1. Male Reproductive System Disorders

• Testes

• Ducts

• Semen

• Penis

Male Reproductive System:

• ____ make sperm and secrete hormones

• _______ transport and store sperm, assist in their maturation, and convey them to the exterior

• ______ contains sperm plus secretions of sex glands

• _____ delivers sperm to the female reproductive tract

Testes (Testicles)

• Paired oval glands in scrotum

• Develop on posterior abdominal wall and descend into scrotum through inguinal canals

• Each lobule is filled with 2 or 3 seminiferous tubules where sperm are formed (spermatogenesis)

  • Meiosis occurs to produce haploid sperm cells

Spermatogenesis

• Spermatogonia (2n) → primary spermatocytes (2n) → secondary spermatocytes (n) → spermatids (n) → mature sperm

• One primary spermatocyte gives rise to 4 spermatozoa (n)

Pathway of Sperm Flowing through Ducts

• Seminiferous tubules → ductus epididymis → ductus (vas) deferens → ejaculatory ducts → urethra

Semen

• A mixture of sperm and seminal fluid

  • Secretions from seminiferous tubules (sperm), seminal vesicles, prostate, and bulbourethral glands (stay tuned…)

• Volume ~2.5 – 5 mL

• 50 – 150 million sperm / mL

• If < 20 million sperm / mL, likely infertile

• Slightly alkaline pH (7.2 – 7.7) → counters vaginal acidity

• Coagulates after ~ 5 min and re-liquefies after ~10 – 20 min to allow for sperm motility through cervix of uterus

ANSWER: B

• What’s the point of clotting, why does semen coagulate?

• we evolved for purpose of reproduction,  evolutionary perspective

• if it does not clot after ejac, the pt get up, get out, no deliver

A failure of semen coagulation, which could be caused by abnormal/low/absent clotting factors, would most impact:

a. Sperm viability

b. Sperm delivery

c. Sperm motility 

d. Sperm morphology 

ANSWER: C

• if stay coag = no helpful, b/c sperm big journey ahead of them to find oocyte

A failure of semen reliquification, caused by defective/low/absent proteolytic enzymes, would impact:

a. Sperm viability

b. Sperm delivery

c. Sperm motility 

d. Sperm morphology 

e. Sperm ATP production

• Seminal vesicles

• Prostate

• Bulbourethral glands

Acessory Sex Glands:

• ______________

  • Secrete alkaline fluid with fructose, clotting proteins

• ______

  • Secretes slightly acidic fluid with citric acid, proteolytic enzymes

• Bulbourethral glands

  • Secrete alkaline fluid and mucus

Penis

• Contains three masses of erectile tissue

  • Spongy structures composed of blood sinuses lined by endothelial cells and surrounded by smooth muscle and elastic CT → fill with blood during erection

• Two corpus cavernosa: dorsolateral, for maintaining erection

• Corpus spongiosum: contains spongy urethra and keeps it open during ejaculation

Erection

• Parasympathetic reflex causes erection

  • Sexual stimulation → dilation of arteries supplying penis (nitric oxide mediates local vasodilation)

  • Expansion of blood sinuses compresses the veins, trapping blood in penis to maintain erection

Ejaculation

• Ejaculation is a sympathetic reflex

  • Peristalsis in epididymis, ductus deferens, seminal vesicles, ejaculatory ducts, and prostate propel semen into spongy urethra

• Urination is prevented during ejaculation

• After ejaculation, arterioles supplying erectile tissue constrict and smooth muscles within erectile tissue contract, making blood sinuses smaller and relieving pressure from veins → blood allowed to drain

• Testosterone

Male Sex Hormones:

• _________ is the primary androgen

  • Produced by interstitial cells in testes

  • Can be converted to other androgens in periphery (skin/liver) e.g. dihydrotestosterone (DHT)

    • 5x more potent than ________

• embryogenesis

• male sexual

• Anabolic

Functions of Testosterone:

