Reproductive Flashcards
What is the epididymis?
The tube located at the back of the testis that stores and carries sperm
Inflammation = epididymitis
+/- inflamed testes (epididymo-orchitis)
How does epididymitis present?
- *Gradual onset (few days / weeks)**
- Painful swelling
- +/- urethral discharge
- Fever
- Dysuria (and also pyuria)
- Urinary frequency
What may an examination show in epididymis?
Very tender
Positive Phrens sign (pain eases with elevation)
Positive Cremesteric sign (testes move up when thigh stroked)
Epididymitis vs torsion?
-Epididymitis gradual vs torsion acute
-Epididymitis gives you +ve signs vs torsion doesnt
(-ve crew because its tied down. -ve Phrens because its still twisted)
-Epididymitis gives you urinary symptoms vs torsion does not
What may bloods and urine show in epididymis?
Raised inflammatory markers
Possible pyuria
What is the investigation of choice for Epididymitis?
What others might you do?
Do an USS (this will rule out torsion!!!!)
Also:
- Dipstick+MSU (↑Nitrates,↑Leucocyte -suggest UTI cause)
- Urethral swab w/ NAATs -(Chlamydia or gonorrhoea)
- Bloods – HIV/syphilis
- IgM/IgG serology if mumps is suspected
Who should you refer to if you suspect Epididymitis?
-Ideally refer to same day/next day sexual health appt.
(if this is not possible just treat depending on risk factors)
e.g young, sexual partners, treat for STI
-If they are very unwell consider admitting to hospital, (particularly diabetic or immunocompromised)
What are the causes of Epididymitis?
- STI – chlamydia, gonorrhoea (common men <35yo)
- UTI from bladder – E.Coli (common men >35yo)
- Mumps orchitis if parodid swelling
- Consider TB in high risk groups
Epididymitis: If sexual health referral within 1 day you would just treat the cause according to risk factors. What are the risk factors and how would you treat accordingly?
Treat before results (based on risk factors)
STI (sexual partners, young)
- Ceftriaxone 1g IM as single dose (gonorrhoea cover)
- Plus doxycycline for 10–14 days (chlamydia cover)
Enteric organism e.g. E coli (35yrs+/low risk sex history/anal intercourse/recent catheter/urological instrumentation
-Ofloxacin for 14 days
What is balanitis?
Inflammation of the GLANS PENIS (head / tip of penis)
Prosthitis- inflammation of the prepuce
Local rash, soreness, itch, odour, can’t retract foreskin, sometimes discharge
COMMONIST CAUSE IS CANDIDA (swab for this)
(can be premalignant)
What is prosthisis?
inflammation of foreskin
Balanoprosthisis is Inflammation of the glans penis AND the foreskin
What can cause balanitis and balanoposthitis?
- Most common cause is CANDIDA (swab for this)
- Poor hygiene
- Contact irritants
- Drug reaction
- Bacterial infection
Rarely:
- Reiter syndrome (arthritis, urethritis, conjunctivitis)
- Phemigus
- Pemphigoid
- Lichen sclerosis
How does balanoposthitis present?
Balanoposthitis
- Localised red itchy rash (it will be sore)
- Inflamed glans
- Can’t retract foreskin
- Erythema and uclerated lesions of the glans or foreskin
- Penile discharge/discharge from ulcerated lesions
- Systemic symptoms may occur eg fever, arthralgias, malaise
How are balanitis and balanoposthitis diagnosed?
- Usually clinical
- KOH (potassium hydroxide preparation )to confirm fungal/yeast (candida)
- Gram stain and culture for bacterial
What is the treatment of balanitis and balanoposthitis?
Conservative
- Daily retraction of foreskin and bathing with warm saline solution
- Avoid irritants
- Topical antifungal if yeast eg clotrimazole (or PO fluconazole)
- Topical corticosteroid for irritant or drug reaction
- Topical bacitracin if bacterial
What are some complications of balanitis and balanoposthitis?
- Postinflammatory phimosis
- Urinary tract obstruction - requires bladder catheterisation
- Recurrent UTIs
- Penile cancer 9link with lichen sclerosis)
What type of balanitis requires circumsision?
