20 Lower Urinary Tract and Male Reproductive Disorders

Common Ureteral Disorders

Congenital anomalies
1. Double ureters
o Due to a double or split ureteral bud
2. Congenital megaloureter
o May be associated with Hirschsprung's disease

Common Ureteral Disorders
Congenital anomalies
1. Double ureters
o Due to a double or split ureteral bud
2. Congenital megaloureter
o May be associated with Hirschsprung's disease
Congenital anomalies
1. Double ureters
o Due to a double or split ureteral bud
2. Congenital megaloureter
o May be associated with Hirschsprung's disease
Ureteritis cystica
1. Manifestation of chronic inflammation
2. Smooth cysts proect from the mucosa into the lumen.
o Similar findings may be present in the bladder.
!. May undergo glandular metaplasia and predispose to adenocarcinoma
Ureteral stones
Ureters are the most common site for stones to cause obstruction.
"etroperitoneal fibrosis
1. Causes
a. Maority are idiopathic.
b. #rgot deri$ati$es used in the treatment of migraines
c. %ssociation with other sclerosing periconditions
i. &rimary sclerosing pericholangitis
ii. Sclerosing mediastinitis' "idel's fibrosing thyroiditis
d. "etroperitoneal malignant lymphoma
2. Complications
a. Hydronephrosis is the most common complication.
b. May cause right scrotal $aricocele (see section )*
+loc,s the drainage of the right spermatic $ein into the $ena ca$a
Ureteral cancers
-ransitional cell carcinoma is the most common cancer.
Urinary Bladder Disorders
Congenital disorders
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1. #1strophy of the bladder
a. De$elopmental failure of the anterior abdominal wall and bladder
i. +ladder mucosa is e1posed to the body surface.
ii. 2ften associated with epispadias (see section 3)*
b. Complications
i. 3nflammation predisposes to glandular metaplasia.
ii. &redisposition for adenocarcinoma of the bladder
2. Urachal cyst remnants
a. Drainage of urine from the umbilicus in a newborn
b. &redispose to adenocarcinoma of the bladder
Most common cause of bladder adenocarcinoma
Congenital disorders
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1. #1strophy of the bladder
a. De$elopmental failure of the anterior abdominal wall and bladder
i. +ladder mucosa is e1posed to the body surface.
ii. 2ften associated with epispadias (see section 3)*
b. Complications
i. 3nflammation predisposes to glandular metaplasia.
ii. &redisposition for adenocarcinoma of the bladder
2. Urachal cyst remnants
a. Drainage of urine from the umbilicus in a newborn
b. &redispose to adenocarcinoma of the bladder
Most common cause of bladder adenocarcinoma
%cute and chronic cystitis
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1. "is, factors for lower urinary tract (4U-* infection
a. 5emale se1
i. Short urethra
ii. %scending infection
b. 3ndwelling urinary catheter
Most common cause of sepsis in hospitali6ed patients
b. Se1ual intercourse
7Honeymoon cystitis7 from trauma to the urethra
c. Diabetes mellitus
d. Cyclophosphamide
&roduces hemorrhagic cystitis
e. Schistosoma hematobium
22 Causes of acute cystitis
a. E. coli
i. Most common uropathogen (809/0: of cases*
ii. Most common cause of sepsis in a hospitali6ed patient
b. %deno$irus
Causes hemorrhagic cystitis
b. Staphylococcus saprophyticus
i. Causes acute cystitis in young se1ually acti$e women
%ccounts for 10: to 20: of 4U- infections
ii. Coagulase negati$e
c. %cute urethral syndrome in women
5emale counterpart to nonspecific urethritis (;SU* in men
i. Chlamydia trachomatis
Most common cause of acute urethral syndrome
3dentification of Chlamydia
&olymerase chain reaction (&C"* testing of $oided urine
ii. 2ther pathogens
Mycoplasma hominis, Ureaplasma urealyticum, Neisseria
gonorrhoeae
d. Clinical findings in 4U- infections
i. Dysuria (painful urination*
ii. 3ncreased fre<uency' urgency' nocturia
iii. Suprapubic discomfort
i$. =ross hematuria
e. 4aboratory findings in 4U- infections
i. &yuria at or abo$e 10 white blood cells (>+Cs* per high9power field (H&5*
in a centrifuged specimen
More than 2 >+Cs?H&5 in an uncentrifuged specimen
ii. +acteriuria' hematuria
iii. &ositi$e dipstic, for leu,ocyte esterase and nitrite
i$. %t or abo$e 10
@
colony9forming units (C5Us*?m4
=old standard criterion of infection
f. %symptomatic bacteriuria in women
i. -wo successi$e cultures with 10
@
or more C5Us?m4 in an asymptomatic
patient
ii. Causes
&regnancy
%cute pyelonephritis may occur in 1: to 2: of cases.