• Important in _________

• Development and maintenance of _________ characteristics

• ______ effects e.g. protein synthesis, musculoskeletal growth

• Spermatogenesis

• Sex drive

• Hypospadias and Epispadias

• Urethritis and Urethral Strictures

• Phimosis and Paraphimosis

• Balanitis

• Peyronie Disease

• Priapism

• Male Sexual Dysfunction

• Carcinoma of the Penis

Disorders of the Penis and Urethra

Hypospadias

• Congenital abnormality in which the urinary meatus is located on the ventral surface of the penis

• Incidence: 1/300 male infants

• Disruption of androgen stimulation during development (genetics or prenatal exposure to toxins, estrogenic compounds)

• Results in embryological defects in development of the urethral groove and penile urethra

• Often associated with:

  • Chordee (ventral bowing of penis)

  • Cryptorchidism (undescended testes)

  • Partial absence of foreskin 

Hypospadias Etiology and pathogenesis:

• standing

Hypospadias signs and symptoms:

• Inability to urinate in ______ position

• Ejaculatory dysfunction

• Inability to penetrate during coitus

• Possible urinary tract obstruction

• Surgical

Treatment of Hypospadias:

• _______ repair

  • Improved micturition and sexual function

Epispadias

• Congenital abnormality in which the urinary meatus is located on the dorsal surface of the penis

• Incidence: 1 in 20,000 live births

• Embryological defect in abdominal wall development → herniation of lower abdominal organs e.g. bladder exstrophy

• Epispadias is a mild form where urethra fails to close normally

Epispadias Etiology and pathogenesis

• Varying degrees of severity

• Open bladder and exposed urethra

• Penis and prostate defects are common

• May involve anal atresia, hypoplasia of the colon and small intestine, and abnormalities in the vertebral column and pelvic bone

Signs and symptoms of Epispadias

• Surgical management to preserve urinary continence and cosmetic appearance of genitalia

Treatment of Epispadias

Urethra

Common structure of both the urinary and reproductive systems in males

Urethritis

• inflammation of the urethra

• Infectious causes e.g. gonorrhea, chlamydia → STIs

• Other causes e.g. urologic procedures, anatomical abnormalities, trauma (Catheterization)

• Dysuria, pruritis, purulent discharge

Urethral stricture

• scarring and fibrotic narrowing

• Commonly due to infections or iatrogenic trauma

• Urethral discharge, urinary retention, hydronephrosis

Phimosis and Paraphimosis

• The foreskin (prepuce) is a retractable double-layered fold of skin and mucous membrane that covers the glans penis and protects the urinary meatus

Phimosis

• Inability to retract foreskin from the glans of the penis (distal to proximal)

• Tight foreskin that cannot be retracted to expose glans

  • Normal in young children; 99% of cases resolved by age 16

• Poor hygiene

Etiology and pathogenesis of Phimosis:

• ___________ leading to chronic inflammation and infection →scarring and narrowing of prepuce

• Irritation and bleeding

• Purulent discharge

• Painful erection

• Dysuria, chronic urinary retention

Signs and symptoms of Phimosis

• Stretching exercises of the prepuce

• Topical corticosteroids, antibiotics

• Circumcision

Treatment of Phimosis

Paraphimosis

• Inability of foreskin that has been retracted to be replaced in its normal position (proximal to distal)

• Foreskin is trapped behind corona of the glans penis

  • Incidence ~1% in adult males

• Phimosis, chronic inflammation

• Iatrogenic e.g. foreskin retracted for cleaning, catheter placement

• Trauma e.g. body piercings = swelling

Etiology and pathogenesis of Paraphimosis

• Penis swelling and pain

• Dysuria and urinary obstruction

• Ischemia and necrosis → tight foreskin → contricts glans penis = no blood flow

signs and symptoms of Paraphimosis

• Pain control e.g. topical anesthetics

• Manual reduction

• Dorsal slit incision

• circumcision

Treatment of Paraphimosis

Balanitis

• Inflammation of the glans penis

  • Incidence ~3% of men globally

  • hand in hand w/ phimosis/paraphimosis

• Inadequate hygiene, infections, chemical irritants

• Buildup of sweat, debris, and exfoliated skin (smegma) between foreskin and glans → inflammation

