Week 2 Flashcards
What are the layers of the covering of the testes?
Skin Dartos External spermatic fascia Cremaster Internal spermatic fascia Tunica vaginalis (parietal and visceral)
How would you distinguish between a hernia and hydrocele in the testes?
Pass a light through; fluid will trans-illuminate
At what time point does the gubernaculum begin to enlarge and pull the testes down?
Weeks 28-35
Which hormones control testicular descent?
INSL-3, anti-Mullerian hormone and testosterone
What are the 4 walls of the inguinal canal?
MALT
M - superior 2 muscles; internal oblique and transverse abdominus
A - anterior 2 aponeuroses; external and internal oblique
L - inferior 2 ligaments; inguinal and lacunar
T - posterior 2 T’s; transverse fascia and conjoint tendon
What is the cause and consequence of testicular dysgenesis syndrome?
Impaired foetal testes development → decreased Leydig and Sertoli function → hypospadias/cryptochidism and infertility/testicular cancer respectively
What is cryptorchidism?
Impalpable or undescended testes which are usually smaller if present, can be bilateral or unilateral and has an uncertain aetiology
What are the classifications of cryptorchidism?
Abdominal (impalpable)
Inguinal (palpable)
Pre-scrotal
Retractile (sit in scrotum but retract over time)
At what age would undescended testes be concerning?
6 months - refer for orchidopexy (up to 18 months)
What are the major risk factors for cryptorchidism?
Low birthweight (<2.5kg) Small for gestational age Premature Maternal/gestational diabetes Environmental (phthalates, smoking)
How can cryptorchidism affect sperm quality?
No sperm production in bilateral (normal in 30% after surgery)
50% normal sperm in unilateral (70% after surgery)
What percentage of testicular cancer arises from cryptorchidism?
5%
Higher risk in bilateral and abdominal
What investigations can be carried out for cryptorchidism?
Ultrasound, CT/MRI, laparoscopy, karyotyping (genetic sex disorders), biochemical (testosterone)
What are the possible complications of surgical treatment of cryptorchidism?
Testicular shrinkage, high recurrence, haematoma, pain
What hormonal treatment is available for cryptorchidism?
hCG stimulation - mimic LH to cause testosterone surge (20% effective, high recurrence)
LHRH test - puberty
Complications - pain, behavioural problems, inflammation, shrinkage
What is hypospadias?
Common congenital abnormality of the penis in which the urethral opening is not in its normal position at the head of the penis but somewhere along the ventral aspect
What are the classifications of hypospadias?
Glanular, coronal, mid-shaft, penoscrotal, scrotal, perineal
What problems/features are associated with hypospadias?
Chordee (bend in penis), hooded foreskin, cryptorchidism, inguinal hernia, urethral strictures, problems urinating
What causes hypospadias?
Unclear
Hormonal fluctuations of testosterone and progesterone, advanced maternal age, IVF pregnancies, endocrine disruptors, reduced androgen sensitivity, genetics
How is hypospadias treated?
Surgically
Very complex, multiple procedures, foreskin used to repair, hormonal treatment given prior
Complications - scarring, curvature, strictures, fistula
Describe how congenital adrenal hyperplasia causes masculinisation of females
Lack of 21-α-hydroxylase → aldosterone/cortisol etc cannot be produced → overproduction of
testosterone in utero → masculinisation of female
What does the enzyme 5-α-reductase do?
Converts testosterone to DHT
What is DHT important for?
External masculinisation
How might disorders of sex development appear in the newborn?
Apparent female - enlarged clitoris, posterior labial fusion, inguinal mass
Apparent male - cryptorchidism, micropenis, hypospadias
Discordance between genital appearance and prenatal karyotype
How are disorders of sex development managed?
All newborns receive gender assignment within 21 days
Multidisciplinary team involved in decision making
Surgical management, sex steroid replacement and psychosocial management options
What lifestyle factors are important in fertility?
Smoking, alcohol, recreational drugs, STIs, radiation, toxins, tight clothing
What drugs can have an adverse effect on male fertility?