- If really RED/ORANGE plaques and angry (zoon balantis-plasma cell infiltration
- Circumsision may be done if topical steroids haven’t helped
What is phimosis?
Tight foreskin than cannot be completely retracted
When does phimosis occur?
Often normal in young children but may be pathological if it develops secondary to scarring
Pathological phimosis most commonly occurs as a complication of balanitis and balanoposthitis (repeated infection caused scarring)
How does physiological/pathological phimosis present?
Physiological phimosis
- meatus healthy
- ballooning on maturation
Pathophysiological phimosis
- meatus is scarred ☹
- painful erections
- haematuria
- recurrent UTIs/weak urinal stream
- preputial pain
- may have swelling/redness/tenderness of foreskin
- may have purulent discharge.
- ± shortened frenulum ± Adhesions
What is the management of phimosis?
<2 years
- this is physiological- reassure parents
> 2 years
- topical steroids
- surgery may be required (release of adhesions or circumsision)
What is paraphimosis?
Condition in which the foreskin has retracted and cannot be returned to its original position
What can cause paraphimosis?
Paraphimosis
- MOTS COMMON IS FAILING TO REPLACE FORESKIN
- scarring from forcible retraction in physiological
- chronic balanoprothisis>scaring and phimosis (esp if diabetic)
- vigorous sex
- penile pericing
Pathophysiology of paraphimosis?
PARAPHIMOSIS IS A MEDICAL EMERGENCY
Tight foreskin retracts and is irreplaceable → prevents venous return → oedema glans → ischaemia/necrosis of glans
What is the management of paraphimosis?
PARAPHIMOSIS IS A MEDICAL EMERGENCY
-Pain control
-Manual reduction (gradually with a saline soaked swab)
± ice to reduce swelling
± squeeze glans (reduce pressure)
± 50% glucose swab (oedema may follow osmotic gradient)
-If failed URGENT referral to urologist
-Surgical intervention may be required (dorsal slit reduction surgery± circumsision)
Define erectile dysfunction
Inability to achieve or sustain an erection sufficient in rigidity of duration for sexual intercourse which is present for a minimum of 6 MONTHS
List some vascular causes of ED
HTN DM CVD Hyperlipidemia Smoking
List some neurogenic causes of ED
Stroke Brain / spinal cord injury Dementia Parkinsons disease MS
List some endocrine causes of ED
Hypogonadism
Hyperprolactinemia
Thyroid disorders
List some medications than can cause ED
Anti HTN - beta blockers, thiazide diruetics
Antidepressants - SSRIs
Dopamine antagonists
How do dopamine antagonists cause ED?
Dopamine receptors blocked in tuberoinfundibulnar pathway, leading to an increase in prolactin secretion from the anterior pituitary
This leads to a decrease in GnRH secretion from the hypothalamus (negative feedback)
This leads to decreased LH secretion from the anterior pituitary which leads to decreased testosterone production from the Leydig cells
This leads to hypogonadotropic hypogonadism
List some iatrogenic causes of ED
Radical prostatectomy
Pelvic radiation
List some other causes of ED
- Trauma
- Alcohol abuse
- Peyronie disease - scar tissue develops on the penis and causes curved, painful erections
- Psychological - depression, anxiety, stress
What bloods are done for ED?
Causes
- Testosterone levels
- SHBG (sex hormone binding globulin)
- Prolactin
- LH
- FSH
- TSH
Risk factors
- Fasting glucose / HbA1c
- Lipid profile
Other than bloods, what investigations can be done for ED?
Nocturnal penile tumescene measurement
- Doppler US or arteriography to identify suspected arterial inflow or venous leaks after injection of a vasodilatory agent
- Organic causes=reduced
- Psychological causes=erections happen throughout night
What is the management of ED? (conservative and medical)
Management of erectile dysfunction Conservative -Treat any comorbidities that may be causing -Review drug chart for causes -Counsiling if psych cause
Medical
- Phosphodiesterase 5 inhibitors 1st line
- Testosterone replacement if needed
- If pituitary/hypothalamic cause>excise pituitary adenoma causing ↑Prolactin
How do phosphodiesterase 5 inhibitors work? Examples?
