Problems of the Male Reproductive system Flashcards
How big is at the normal prostate gland
- 3cm long
- 4cm wide
- 2cm in AP depth
What is the function of the prostate gland
makes about 1/3 of alkaline seminal fluid that contains an
anticoagulant (PSA) to that sperm can swim and survive in the female vaginas
acidic environment.
what does seminal fluid contain that keeps it fluid d
it contains an anticoagulant (PSA) that keeps it liquid and the sperm liquid
what are the 3 zones that make up the prostate
- peripheral zone
- central zone
- transitional zone
describe the peripheral zone
- 70%
* Surrounds urethra
describe the central zone
- 25%
- Surrounds ejaculatory ducts
- Just underneath the peripheral zone
describe the transitional zone
- 5%
* Surrounds proximal urethra
what zone is prostate cancer found in
peripheral zone
what zone is Benign prostate hyperplasia BPH found in
transitional zone
describe the histology of the prostate gland
- made up of glandular tissue and smooth muscle
- there is a lot of smooth muscle around the urethra
- glandular ducts are also present as the seminal fluid from the prostate has to be added to the ejaculatory ducts in the central zone
what cells do you get hyperplasia and hypertrophy of in the transitional zone leading to BPH
- Get both hyperplasia (proliferation)and hypertrophy (enlargement) of the epithelial cells and stromal cells (made up of collagen, fibroblasts and smooth muscle cells) in the transitional zone
- mores smooth muscle and more fibroblasts in the transitional zone therefore there are larger fibromsucular septa between the proliferating glands
- Epithelium = have an outer columnar layer and a more inner cuboidal layer
what is the difference between hyperplasia and hypertrophy
Hyperplasia is proliferation of tissue
hypertrophy is enlargement of tissue
what can block the outflow of seminal fluid
Corpora amylacea
- accumulation of calcified material in ducts which is protein based and insoluble common in BPH rare in adenocarcinoma
what is the difference between benign prostate enlargement and prostate cancer
- in benign prostate hyperplasia this is in the transitional zone therefore you cannot feel in enlargement as it is mainly inwards, therefore the prostate feels smooth
- Prostate cancer tends to be in the peripheral zone therefore you can feel the nodules enlarge when you do a DRE
- can often feel it be irregular hard and enlargement is on one side
what do you use a DRE for
- can feel the prostate and see if it is bumpy or smooth, can be used as an intial investigation for more tests for cancers
- use an index finger
what is a normal ration in a DRE
normal ratio when you feel the rectum you can put one index finger over the prostate gland,
what can cause benign prostatic expansion
dvancing age
• Age related enlargement caused by increased cell proliferation and decreased apoptosis
– Testicular androgens = testosterone
– Other contributing factors
• Oestrogens
• Prostatic stromal and epithelial tissue interactions
• Neurotransmitters from the gland
due to advancing age what happens in terms of proliferation and apoptosis
there is less apoptosis and more proliferation means that there is more cells overall
What happens when the transitional zone enlarges
- it presses on the narrowed urethra
- this eventually can block the outflow of the bladder
Explain the mechanism of action behind proliferation versus apoptosis of the cells in the prostate gland
- in the stomal cell testosterone is converted to estradiol via aromatase this causes cell proliferation when estradiol binds to ER alpha
- some of the oestradiol leaks across into the basal and luminal epithelium through the basement membrane and this causes apoptosis when the estradiol binds to ERbeta
- But Testosterone is converted to DHT via 5 alpha reductase in the basal epithelium, then testosterone can either bind directly to AR or bind to AR by DHT
- the binding to AR prevents epithelial cell apoptosis
- but in old age too much DHT and testosterone is produced therefore there is too much proliferation and not enough oestraiol causing apoptosis
What are the sings of BPE
- SHITE = Slow stream, Hesitancy, Intermittent flow, Terminal dribbling, Emptying is incomplete.