Alcohol, antipsychotics, arsenic, aspirin, caffeine, calcium channel blockers, pesticides, lead, antidepressants
What investigations are carried out in primary care for fertility?
Rubella status, STI screen, BMI, cervical smear
What is the WHO classification of anovulation?
Group 1 - HP failure (10%)
Group 2 - HPO dysfunction (85%)
Group 3 - ovarian failure (5%)
How can HP failure, HPO dysfunction and ovarian failure be treated?
HP - lifestyle, GnRH, gonadotrophins
HPO - metformin, gonadotrophins
Ovarian - oocyte donation
What should the pH of semen be?
7.2
What is a normal sperm concentration and count?
15 million per ml
39 million per ejaculate
What features of sperm are considered in fertility?
Motility, viability and morphology
What is HyCoSy?
Hysterosalpingo-contrast-sonography
Simple and well-tolerated outpatient ultrasound procedure used to assess the patency of the fallopian tubes and detect abnormalities of the uterus and endometrium
What is a HSG?
Hysterosalpingogram
Used to check for uterine tube blockage
What tests may be carried out for fertility?
Cystic fibrosis screening, karyotyping, FSH levels, surgical sperm retrieval
What are the main areas which can be the cause of infertility?
Semen
Uterine tubes
Uterus and peritoneum
Unexplained
What tests/treatments are invalid for infertility?
Post coital cervical mucous assessment Inhibin levels Ovarian volume Ovarian blood supply Gamete intrafallopian transfer
What is the holy triad of fertility?
Ovary, uterine tube and sperm
Uterus and peritoneum also important
What needs to be done before IVF/ICSI can take place?
Hep B/C and HIV tests
HFEA paperwork
Counselling of realistic expectations
Pregnancy rate calculation
Define transgender, transsexual, genderqueer/non-binary and agender
Transgender - a person whose gender identity differs from the sex the person had or was identified as having at birth
Transsexual - a person having a strong desire to assume the physical characteristics and gender role of the opposite sex
Genderqueer/non-binary - a person who does not subscribe to conventional gender distinctions but identifies with neither, both, or a combination of male and female genders
Agender - lacking gender
What non-binary pronouns are there?
They, them, their, theirs, theirself Ze, zey, zem, zeir, zeirs, zeirself Zie, zim, zir, zirs, zirself Ey, em, eir, eirs, eirself One
What is WPATH?
World Professional Association for Transgender Health
Worldwide association of multi-disciplinary practitioners working with trans patients
What is dual-role transvestism?
Wearing clothes of the opposite sex to
enjoy the temporary experience without any desire for a sex change or sexual excitement
What is gender identity disorder of childhood?
Manifests during early childhood and is
characterised by a persistent and intense distress about assigned sex and desire to be (or insistence that one is) of the other sex; requires a profound disturbance of the normal gender identity
How can fertility be preserved in transgender people?
FTM - collect and store oocytes
MTF - collect and store semen
What are the WPATH standards of care criteria for hormone therapy for transgender people?
- Persistent, well-documented gender dysphoria
- Capacity to make a fully informed decision and to consent for treatment
- Age of majority in a given country (if younger, follow the Standards of Care outlined in section VI)
- If significant medical or mental health concerns are present, they must be reasonably well controlled
What hormonal therapy can transmen receive and what changes occur?
Testosterone - sustanon injection, testim gel, nebido injection
Effects - lower voice, facial and body hair growth, increased muscle bulk, amenorrhoea, clitoromegaly, aggression
What are the risks of testosterone therapy?
Polycythaemia, liver dysfunction, CVD, weight gain, diabetes, mental health problems
How can menstruation be suppressed in transmen?
Testosterone, contraceptive injection (depo provera), GnRH analogues, contraceptive implant
What hormonal therapy can transwomen receive and what changes occur?
Oestrogen - oestradiol valerate injection, oestradiol transdermal patch
Anti-androgen - GnRH analogues, cyproterone acetate, finasteride, spironolactone
Effects - breast growth, softer skin, less facial and body hair, fat redistribution to hips, more emotional
What are the risks of oestrogen therapy?
Venous thromboembolism, weight gain, increased BP, breast cancer
What is the GMC guidance for prescribing for transgender people?