#lderly women in nursing homes
Diabetes mellitus
2. Sterile pyuria
g. ;eutrophils in the urine and negati$e standard culture after 2. hours
&ositi$e leu,ocyte esterase' negati$e nitrite
c. Causes
i. Chlamydia trachomatis
ii. "enal tuberculosis
iii. %cute tubulointerstitial nephritis
!. Malacopla,ia
h. %ssociated with a chronic E. coli infection of the bladder
i. Microscopic findings
i. Aellow' raised mucosal pla<ues
ii. 5oamy macrophages filled with laminated minerali6ed concretions
Called Michaelis9=utmann bodies
Defecti$e phagosomes that cannot degrade bacterial products
Miscellaneous disorders
1. %c<uired di$erticula
a. Most are due to benign prostatic hyperplasia (+&H*
b. Causes obstruction of urine outflow and increased intra$esical pressure
c. Di$erticulitis and stone formation are common complications
2. Cystocele
a. Common in middle9aged to elderly women
b. Mechanism
i. "ela1ation of pel$ic support causes descent of the uterus
ii. +ladder wall protrudes into the $agina
Creates a pouch that collects residual urine
!. Cystitis cystica and glandularis
a. +ladder rendition of ureteritis cystica
b. 3ncreased ris, for de$eloping bladder adenocarcinoma
+ladder tumors
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1. +ladder papilloma
o )ery uncommon benign tumor
2. -ransitional cell carcinoma (-CC*
a. Most common bladder cancer (B/@: of cases*
b. Male dominant
c. Multifocality and recurrence are the rule.
i. Common malignant stem cell abnormality
ii. "eimplantation of the tumor from another site
d. Causes
i. Smo,ing cigarettes
ii. %niline dyes
iii. Cyclophosphamide
i$. Schistosoma hematobium
C0: produce s<uamous cell carcinoma' !0: -CC
e. =ross and microscopic findings
i. 4ow9grade cancers
Usually papillary and are not usually in$asi$e
ii. High9grade cancers
&apillary or flat and are usually in$asi$e
iii. Most common sites
4ateral or posterior walls at the base of the bladder
i$. Significance of blood group antigens (%' +' or H*
+etter prognosis if the tumor has the antigens
f. Clinical findings
i. &ainless gross?microscopic hematuria
Most common sign (C09/0: of cases*
ii. Dysuria' increased fre<uency of urination
2. S<uamous cell carcinoma of the bladder
a. #pidemiology
i. %ssociation with Schistosoma hematobium
#ggs are located in the urinary bladder $enous ple1us.
ii. Common cancer in #gypt
iii. C0: of cancers are s<uamous cell carcinoma' !0: are -CC
b. &athogenesis of s<uamous cell carcinoma
i. #ggs are surrounded by eosinophils.
ii. 3g# antibodies are attached to the eggs.
iii. #osinophils ha$e 5c receptors for 3g#.
i$. #osinophils attach to receptors and release maor basic protein' which
destroys the egg.
-ype 33 hypersensiti$ity reaction
$. Chronic bladder irritation?infection produces s<uamous metaplasia
Metaplasia can progress to dysplasia and s<uamous cell
carcinoma.
!. %denocarcinoma of the bladderD causesE
a. Urachal remnants (most common cause*
b. Cystitis glandularis
c. #1strophy of the bladder
.. #mbryonal rhabdomyosarcoma (sarcoma botryoides*
a. Most common sarcoma in children
b. Most common site for boys is urinary system.
