Andrology Flashcards
1
Q
What determines penile erection?
A
The tone of penile smooth muscle
relaxation –> erection
contraction –> flaccidity
2
Q
What is the patophysiology for the penile erection?
A
Nerve stimulation (Norepinephrine is released)—>
Nitric oxide (NO) is released –>
which transformes
Guanylate cyclase (GTP)–> to cyclic guanylate cyclase (cGMP)
this lowers the intracellular concentration of Ca2+ –>
relaxation of smooth muscle and increased blood flow
3
Q
What is the patophysiology for PDE-5 inhibitors?
A
PDE-5 is an enzyme that breaks down cGMP which leads to a contraction of smooth muscle
4
Q
What is the prevalence of ED (erectile dysfunction) for men aged 40-70?
A
52%
5
Q
What is the prevalence of complete ED (erectile dysfunction) for men aged 40-70?
A
10%
6
Q
What are risk factors for ED (erectile dysfunction)?
A
age dyslipidemia hypertention diabetes smoking sedetary lifestyle obesity depression CAD, peripheral vascular disease
7
Q
What can erectile dysfunction predict?
A
Coronary events
8
Q
How can you improve ED without medication?
A
Lifestyle changes (regular exercise and decrease in body mass index)
9
Q
What is the basic investigation that should be conducted for ED (erectile dysfunction)?
A
Complete medical and sexual history
Use validated questionnaire
Physical examination
Routine laboratory tests (including glucose-lipid profile, testosterone)
10
Q
What are the indications for specialised investigation of ED?
A
Primary ED (lifelong) Perineal or pelvic trauma Anatomical penile deformities Psychiatric disorder/ psychological problem Complex endocrine disorder Patiens request Medicological reasons
11
Q
Specific diagnostic tests for patients with ED:
A
Rigiscan (NTPR) Vascular studies - colour doppler scanning - Cavernosography Neurological studies Endocrinological studies Specialised psychodiagnostic evalutation
12
Q
What share of obese men can get an improvement in sexual function from lifestyle changes?
A
One third
13
Q
What PDE5-inhibitor can be used daily for spontaneous sexual activities?
A
Tadalafil 5 mg
14
Q
What is the role of Low-intensity extracorporeal shock wave therapy in the treatment of ED?
A
There is limitied data but positive short-term clinical and physiological effects
Preliminary data shows improvement in penile haemodynamics and endothelial function in severe ED
15
Q
What are the side-effects of topical Alprostadil?
A
penile erythema
penile burning and pain
16
Q
What is the success rate of intracavernous injection of Alprostadil on ED?
A
85%
17
Q
What are the side-effects of intracavernous injection of Alprostadil?
A
Pain
Dizziness
Priapism
18
Q
What is the first line of treatment for ED?
A
PDE5-inhibitors
19
Q
What is the second line of treatment for ED?
A
Intracavernous injections
20
Q
What is the third line of treatment for ED?
A
Penile prosthesis
21
Q
What penile curvature is most common?
A
Ventral
22
Q
What surgical techniques can be used on penile curvatures?
A
Plication
Nesbit (boatformed excision of the tunica albuginea)
Grafting
Penile Prosthesis
23
Q
When should a penile curvature be corrected?
A
After puberty, otherwise any time in adult life
24
Q
What is the pathophysiology of Peyronie’s disease?
A
Fibrotic lesions or plaques are formed in the tunica albuginea
This happens in two phases:
- Acute inflammatory phase (can be painful)
- disease stabilisation/formation of plaques
25
In Peyronie's disease what clinical factors should be evaluated?
```
duration of disease
penile pain
change of deformity
dificulty in vaginal intromission
erectile dysfunction (ED)
```
assessment of palpatable plaques
penile length
extent of curvature
26
What treatment for Peyronie's disease should NOT be used?
Oral treatment with vitamin E and tamoxifen
27
When can surgical treatment for Peyronie's disease be considered?
After 3 months of stable disease
| and when intercourse is compromised
28
When can plication techniques be used on Peyronie's disease?
Adequate penile lenght
curvature <60°
no hour-glass deformity
29
What is the difference between physiological erection and priapism?
It is limited to the cavernous bodies, not affecting the corpus spongiosum or the glans
30
What type of priapisms are there?
```
Low flow (acute)
High flow (not acute)
```
31
What can you find in Low flow priapism but not usually in High flow priapism?