Etiology and pathogenesis of Balanitis

• Redness, pain, and swelling

• Thick white discharge under foreskin

• Phimosis

• Painful urination

Signs and symptoms of Balanitis

• Genital hygiene

• Topical antifungals, antibiotics or steroids

• Circumcision

Treatment of Balanitis

Peyronie disease

• Localized fibrotic disorder of the tunica albuginea

• Incidence ~5% in adult men

• Genetics, trauma, and tissue ischemia

• Localized abnormal wound healing → upregulation of cytokines and growth factors → fibrous plaque that alters penile anatomy

etiology and pathogenesis of Peyronie disease

• Penile pain and deformity (often causes curve)

• Palpable plaque or nodule

• Erectile pain and dysfunction

signs and symptoms of Peyronie disease

• Oral phosphodiesterase inhibitors → coping strategy using viagra to vasodilate penis

• Intralesional collagenase injection → enzymes break down the collagen

• Surgery – plication, grafting 

treatment of Peyronie disease

Priapism

• Persistent painful erection of the penis in the absence of sexual desire or stimulation

• May last from hours to days

• Incidence ~1:100,000 men; can occur in any age group

• Most are idiopathic

• Underlying disease

  • Hematologic – e.g. sickle cell disease

  • Metabolic – e.g. diabetes

• Drugs

  • E.g. antipsychotics, impotence treatments

• Spinal cord trauma

etiology of Priapism

• Obstruction of venous drainage → ischemia and structural damage to erectile tissue

pathogenesis of Priapism

• Painful and rigid erection

• May present with penile gangrene

signs and symptoms of Priapism

• Oral analgesics

• Decompression by aspirating blood

• Intracavernosal injections of sympathomimetics

• Surgery e.g. shunt procedures

treatment of Priapism

• Duration of priapism strongly associated with subsequent erectile dysfunction

  • 90% of men with ischemic priapism lasting >24 hours lose ability to have sexual intercourse

prognosis of Priapism

Male Sexual Dysfunction

• Any disorder that interrupts cycle from arousal to orgasmto resolution

  • E.g. decreased libido, erectile dysfunction, ejaculatory disorders

  • May be due to psychological, emotional, or physiological factors

  • Survey data indicate ~30% of men aged 18 – 59 suffer from sexual dysfunction; incidence increases with age

• Neural

• Vascular

• Hormonal

• Psychological

Components of normal sexual function:

• _______ – perceive sensory input; autonomic output

• ______ – sufficient blood flow and nitric oxide (NO) activity

• _______ – testosterone enhances libido and NO synthesis

• ___________ and social factors

Erectile Dysfunction

• Consistent inability to acquire or sustain an erection of sufficient rigidity and duration for sexual intercourse

  • Estimated prevalence 16% in men 20 – 75 years old

• Age

• Obesity

• Smoking

• Local penile factors e.g. Peyronie disease

• Trauma e.g. pelvic fracture, iatrogenic procedures

• Endocrine disorders e.g. hypogonadism

• Chronic medical problems e.g. diabetes, hypertension, CKD, MS, PD

• Drugs e.g. antidepressants, antihypertensives, alcohol

• Psychogenic e.g. trauma, anxiety, stress

Etiology and pathogenesis of Erectile Dysfunction

• Address underlying etiology

• Lifestyle modifications e.g. smoking cessation, exercise

• Testosterone therapy

• Phosphodiesterase-5 inhibitors e.g. sildenafil (Viagra)

• Vacuum devices

• Surgery e.g. revascularization, prosthetics

treatment of Erectile Dysfunction

Premature Ejaculation

• Rapid ejaculation that occurs with brief latency, inability to delay ejaculation, and causes negative personal consequences