&resents as grape9li,e masses protruding from the urethral orifice
22 Most common site in girls is the $agina.
2. Cancers in$ading the bladder
22 3n$asi$e cer$ical cancer and prostate cancer
22 &roduce obstruction of the urethra and the ureters
22 &roduces hydronephrosis' postrenal a6otemia' and death by renal failure
Urethral Disorders
3nfections
1. Chlamydial and gonococcal infections in men and women
o Most common site for these se1ually transmitted diseases
2. ;on$enereal diseases causing urethritis
a. Most commonly due to E. coli
b. Complications
i. Cystitis in women
ii. &rostatitis in men
2. Chlamydial urethritis is a common component of "eiter's syndrome in men.
a. Urethritis
b. Sterile conuncti$itis
c. H4%9+2C9associated arthritis
3nfections
1. Chlamydial and gonococcal infections in men and women
o Most common site for these se1ually transmitted diseases
2. ;on$enereal diseases causing urethritis
a. Most commonly due to E. coli
b. Complications
i. Cystitis in women
ii. &rostatitis in men
2. Chlamydial urethritis is a common component of "eiter's syndrome in men.
a. Urethritis
b. Sterile conuncti$itis
c. H4%9+2C9associated arthritis
Urethral caruncle
1. 5emale dominant disease
2. 5riable' red painful mass is present at the urethral orifice.
!. Chronically inflamed granulation tissue causes bleeding.
S<uamous cell carcinoma
Most common cancer of the urethra
Penis Disorders
Malformations of the urethral groo$e
1. -ypes of malformations
a. Hypospadias
Most common malformation
b. #pispadias
2. &athogenesis
a. Hypospadias
22 %bnormal opening on the $entral surface of the penis
222 Due to faulty closure of the urethral folds
b. #pispadias
22 %bnormal opening on the dorsal surface of the penis
222 Due to a defect in the genital tubercle
Malformations of the urethral groo$e
1. -ypes of malformations
a. Hypospadias
Most common malformation
b. #pispadias
2. &athogenesis
a. Hypospadias
22 %bnormal opening on the $entral surface of the penis
222 Due to faulty closure of the urethral folds
b. #pispadias
22 %bnormal opening on the dorsal surface of the penis
222 Due to a defect in the genital tubercle
&himosis
1. 2rifice of the prepuce is too small to retract o$er the head of the penis
2. Commonly associated with infections
+alanoposthitis
1. 3nfection of the glans and prepuce
a. Usually occurs in uncircumcised males with poor hygiene
b. %ccumulation of smegma leads to infection.
Candida, pyogenic bacteria' and anaerobes
2. 3nflammatory scarring may produce an ac<uired phimosis.
Miscellaneous disorders
1. &eyronie's disease
a. -ype of fibromatosis
b. &ainful contractures of the penis
Causes lateral cur$ature of the penis
c. May cause infertility
2. &riapism
a. &ersistent and painful erection
b. Causes include sic,le cell disease' penile trauma
Carcinoma in situ (C3S*
1. +owen's disease
a. 4eu,opla,ia in$ol$ing the shaft of the penis and scrotum
i. &atients usually o$er !@ years old
ii. %ssociation with human papilloma$irus (H&)* type 1F
b. &recursor for in$asi$e s<uamous cell carcinoma (10: of cases*
c. %ssociation with other types of $isceral cancer
2. #rythroplasia of Gueyrat
a. #rythropla,ia located on the mucosal surface of the glans and prepuce
b. H&) type 1F association
c. &recursor for in$asi$e s<uamous cell carcinoma
!. +owenoid papulosis
a. Multiple pigmented reddish brown papules on the e1ternal genitalia
b. %ssociation with H&) type 1F
c. Does not de$elop into in$asi$e s<uamous cell carcinoma
2nly C3S with no predisposition for in$asion
S<uamous cell carcinoma
1. Most common cancer of the penis
a. Usually affects men .0 to C0 years old
b. Most common sites
=lans or mucosal surface of prepuce
2. H&) type 1F' 18 association in two thirds of cases
o Smo,ing may act as a cocarcinogen with H&).