Corpora cavernosa fully rigid
Penile pain
Abnormal cavernosus blood gases
Sometimes:
Blood abnormalities/hmatologic malignancy
Recent cavernosus vasoactive drug injections
Seldom (but usually present in High flow priapism):
Chronic, well tolerated tumescence without full rigidity
Perineal trauma (sometimes with High flow)
32
Describe Low flow priapism:
veno-occlusive
more frequent
greater potential of permanent alteration of erectile function
partial or complete obstruction of corpora caveronsas drainage
33
Describe High flow priapism:
arterial
- the cavernosus artery, or one of its branches, is lacerated, forming an arterio-lacunar fistula
- in the area adjacent to the fistula tubulent blood flow creates mechanical forces on the endothelial which promotes NO production
34
What is the most common cause of priapism in childhood?
Sickle cell anemia
35
In patients with priapism what labaratory tests should be performed?
complete blood count
white blood count with blood cell differential
platelet count
coagulation profile
+ blood gas from penile blood
36
What exam can help differentiatie between ischemic priapism and non-ischemic priapism if the blood gas is inclonclusive?
colour duplex ultrasound of the penis and perineum
37
In case of prolonged ischaemic priapism what imaging can be done to predict smooth muscle viability and confirm erectile function restoration?
MRI
38
What should be performed before embolisation of non-ischemic priapism?
selected pudendal arteriogram
39
What are are the diagnostic findings of Ischemic priapism?
Painful, rigid erection
Blood gas: Dark blood, hypoxia, hypercapnia and acidosis
US: sluggish or non-existent blood flow
40
What are are the diagnostic findings of non-ischemic priapism?
Perineal or penile trauma, painless, fluctuating erection
Blood gas: Bright red blood, arterial blood gas values
US: normal arterial blood flow, may be turbulent at site of a fistula
41
Treatment of ischemic priapism (4 steps):
1.
Local anastesia of the penis
Insert needle (butterfly) 16-18 G through the glans penis into the corpora cavernosa
Aspirate until bright arterial blood
2.
Cavernosal irrigation: irrigate with saline solution
3.
Inject intercavernosal adrenoceptor agonist
(Phenylephrine 200µg every 3-5 min max 1 mg within an hour)
4.
Surgery:
Shunting or
Consider primary penile implantation if priapism >36H
42
Describe 3 cavernoglanular or coporoglanular shunts:
Winter technique: large biopsy needle inserted through the glans
Ebbehoj technique: scalpel inserted percutaneously through the glans
Al-Ghorab shunt: excising a piece of the tunica albuginea at the tip of the corpus cavernosum
43
In proximal shunts igive 2 examples of vessels that the corpora cavernosa can be grafted to:
Spongiosum
| Saphenous vein
44
What are the benefits of early insertion of penile prosthesis as a treatment for priapism?
Maintains penile lenght
Easy insertion
Treats the condition
45
What are the the drawbacks of late insertion of penile prosthesis after priapism?
Penile shortening
| Difficult implantation
46
How should your treat priapism due to sickle cell anemia?
```
The same way as "ordinary" priapism
and
other supportive measures:
intravenous hydration
oxygen administation
alcalisation with bicarbonates
blood exchange transfusions
```
47
How should non-ischemic priapism be treated?
Superselective arterial embolisation, using temporary material
48
In how many couples is it male factors that cause infertility?
30%
| 40% contribuary
49
How is infertility defined?
Failure to conceive after regular, unprotected intercourse for at least 12 months
50
How many couples are affected by infertility?
15%
51
How often is Azoospermia found in infertile men?
15-20%
52
What is the difference between primary and secondary infertility?
Primary: failure to achieve first pregnancy
Secondary:failure to achieve second pregnancy
53
What are the most common causes of male infertility (8/%)?
```
Unexplained 34%
Varicocele 17%
Hypogonadism 10%
Urogenital infections 9%
Undescended testes 8%
Sexual factors 6%
Immune system factors 5%
Systematic disease 3%
```
Testicular dysgenesis syndrome TDS: environmental causes
54
What hormonal system regulates testosteron?
The HPG-axis
```
Hypothalamus: GnRH
-->
Pituitary (hypofys): LH + FSH
--->
Testes: testosterone
```
55
What does the basic investigation of the infertile man include?
Semen analysis
Hormone measurement
Imaging
Testis biopsy
56
What hormones should be assesed in an infertile man?
```
LH
FSH
Prolactin
Testosteron
SHBG
```
57
How should semen samples be collected?
