Problems of the male reproductive system

Question 1

Which two structures pass through the prostate? [2]

Answer 1

prostatic urethra [1]

ejaculatory ducts [1]

Question 2

Which of the following is the seminal gland

A
B
C
D
E
F

Answer 2

Which of the following is the seminal gland

A
B
C
D
E
F

Question 3

Describe / draw the structure of the prostate [4]

Answer 3

4 main areas (3 of which are glandular)

• Peripheral zone
• Central zone
• Transition zone
• Anterior fibromuscular zone

Question 4

Which part of the prostate is outlined

• Peripheral zone
• Central zone
• Transition zone
• Anterior fibromuscular zone

Answer 4

Which part of the prostate is outlined

• Peripheral zone
• Central zone
• Transition zone
• Anterior fibromuscular zone

Question 5

Which part of the prostate is outlined

• Peripheral zone
• Central zone
• Transition zone
• Anterior fibromuscular zone

Answer 5

Which part of the prostate is outlined

• Peripheral zone
• Central zone
• Transition zone
• Anterior fibromuscular zone

Question 6

Which part of the prostate is outlined

• Peripheral zone
• Central zone
• Transition zone
• Anterior fibromuscular zone

Answer 6

Which part of the prostate is outlined

• Peripheral zone
• Central zone
• Transition zone
• Anterior fibromuscular zone

Question 7

Which area of the prostate is made from fibromuscular stroma? [1]

Answer 7

Anterior fibromuscular stroma

Question 8

Histology xx

Question 9

When conducting a benign prostate enlargement (hyperplasia) exam, which part of the prostate are you feeling?

What would indicate this compared to prostate cancer?

Answer 9

Posterior zone

BPE is enlarged - but remains smooth (cancer causes hard hard and lumpy)

Question 10

Why is BPE problematic? [1]

What is the main cause of BPE? [1]

Answer 10

Urethra becomes compressed: narrows it.

Increased tesosterone / other testicular androgens. Also caused by oestrogens

Question 11

What is outlined by the arrow [1] and circle [1] on this histology of prostate?

Answer 11

Arrow: (interdigitating) skeletal muscle fibers

Circle: paired ejaculatory ducts

Question 12

The [] zone is the area commonly affected in benign prostate enlargement.

Answer 12

The transitional zone is the area commonly affected in benign prostate enlargement.

Question 13

Explain mechanism of proliferation versus apoptosis in normal prostate vs BPE

Answer 13

Testosterone is converted to oestradiol in the stromal cells via the enzyme aromatase.

oestradiol then goes to the enzyme oestrogen receptor alpha and drives cell proliferation after it binds to in the stromal cells.

Oestradiol also goes into the epithelial cells and activate oestrogen receptor beta of the glands (in both the basal and luminal epithelial cells) and causes apoptosis

Testosterone can also enter directly into the basal epithelial cells converted to Dihydrotestosterone (DHT) by 5-alpha reductase in the epithelial cells. DHT can then pass into luminal epithelial, binds to androgen receptor and stops apoptosis

With BPE most of the oestradoil goes to the stomal cells and ERa and causes proliferation. Very little goes to ERbeta to cause apoptosis.

Due to increased Testosterone and therefore DHT: get more of androgen receptor, which drives luminal cells to hypetrophy.

Get proliferation of stromal cells and hypertrophy of epitheilial cells

Question 14

FYI

Answer 14

All men over 40 have this

50% will develop histological hyperplasia
50% of these with have lower urinary tract symptoms (LUTS)
Some will develop significant enlarged prostate (EP)
Some will develop bladder outlet obstruction (BOO)

Question 15

What are symptoms of BPE? [5]

Answer 15

Symptoms
* Weak or interrupted flow of urine
* Frequent urination (nocturia)
* Trouble urinating
* Pain or burning during urination (urine gets stuck in bladder - causes infection)
* Blood in urine or semen

SHITE = Slow stream, Hesitancy, Intermittent flow, Terminal dribbling, Emptying is incomplete.