Slidenafil (viagra), tadalafil, vardenafil
Inhibit PDE 5 enzyme that normally breaks down cyclic GMP→ ↑cyclic GMP levels ↑ intracavernosal NO →vasodilation
What are some considerations for prescribing phosphodiesterase 5 inhibitors?
- Contraindicated in patients taking NITRATES due to profound HYPOTENSION
- May cause orthostatic hypotension in those taking alpha-adrenergic antagonist eg for BPH, take 4 hrs apart
How do nitrites work? Examples
Increase the release of nitric oxide (NO) in vascular smooth muscle cells, which leads to smooth muscle relaxation and subsequent vasodilation
Eg nitroglycerin, sodium nitroprusside, isosorbide mononitrate
What is the mechanical management of ED?
Vacuum pump
- hollow cylinder that is placed onto the penis with a penis ring
- blood sucked into the penis
- tube taken off but the ring stays there>maintains erection
What is the surgical management of ED?
Implantation of penile prosthesis
Last resort
What is hypospadias?
Common places for it to happen?
Common congenital malformation
-Incorrect positioning of the urethral meatus due to failure of urethral folds and foreskin to fuse on ventral penis
-The meatus may be located centrally (penile shaft), anteriorly/distally (glans/corona), or posteriorly/proximally (scrotum or perineum)
How may hypospadias present?
- Abnormal foreskin - DORSAL HOOD
- Ventral penile curvature
- May have two meatal openings
- Proximal hypospadias are associated with BIFID scrotum
- Associated with inguinal hernias and cryptorchidism
What is the management of hypospadias?
Significant displacement or symptomatic micturition may need surgery:
- Reconstruction of urethra, penis and scrotum (between 6months-2 years) (urethroplasty / orthoplasty)
(if they have curvature problems correct these first then do urethroplasty at least 6 months later)
What is contraindicated in hypospadias?
Circumcision (they need the foreskin in the operation)
What is cryptorchidism?
Failure of one or both testicles to descend to their natural position in the scrotum
What are possible variations of cryptorchidism?
Inguinal
Intra-abdo
Ascending
What is the management of cryptorchidism?
Surgery between 6-18 months
Orchidopexy - exposure and fastening of the testicle to the scrotum (open or laparoscopic)
When would you re examine if they had unilateral cryptorchidism?
At birth: re-examine the infant at 6–8 weeks of age.
At 6–8 weeks of age: re-examine the infant at 4–5 months of age
At 4–5 months: (corrected for gestational age), if still undescended, arrange to paediatric surgery/urology to be seen by 6 months
If they are bilateral undescended testes at birth what should you do?
If bilateral at birth: urgent pads referral (24 hours) to look for endocrine/sexual disorders
-If still bilateral at 6-8 weeks: urgent 2 week referral to pads
What is the management of cryptorchidism?
Surgery between 6-18 months
Orchidopexy - exposure and fastening of the testicle to the scrotum
If non-palpable, potentially therapeutic open or laparoscopic orchidopexy
What tumour markers are associated with germ cell/testicular cancers?
Alpha fetoprotein (aFP) hCG
*do a LDH blood test as well (high cell turnover)
How may testicular cancer present?
- Slow progression (weeks to months)
- Usually painless testicular mass
- May feel dull ache / heavy sensation
What may an examination show in testicular cancer?
- Palpation of solid mass
- Possible manifestations of metastatic disease eg LN/cannon ball mets)
- Possible ipsilateral lower limb swelling = venous engorgement due to obstruction
What are the most common forms of testicular cancer?
Germ cell tumours are the most common (95%)
- These can be broken down further:
a) Seminoma (most COMMON type of germ cell)
b) Embronal/Teratoma/Teratocarcinoma
Non germ cell (from leydic or sertoli cells)
Diagnostic imaging for testicular cancer?
USS is diagnostic!!
NEVER DO BIOPSYS IN TESTICULAR CANCER
Whats the treatment for testicular cancer?
Surgery
-inguinal orchidectomy (reduce the risk of seeding)
Medical
-if METASTATIC (present with cannon ball mets)
DO CHEMO 1ST LINE (responds well) before surgery
-chemotherapy after surgery if needed
Hydrocele vs epidydmal cyst?
- both painless swellings the DO transilluminate
- epidydimal cysts can be separated from testes
- hydrocele CANNOT be separated (surround testes)