Abstinence 2-5 days
Collection without spericides
Transport within an hour
At least 2 samples a month apart
58
What is a normal semen sample?
```
Volume 1,4-1,7 mL
Total sperm number 33-46 million
Sperm concentration 12-16 million/mL
Total motility 38-42
Progressive motility 31-34%
Vitality (live speratozoa) 55-63%
Sperm mofphology 3,0-4,0%
```
59
Aspermia
The patient produces no semen
60
Azoospermia
The patient produces semen that does not contain sperm
61
Oligozoospermia
low sperm concentration < 15 million /mL
62
Asthenozoospermia
Reduction in motility
63
Teratozoospermia
abnormally shaped sperm
64
Necrospermia
all sperm are dead
65
Pyospermia/Leucospermia
presence of large number of white blood cells in teh semen, often associated with an infection
66
What glands contributes to semen volume?
Seminal vesicles 2,0 mL
Prostate 0,5 mL
Cowpers glands 0,1 mL
67
What is a normal pH for the ejaculate?
7,9-8,1
68
Infections that cause male infertility through orchitis:
```
Mumps
Brucellosis
Typhoid
Influenza
Syphilis
```
69
Infections that cause male infertility through obstruction:
```
Tuberculosis
Gonorrhoea
Chlamydia
Filariasis
Smallpox
```
70
What is SHBG and what role does it play in the blood?
SHBG= sex hormone binding globulin
Binds 60% of testosteron in the blood
48% is loosely bound to albumin
2 % is free
71
Factors that decrease SHBG:
--> resulting in more bioavailable testosteron
Obesity
Diabetes
Hypothyroidism
Nephrotic syndrome
Use of glucocorticoids, progestins and androgenic
72
Factors that increase SHBG:
```
--> resulting in less bioavailable testosteron
aging
hepatic cirrhosis
hyperthyroidism
HIV infection
Estrogens
```
73
Oestrogen antagonists- mechanism of action:
indirect stimulation of FSH and LH by blocking oestrogen receptors in the hypothalamus and pituatary
--> increase in GNRH
The effect is a stimulation of Leydig cells to produce testosteron and Sertolicells to augment testicular environment for spermatogenes
74
What is the role of Sertoli cells?
They make a favourable environment for the spermatogenesis
75
What is the role of Leydig cells?
They produce Testosteron
76
Aromatase inhibitors -mechanism of action:
They decrease the conversion of androgens to estrogens by feedback inhibition of pituitary/hypothalamus resulting in release of GNRH
--> increase in androgens
77
How do you treat men with hypogonadotropic hypogonadism?
coctail of:
hCG
hMG (human menopausal gonadotropins)
recombinant FSH
78
What is hypogonadotropic hypogonadism?
or secondary hypogonadism
absent or inadequate hyupothalamic GnRH-secretion
or
abnormal pituitary gonadotropin levels (LH and FSH)
-->
gonadal failure
79
Should patients with primary and secondary hypogonadism get testosteron replacement therapy?
Yes IF
they have symptoms and
do not wish parenthood
80
What is the incidence of chromosomal anomalies in the general population?
0,4-0,6%
81
What is the Human Azoospermia Factor?
AZF-gene
on Y chromosome
11q position
Deletions --> Azoospermia /Oligospermia
82
How is cystic fibrosis linked to infertility?
It can cause vasal aplasia
83
How common is cystic fibrosis?
1/600
84
What is important to inform patients about before intracytoplasmic sperm injections (ICSI) is performed if the patient has a Yq microdeletions?
The microdeletion will be passed on to sons but not to daughters
85
If the patients has a structural abnormality of the vas deferens, what should be done?
Testing for cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations
86
When do you do a TRUS in an infertility investigation?
Low volume ejaculation (exclude retrograde)
Acidic pH
Palpable vasa
Normal hormonal profile
87
Grad I Varicocele:
Palpable only with vasalva
88
Grade II Varicocele:
Palpable in standing position
89
Grade III Varicocele:
Visible through the scrotal skin and palpable when the patient is supine
90
Grade IV Varicocele:
Only US-diagnosis
| reflux while performing valsalva
91
Grade V Varicocele:
Only US-diagnosis
| reflux always
92
Pathophysiology of Varicocele induced changes in the testis:
Hyperthermia
Raised venous pressure- reduced arterial flow
Hormonal imbalance- reduced testosteron- reduced Leydig cell function
Toxic substances - catecholamines
Teactive oxygen species
--> Sperm DNA fragmentation
93
What are the three ligation techniques for Varicoceele
Subinguinal
High inguinal
Retroperitoneal
94
When should treatment for a varicocele be considered?
clinical varicocele, oligospermia, duration of infertility of at least 2 years and otherwhise unexplained infertility in the couple
95
What are the reconstructive options for obstruction of vas?