2. "is, factors
a. 4ac, of circumcision
=reatest ris, factor
b. +owen's disease' erythroplasia of Gueyrat
!. Metastasi6es to inguinal and iliac nodes
Testis, crotal ac, !pididymis Disorders
Cryptorchidism
1. ;ormal descent of testes
a. -ransabdominal phase
i. -estes descend to lower abdomen or pel$ic brim
ii. MHllerian inhibitory factor is responsible for this phase
b. 3nguinoscrotal phase
i. Descent through the inguinal canal into the scrotum
ii. %ndrogen9dependent
2. Cryptorchidism
a. Complete or incomplete descent of the testis into the scrotal sac
b. 4ocations
i. 3nguinal canal most common site
&alpable mass
Maority are unilateral
ii. 3ntra9abdominal (@910: of cases*
c. Complications if uncorrected
i. &otential for infertility
%rrest in germ cell maturation
-esticular atrophy
Similar changes occur in the normally descended contralateral
testis.
ii. 3ncreased ris, for de$eloping a seminoma
5i$e9 to tenfold increased ris, for cancer in cryptorchid testis
"is, also applies to the normally descended testicle
Cryptorchidism
1. ;ormal descent of testes
a. -ransabdominal phase
i. -estes descend to lower abdomen or pel$ic brim
ii. MHllerian inhibitory factor is responsible for this phase
b. 3nguinoscrotal phase
i. Descent through the inguinal canal into the scrotum
ii. %ndrogen9dependent
2. Cryptorchidism
a. Complete or incomplete descent of the testis into the scrotal sac
b. 4ocations
i. 3nguinal canal most common site
&alpable mass
Maority are unilateral
ii. 3ntra9abdominal (@910: of cases*
c. Complications if uncorrected
i. &otential for infertility
%rrest in germ cell maturation
-esticular atrophy
Similar changes occur in the normally descended contralateral
testis.
ii. 3ncreased ris, for de$eloping a seminoma
5i$e9 to tenfold increased ris, for cancer in cryptorchid testis
"is, also applies to the normally descended testicle
2rchitis
1. Mumps
a. 3nfertility is uncommon.
b. Most cases are unilateral.
c. 2rchitis is more li,ely in an older child or adult.
2. Congenital or ac<uired syphilis
!. Human immunodeficiency $irus
.. #1tension of acute epididymitis
#pididymitis
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1. Causes
a. &athogens in patients youngers than !@ years old
i. Neisseria gonorrhoeae
ii. Chlamydia trachomatis
b. &athogens in patients o$er !@ years of age
i. E. coli
ii. Pseudomonas aeruginosa
c. -uberculosis
i. +egins in the epididymis
Spreads to the seminal $esicles' prostate' and testicles
ii. Caseating granulomatous inflammation
2. Signs and symptoms of acute epididymitis
a. Scrotal pain with radiation into spermatic cord or flan,
b. Scrotal swelling' epididymal tenderness
c. Urethral discharge
3f it is se1ually transmitted
b. &rehn's sign
#le$ation of the scrotum decreases pain.
)aricocele
1. Most common cause of left9sided scrotal enlargement in an adult
a. 7+ag of worms7 appearance
b. 4eft spermatic $ein drains into the left renal $ein
i. 3ncreased resistance to blood flow
ii. +loc,age of left renal $ein can also produce a $aricocele.
#1ample9renal cell carcinoma in$ading renal $ein
c. "ight spermatic $ein drains into the $ena ca$a
i. +loc,age of right spermatic $ein produces right9sided $aricocele.
ii. #1ample9retroperitoneal fibrosis
2. )ery common cause of infertility
o Heat decreases spermatogenesis.
-orsion of the testicle
1. &redisposing factors
a. )iolent mo$ement or physical trauma
Most common causes
b. Cryptorchid testis
c. %trophy of testis
2. -wisting of the spermatic cord cuts off the $enous?arterial blood supply
o Danger for hemorrhagic infarction of the testicle
2. Clinical findings
a. Sudden onset of testicular pain
b. %bsent cremasteric refle1
Stro,ing the inner thigh with a tongue blade normally causes the scrotum to
retract.
c. -esticle is drawn up into the inguinal canal.
