when the testes do not descend aka undescended testicle _Risk factors_: premature infants (30%) vs full term infants (5%) most common in R testicle increases risk of cancer and infertility _Dx_: referral made to urology if testicles have not descended by 3 months of age surgery between 6months - 1 year of age (orchiopexy)

Male Reproductive Flashcards by Gillian Collom

Erectile Dysfunction: Definition, Types, & Risks

Definition:
- inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance
Types:
- vascular = MC
- arteriogenic, veno-occlusive), neurogenic, hormonal, anatomic, drug-induced, psychogenic
Risks:
- DM, HTN, CAD, dyslipidemia, EtOH, smoking, obesity, anxiety, depression, PTSD, neurological disease, pelvic or vascular surgery, meds (anti-HTN, antidepressants), endocrine disorders, urologic disorders

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Organic vs Psychogenic Erectile Dysfunction

Organic:
- **Gradual Onset
- -lack of tumescence (to become swollen as a response to sexual arousal)
- normal ejaculation & libido
- medical risk factors
- medications, smoking, EtOH, recreational drug use
Psychogenic:
- **Sudden onset
- easy loss of erection
- Better quality with self-stimulation
- premature ejaculation
- relationship or psychological problems major life events

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Erectile Dysfunction: Dx & Tx

Dx:
- clinical dx
- labs to order:
  - fasting plasma glucose to assess for DM
  - lipid profile
  - BUN, Cr
  - AST/ALT (serum transaminases)
  - TSH
  - Serum total testosterone
Tx:
- *Drugs MOA: nitric oxide (PGE1) → increase in cGMP → reduced calcium influx into vascular smooth muscle → increase in cavernosal blood flow
- Phosphodiesterase-5 inhibitors (Sildenafil, vardenafil, Tadalafil, avanafil;
  - do NOT use with nitrates (hypotension), use with caution with alpha-adrenergic blockers; SEs: HA, GI, visual changes
- Prostaglandin E1: alprostadil, transurethral, used in men with contraindication or failed PDE-5 inhibitors

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Male Hypogonadism: definition, etiology, S/sxs

Definition:
- decrease in either or both of the primary fnx of the testes (testosterone & sperm production)
Etiology:
- Primary:
  - decreased function of Leydig cells → decreased testosterone; aging, obesity, meds, anorchia, cryptorchidism, Klinefelter’s, trauma
- Secondary:
  - disorder of the pituitary gland or hypothalamus; cirrhosis, feedback inhibition by high estrogen, hypothyroid, hyperprolactin, opiates, THC, Crohn’s, arthritis
S/sxs:
- Decreased muscle mass & increased fat mass
- decreased bone mass and increased risk of fracture
- depression, loss of motivation, fatigue, decreased labido
- erectile dysfunction
- Adolescents: failure to undergo puberty

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Male Hypogonadism: PE, Dx, & Tx

PE:
- Evidence of hypothyroid or cortisol excess: dry skin, hair loss, moon face, flushing
- Jaundice (d/t liver failure, hepatitis)
- Rash or oral lesions (HIV)
- BMI, Waistline > 40in (HTN, CVD, DM II)
- obesity, striae, bruits of the abd
- testicular problems with size, volume, consistency
Dx:
- Morning total serum testosterone: initial screen, decreased (<300 ng/dL)
- *If decreased → then run total testosterone panel: total, free (2%), sex steroid hormone binding globulin (68%)
- Then run LH: to determine primary vs. secondary
- Then run Prolactin: if T < 140 ng/dL
Tx:
- Testosterone Supplements: IM injections, subdermal pellets, dermal patches, axillary liquid, nasal gel (oral formulations not recommended)
- Smoking cessation, diet, exercise

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Complications Associated with Low Testosterone

increased risk of MI or stroke, obesity, DM, metabolic syndrome, OSA

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Risks of Testosterone Replacement & Monitoring

elevated LFTs, altered HDL/LDL ratio, increased hematocrit, progressive OSA, promotion of prostate cancer, increased aggressiveness, dependency → monitor LFTs, hematocrit, lipid panel, PSA, total testosterone