  • Estimated prevalence up to 30% of all males

• Unclear; biological and psychosocial factors involved

• Low serotonin in the brain, hormonal abnormalities

• Depression, anxiety, unrealistic expectations about sexual performance, poor body image

etiology and pathogenesis of Premature Ejaculation

• SSRIs

• Topical anesthetics, condoms

• Psychotherapy

treatment of Premature Ejaculation

Carcinoma of the Penis

• Squamous cell carcinomas account for 95% of penile carcinomas

  • Rare (<1% of cancers in men) in developed countries, but accounts for ~10 – 20% of cancers in Africa, Asia, and South America

• Age

• Medical conditions of the penis e.g. UTIs, phimosis

• Infections e.g. HPV, HIV

• Smoking

etiology of Carcinoma of the Penis

• Skin abnormality or palpable lesion on penis

• Majority present on the glans or prepuce

• Rash

• Bleeding

• Balanitis

signs and symptoms of Carcinoma of the Penis

• Topical chemotherapy

• Radiation

• Partial or total penectomy

• Removal of lymph nodes

treatment of Carcinoma of the Penis

• If localized to penis, 5-year survival ~85%

• If metastasized beyond inguinal lymph nodes, 5-year survival is less than 10%

prognosis of Carcinoma of the Penis

Disorders of the Scrotum and Testes

• Cryptorchidism

• Varicocele, hydrocele, and spermatocele

• Testicular torsion

• Epididymitis and orchitis

• Testicular cancers

• Male infertility

Cryptorchidism

• “Hidden testes” – a testis that is not within the scrotum, or does not descend spontaneously by 4 months of age

  • Testis may be undescended, absent, or ectopic

  • Can be unilateral or bilateral

  • Incidence ~1% in male infants at 1 year of age

• Premature birth or low birth weight

• Prenatal exposure to endocrine disruptors e.g. pesticides

• Genetic disorders leading to abnormalities in development or endocrine function

• Interaction between mechanical, hormonal, and neurotransmitter effects required for normal testes descent

etiology and pathogensis of Cryptorchidism

• Empty or hypoplastic scrotum

• Undescended testes may be palpable

signs and symptoms of Cryptorchidism

• Testicular torsion

• Testicular trauma

• Infertility

• Malignant transformation

complications of Cryptorchidism

• Palpation

• Imaging – ultrasound, CT scan

diagnosis of Cryptorchidism

• Human chorionic gonadotropin (hCG) injections

• Orchidopexy

  • Surgical operation in which undescended testis is mobilized and fixed within scrotum

  • Generally performed before 2 years of age

• Orchiectomy

  • Performed if cryptorchidism is identified after puberty

treatment of Cryptorchidism

Varicocele

• Varicosities in pampiniform plexus that supplies the testes

• Found in ~20% of post-pubertal males, mostly on left side

• Incompetent or absent valves in testicular veins

etiology and pathogensis of Varicocele

• ‘Bag of worms’ upon palpation

• May be asymptomatic or associated with pain and scrotal fullness

• Testicular atrophy and decreased fertility

clinical features of Varicocele

• Surgical ligation

• Venous embolization

treatment of Varicocele

Hydrocele

• Collection of peritoneal fluid between layers of the tunica vaginalis

  • More common in men >40 years of age

• Imbalance of fluid secretion and reabsorption

• Idiopathic or secondary to inflammatory conditions (e.g. STIs, epididymitis, orchitis)

etiology of Hydrocele

• Can be small and soft, or large and firm

• Pain proportional to size of cystic mass

• Transilluminates well

clinical features of Hydrocele

• Surgical excision of hydrocele sac

treatment of Hydrocele

Spermatocele

• Painless, sperm-containing cyst that forms at the end of the epididymis

  • May be difficult to distinguish from hydrocele, but aspirated fluid from spermatocele contains spermatozoa