- FUN = Frequency, Urgency, Nocturia
others
- pain or burning during urination
- blood in urine or semen due to infections as the urine is stagnated in the bladder and does not have an exit
How common is BPE
- All men over the age of 40 will have an enlarged prostate
- Not all well develop symptoms
- 50% will develop histological hyperplasia
- 50% of these with have lower urinary tract symptoms (LUTS)
- Some will develop significant enlarged prostate (EP)
- Some will develop bladder outlet obstruction (BOO)
how do you diagnose BPE
- History
- Digital rectal exam
- Ultrasound – biopsy
- Blood test PSA (gamma-seminoprotein or kalikrein-3 can also be used)
What does an ultrasound in the diagnosis of BPE allow you to find
- allows an estimate of the width/height/length of prostate.
- Can also take a biopsy to check for cancer
how can you use a blood test to diagnose BPE/prostate cancer
- look for prostate specific antigen (PSA)
- This can be raised with prostate cancer
Averages
- 40-49 years, 0-2.5 ng/ml
- 50 -59 yrs 0 – 3 ng/ml
- 60 - 69 yrs 0 – 4 ng/ml
- > 70 yrs 0 – 5 ng/ml
- Less than 10ng/ml is usually due to BHP
What two medical treatments can you use for BPE
Alpha 1 adrenergic blockers
5 alpha redcutase inhibitors
Give an example of an alpha 1 adrenergic blocker
(Tamulosin).
give an example of a 5 alpha reductase inhibitor
dutasteride and finasteride.
How do alpha 1 adrenergic blockers such as tumulosin work
• This is an antagonist to the alpha 1 receptor, this causes the smooth muscle to relax and allow the outflow of the urine from the bladder, improves urine outflow
How do 5 alpha reductase inhibitors such as finasteride and dutasteride work
- can reduce the amount of growth in the prostate
- these inhibit 5 alpha reductase which is responsible for the conversion of testosterone into DHT
- DHT drives the proliferation of the epithelial cells so without this apoptosis commences as there is now a less high ratio between DHT and oestradiol allowing apoptosis to be driven
Name the types of BPE surgery that you can have
- TURP
- open prostatectomy
- Urolift
- laser ablation
- transuthral microwave
- high energy ultrasound
how does TURP work
- go through the urethra and cut out the transitional zone
-
What does TURP stand for
transurethral resection of the prostate
Who is TRUP for
people with symptoms
- voiding
- recurrent urinary tract infection
- recurrent haematuria
Who is an open prostatectomy for
For very large prostates (>75g).
what happens in uroLift
- stationary tags put into the prostate
- and these pull the urethra open again
what happens in laser Ablation/Transurethral Microwave/High Energy US Therapy
- cook the transitional zones and remove the cells around it increasing the area for the urethra
when is PSA higher in BPE or in prostate cancer
in prostate cancer PSA is higher
describe indirect hernias
- goes through the superificla and deep inguinal rings
- more serious as they can get strangulated
- congenital
- lateral to the inferior epigastric vessels
describe direct hernias
- go through hasselbachs triangle
- direct behind the sueprifical ring
- medial to the inferior epigastric vessels
- common in elderly men with weak abdominal muscles
what travels underneath the inguinal ligament
- Femoral artery
- Femoral vein
- Femoral canal
what are the two types of hernia
direct hernia
indirect hernia
how any people have hernias
- Approx 25% of males will have inguinal hernias in their lifetime
o 2% of females – don’t have a vas deferens therefore the inguinal canal is a bit more closed and fibrotic in us, more common to have a femoral hernia where it goes underneath the inguinal ligament
what is a femoral hernia
- a hernia that goes under the inguinal ligament
What are the three borders of hasselbachs triangle
made out of the inferior epigastric vessels, rectus abdominis, and inguinal ligament
What is the three finger test for hernias
index finger on DIR, middle finger on SIR and ring finger on saphenous opening. Ask cough:
Indirect: deep inguinal ring
Direct: superficial inguinal ring.