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Nerves involved in the sexual response in Men

pelvic sympathetic & parasympathetic nerves merge to form the cavernous nerves which regulate blood flow through sexual response; pudendal nerve provides somatic sensation contract/relax muscles around penis

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Effects of Testosterone & it’s metabolites in men

Testosterone:
- muscle mass, skeletal growth, spermatogenesis, sexual fnx
Dihydrotestosterone (DHT):
- facial & body hair, acne, scalp hair loss, prostate growth
Estradiol:
- bone formation, breast tissue, libido

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Cryptorchidism

when the testes do not descend aka undescended testicle
Risk factors:
- premature infants (30%) vs full term infants (5%)
- most common in R testicle
increases risk of cancer and infertility
Dx:
- referral made to urology if testicles have not descended by 3 months of age
  - surgery between 6months - 1 year of age (orchiopexy)
    *

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Peyronie Disease Etiology, S/sxs, Dx, & Tx

buildup of fibrous hardened tissue in the corpus cavernosum → often caused by repeated injury (sex, physical activity) and genetic susceptibility is involved

S/sxs:
- penile pain worsened with erection
- curvature of penis on erection
- interference with sexual function
- thick circumferential plaque at the coronal sulcus
Dx:
- hx and penile exam
Tx:
- stable, mild curvature (≤ 30 degrees) with satisfactory sexual function:
  - observation = okay
- worsening curvature or sexual dysfunction:
  - pentoxifylline (vasodilator & anti-inflammatory) = best if initial tx within 3 months of onset
  - > 3 months of deformity?
    - intralesional injection with collagenase
  - >12 months and wont respond to other txs?
    - surgical management
      *

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Epididymitis S/sxs, PE, Dx, and Tx

Pathogens:
- Men < 35 = chlamydia and gonorrhea
- Men ≥ 35 = E.coli
S/sxs:
- dull, aching scrotal pain that gradually increases
- dysuria, unilateral scrotal pain & swelling
PE:
- (+) Phren’s sign → relief of sxs with elevation = Classic Sign
- tender scrotum on posterior
Dx:
- important to r/o testicular torsion → Rapid onset, higher testis → u/s with doppler
- urinalysis & cx + GCCT → pyuria (WBCs in urine) and bacteriuria
Tx:
- <35 or suspected STD: ceftriaxone IM + doxycycline
- ≥ 35 with suspected enteric organism:
  - levofloxacin or double strength Trimethoprim-Sulfamethoxazole (Bactrim)

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Orchitis s/sxs, PE, Dx, & Tx

Mumps = most common cuase in kids
orchitis without epididymitis = very uncommon in adults
S/sxs: unilateral scrotal pain
PE:
- tender, swollen testicle
  - shininess of the overlying skin
  - scrotal edema with erythema
Dx:
- r/o testicular torsion with u/s with doppler
- urinalysis with cxs: pyuria and bacteriuria with cxs positive for suspected organisms
Tx:
- rest, NSAIDS, scrotal support, ice, and abx (if bacterial)
- Age <35 or sexuallya ctive post-pubertal males → tx like epididymitis
  - → ceftriaxone IM + doxycycline
- Age ≥ 35 (STI not suspected) →levofloxacin

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Acute Bacterial Prostatitis S/sxs, PE, Dx, & Tx

Men < 35: chlamydia & gonorrhea
Men ≥ 35: E.coli
most common in younger men and more serious
S/sxs:
- fever, chills, malaise
- dysuria (pain with urination), urgency, frequency
- perineal and low back pain
PE:
- DRE (digital rectal exam):
  - boggy, warm, tender, enlarged prostate
- if you suspect prostatitis DO NOT MASSAGE THE PROSTATE → can lead to SEPSIS
Dx:
- urinalysis: pyuria +/- hematuria
- urine cx: positive
- prostatic fluid/secretions: may show leukocytosis with a cx → typically positive for E.coli
- U/S CT scan Cystoscopy for men with significant voiding issues
- Blood Tests: CBC, blood cx if clinical findings suggestive of bacteremia → BUN, creatinine levels for pts with urinary retention/obstruction
  - → serum PSA may be elevated
Tx:
- Men < 35: ceftriaxone + doxy
- Men ≥ 35: fluoroquinolones or Bactrim for 3-6 weels
- URETHRAL CATHETERIZATION IS CONTRAINDICATED IN THESE PATIENTS

