reproductive

what is peyronie disease

localized, progressive FIBROSIS of unknown origin

plaque most notable at dorsal midline of shaft → upward bowing

scars on dorsal AND ventral aspect → shortening or lateral bending during erection → painful intercourse/erection

complications of peyronie disease

fibrotic tissue calcifies to form rigid tissue

how is peyronie disease diagnosed?

treated?

hx and physical exam, doppled ultrasound to detect scarring

surgical release

erectile dysfunction is associated with what pathology?

atherosclerosis (inadequate blood flow)

morning wood associated with low risk of atherosclerosis

erection stimulated by ___.

ejaculation stimulated by ___.

somatic sensation carried by ___

parasympathetic NS

sympathetic NS

pudendal nerves `

what part of the spinal cord carries parasympathetic innervation to penis

sacral segments

• nitric oxide released → relaxed corpus cavernosa smooth muscle and blood flow into sinuses

what is required for an erection to occur?

what required for detumescence to occur?

erection: intact parasympathetic innervation, nitric oxide synthesis

detumescence: sympathetic innervation to trabecular smooth muscle

what is erectile dysfunction?

psychogenic causes?

organic causes?

persistant inabiluty to achieve and maintain erection for intercourse

performance anxiety, strained relationship, DEPRESSION, psychotic disorders

neurogenic, hormonal, VASCULAR, drug induced, penile, etc

describe different organic causes of ED

arteriosclerosis: limiting artery filling and dilation - ED early warning sign for CARDIAC pathologies

neurologic: MS, parkinsons, metal poisining, stroke, cerebral trauma. SPINAL CORD AND NERVE INJURIES from trauma or surgery

DIABETES directly related to ED: 35-75% males with T2DM - hardened arteries, peripheral neuropathy

endocrine: hypogonadism, prolactinemia

• prolactin inhibits GnRH from hypothalamis 0> reduced FSH, LH, T

HTN: stenosis, reduced production and utilization of NO

drugs: antidepressants, cigarettes, alcohol

• 1-2 drinks/hour increases libido and erection, 2-4 drinks/hour causes transient ED

aging

diagnosis of ED?

treatment?

hx and exam to rule out organic causes, drug hx, need to determine cause

physical exercise (CDC aerobic recommendation, pelvic floor strength training

how to treat ED

PDE5 (phosphodiesterase 5) inhibitors

• PDE5i and nitrates is contraindicated - high risk of severe hypotension

ICI (intracavernosal injection) paired with vasodilators

• prostaglandin E1: relax arterial and trabecular smooth muscle

• phentolamine: adrenergic receptor antagonist

surgical if conservative therapy failed

• peyronie, severe vascular compromose, cavernosum fibrosis

• malleable/inflatable penile implants

what is PDE5i also known as?

what does it do?

what happens with too many or too high of a dose?

viagra, originally made to treat HTN

smooth muscle relaxation

emergent priapism

what is a priapism

involuntary, persistent penile erection continuing hours beyond sexual stimulation

• MUST BE >4 HOURS

• stasis of blood → clot → acidic (CO2 and waste products)

  • emergent, ischemia and fibrosis

who gets priapism

any age

noted in younger populations with sickle cell disease or neoplasm

ischemic vs nonischemic priapism

ischemic: low flow - blood in, not enough out - painful, emergent

nonischemic: high flow - some blood in, some out, reduced acidity, indicative of impaired flow

• can be from PDE5i or something else

causes of priapusm

sickle cell disease, leukemia, thrombocytopenia

neurologic: stroke, SCI → affect vascular function

drugs: antihypertensives, antivoahulants, antidepressents, alcohol

how to diagnose priapism?

treat?

physical exam, doppler to assess penile blood glow, CT to assess for pelvic pathologies

analgesics, sedation, and hydration initially - alphaadrenergic drugs - surgical

what is penile cancer

squamous cell cancer of penis

relatively rare - associated with HPV (human papilloma virus), SMOKING, and repeated infection, and PHIMOSIS (foreskin too tight)

surgical treatment for penile cancer

mohs: surgeon takes tumor and assesses, progressively more tissue taken until clear on all borders

what HPV subtypes does the gardasil vaccine prevent infection from

6, 11, 16, 18

which HPV subtypes are directly associated with cervical and penile cancer

16 and 18

what is cryptorchidism?

primary vs secondary?

