هذه المادة العلمية للمرور Round في أمراض الذكورة لطلاب الفرق السادسة يكلية طب الزقازيق، وفيها شئ من التوسع يصلح أن يكون مفيدا للأطباء عامة و لطلاب الماجستير في جراحة المسالك البولية وأمراض الذكورة.
ANDROLOGY
Male reproductive dysfunction
Andrology is the male equivalent of gynecology and deals with disorders of the male reproductive organs.
The following subjects are within the field of responsibility of Andrology
1. Male fertility and infertility
2. Erectile dysfunction and sexual disturbances (libido, ejaculation and orgasm)
3. Penile problems e.g. priapism, fracture and deviation
4. Testicular problems e.g. varicocele
5. Prostatic disorders
6. Male reproductive tract inflammation
7. Ageing male and hormone replacement therapy
8. Primary and secondary hypogonadism and delayed puberty
9. Male contraception
10. Cryopreservation of semen
Prevalence
· ≈10% of men over n age of 40 complaining of Erectile dysfunction & increasing with age.
· ≈7% of males complaining from male factor infertility.
· ≈ 50% of cases of infertility have male factor infertility.
Erectile dysfunction
(Formerly called impotence)
Physiology of erection
Nitric oxide is a vasodilator which is present in cavernous tissue is secreted due to impulses transmitted through parasympathetic pudendal nerve as a cause of sexual erotic stimuli.
Vasodilatation of cavernous tissue resulted in vigorous blood flow through sinusoids and subsequently its distension and closure of emissary veins which adds to the erection its rigidity
Ejaculation occurs also autonomically after stimulation of central ejaculatory center through the sympathetic hypogastric nerve which causes contraction of cavernous smooth muscle and detumesence.
Erectile dysfunction
Definition:
Inability to obtain or maintain sufficient erection to permit sexual intercourse
Causes
Psychogenic versus organic, ED is essentially a vascular disease
Psychogenic ED
Mechanism: supraspinal inhibition of the sacral erection or increased sympathetic activity
Primary (developmental factors)
Negative family attitude toward sex
Traumatic sexual experience e.g. assault
Gender identity disturbance
Secondary
Type 1: Cognitive factors; Unrealistic expectation, acceptance of cultural myths e.g. witchcraft
Type 1: Affective: anxiety; fears of performance, first night impotence, widower syndrome
Type 2: depression
Type3: interpersonal factors e.g. lack of communication or hostility towards the partner, lack of attraction in the female (arousal disorder)
Type 4: obsessive compulsive neurosis, paraphilia
Differentiation between psychogenic and organic ED
By Hx
Sudden onset or related to stressful event
Intermittent course
Presence of morning erection
Selective impotence: may still have satisfactory masturbation
Reduction of libido
Absence of organic disease
Work up (W\U)
1. Nocturnal penile tumescence testing (Rigiscan)
2. Duplex US of cavernosal arteries
Treatment of psychogenic ED (triple approach)
· Cognitive: sex education, problem explanation and marital therapy
· Behavioral: reassurance, changing sexual attitude, helping to attain successful sexual attempts relieves stress and will improve erection
· Medical: most of cases are in need for temporary assistance to achieve sufficient erection but some of them may fail to respond to medical aid and be candidate to surgical interference by insertion of penile prosthesis
Poor prognostic factors in psychogenic ED
· Long standing disturbance
· Severe marital problems
· Marked loss of libido
Organic ED
Vasculogenic (the most common organic cause)
Arteriogenic
Causes (decrease in penile blood flow leading to failure of filling of cavernous tissue)
Atherosclerosis which is predisposed by diabetes, hyperlipidemia, hypertension, cigarette smoking, and sedentary lifestyle.
Trauma: pelvic fracture may lead to injury to internal pudendal artery
Diagnosis: Doppler us revealed Peak systolic velocity below 25 cm\sec
Treatment
1. Traumatic: revascularization operation e.g. inferior epigastric artery anastomosis with deep dorsal vein
2. Atherosclerotic:
o vasoactive drugs, yohimbine: in early cases
o Oral phosphodiesterase inhibitors (PDE) sildenafil (Viagra), vardenavil (Livitra) or tadalafil (Cialis) causing unopposed action of the vasodilator neurotransmitter Nitric oxide in cavernous tissue, for mild and moderate cases
o Intracavernous injection (ICI) of vasodilator e.g. papaverine, prostaglandin E2 , phenoxybenzamine and atropine (Quadrimix solution) is used in moderate and severe cases.
o Implantation of penile prosthesis (PP) for severe cases, either semirigid or inflatable types.
Venogenic ED
o Mechanism: excessive venous outflow prevents achievement of full erection
o Causes & treatment
Type 1
Congenital; large veins exiting directly from corpora cavernosa causing primary ED in young men but fortunately is rare and usually associated with other congenital penile abnormalities e.g. hypospadias or curvature
Venoligation operation
Type 2
incompetence of venous occlusive mechanism due to weakening of tunica albuginea due to aging, post extensive penile fracture or due to diabetes:
Poor response to venoligation
PDE or ICI in mild cases
Penile prosthesis (PP) is the most satisfactory treatment
Type 3
Failure of smooth muscle relaxation to occlude venous sinuses as a result of prolonged ischemia caused by DM(endarteritis leads to replacement of cavernosal smooth muscle by fibrous tissue) or atherosclerosis
Type 4
Inadequate release of neurotransmitters due to DM, psychogenic, neurogenic or heavy smokers.