Question 16

How do you diagnose BPE? [5]

Answer 16

• Hx
• Digital rectal exam
• Ultrasound - measure the size of the prostate (also check isnt cancer)
• Biospy
• Blood test (prostate speficic antigen - although not that specific for BPE)

Question 17

How can you treat BPE? [6]

Answer 17

α1-adrenergic blockers
* Relaxes smooth muscle in bladder neck and prostate improving urine flow rate

5-α-reductase inhibitors
* 2 isoforms type I and type II (type II predominant prostatic reductase) blocks the formation of DHT.
Dutasteride
Finasteride

Combinations

Surgery
* Open prostatectomy (for very large prostates, >75g)
* UroLift

Laser ablation

Transurehral microwave

High energy ultrasound therapy

Question 18

What do need to think about with regards to BPE and prostate cancer? [1]

How can you distinguish between the two? [1]

Answer 18

Symptoms of BHP may be similar to prostate cancer

PSA (if raised) tends to be much higher than in BPH

Question 19

Describe the relationship of direct and indirect inguial hernias to inferior epigastric vessels [2]

Answer 19

Direct: medial to IPV
Indirecct: lateral to IPV

Question 20

What are the borders of Hesselbachs triangle? [3]

Which type of inguinal hernias pass through Hesselbachs triangle? [1]

Answer 20

Medial – lateral border of the rectus abdominis muscle.
Lateral – inferior epigastric vessels.
Inferior – inguinal ligament.

Direct inguinal hernias pass through

Question 21

Which side is more common to have indirect inguinal hernia in? [1]

Answer 21

Right = 80%

Question 22

What causes indirect inguinal hernia? [1]

How do you treat? [1]

Answer 22

processus vaginalis doesnt close - means loop of intestine can fall into the scrotum

Treat with surgery

Question 23

The inferior epigastric artery forms the lateral border of inguinal triangle. From which artery does it arise?

Inferior mesenteric

External pudendal

Common iliac

External iliac

Answer 23

The inferior epigastric artery forms the lateral border of inguinal triangle. From which artery does it arise?

Inferior mesenteric

External pudendal

Common iliac

External iliac

Question 24

Which type of hernia occurs through Hesselbach’s triangle?

Direct inguinal

Incarcerated femoral

Paramedian

Deep inguinal

Answer 24

Which type of hernia occurs through Hesselbach’s triangle?

Direct inguinal

Incarcerated femoral

Paramedian

Deep inguinal

Question 25

Which structure forms the medial border of the inguinal triangle? External oblique Linea alba Rectus abdominis Transversus abdominis

Answer 25

Which structure forms the medial border of the inguinal triangle? External oblique Linea alba **Rectus abdominis** Transversus abdominis

Question 26

Which of the following zone of prostate surrounds the proximal urethra? Peripheral zone Central zone Transition zone Anterior fibromuscular stroma

Answer 26

Which of the following zone of prostate surrounds the proximal urethra? Peripheral zone Central zone **Transition zone** Anterior fibromuscular stroma

Question 27

Which of the following zone of prostate surrounds the ejaculatory ducts? Peripheral zone Central zone Transition zone Anterior fibromuscular stroma

Answer 27

Which of the following zone of prostate surrounds the ejaculatory ducts? Peripheral zone **Central zone** Transition zone Anterior fibromuscular stroma

Question 28

.

Answer 28

.

Question 29

what are the erectile tissues in males? [4]

Answer 29

_what are the erectile tissues in males? [2]_ * *corpus spongiosum (**mouth of insect) * *corpus cavernersa** (eyes of insect) * *bulbospongiosus (**superifical to corpus spongiosum) * *ischiocavernosus (**superifical to corpus spongiosum)

Question 30

which of the following is the urethra found in? corpus spongiosum corpus cavernersa bulbospongiosus ischiocavernosus

Answer 30

which of the following is the urethra found in? **corpus spongiosum** corpus cavernersa bulbospongiosus ischiocavernosus

Question 31

which of the following is this highlighted muscle? corpus spongiosum corpus cavernersa bulbospongiosus ischiocavernosus

Answer 31

``` which of the following is this highlighted muscle? ​ **corpus spongiosum** corpus cavernersa bulbospongiosus ischiocavernosus ```

Question 32

``` which of the following is this highlighted muscle? ​ corpus spongiosum corpus cavernersa bulbospongiosus ischiocavernosus ```