Prescribing medicines recommended by a gender specialist
Following recommendations for safety and treatment monitoring
Making referrals to NHS
services that have been recommended by a specialist
What is a bridging prescription and when is it acceptable to issue?
Prescribing hormonal therapy before approval from the gender identity clinic
Patient is already self-prescribing from an unregulated source, mitigation of suicide/self-harm, advice sought from specialist to provide lowest dose
What surgical options are there for transmen?
Bilateral mastectomy, male chest reconstruction, hysterectomy, oophorectomy, metoidioplasty, phalloplasty
What surgical options are there for transwomen?
Thyroid chondroplasty, penectomy/orchidectomy/clitoroplasty/vulvoplasty/penile inversion vaginoplasty/colovaginoplasty, breast augmentation
What are the complications for FTM surgery?
Dislodgement of erectile cylinders, mechanical failure of erectile mechanism
Neo-urethral stenosis, urethral fistula
What are the complications for MTF surgery?
Granulation tissue, hairballs, vascular occlusion of arterial supply to neo-clitoris, neovaginal stricture
Urinary spraying, increased risk of UTI due to shortened urethra
What screening would transgender people undergo?
Smear test - if FTM and cervix is still present (no hysterectomy)
Prostate - MTF
Breast - FTM (and offer to MTF)
Which structure opens into the prostatic urethra?
Ejaculatory ducts
What is a spermatid?
Haploid cell that undergoes physical modification and cytoplasmic reduction to produce residual bodies and the final product of spermatogenesis
Why is the inguinal canal of clinical importance?
Patient may develop an inguinal hernia
What does the inguinal canal transmit in the male and female?
Male - spermatic cord and ilioinguinal nerve
Female - round ligament of the uterus and ilioinguinal nerve
Where is the deep inguinal ring located?
Inguinal canal; transversalis fascia
Where is the superficial inguinal ring located?
Inguinal canal; aponeurosis of external oblique
What feature strengthens the aponeurosis of the external oblique to prevent splitting?
Intercrural fibres
What is the length of the inguinal canal?
4cm
What is the difference between a direct and indirect inguinal hernia?
Direct - protrusion medial to inferior epigastric vessels
Indirect - passes through the deep ring, lateral to epigastric vessels
Where does the spermatic cord begin and end?
Inferior abdomen to scrotum
Where does the round ligament of the uterus begin and end?
Uterine horns to the labia majora
What is the covering of the round ligament of the uterus?
Transversalis fascia
What are the coverings of the spermatic cord?
External spermatic fascia, cremaster muscle and internal spermatic fascia
What do the urethral folds become in the male and female?
Male - scrotal raphe, spongy urethra, ventral aspect of penis
Female - labia minora
What do the genital swellings become in the male and female?
Male - scrotum
Female - labia majora
What does the mesonephric duct become in the male?
Epididymis, vas deferens and seminal vesicle
What is the embryonic layer origin of the cloaca?
Endoderm
What is the proctodeum?
Surface depression in which the cloacal membrane sits
What do the cloacal folds join to form?
Genital tubercle
Why is it inappropriate to use genital tubercle length to identify foetal sex via ultrasound?
Tubercle is larger in the female than the male during early development
What are the boundaries of the femoral triangle?
Base - inguinal ligament
Medial - adductor magnus
Lateral - sartorius
Apex - where sartorius crosses medial
What are the contents of the femoral triangle?
Femoral nerve, artery, vein
Inguinal lymph nodes and vessels
What is the femoral sheath and what is its importance?
Tube of fascia enclosing vessels in the femoral triangle, creating a femoral canal medially
Allows the vessels to glide deep to the inguinal ligament during movement of the hip
What is the function of the femoral canal?
Allows expansion of the femoral vein if there is an increase in venous return from the lower limb
What is the femoral ring?
Wide upper end of the femoral canal; weakness which can be enlarged by stretching of the inguinal ligament (e.g. in pregnancy)
What are the boundaries of the femoral ring?
Anterior - inguinal ligament
Medial - lacunar ligament
Posterior - pubic bone
Lateral - femoral vein