undescended testes when one or both fall into scrotal sac (mostly unilateral)

primary: testes don’t descend at all - stuck in abdomen or in ectopic position

secondary: retractile - testes were in scrotum, pulled into suprascrotal position from scarring

incidence of cryptorchidism?

when do testes normally descend

2-4% male population, upto 30% premature newborns

spontaneous within first 6 months postnatal

cryptorchidism can directly lead to ___

testicular cancer

what pulls testes from abdominal cavity to scrotal sac

fibrous gubernaculum

how to diagnose cryptorchidism?

treat?

undescended testes have never been palpated - differentiate from retractile testes (exaggerated cremaster reflex)

surgical intervention

• 20-40x higher risk of malignancy if not treated

3 nonpainful, benign scrotal and testicular disorders

hydrocele: open communication, peritoneal fluid into scrotal sac - should close shortly after birth

spermatocele: cyst of spermatic fluid

varicocele: blood backed up into pampinoform plexus

2 painful scrotal and testicular disorders

torsion, epidydimitis

presentation and management of hydocele

presentation

• tunica vaginalis should have fluid within inner visceral and parietal layers for testicular sliding

• injury or congenital abnormality → patent processus vaginalis (outpouched peritoneum through internal inguinal ring that closes after testicular descent

• transilluminate

  • water/clear shows hydrocele

  • likely varicocele, torsion, or cancer if not

management

• observation first 1-2 years of life

• surgical repair if persistent, need to exclude cancer or infection as cause

hematocele vs spermatocele

H: blood accumulated into tunica vaginalis - dark red/purple scrotum

S: cyst of sperm at end of epididymis, freely movable, transilluminate - only removed if large and painful

what is varicocele?

varicosity of pampiniform plexus (veins draining testes)

• LEFT more common than right

• VALVE incompetense

• usually idiopathic but can be associated with TRAUMA and TUMOR

BAG OF WORMS palpation

how is varicocele treated?

why is it important to treat?

surgical ligation

improve fertility rate, decreased ‘heavy’ sensation, spermatogenesis disrupted if temperature remains increased

what does the gonadal vein drain into

renal

what is testicular torsion?

presentation?

testes not adhered to tunica vaginalis → spermatic cord twisted → lose blood supply to testicle

• rapid cause of ischemia/necrosis - looks like inguinal hernia

asymmetry, LOST CREMASTER REFLEX

why is testicular torsion a urologic emergency

viability plummets after 6 hours from symptom onset → lose fertility

intravaginal vs extravaginal torsion

intra: tunica vaginalis normaly attached to posterolateral testicle → torsion if attachment is higher up

• sudden cremaster contraction, followed by LOSS OF CREMASTER

extra: exclusive to neonates (cryptorchidism) - testes not attached to tunica vaginalis

• usually diagnosed in first 7-10 days of life

presentation of epididymitis

common - gradual onset posterior testicular pain from inflamed epididymis

unilateral, pain radiates into lower abdomen

chronic if >6 weeks

PHYSICAL ELEVATION DECREASES PAIN

cause of epididymitis

STIs: GONORRHEA, CHLAMYDIA

• common in males 14-35

associated with e coli

what can an ultrasound tell you about blood flow in testes (differential dx)

lack of blood flow: likely torsion

good blood flow: epididymitis

infection associated with epididymitis backing up into testes can cause ___

infertility

how to treat epididymitis

cure cause of infection

NSAID and rest for pain

inform all sexual partners within 60 days of onset

• avoid intercourse until antibiotic therapy is completed and pt is asymptomatic

clinical presentation and diagnosis of testicular cancer

FAMILY HX

enlarged testicle

discomfort in testes, groin, and abdomen - treatment normally sought

ALPHA-FETOPROTEIN AND BETA-HCG

what is used to differentiate testicular cancer from orchitis or epidydimitis

testicular ultrasound

how to treat testicular cancer?

complications

orchiectomy

complications

• dr doms dad - gonadal artery not fully ligated → hemorrhage, bloody varices

• infertility from retrograde ejaculate

incidence of prostate cancer in the US

most common non skin cancer

THIRD in cancer related DEATHS - behind lung and colorectal

• normally ASYMPTOMATIC - symptoms onset once metasticized or advanced

what causes prostate cancer

risk factors: family hx, age, genetics, red meat diet, low fruits and veggies, smoking, obesity

adenocarcinoma: often on peripheral prostate → invade prostatic capsule, invade bladder or lungs

how to screen for prostate cancer

digital rectal exam (standard)