Answer 32

``` which of the following is this highlighted muscle? ​ corpus spongiosum **corpus cavernersa** bulbospongiosus ischiocavernosus ```

Question 33

what is highlighted here? [1]

Answer 33

crux of penis which of the following is this highlighted muscle? ​

Question 34

which is this muscle? corpus spongiosum corpus cavernersa bulbospongiosus ischiocavernosus

Answer 34

which is this muscle? ​corpus spongiosum corpus cavernersa bulbospongiosus **ischiocavernosus**

Question 35

Which part of the urethra is located in the corpus spongiosum of the penis? [1]

Answer 35

Acceptable responses: **spongy, spongy part, penile**

Question 36

which 1-5 is the corpus cavernersa ``` 1 2 3 4 5 ``` ​

Answer 36

which 1-5 is the corpus cavernersa ``` **1** 2 3 4 5 ``` ​

Question 37

which 1-5 is the bulbospongiosus ``` 1 2 3 4 5 ``` ​

Answer 37

which 1-5 is the bulbospongiosus ``` 1 2 **3** 4 5 ``` ​

Question 38

which 1-5 is the corpus spongiosum ``` 1 2 3 4 5 ``` ​

Answer 38

which 1-5 is the corpus spongiosum ``` 1 **2** 3 4 5 ``` ​

Question 39

which 1-5 is the Superficial transverse perineal muscle ``` 1 2 3 4 5 ``` ​

Answer 39

which 1-5 is the Superficial transverse perineal muscle ``` ​1 2 3 4 **5** ``` ​

Question 40

which 1-5 is the Ischiocavernosus ``` 1 2 3 4 5 ``` ​

Answer 40

which 1-5 is the Ischiocavernosus ``` ​1 2 3 **4** 5 ``` ​

Question 41

what are the 3 nerve branches of the perineum? [3] what do they supply [3]

Answer 41

**Inferior rectal -** supplies the external anal sphincter and inferior anal canal **Perineal** - supplies the anterior perineum **Dorsal nerve of penis/clitoris** - supplies the external genitalia

Question 42

The pudendal nerve can be located clinically by palpating for the WHAT? [1]

Answer 42

The pudendal nerve can be located clinically by palpating for the **ischial spine**, as the nerve loops around it posteriorly.

Question 43

A young man attends his GP because he has been experiencing erectile dysfunction. Fibres from which branch of the autonomic nervous system are responsible for genital erection? [1]

Answer 43

Acceptable responses: **parasympathetic, parasympathetic nervous system**

Question 44

Erectile dysfunction can be subclassified as WHAT? [3]

Answer 44

Complete inability to have an erection Inconsistent ability to achieve an erection Ability to have short-term erections

Question 45

Label A-G

Answer 45

Question 46

Explain bloodflow mech. for creating an erection

Answer 46

During an erection: get relaxation of smooth muscle in **corpus cavernosa**. **Compresses venous outflow**: stops **blood getting out** = maintains erection

Question 47

Explain biochem mechanism for getting an erection

Answer 47

**NANC neuron** comes down: Increases **nitric oxide**. Diffuses into smooth muscle, where **guanyll cyclase** converts **GTP** to **cGMP**: creates **less Ca2+** creates **relaxation** Also get **eNOS** from blood vessels creating more NO that activates

Question 48

Which drugs would you use to treat erectile dysfunction? [3]

Answer 48

**Sildenafil** (viagra) a **PDE-5 inhibitor** **Vardenafil** (levitra), **Tadalafil** (cialis) also PDE-5 inhibitors

Question 49

How do ED treatments work? [2]

Answer 49

- Sildenafil inhibits the action of **phosphodiesterase (PDE) type 5,** - **increasing the intracellular concentration of cGMP.**

Question 49

How do ED treatments work? [2]

Answer 49

- Sildenafil inhibits the action of **phosphodiesterase (PDE) type 5,** - **increasing the intracellular concentration of cGMP. **

Question 50

Whats a non-pharmalogical treatment of ED?

Answer 50

penile prosthesis

Question 51

What is Peyronie’s disease? [1] What is it caused by? [1] What are treatment options? [2]

Answer 51

Peyronie’s disease = Bent Penis Caused by: **scar tissue** forming in the **shaft** of the penis. Painful erections! Treatment: Surgical Non-surgical: * **stretching** * **topical verapamil** (calcium channel blocker), * **Para-aminobenzoate** (type of B vitamin: increase o2 to tissues to reduce scar tissue forming)

Question 52

What is varicocele? Which testis does it occur in and why?

Answer 52

**Varicose veins of the scrotum** (pampiniform venous plexus) Very common 10-15% and always in the **left testis** Usually harmless but can be a **cause infertility** On the left because venous drainage takes right angle into left renal vein, but on the right goes to IVC. Causes greater backflow into the left