Vasovasostomy
Vasoepididymostomy
Transurethral incision of ejaculatory duct
96
Pregnancy rate of vasoepididymostomy:
18-30%
97
What is the pregnancy rate after microsurgical reconstructional vasovasostomy after vasectomy?
76% if 3 years or less
| 30% if 15 years or more
98
What are the indications for sperm retrieval?
Non obstructive Azoospermia
```
Obstructive Azoospermia:
vasal aplasia
vasal obstruction
Intratesticular obstruction
Ejaculatory duct obstruction
Epididymal obstruction
```
99
How do you avoid recanalisation after a vasectomy?
Cauterisation and
| fascial interposition
100
What are the complications of a vasectomy?
Infection 0,5-1,5%
Bleeding/haematoma 4-22%
Re-canalisation 1:2000
Chronic orchalgia 1-14%
101
What are the most common forms om primary hypogonadisms?
```
Maldescended or ectopic testes
Testicular cancer
Orchitis
Acquired anorchia
Secondary testicular dysfunction
(idiopathic) testicular atrophy
Congenital anorchia
Klinefelters syndrome
46 XY disorders of sexual development (DSD)
Gonadal dysgenesis
46 XX male syndrome
Noonan syndrome
Inactivating LH receptor mutations, Leydig cell hypoplasia
```
102
Most common forms of secondary hypogonadism
Hyperprolactinemia (adenom, drug-induced)
Isolated hypogonadotrophic hypogonadism (mutations affecting GnRH synthesis or action)
Kallmann syndrome (1: 10 000)
Secondary GnRH deficiency (medication, drugs, toxins,systemic diseases)
Hypopituitarism
Pituitary adenomas
Prader-Willi syndrome (1: 10 000)
Congenital adrenal hypoplasia with hypogonadothrophic hypogonadism (1: 12 500 X-chromosomal recessive disease)
Pasqualini syndrome (isolated LH deficiency)
103
What is primary hypogonadism?
Problem is on Testicular level, no testosteron is produced
104
What is secondary hypogonadism?
Problem is on a hypothalamic or pituitary level, no stimulation with GnRH, LH or FSH --> no testosteron
105
What are the effects of testosterone deficiency?
```
Fatigue
Depression
Increased risk of alzheimers
Increased fat tissue
Increased risk of ED & low libido
Increased risk of osteoporosis
```
106
When should you measure testosteron?
In the morning before 11.00 preferably in the fasting state
107
Clinical signs of androgen deficiency (12):
```
Reduced testis volume
Male-factor infertility
Decreased body hair
Gynaecomastia
Decrease in lean body mass and muscular strength
Visceral obesity
Metabolic syndrome
Insulin resistance and type 2 diabetes
Osteoporosis, low trauma fractures
Mild anemia
Sexual symptoms (less desire/activity, ED, less nocturnal erections)
Cognitive and psychovegetative syptoms (hot flushes, moodchanges, fatigue, sleep disturbances, depression, diminished cognitive function)
```
108
Criteria for the definition of the Metabolic syndomre:
3 of 5
Waist circumference > 94-102 cm
Triglycerides > 150 mg/dl (or treatment)
HDL-Cholesterol < 40 mg/dl (or treatment)
Arterial Blood Pressure >130 systolic and/or 85 diastolic (or treatment)
Fasting glucose > 100 mg/dl (or type 2 diabetes)
109
What is the single most powerful predictor of secondary hypogonadism in ageing men in the general population?
Obesity
110
What factors should be considered when measuring testosteron?
Two measurements of total testosteron (before 11:00 in the morning)
If the level is close to normal range or suspected/known abnormal SHBG-lewels
111
What are the contraindications for Testosteron treatment?
```
Locally advanced or metastatic prostate cancer
Male breast cancer
Men with active desire to have children
Haematocrit >0,54
Severe chronic cardiac failure /NYHA IV
```
112
What labratory tests should be monitored during testosteron treatment?
Testosterone
Haematocrit
Haemoglobin
PSA
at three, six and twelve month, then anually