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Chronic Prostatitis S/sxs, PE, Dx, & Tx

usually men age 40-70
can be bacterial/abacterial; chronic bacterial = most common form of prostatitis
S/sxs:
- can be asymptomatic
- hx of recurrent UTIs
- perineal/low back pain; suprapubic discomfrot
PE: DRE → enlarged, non-tender prostate
Tx: fluoroquinolones or Bactrim x 6-12 weeks

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Urethritis Etiology, S/sxs, Dx, & Tx

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infx of the urethra

Etiology: STIs: chlamydia, N. gonorrhoeae, trichomonas vaginalis & HSV = common cause in both sexes
Sxs: dysuria
- in men: urethral discharge → can be purulent, whitish, or mucoid
Dx; first void or first-catch urine sometimes with cx
- positive leukocyte esterase on urine dipstick
  - or ≥ 10WBCs/HPF
- nucleic acid amplification test = allows for identification of N. gonorrhoeae, C. trachomatis
Tx: should treat empirically for STDs in sexually active pts pending test results
→ceftriaxone 500mg IM + doxycycline 100mg PO BID x7 days
- → can consider replacing doxy with azithromycin 1g PO if compliance in question or pregnancy

Penile Cancer Etiology, Risks PE, Dx, Tx & Prevention

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squamous cell carcinoma = most common type

mean age of diagnosis = 60 years old
Etiology: HSV & HPV 18
Risk factors: uncircumcised, poor hygiene
PE: mass or blister that can become wart-like growth that discharges blood or foul-smelling fluid
- penile mass or ulcer, especially those who have not been circumcised
Dx: biopsy
Tx: surgery = most common
- radiation & chemo = also options
Prevention:
- condom use and HPV vaccine

Prostate Cancer Etiology, S/sxs, PE, Dx, Tx

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most are adenocarcinomas
associated with the BRCA1 gene
Risk factors: african american, old age, family hx
S/sxs: urinary retention (more likely sign of BPH), decrease in urine stream strength
- back pain (metastatic disease)
- painful ejaculation
PE: DRE: hard, nodular, enlarged, and asymmetrical prostate
Dx:
- indications for transrectal biopsy with normal rectal exam → PSA > 10 or abnormal transrectal U/S
- PSA > 4: U/s with needle biopsy
- PSA >10: bone scan to r/o metastases
Tx;
- radical prostatectomy → complication = erectile dysfunction & urinary incontinence
- with metastases: need androgen deprivation therapy (leuprolide) → type of medical castration, but can be reversible
  *

Testicular Cancer Etiology, PE, Dx, & Tx

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Most common solid tumor in young men ages 15-40 (avg 42 yo)
5 year survival =90%
most common type =germ cell tumor
- 2 types: seminomas
  - nonseminomatous germ cell tumor (NSGCT)
- Seminomas:
  - classic seminoma (95%)
  - spermatocytic seminoma
- NSGCTs
  - emrbyonal carcinoma
  - yolk sac carcinoma
  - choriocarcinoma
PE:
- firm, painless, nontender, fixed mass on testicle
Dx: Scrotal U/x
- radiologic studies to search for metastases → most commonly in brain, belly, lungs
- tumor markers: alpha-fetoprotein (AFP) → + in NSGCT, not seminomas
  - human chorionic gonadotropin + in both NSGCT and seminomas
  - lactate dehydrogenase (LDH)
Tx:
- orchiectomy +/- chemo and radiation depending on cell type
- NSGCT = radioresistant
- Seminomatous tumors = radiosensitive and can be treated with radiation therapy

