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Flashcards in Male reproduction Deck (16):
1

urethritis

can be 2/2 STD
chlamydia trachomatis
neisseria gonorroeae

or
mycoplasma
ureaplasma

H and P:
dysuria
urgency
frequency
purulent urethral discharge
burning on urination

labs:
gram stain (pos diplococci with neisseria, neg with chlamydia)
DNA amplification testing to confirm g and c

treatment:

1x IM ceftriaxone
PO doxycylcine or azithromycin
treat partner
may need to report

Complications:
reinfection of partner
urethral strictures or scarring
narrowing of urethral lumen

2

Prostatitis causes, most likely by age

non-bacterial causes are more likely

Men35 or anal intercourse: enterobacteriaceae, gram neg infections

H and P:
perineal pain
dysuria
frequency
urgency
fever, systemic sx when acute
tender and boggy prostate

Treatment:
TMP-SMX
Fluoroquinolone
4-6 weeks

3

BPH

beginning around age 40, increases in prevalence as men get older

central prostate
not a/w prostate cancer which forms more in the peripheral zone

H and P: bladder outlet obstruction
weak or intermittent stream
straining to void
urinary hesitancy
dribbling

also, urinary frequency
urinary urgency
nocturia
urge incontinence

4

How is bph diagnosed?

clinical diagnosis

rule out other pathologies that may cause similar symptoms using history and the following tests:
-digital rectal exam to detect malignancy
-UA: hematuria indicating infection, calculi, prostatis
sCr: possible renal or prerenal disease

Other useful but optional tests:
-serum PSA
-postvoid residual
-maximum urinary flow rate

5

Treatment for BPH?

1. behavior modification (no fluid before bed)
2. alpha1-adrenergic antagonists
-relax smooth muscle of bladder neck, prostate capsule, and prostatic urethra, can cause ejaculatory dysfunction, and be careful if combinine with
-terazosin and doxazosin cause postural hypotension, so start these at bedtimephosphodiesterase inhibitors
-Tamsulosin, alfuzosin, silodosin are more uro-specific with less hypotensive effect

3. 5-alpha reductase inhibitors (finasteride, dutasteride)
-block conversion of testosterone to dihydrotestosterone, which grows the prostate
-decreases size of prostate

These drugs can be taken longterm, but symptoms return when the meds are stopped

side effects: erectile, ejaculatory dysfunction, decreased sex drive

decreases PSA by 50% in the first 3-6 months. If PSA doesn't drop when you start these meds, then you should worry about prostate cancer

4. Anticholinergics (oxybutynin, tolteridine, darifenacin)
5. Phosphodiesterase inhibitors (tadalafil), improved urine flow rates after about 12 weeks
6. Transurethral surgery if meds not tolerated (TURP)

6

Prostate cancer

peripheral zone of the prostate gland (DRE)
adenocarcinoma

mc non-derm ca in men
less aggressive than lung cancer

RF:
advancing age
family hx
high fat diet

H and P:
asx
weakened urinary stream, urinary retention
weight loss, back pain
mets to bones, osteoblastic
nodularity or irregular areas of induration
rectal exam may be normal

labs:
increased PSA
UA- hematuria, pyuria
increased alkaline phosphatase

diagnosis: tissue biopsy
transrectal US
bone scan
CT scan
CXR

Treatment:
surgery
radiation
hormonal therapy

if detected early, prognosis is good

active surveillance, regular evaluation of PSA

Side effects of surgical therapy, which is curative in younger men:
erectile dysfunction (damage to cavernosal nerves)
urinary incontinence (impacts sphincter mechanism)
external beam radiation can treat localized prostate cancer but can lead to urgency, frequency urinary symptoms

Treatment for advanced/metastatic disease: -antiandrogen (hormonal therapy)
-surgical castration
-chemical castration (GNRH, leuprolide or goserelin, with continuous administration)
-flutamide (androgen receptor blocker), often used as an adjunt to GnRH therapy, seldom monotherapy

Screening:
digital rectal exam
PSA (around age 50)

7

Patient presents to ED with scrotal pain- ddx

torsion versus epididymitis

differentiate the 2 based on
onset
infection
visual changes
support
cremasteric reflex
ultrasound

Treat torsion with detorsion and b/l orchiopexy within 6 hours

Treat epididymitis with
under 35yo- GC/chlamydia- IM ceftriaxone and then doxycycline for 10 days

over 35yo or ho anal intercourse consider enterobacteriaceae terat with fluoroquinolone 10-14 days

