What is generally how the sperm are matured in the testis?
Produced by the germ cells, then Sertoli Cells surround the developing sperm providing them nutrients/DHT/estrogen to develop properly.
- Sertoli Cells are stimulated by FSH
- Leydig Cells are stimulated by LH and produce Testosterone, which Sertoli cells convert into DHT/Estrogen for sperm development.
What are frequent pre-testicular causes of infertility in men?
- endocrine abnormalities, not enough stimulation
- - such as pituitary tumors / secretory tumors
What are the testicular / anatomical causes?
- varicoceles / toxins affecting gonads
- obstruction / dysfunction of ejectulation
If a 29 year old male presents to the urology clinic after being unable to conceive for 8 months. He does not have any significant medical problems, but upon exam you palpate “bag of worms” on the left side of his scrotum.
What might be the pathology, does it influence fertility?
- Varicocele, dilation of venous flow out of the testis, mostly on the left side.
- warms up the scrotum and can cause improper maturation of the spermatids.
- *Most common cause of infertility**
What are the first things that should be done, upon evaluation for infertility?
Detailed History – to r/o easy things
Semanalysis
What is most important when evaluating results of a semanalysis?
- Total Sperm Concentration
- Motile Sperm
- Notoriously inconsistent, should get two samples two different days
If a 32 year old male present with infertility over the last 7 months who does not have any family history that is significant. Upon exam he is a morbidly obese, but otherwise normal exam. What might be the top differential for why?
– Low Testosterone, from increased adipose tissue that has aromatase to convert testosterone into estrogen
A patient recently found out he has a pituitary prolactinoma, why is he most likely infertile?
– Prolactin, suppresses FSH/LH secretion from the anterior pituitary, which would prevent maturation of sperm in the testis
After intervention on a known pathology, when might a patient expect to see improvement of his semanalysis?
Approximately 90 days (3 months)
A 34 year old male presents to the urology clinic for infertility for 2 years. Upon semanalysis there is volume without any identified sperm and exam the vas deferens seems to be unable to be palpated. What are you suspicious of?
Congenital Absent Vas Deferens
- Commonly associated with at least one gene of Cystic Fibrosis containing and the 5T Allele.
- Patient may be completely asymptomatic from cystic fibrosis.
If a patient is found to have CFTR gene causing his infertility, what else needs to be done?
– Test his partner and genetic consulting
Assess risk of conception of Cystic Fibrosis child
A 34 year old male presents to the urology clinic for infertility for 2 years. Upon semanalysis there is volume without any identified sperm and exam the vas deferens seems to be unable to be palpated. He tested negative for CFTR genes. What might be causing this?
Congenital Renal Agenesis
- defects in the 6th week of development with the mesonephric duct – NO Kidney on one side.
- Eval w/ Renal US to confirm
How do commensals help prevent pathogens in the female vagina?
Most common commensal in female
– Lactobacillus
excretes H2O2 and lactic acid lowering pH in the vagina and using up resources creating an environment that is unfriendly to outside bacteria
What are the common defenses of the GU tract?
- Physical Force of urine explusion
- Exfoliation of cells infected
- AMPs and Tamm-Hersfail protein
What are the risk factors of developing UTIs?
- Foreskin
- Female
- Prostate Obstruction
- Urine Statsis
- Sexual Intercourse
If a 28 year old female presents to the office with dysuria and UA is +leukoesterase, and she has hx of several UTIs in the last year and is being treated RA. What kind of therapy might you need to place her on?
– Complicated UTI
7-14 day course of antibiotics
Recommend alternative therapy for RA to prevent immune compromise
If a patient has gotten 6 UTIs in the past 18 months without any known risk factors, what might be the treatment options?
- Consider Imaging – further evaluation
- - Prophylaxis Abx - subtherapuetic dose of abx daily
What are non-medication related options for prevention of UTIs?
- Methenamine Salts
- Cranberry Juice
- Ascorbic Acid
What might be the positive findings on a UA if it were positive for UTI?
+ Leukoesterase
+ Nitrites
+ Trace Blood (rare gross blood)
+ 100,000 colony count
What are common symptoms of a UTI?
- Dysuria
- Increased frequency and urgency
- Cloudy urine
What is a complication of a UTI if it is not addressed?
- Pyelonephritis
- Urosepsis
What are the most common pathogens associated with UTIs, both simple and complicated?
- Simple – E. Coli / S. Saprophyticus
- Complicated – E. Coli / Enterobacteriacaie
What should you always do after you have diagnosed a UTI in a patient?
- Culture the specimen
- - Start on reasonable empiric therapy
What if a patient is asymptomatic and has a positive culture come back?
LIkely colonized bacteria, if no symptoms do not treat
– will likely reoccur and increased risk of resistance
If pregnant = Treat
If a 5 year old has been complaining of dysuria and her UA tests positive for leukoesterase and nitrites, what might be the culture to return?
Enterobacter
Klebsiella
If a patient develops a UTI after being admitted to the hospital for pneumonia, what might the culture return positive?
– Pseudomonas Aeruginosa
Most common hospital acquired / catheter colonized
What are various factors that can complicate UTIs?
- Urine stasis – BPH/Stones
- Vesicouretal reflex
- Neurogenic bladder
- Immune compromised