Hypospadias/Epispadias Dx and Tx

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Hypospadias: when the urethral meatus open onto the ventral (bottom/underside) of the penile shaft
- genetic heritability
- IVF has been associated with increased risk of hypospadias
Epispadias: when the urethral meatus opens onto the dorsal (topside) of the penile shaft
Dx: usually made during the newborn exam but imaging studies (excretory urogram) can be helpful
Tx: surgical repair before 1-2 years of age
- DO NOT CIRCUMCISE → may use foreskin in surgical repair

Paraphimosis Dx & Tx

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entrapment of the foreskin in the retracted position → Medical Emergency
- Paraphimosis needs a Paramedic
***always remember to reduce the foreskin after urethral catheterization***
Dx: clinical
Tx: firm circumferential compression of the glans with the hand may reduce the edema enough to allow the foreskin back to its normal position
- → if not successful, dorsal slit using local anesthetic temporarily relieves the problem → CIRCUMCISION after edema is resolved

Phimosis Dx and Tx

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foreskin in normal position and cannot be retracted
adult phimosis often caused from scarring after trauma, infx (such as balanitis) or prolonged irritation
Dx: clinical
Tx: in children, will normally resolve by age 5
- tx not usually required in absence of other issues such as balanitis, UTIs, urinary obstruction
- betamethasone cream 0.05% BID-TID
- gently stretch the foreskin

When to screen for PSA

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DISCUSS WITH PATIENT

men age 55-69 yo
50 years old if first degree family hx
45-50 if african american

BPH S/sxs, PE, Dx, & Tx

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Benign Prostatic Hyperplasia

50% of men have BPH by age 60, >90% by age 85
S/sxs: difficulty starting stream, post-void dribbling, hesitancy (start and stop)
- nocturia
- weak urinary stream
PE: digital rectal exam → uniformly enlarged firm and rubber prostate
Dx:
- DRE +PSA
- PSA < 4 = normal
- PSA > 4 → BPH, prostate cancer, prostatitis
- UA to r/o other causes
Tx:
- if mild → watchful waiting
- alpha blockers can provide the most rapid relief (smooth muscle relaxation of prostate and bladder neck
  - tamsulosin, prazosin, terazosin (shrink size of prostate)
- TURP (transurethral resection of the prostate) if unresponsive to meds
- 5-alpha reductase inhibitors
  - finasteride & dutasteride (Prevent conversion of testosterone → DHT (active form)

Hydrocele PE, Dx, & Tx

* mass of fluid-filled congenital remnants of the tunica vaginalis * infants: will usually close within the 1st year of life * _PE_: * **painless scrotal swelling** (most common cause of this) * **+ transillumination** vs tumor or varicocele which both do not transilluminate * _Dx_: **Scrotal U/S** * _Tx_: in infants → will usually close in the 1st year of life, but may require surgery if clinically indicated * **have parents practice watchful waiting for 1 year**

Varicocele PE, Dx & Tx

venous varicosity within the spermatic vein * _PE_: feels like a "**bag of worms**' superior to the testicles * **dilation worse when the pt is upright or with valsalva** → decrease in size with elevation of the scrotum or supine position * negative transillumination → chronic non-tender mass that does not transilluminate * _Dx_: **Scrotal U/s** * _Tx_: **surgical repair** if varicocele is painful or appears to be cause of **infertility**

Testicular Torsion S/sxs, PE, Dx, & Tx

* _Risk Factors_: **after vigorous activity** or minor trauma * usually **post-pubertal boys** (65% in boys age 10-20) * more common in pts with a hx of **cryptorchidism** * _S/sxs_: * *severe, acute onset lower abdominal pain***,** sharp pain that may radiate into thigh * vomiting * _PE_: **negative phren's sign** * loss of **cremasteric reflex** ( elevation of the testes in response to stroking of the inner thigh) * **Blue dot sign**: tender nodule 2-3mm in diameter of the upper pole of the testicle * _Dx_: **U/s with doppler** = best initial test * **Radionuclide scan** demonstrates decreased uptake in the affected testes **→ GOLD STANDARD** * _Tx_: * need to de-torse the testicles in **_\< 6 hours_** (90% salvage rate) * \>24 hours? \<10% salvage * **orchiopexy** (permanent fixation of the testicle)