PSA (prostate specific antigen) testing

• positive: possible prostate cancer, benign prostatic hyperplasia, or prostatitis - not diagnostic

• PSA levels increase with age

  • MALES OVER 50 should get ANNUAL PSA and DRE for EARLY detection

how is prostate cancer confirmed?

describe staging.

biopsy

staging

• T1: discovered on histology

• T2: palpable on digital exam, confined to prostate

• T3: beeyond prostate, usually to seminal vesicles

• T4: beyond prostate and adjacent structures - bladder, rectum, pelvic wall

• Nodal

• Metastasis (1a to lymph nodes, 1b to bone, 1c to organs or distal sites)

how to treat prostate cancer

radical proastatectomy

• cannot produce seminal fluid/ejaculate

• most remain continent, most regain by 12 months

brachytherapy

• radioactive pellets into prostate, reduce cancer replication, need to stay away from children

orchiectomy

• extend survival

GnRH analogs

• block LH and FSH release, reduce T to improve survical

5 year survical rate for localized vs metastatic prostate cancer

local: 100%

metastasis: 32%

what is BPH

benign prostatic hyperplasia - enlarged, but not cancerous

describe growth of prostate throughout life

early puberty: double in size

25: continuous, IMPINGEMENT ON URETHRA

• dribbling, insufficient urination, urgency

• >75% males over 80

what causes BPH

DHT (dihydrotestosterine) produced and accumulated, major contributor to BPH

• 5 alpha reductase inhibitors prevent formation of DHT, limit growth of pristate

clinical presentation of BPH

polyuria ≥8x/day

symptoms start with use of DECONGESTANTS that orevent bladder neck from relaxing to allow urination

how to diagnose BPH?

treat?

digital rectal exam - hardebed areas may suggest cancer

5 alpha reductase inhibitors and alpha adrenergic blockers to improve urinary tract symptoms / transurethral removal if symptomatic

what is it called when an organ shrinks from decreased use?

involution - thyroid, ovaries

• ovaries start involution at menopause

each ovary is attached to posterior surface of broad ligament by ___.

___anchors ovary to uterus.

mesovarium

ovarian ligament

distal uterine tubes curve around ovary with ___

fimbrae

how does an ectopic pregnancy occur

only one fimbria attaches to ovary

loose attachment → pregnancy begins in pelvic cavity instead of in uterus

release of ovum at end of oogenesis at ___

ovulation

phases through oogenesis

primary follicles → granulosa cells → secondary follicle → oocyte and granulosa cells in vesicular ovarian follicle → ovulation

egg released → corpus luteu thickens and degenerates

repeat

simple reason behind why geriatric pregnancies are at higher risk

good eggs are used first, bad ones are left

describe anatomy of uterus

fundus: for strong contractions (oxytocin from neurohypophysis)

body: upper wide portion

cervix: lower narrow neck

muscles of the pelvic floor that converge upon uterus are called the ___

perineal body

common abnormal positioning of uterus

retroflexion (back tilting) → more susceptible to prolapse

prolapse: uterus drops inferiorly

list the 3 laters of the uterine wall

endometrium

myometrium

perimetrium

describe the endometrium

uterine glands to produce mucus - notable dense around cervix

3 layers

• compact layer: partially ciliated, simple columnar

• spongy layer: aka functional layer - loose fibrous connective tissue

• basal layer: dense, attaches endometrium to myometrium

MENSTRUATION → COMPACT and SPONGY layers of endometrium slough off

• endometrial

thickness varies from 0.5-5mm

describe myometrium

thick - longitudinal, transverse, and oblique layers

thickest at fundus

describe perimetrium

external layer of serous membrane - forms part of VISCERAL PERITONEUM

major divisions of uterine tubes

isthmus: medial third from upper outer angle of uterus

ampulla: intermediate dilater portion - winding path over ovary

infundibulum: funnel above and lateral to ovary

• fibrae to attach to ovary

what muscles unite at midline to form hammock shaped pelvic floro

levator ani

• damage → incontinence

less severe cases of prolapse with just urine leakage can be treated wirh ___

kegels

what does the pelvic floor hold superior to it

bladder → urethra

uterus → vagina

rectum → anus

spine

what are the different parts of the vulva

mons pubis: skin covered fat pad over pubic symphysis

labia majora: covered with pigmented skin, composed of fat and connective tissue with numerous sweat and sebaceous glands