!. Surgery is imperati$e.
Hydrocele
1. Most common cause of scrotal enlargement
o Due to a persistent tunica $aginalis
2. Diagnosis
o Ultrasound distinguishes fluid $ersus a testicular mass causing scrotal enlargement.
!. 2ther fluid accumulations
a. Hematocele contains blood.
b. Spermatocele contains sperm.
-esticular tumors
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1. #pidemiology
a. Most common malignancy between ages 1@ and !@
b. 2ccurs more often in whites than blac, %mericans
2. -ypes of testicular tumors
a. Malignant testicular tumors are most often germ cell in origin (/@: of cases*.
b. +enign testicular tumors are usually se19cord stromal tumors (@: of cases*.
c. Classification of germ cell tumors
i. .0: are of one cell type
Seminoma is the most common type.
ii. F0: are mi1tures of two or more patterns
Most common mi1ture is embryonal carcinoma' teratoma'
choriocarcinoma' yol, sac tumor.
iii. +est classified as seminomas or nonseminomatous
!. "is, factors
a. Cryptorchid testicle
i. 2$erall most common ris, factor
ii. =reatest ris, is an intra9abdominal cryptorchid testis.
b. -esticular femini6ation
c. Ilinefelter's syndrome (JJA*
.. Clinical finding
o Unilateral' painless enlargement of the testis
2. -umor mar,ers
a. K95etoprotein (%5&*
Aol, sac (endodermal sinus* tumor origin
22 Human chorionic gonadotropin
Choriocarcinoma
22 4actate dehydrogenase
i. ;onspecific cancer en6yme
ii. Degree of ele$ation correlates with tumor mass
@. Summary of testicular tumors
Ta"le 20#$% Testicular Tumors
Tumor
&'e
()ears* Morpholo'ic+Clinical ,indin's
Tumor
Mar-er(s* Pro'nosis
Seminoma !09!@D BF@ Most common germ cell tumor
=ray tumor without hemorrhage or
necrosisD composed of large cells with
centrally located nucleus containing
prominent nucleoliD lymphocytic
infiltrate.
MetastasisE lymphatic (para9aortic
lymph nodes* before hematogenous
(lungs*
Spermatocytic $ariant occurs in older
indi$iduals and rarely metastasi6es
hC= increased
in 10: of
cases
#1cellent
#1tremely
radiosensiti$e
#mbryonal 2092@ +ul,y tumor with hemorrhage and %5& and hC= 3ntermediate
carcinoma necrosisD other tumor types often
present
MetastasisE hematogenous before
lymphatic spread
increased in
/0: of cases
4ess radiosensiti$e
than seminomas
Aol, sac
(endodermal
sinus* tumor
Most
common
testicular
tumor in
children L.
Characteristic Schiller9Du$al bodies
resemble primiti$e glomeruli
%5& increased
in all cases
=ood
Choriocarcinoma 209!0 Most commonly mi1ed with other tumor
types
Contains trophoblastic tissue
(syncytiotrophoblast and
cytotrophoblast*
May produce gynecomastia (hC= is an
4H analogue*
hC= increased
in all cases
&oor
Most aggressi$e
tumorD hematogenous
spread to lungs
-eratoma %ffects
males of all
ages
Contains deri$ati$es from ectoderm'
endoderm' mesoderm
Mi1ed with embryonal carcinoma
(teratocarcinoma*
%5& and?or
hC= increased
in @0: of
cases
=ood
Usually benign in
children and malignant
in adults (usually
s<uamous cell
carcinoma*
Malignant
lymphoma
Most
common
testicular
cancer in
men BF0
Secondary in$ol$ement of both testes
by diffuse large cell lymphoma
;one &oor
%5&' K9fetoproteinD hC=' human chorionic gonadotropinD 4H' luteini6ing hormone.