Treatment of the cause or even PDE, ICI or PP
Type 5
Iatrogenic creation of a shunt between glans and corpora for a last resort treatment for priapism.
Surgical correction of the shunt
1. Diagnosis of Venogenic ED
1. by Doppler us , end diastolic velocity more than 5 cm\sec
2. by cavernosography : evidence of pelvic veins filling of dye
3. by cavernosometry: detection of venous flow
Neurogenic ED
Causes
4. Peripheral nervous system
o Pelvic fracture
o Peripheral neuropathy e.g. due to DM or alcoholism
o Cauda equina lesions e.g. due to trauma or tumor
5. Central nervous system
· Spinal cord lesions: spinal cord injury; Multiple sclerosis
· Brain lesions: trauma, neoplasm or vascular lesions especially temporal lobe
Treatment:
1. PDE or ICI in small doses due to presence of hypersensitivity syndrome
2. PP : inflatable is preferred as absent sensation ( fear of erosion with semi rigid ones)
Endocrinological ED
causes
1. Low plasma testosterone
· Primary (hypogonadism) either as a pituitary deficient secretion of LH (hypogonadotroipc hypogonadism) or testicular failure of secretion e.g. in Kline filter syndrome (hypergonadotropic hypogonadism), manifested by hypoandrogenized gonads and absent secondary sexual characters
· Secondary: Orchictomy as a treatment for advanced prostate cancer or ADAAM syndrome (acquired deficiency of androgen in aged males).
2. Anti-androgenic effect of Hyperprolactinemia, hepatic failure, renal failure, DM, thalassemia or drugs e.g. spironolactone or cimetidine,
· Treatment: of the cause e.g. hyperprolactinemia and testosterone replacement
Structural ED (Failure of intromission of erect penis)
· Micropenis (congenital or as a manifestation of hypogonadism or as post priapism fibrosis).
· Chordee
Congenital with hypospadias (ventral) or epiapadias (dorsal) or without any other abnormality (usually to the left) treated surgically if angle is greater than 30
Acquired; Peyronie disease: idiopathic fibrotic plaques in tunica albuginea causing ipsilateral curvature and painful erection which is a benign disease but resistant to many forms of treatment and finally my need a PP implantation.
Iatrogenic Ed
· Drug induced
1. Old antihypertensives e. g. B blockers
2. Antipsychotic drugs
3. Antiandrogen drugs e.g. estrogen, cimetidine, spironolactone
4. Alcohol: it provokes desire but it takes away performance.
5. Hashish, cocaine and heroin and heave smoking
· Surgical
1. Transurethral resection of prostate: affects 10% only
2. Radical prostatectomy for localized prostate cancer.
Male Infertility
Epidemiology
· chance of normal couple conceiving à 25% / month, 75% by 6 moths and 90% by 1 year
· C 10% of couples are infertile
· ≈ 20% are male factor alone and 30% are combined male and female factors
Causes of male infertility
Pretesticular
Endocrine: Hypogonadotropic hypogonadism, Prolactin Excess, chronic medical disease
Testicular causes
Idiopathic infertility syndrome (most common cause), Klinefelter’s syndrome, bilateral anorchia, cryptorchidism, varicocele, gonadotoxins, chemotherapy, radiation, alcohol, cigarettes, caffeine, orchitis, immunologic.
Post testicular causes
duct obstruction or ejaculatory dysfunction.
Varicocele
· Abnormal dilatation of testicular veins (Pampiniform plexus of veins)
· Found in 20% of adult males
· Found in 30% of infertile males
· Clinically ( examined in standing position ):
· Subclinical: detected on Doppler US only
· Grade I: palpable on Valsalva maneuver
· Grade II: palpable
· Grade III: visible
· More common in left side for several anatomical and functional causes e.g. nutcracker phenomenon (left testicular vein is compressed between SMA and Aorta)
· If detected in right side only suspect thrombosis, IVC occlusion or situs inversus
· Mechanism of affection on spermatogenesis: most probably higher intrascrotal and intratesticular temperatures
· Varicocele causes decreased motility& decrease number of sperms and \ or stress pattern of morphology
· Repair by surgical ligation of veins improves semen parameters in ~ 70% of cases and conception rate is about 40%.
· Not all varicoceles are associated with infertility therefore most don’t require correction
· Indication for OR: clinically detected varicocele, associated with ABN semen analysis in couple with infertility ( woman has been evaluated)
Adolescent varicocele
· Surgical repair if Grade II- III and associated with ipsilateral testicular growth retardation
Idiopathic Infertility
~ 25% yield semen analysis that are abnormal, no etiology can be identified.
Unfortunately, few agents are effective for treatment, and assisted reproductive techniques (ART) may offer help to get children.
POST TESTICULAR CAUSES
Ductal obstruction
Accounts for 7 % of infertile male patients
· Congenital bilateral absence of vas deferens (CBAVD) – low volume azoospermia with active spermatogenesis on biopsy, associated with renal agenesis, treated by offer ART.
· Epididymal/vasal obstructionà microsurgical repair.
· Ejaculatory duct obstruction treated by transurethral resection of ejaculatory duct (TURED)