labia minora: medial to majora

• vestibule between both minora

vaginal orifice: posterior to urinary meatus

greater vestibular glands: either side of vaginal orifice

• lesser: skene’s on either side of urethra

what do estrogen, progesterone, and oxytocin do in the breasts

estrogen:growth of ducts in mammary glands

progesterone: development of secreting cells

oxytocin: ejection of milk into ducts

what kind of feedback loop happens for lactation

positive feedback

what does prolactin do in the breasts

secrete lactation → colostrum released 3-4 days after delivery

between ___ and ___, the female reproductive system undergoes the cucle changes called the menstrual cycle

menarche, menopause

primary vs secondary amenrorrhea

1: never had

2: had, no longer does

menstrual cycle and hormonal control involves synthesis of estrogen in ___ tissue

adipose

evidence demonstrates that a female must have a minimum ___ and ___ for menarche to occur and to maintian cycle

bodyweight, fat content

in amenorrhea, ___ release and responsiveness to GnRH ___ to prepubertal levels

LH, reverts

___is associaed with oligomenorrhea and amenorrhea and infertility.

believed that ___ in turn leads to increased ___ androgen production.

also, ___ from adipose

obesity

hyperinsulemia, androgen

excess estrogen

describe the phases of the menstrual cycle

follicular: high estrogen, hypertrophy of uterine lining

ovulation: LH surge, ovum released from ovary

luteal: corpus luteam forms and secretes progesterone to maibtain uterine lining to prep for fertilization

menstruation: corpus luteam breaks fown and progesterone drops, endmetrial constriction and shedding

what is spinnbarkeit

ability of cervical mucus to stretch without breaking (stretched, mm measured before break)

• can exceed 10cm at ovulation

when do you want thick vs thin/pliable mucus

thick: pregnancy, nothing in or out of cervix - form a plug

• low spinnbarkeit (<1cm)

thin: support fertilization

• high risk in pregnancy

what is perimenopause

abnormal, irregular menstruation, night sweats, hot flashes, fatigue, weight gain

• decreased body hair, subcutaneous fat, breast tissue mass, ovarian/uterine size

~4 years before menopause

who is considered menopausal

FSH >20 mIU/mL

no menstruation for over a year

why is FSH level used to consider menopause

no functioning oocytes → anterior pituitary thinks body needs FSH → secrete more

what pH indicates estrogen deficiency?

how does this happen

>4.5

cervix and vagina more friable and pale → lose functional mucus

what pathology is menopause associated with?

how to treat this pathology?

osteoporosis (estrogen plays role in bone density)

closed chain axial loading

• weighted - wolf’s law, bone deposition

what kind of cancer is menopause associated with

type 2 ovarian

what complications come from urogenital atrophy in menopause

incontinence

vasomotor instability (decreased estrogen) → headache, hot flashes, palpitation, dizziness

hormone therapy for menopause associated with ___% reduction in coronary heart disease and postmenopausal mortality

50%

2 types of hormone therapy for menopause

CSEPT: continuous sequential estrogen-progestin therapy

• cyclic progesterone addition following hysterectomy

• study for risk - risk of breast cancer and CVD outweigh potential benefit

EPT: estrogen-progestogen therapy

• for females with intact uterus

• uterine shredding → inhibited endometrial development → prevent hyperplasia, minimize risk for endometrial cancer

significance/risk of estrogen therapy alone

unopposed estrogen → increased risk for breast and ovarian cancer

breast cancer cells present for 8-10 years before detection - estrogen may rapidly accelerate growth

current recommendations for hormone therapy for menopause

estrogen replacement should not be preventative

• critical window: 2 years after menopause to initiate hormone therapy to keep low risk

use for relief of postmenopausal symptoms

• LOW DOSE AND SHORT DURATION

consider alternative therapies if asymptomatic - avoid risks

alternatives to hormone therapy for menopause

soy and red clover → 15% reduction in breast cancer risk in Asian women

activity → 15% decrease in breast cancer at 60+ MET hours/week

what leads to cancer of external genitalia

HPV, STI, STD

what are bartholin gland cysts?

symptoms?

fluid filled sac from occluded duct system in bartholin gland

tenderness, pain, dyspareunia (pain with intercourse)