old age not enough to stop gland overgrowth

Question 25

How does erectile dysfunction present?

Answer 25

• complete inability to have erection
• inconsistent ability to achieve erection
• ability to have ST erections

Question 26

What are the causes of erectile dysfunction?

Answer 26

Poor/insufficient blood supply
Vascular disease
MS
Diabetes Mellitus
Spinal cord injury
Endocrine disorders

Question 27

What anatomical structures make up the penis?

Answer 27

• corpus cavernosa x 2 (vascular engorgement)

- corpus spongiosum (urethra passes down stopping it from being compressed)

Question 28

How does blood allow erection?

Answer 28

Increased blood flow stays in sinusoids of corpus cavernosa as arteries relax

• expands them making penis rigid
• outflow becomes compressed

Question 29

What is the mechanism of SM in erection?

Answer 29

• non-adrenergic non cholinergic PS neuron releases NO which diffuses to SM
• NO binds to soluble guanylyl cyclase producing cGMP
• causes SM relaxation decreasing calcium inflow
• signals from sympathetic neuron does the opposite
• artery dilation = increases blood flow

Question 30

What are the phospdiesterase type 5 inhibitors?

Answer 30

Sildenafil (Viagra)
Vardenafil (Levitra)
Taladafil (Cialis)

Question 31

What is Peyronie’s disease?

Answer 31

• bent penis

- scar tissue forms on shaft of penis = bending/deformity of penis = painful erections

Question 32

What is the treatment for Peyronie’s disease?

Answer 32

Non surgical (stretching)
Pharmacological (para-amino benzoate)
Surgical

Question 33

What is variocele?

Answer 33

Varicose veins of scrotum (pampiniform venous plexus)

• always in left testis
• usually harmless but can cause infertility