8

Testicular cancer

95% germ cell
-seminoma
-nonseminoma

5% stromal
-leydig
-sertoli
-granulosa

RF:
undescended testicle
history of testicular cancer
family history of testicular cancer

H and P:
painless, firm, testicular mass
gynecomastia
lower abdominal pain
GI symptoms
Pulmonary symptoms

9

Lab tests and imaging to test for testicular cancer

1. beta-hCG elevated in
choriocarcinoma
seminoma

2. alpha-fetoprotein
produced by yolk sac elements of nonseminomatous tumors

if elevated, you may have several types of germ cell tumors mixed together

3. estrogen increased in stromal cell tumors


*scrotal ultrasound
-solid testicular mass on affected sied
-confirm normal testis on other side

*CT scan of abdomen/pelvis and CXR to evaluate for nodal metastases

rarely do a biopsy, as biopsy alters lymphatic flow, thereby increasing risk of mets
radical orchiectomy is preferred to bx

10

Treatment: early stage seminoma

chemotherapy or radiation to retroperitoneum

high cure rates
observation protocols with strict surveillance

11

Treatment: nonseminoma

retroperitoneal LN dissection or chemotherapy after radical orchiectomy for micromets

observation protocol if no sign of metastasis

high cure rates, with a slightly lower cure rate than seminomatous tumors

retroperitoneal LN dissection can result in ejaculatory dysfunction, which results from sympathetic nerves during dissection

12

male infertility

unable to conceive after 1 year

H and P:
testicular trauma
surgery
chemotherapy
undescended testes

Labs:
semen analysis (morphology and motility of sperm)
serum hormone levels (FSH if elevated, then the testical has primary failure unable to respond)

Treatment:
DO NOT treat with exogenous testosterone which would inhibit endogenous release of gonadotropin

treat underlying condition
surgical correction of anatomical defects

hormone therapy

in vitro fertilization

13

Varicocele

dilation of veins of pampiniform plexus

the valves become incompetent, and you get a backflow of blood toward the testicle, which dilates the veins

often seen on routine exam

dull, aching scrotal pain usually on the left (left-sided varicoceles are 10 times more common than right- sided)
A solitary right- sided varicocele, suspect RCC (these are very uncommon)

Testicular atrophy on the affected side

infertility is common; varicoceles are present in 25% of infertile men vs. only 11% of fertile men

Color Doppler US showed retrograde flow to the scrotum

Treatment: surgery. Tie off incompetent veins

14

Erectile dysfunction

inability to achieve or maintain an erection during sexual activity

causes: neurogenic, or prior surgery on prostate or retroperitoneum, diabetic neuropathy, vasculogenic

RF: htn, hypercholesterol, smoking
hypogonadism, hypothyroid
drug abuse, heavy alcohol use
psych

history:
-discuss onset, duration
-symptoms of depression
-medications and drug use
-psychological stressors and interpersonal conflict
-if dysfunction is situational (only with one particular partner)
-presence of nocturnal or early- morning erections (absent if organic cause, present if psychogenic)

On physical exam:
-anal tone (neuro dysfunction)
-lower extremity sensation (neuro dysfunction)
-cremasteric reflect (neuro dysfunction)
-femoral and peripheral pulses (vasculogenic cause)
-penis (Peyronie disease)
-testes (hypogonadism)
-secondary sexual characteristics (hypogonadism)
-visual fields (pituitary tumor)
-gynecomastia (prolactinoma)

serum lab tests:
-total testosterone
-prolactin
-TSH
-PSA to establish baseline

if vasculogenic- cardiac stress test to assess for cardiac endothelial damage as well

MRI head if you suspect pituitary mass

15

What medications are known for causing erectile dysfunction?

Most antidepressants, esp SSRIs

Spironolactone

Sympathetic blockers: clonidine, guanethidine, methyldopa

Thiazide diuretics, beta blockers

Ketoconazole

Cimetadine (not ranitidine or famotidine)

Antipsychotics

16

Treatments for erectile dysfunction

1. phosphodiesterase inhibitors: sildenafil (viagra), vardenafil (levitra), tadalafil (cialis)
2. penile self- injectable drugs: papaverine, phentolamine, alprostadil
vacuum and constriction devices
3. penile prosthesis implantation
other: androgen replacement if hypogonadal