Femoral: at the saphenous.
How do you treat direct hernias
- Reducible = truss which pushes the itnesitnes back into the abdomen and this is usually a reducible hernia
- Or surgery
How do you treat indirect hernias
- surgery
what side are you more likely to have an indirect hernia in
- right testes
- this is because the right is a bit slow and delayed and thus arrives later in the scrotum therefore the processes vaginalis doesn’t have time to close up and doesn’t heal
How many people does erectile dysfunction effect
1 in 10 men
- increase with age
what is erectile dysfunction
- Complete inability to have an erection
- Inconsistent ability to achieve an erection
- Ability to have short term erections
what causes erectile dysfunction
- reduction in blood flow in the cavernosal arteries
- there is a problem with the nervous supply to the penis that causes erectile dysfunction
what is the penis made out of
2 X corpus cavernosa: for vascular engorgement. -cavernosal arteries run down the centre of here and are the thing that can go wrong in an erection
1 X corpus spongiosum: urethra passes down: stops it from being compressed.
What happens in an erection
Normally: blood comes into the corpus cavernosa and leaves at the same rate.
Erection: increased blood flows stays in the sinusoids as arteries and smooth muscle relax.
This expands them and this
makes the penis rigid.
Causes the outflow to be
compressed therefore the blood cannot leave
What does dilation of the arteries cause
increase in blood flow
describe the nerve supply that is important in erections
- parasympathetic neurone (non adrerongic and non cholinergic) - causes the erection
- sympathetic causes the ejaculation
- point and shoot
describe the mechanism fo action of the smooth muscle relaxation during an erection
- Parasympathetic neurone which is non adrenergic and non cholinergic allows calcium to enter the synapse and causes the release of nitric oxide
- the nitric oxide then diffuses across the smooth muscle
- NO binds to soluble gauntly cylases and produces cGMP this causes the smooth muscle to relax and decreases calcium inflow
- then signals from the sympathetic neurone does the opposite
How do you lose an erection
PDE5 causes the breakdown of cGMP to 5’GMP
How does viagra work
It inhibits PDE5 therefore slowing the breakdown of cGMP
Name some phosphodiesterase type 5 inhibitors (PDE5)
Phosphodiesterase type 5 inhibitor. o Sildenafil (Viagra) o Vardenafil (Levitra) o Taladafil (Cialis)
when does PDE5 only work
- takes about 20-60 minutes and lasts for 6 hours, it only works if you are still in the mood as you need the parasymatpehtic nervous system to fire to allow nitric oxide release
what surgery can you get for loss of erection
- Penile prosthesis
- it replaces the corpus cavernous, two fluid filled tubules which are expandable, fluid filled reservoir and a pump
- The pump goes into he scrotum
- If you pump it will move the fluids into the tube and give you an erect penis
What is peyronies disease
- Bent penis – effects 5% of men
What causes peryonies disease
- Scar tissue forms in shaft of penis
o Causes bending or deformity of the penis
o Painful erections and difficulties with sexual intercourse
o When it expands the scar tissue is not as stretcy and stops the scar tissue from becoming erect normally
How do you treat peryronies disease
o Non-surgical
Stretching – break down sar tissue
Para-aminobenzoate – b vitamin that you can take and rub on, increases oxygen to the penis and improves the scar tissue
Topical verapamil
o surgical
What is a varicocele
• Varicose veins of the scrotum (pampiniform venous plexus)
what sides does a varicocele happen on
– Very common 10-15% and always in the left testis (80-90%) on the left side it drains into the renal vein whereas on the right side drains straight into the vena cava
what can a varicocele do that is harmful
– Usually harmless but can be a cause infertility
• 35-40% of infertile men have variocle (15% of men with variocele are infertile)
• this might be cause it causes a 2 degree rise in temperature
