Male Reproductive System

Question 1

cryptorchidism

Answer 1

undescended testes

Question 2

cryptorchidism management

Answer 2

testicular US
referral to pediatric urologist for patient under 6 months old
diagnostic laproscopy
Hormonal therapy not effective

Question 3

phimosis

Answer 3

foreskin cannot be retracted over
(normal in children 1-3 years old)

Question 4

paraphimosis

Answer 4

retracted but cannot be forwarded

Question 5

paraphimosis management

Answer 5

medical emergency
manual or surgical retraction to prevent necrosis

Question 6

hypospadias

Answer 6

abnormal ventral placement of the urethral opening

Question 7

hypospadias management

Answer 7

urgent surgical referral for repair

Question 8

Peyronie Disease

Answer 8

Inelastic scar, or plaque, that shortens the tunica albuginea of the corpora cavernosa results in a curve of the penile shaft in erection

Question 9

Peyronie Disease Pathophysiology

Answer 9

Trauma/flexion of the tunica albuginea results in tears [bleed and clots], subsequent fibrin deposition and perivascular inflammation and finally plaque like scarring

Question 10

Peyronie Disease most common in _____ (age) due to ____

Answer 10

Most common in males 40 and 65 years of age, with loss of penile collagen

Question 11

Peyronie Disease Management

Answer 11

referral to urology

Collagenase clostridium histolyticum (CCH) & steroid injections are probably most effective during the initial formation of Peyronie’s plaque, but success is limited with mature plaques.

Most common placing a suture on the opposite side of the graft to adjust curve OR

Nesbit procedure, involves excision of the plaque accompanied by “patch grafting”

Question 12

Balanitis pathophysiology

Answer 12

Accumulation of glandular secretions (smegma), epithelial cells or mycobacterium smegmatis, candidiasis

Question 13

diagnosis of balanitis

Answer 13

Subpreputial swab for C&S

Question 14

Balanitis Management

Answer 14

hygiene
treat underlying cause:
Dermatitis—prescribe hydrocortisone 1% for up to 14 days.

Candidal balanitis—an anti-fungal “azole” cream until symptoms disappear or for up to 14 days. If there is uncomfortable inflammation, consider adding in hydrocortisone 1% cream for up to 14 days.

Bacterial balanitis—prescribe oral cloxacillin/cephalexin (clarithromycin if allergic) for 7 days.

If there is uncomfortable inflammation, consider adding in hydrocortisone 1% cream for up to 14 days.

Question 15

Urethritis causes (2 types)

Answer 15

Neisseria gonorrhoeae develops 2 to 6 days after acquisition

Non-gonococcal urethritis (NGU) develop 1 to 5 weeks after acquisition

Question 16

Treatment of urethritis

Answer 16

Gonococcal urethritis
Ceftriaxone 250 mg IM – single dose
PLUS EITHER
Doxycycline 100 mg PO bid for 7 days
OR Azithromycin 1 g PO in a single dose preferred compliance.

Non-gonococcal urethritis
Doxycycline 100 mg PO bid for 7 days
OR Azithromycin 1 g PO in a single dose preferred compliance

Question 17

Epididymitis causes

Answer 17

Infectious
Rare causes: sterile acute
Behçet disease and Henoch Schönlein

Question 18

Epididymitis Management

Answer 18

For epididymitis most likely caused by: STI chlamydial or gonococcal infections:

Ceftriaxone 250 mg IM in a single dose*
PLUS Doxycycline 100 mg PO bid for 10–14 days
OR Ciprofloxacin 500 mg PO in a single dose (ONLY with known sensitivity + ability to do test of cure)
OR Azithromycin 1 g PO – in Ontario due to resistance to Ciprofloxacin/quinolones

For epididymitis most likely caused by enteric organisms [e-coli and other gram negative bacilli]:
Ciprofloxacin 500 mg BID or 1 g (extended release daily) x 10 days
OR Levofloxacin 500 mg once daily x 10 days

Question 19

Prostatitis pathophysiology

Answer 19

Prostatitis is generally NOT considered a sexually transmitted infection (STI)

Pathology of prostatitis is thought to be an alteration in the mechanical defenses of the urogential tracts: structural malformations, instrumentation of the tract can impact this.

Question 20

Benign Prostatic Hyperplasia

Answer 20

BPH is a non-malignant prostate enlargement caused by excessive growth of epithelia (glandular) cells and smooth muscle cells. Overgrowth = obstruction of the urethra [aka s/s of BPH]

Question 21

Function of prostate is

Answer 21

to produce fluids that contribute to ejaculation volume

Question 22

BPH Management 2 major classes

Answer 22

1st line therapy:
5-α-reductase inhibitors
α1-adrenergic antagonists

Question 23

5-α-reductase inhibitors
MOA

Answer 23

Dutasteride (Avodart), Finasteride (Proscar)
1st line for large prostates with mechanical obstruction
MOA = Reduce dihydrotestosterone production, which causes the prostate to shrink, which reduces mechanical obstruction of the urethra. May also delay BPH progression.
Benefits take months to develop.