Priapism

* _Definition_: a prolonged (\>4 hours), painful erection * _Etiology_: * medications: PDE-5 inhibitors, PGE-1, phentolamine, papaverine, bupropion, * Blood disorders: **sickle cell anemia**, leukemia * Alcohol, marijuana, cocaine * _Complications_: * may result in severe ischemia, fibrosis & impotence after 12 hours * _tx_: * ice packs * decongestants: phenylephrine * Procedures: injections, needle aspiration, surgery

Premature Ejaculation

* _Definition_: an orgasm before intercourse or less than one minute after starting * _Causes_: * unclear – psychogenic, penile hypersensitivity, cultural basis * _Epidemiology_: * ~30% of men worldwide * _s/sxs_: * loss of control * significant distress to man or partner * _Tx_: * SSRI: paroxetine (PRN vs continuous) * -TCA: clomipramine * -Topical lidocaine/prilocaine * -Psychological: sex therapy * -Behavioral: distraction techniques, prolonged arousal time, sex holidays

Retrograde Ejaculation

* _Definition_: * semen enters the bladder instead of emerging through the penis during orgasm * _Causes_: * longstanding DM, relaxation of the urethral sphincter by meds (alpha adrenergic antagonists), prostate surgery * _S/sxs_: * little to no semen during orgasm * _Tx_: * trial of Pseudoephedrine

Decreased Libido

* _Definition_: * decrease in sexual interest, initiative, frequency and intensity of responses to internal or external erotic stimuli * _Causes_: * psychogenic, neurologic disorders, androgen deficiency, meds (Thiazides, spironolacton, SSRI, TCA, opiates), alcoholism, depression, fatigue, drugs, relationship problems, sexual dysfunction, systemic illness * _Dx_: * metabolic & hormonal eval (testosterone): for s/sxs of hypogonadism * _Tx_: * address underlying cause * change class of meds

Male Hypogonadism

* _Definition_: * decrease in either or both of the primary function of the testes (testosterone & sperm production) * _Etiology_: * **Primary: decreased function of** **Leydig cells** → decreased testosterone; aging, obesity, meds, anorchia, cryptorchidism, Klinefelter’s, trauma * **Secondary: disorder of the** **pituitary gland** **or** **hypothalamus**; cirrhosis, feedback inhibition by high estrogen, hypothyroid, hyperprolactin, **opiates, THC**, Crohn’s, arthritis * _S/sxs_: * decreased muscle mass & increased fat * decreased bone mass and increased risk of fracture * depression, loss of motivation, fatigue * decreased labido, erectile dysfunction * adolescents: failure to undergo puberty * _PE_: * Evidence of hypothyroid or cortisol excess: dry skin, hair loss, moon face, flushing * Jaundice (d/t liver failure, hepatitis) * Rash or oral lesions (HIV) * BMI, waistline \> 40in (HTN, CVD, DM II) * obesity, striae, bruits of the abd * testicular problems with size, volume, consistency * _Dx_: * **Morning total serum testosterone: initial screen:** decreased (\<300 ng/dL) * \*If decreased → then run total testosterone panel: total, free (2%), sex steroid hormone binding globulin (68%) * Then run LH: to determine primary vs. secondary * -Then run Prolactin: if T \< 140 ng/dL * _Tx_: * **Testosterone** **Supplements**: IM injections, subdermal pellets, dermal patches, axillary liquid, nasal gel (oral formulations not recommended) * Smoking cessation, diet, exercise * No evidence supports natural testosterone boosters

Low Testosterone Complications

increased risk of MI or stroke, obesity, DM, metabolic syndrome, OSA

Testosterone Replacement Risks

* elevated LFTs, altered HDL/LDL ratio, increased hematocrit, progressive OSA, **promotion of prostate cancer**, increased aggressiveness, dependency → **monitor LFTs, hematocrit, lipid panel, PSA, total testosterone**

Male Reproductive Flashcards

(34 cards)