• Idiopathic or secondary to infections, trauma

etiology and pathogenesis of Spermatocele

• Generally asymptomatic

• May cause chronic pain

clinical features of Spermatocele

• Surgical excision

treatment of Spermatocele

Testicular Torsion

• Urologic emergency where testis twists on spermatic cord

  • More common in neonates than adults

  • Accounts for 25 – 50% of hospitalizations for acute scrotal pain

• May be spontaneous or triggered (e.g. trauma)

• Lower pole of testis is inadequately fixed to tunica vaginalis → testis twists → ischemia and infarction

• Irreversible testis damage after several hours

etiology and pathogenesis of Testicular Torsion

• Acute onset of moderate to severe testicular pain

• Nausea, vomiting, and diffuse lower abdominal pain

• Asymmetric high-riding testis

• Swelling and redness of scrotal wall

• Palpable ‘knot’ superior to the testis

signs and symptoms of Testicular Torsion

• Manual detorsion

• Surgery for detorsion and fixation of testis

treatment of Testicular Torsion

Epididymitis

• Inflammation of the epididymis

  • Most common cause of acute scrotal pain in adults

• Males ages 20 – 40: STIs e.g. gonorrhea, chlamydia

• Elderly males: UTIs, retrograde urine flow e.g. E. coli

• Other causes: sports trauma, drugs, viruses

etiology and pathogenesis of Epididymitiss

• Intra-scrotal pain and swelling

• Possible fever, UTI symptoms

signs and symptoms of Epididymitis

• Antibiotics

• Bed rest and scrotal elevation

treatment of Epididymitis

Orchitis

• Inflammation of the testes

  • Usually occurs in conjunction with epididymitis

  • Most cases of isolated orchitis are due to mumps infections

• Viral: mumps, rubella

• Bacterial: E. coli, Klebsiella, Pseudomonas, Staphylococcus, Streptococcus

etiology and pathogenesis of Orchitis

• Acute onset of testicular pain and swelling

• Fever, malaise, chills

• Testicular atrophy → sterility

signs and symptoms of Orchitis

• Antibiotics for bacterial causes

• Analgesics and antipyretics

• Scrotal support

treatment of Orchitis

Testicular Cancers

• Account for 1% of all male malignancies, but are the most common cancers affecting males between ages 15 – 35

• Majority (>90%) of testicular cancers are malignant

• Good prognosis – 5-year survival rate >95%

Germ cell tumours (90%)

• Derived from cells that give rise to spermatogonia

• Broadly classified as seminomas and non-seminomas

Sex cord-stromal tumours (5%)

• Derived from ‘support’ cells in the testes

• Include Leydig (interstitial) cell tumours and Sertoli (sustentacular) cell tumours

• Genetic associations

• Cryptorchidism

• Prenatal exposure to estrogens

Risk factors for Testicular Cancers

• Testicular enlargement that may become painful

• Heavy sensation in lower abdomen, perianal area, or scrotum

• Metastasis

  • Lungs – cough, dyspnea, hemoptysis

  • CNS – visual defects, dizziness, seizures

• Gynecomastia if tumour produces hCG or estrogens

signs and symptoms of Testicular Cancers

• Testicular examination

• Scrotal ultrasound

• Serum tumor markers (e.g. hCG, alpha fetoprotein, lactate dehydrogenase)

• Radical inguinal orchiectomy

• Retroperitoneal lymph node dissection

diagnosis of Testicular Cancers

• Orchiectomy and node dissection

  • Some males require hormone replacement therapy, sperm banking

• Chemotherapy or radiation

treatment of Testicular Cancers

Seminomas

• Account for ~45% of testicular cancers

• Malignant tumour derived from seminiferous epithelium that retains characteristics of primary spermatogonia

  • Neoplasm generally consists of a single cell type

• Slow growth and lymphatic spread

  • Mostly limited to testicle or retroperitoneal nodes

• Good prognosis due to radio-sensitivity