Question 24

α1-adrenergic antagonists selective

Answer 24

Silodosin [Rapaflo],
Tamsulosin [Flomax

Question 25

α1-adrenergic antagonists nonselective

Answer 25

Alfuzosin, Terazosin

Question 26

α1-adrenergic antagonists MOA

Answer 26

1st line for smaller prostates with more dynamic obstruction s/s MOA = Blockade of α1a receptors relaxes smooth muscle in the bladder neck, prostate capsule, and prostatic urethra, and thereby decreases dynamic obstruction of the urethra. Benefits develop rapidly.

Question 27

____ (Rx) can be used for both ED and BPH due to MOA = smooth muscle relaxation in bladder, prostate and urethra supports both conditions [see ED]

Answer 27

phospodiesterasie-5 inhibitor [PDE5 inhibitors]

Question 28

s/e of α1-adrenergic antagonists

Answer 28

Hypotension, fainting, dizziness, somnolence, and nasal congestion (from blocking α1 receptors on blood vessels)

Question 29

s/e of 5-α-reductase inhibitors

Answer 29

Decreased ejaculate volume and libido

Question 30

Erectile Dysfunction pathophysiology

Answer 30

Sexual arousal [increased parasympathetic nerve impulse to the penis releasing local nitric oxide]. NO then activates guanylyl cyclase, enzyme that makes cyclic guanosine monophosphate (cGMP). cGMP = arterial dilation and trabecular smooth muscle relaxation Increase blood flow/pressure and trabecular relaxation = engorgement of sinusoidal spaces in the corpus cavernosum This cases venous occlusion/reduced venous outflow = erection Erection stops when cGMP is inhibited by Phosphodiesterase type 5 (PDE-5) Relaxation of arterial and trabecular smooth muscle [pre-erection/flaccid states]

Question 31

1st line therapy for Erectile Dysfunction

Answer 31

PDE-5 inhibitors

Question 32

2nd line therapy for ED

Answer 32

Prostaglandin E1 Analogues &Vacuum erection devices [VED] [need referral to Urology]

Question 33

Contraindications of PDE-5 Inhibitors

Answer 33

concurrent use of nitrates, symptomatic hypotension previous priapism

Question 34

Scrotal/Testicular Masses and Swelling (painful)

Answer 34

Epididymitis Testicular Torsion (medical emergency) Orchitis

Question 35

Scrotal/Testicular Masses and Swelling (non- painful)

Answer 35

Varicocele Hydrocele Spermatocele Testicular cancer

Question 36

RED FLAGS: TWIST SCORE

Answer 36

Testicular Workup for Ischemia and Suspected Torsion. Hard testicle Swelling Nausea/vomiting No scrotal reflex or Cremasteric reflex High riding testicles

Question 37

Prehn sign

Answer 37

Painful, usually unilateral, not relieved by scrotal support

Question 38

orchitis

Answer 38

Acute inflammation of the testicles/scrotal sack often due to infection of the epididymis (see previous slides) or a systemic illness such as mumps & COVID 19

Question 39

Varicocele

Answer 39

Dilation of a vein within the spermatic cord 90% on LEFT side

Question 40

Red Flags: Varicocele

Answer 40

Older men is a late sign of a renal tumor

Question 41

Hydrocele

Answer 41

Fluid in the tunica vaginalis and most common cause of scrotal swelling

Question 42

Hydrocele diagnostic testing

Answer 42

transillumination and ultrasound

Question 43

Hydrocele Treatment

Answer 43

Always a referral to urology, self-limiting, treat underlying cause, may aspirate for comfort depending on size and not associated with infertility

Question 44

Spermatocele

Answer 44

Diverticulum of the epididymis Not associated with infertility

Question 45

Testicular Cancer Clinical Manifestations

Answer 45

Mass on right>left side with 1-2% being bilateral Painless testicular enlargement or heaviness in scrotum, dull ache in abdomen Hydrocele Gynecomastia Metastasis: cough, back pain, SOB, bloody sputum, supraclavicular nodes, dysphagia, CNS symptoms

Question 46

Prostate Cancer Red flag:

Answer 46

UTI or previous prostatitis without resolution/recurrence

Question 47

Prostate Cancer Screening & Diagnosis

Answer 47

Initial screening should include DRE Offer PSA screening to men with life expectancy > 10 years, starting at age 50 (45 if increased risk)

Question 48

Penile Cancer Cause

Answer 48

mostly squamous cell carcinoma (glans or foreskin) the more lesions, the worse the prognosis

Question 49

Penile Cancer Risk Factors

Answer 49

HPV, smoking, psoriasis tx with psoralen and UV light, uncircumcised, hx of phimosis and AIDS

Question 50

PDE5-inhibitor pharmacology

Answer 50

Absorption is inhibited for sildenafil with high-fat meals CYP3A4 inhibitors can significantly decrease metabolism of the PDE5 inhibitor. [e.g. Grapefruit juice avoided/elevate levels] CYP3A4 inducers may decrease efficacy of the PDE5 inhibitor