Prostate Disorders
Clinical anatomy
1. Dihydrotestosterone (DH-* is responsible for de$eloping the prostate.
2. Mones of the prostate
a. &eripheral 6one
i. &alpated during a digital rectal e1amination (D"#*
ii. &rimary site for prostate cancer
b. -ransitional 6one
&rimary site for the glandular component of +&H
b. &eriurethral 6one
&rimary site for the fibromuscular (stromal* component of +&H
Clinical anatomy
1. Dihydrotestosterone (DH-* is responsible for de$eloping the prostate.
2. Mones of the prostate
a. &eripheral 6one
i. &alpated during a digital rectal e1amination (D"#*
ii. &rimary site for prostate cancer
b. -ransitional 6one
&rimary site for the glandular component of +&H
b. &eriurethral 6one
&rimary site for the fibromuscular (stromal* component of +&H
%cute?chronic prostatitis
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1. Causes
a. %cute prostatitis
i. 3ntraprostate reflu1 of urine from the posterior urethra or urinary bladder
ii. &athogens
E. coli, P. aeruginosa, K. pneumoniae
b. Chronic prostatitis
i. Maority are abacterial
ii. Chronic bacterial infection
Due to recurrent acute prostatitis
2. Clinical findings
a. 5e$er occurs in acute prostatitis.
b. 4ower bac,' perineal' or suprapubic pain
c. &ainful?swollen gland on rectal e1amination
d. Dysuria' hematuria
!. 5ractionated urine culture and e1amination for >+Cs
a. Specimen collections
i. 5irst 10 m4 is the urethral component.
ii. Second midstream sample is the bladder component.
iii. -hird specimen at the end of micturition is the prostate component.
i$. 5ourth specimen is secretions mil,ed out after prostate massage.
b. Diagnosis of prostatitis
i. More than 20 >+Cs?H&5 in the third and fourth sample suggests acute
prostatitis.
ii. 3ncreased bacterial count in third and fourth specimens is confirmatory.
+enign prostatic hyperplasia (+&H*
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1. #pidemiology
a. %ge9dependent change
%ll men de$elop +&H as they age.
b. More common in blac, %mericans than whites
c. De$elops in the transitional and periurethral 6ones
d. D"# has a sensiti$ity of @0: in detecting +&H.
2. &athogenesis
a. DH- is the primary mediator.
Causes hyperplasia of glandular and stromal cells
b. Stromal cells are the site of DH- synthesis.
c. #strogen is a co9mediator.
3ncreases the synthesis of androgen receptors
!. =ross and microscopic findings
a. Hyperplasia of glandular cells and stromal cells
22 4eads to nodule formation
222 ;odules are yellow9pin, and are soft.
b. =landular hyperplasia de$elops nodules in the transitional 6one.
c. Stromal hyperplasia de$elops nodules in the periurethral 6one.
Most responsible for obstruction of the urethra
22 Clinical and laboratory findings
a. Signs of obstruction
22 -rouble initiating and stopping the urinary stream
222 Dribbling' incomplete emptying
2222 ;octuria' dysuria
b. Hematuria
c. &rostate9specific antigen (&S%*
22 &roteolytic en6yme
3ncreases sperm motility
Maintains seminal secretions in the li<uid state
222 &S% is neither sensiti$e nor specific for +&H.
2222 Usually normal (09. ng?m4* or between . and 10 ng?m4
"arely o$er 10 ng?m4
d. Complications
22 2bstructi$e uropathy
Most common complication
&ostrenal a6otemia
&otential for progressing to acute renal failure if left
untreated
+ilateral hydronephrosis
+ladder di$erticula from increased pressure
+ladder wall smooth muscle hypertrophy
222 +ladder infections due to residual urine
2222 &rostatic infarcts
&ain on D"#
#nlarged' indurated gland
3ncreased &S% $alues due to infarction
2v2 No ris, for progression into carcinoma
&rostate cancer
1. #pidemiology
a. Most common cancer in adult males
Second most common cause of death due to cancer in adult males
b. Uni$ersal in all men if they li$e long enough
c. More common in blac, %mericans than whites
"are in %sians
d. Usually asymptomatic until ad$anced
e. "is, factors
22 %d$ancing age
Most important ris, factor
222 5irst9degree relati$es (father and brothers*
2222 +lac, %mericans
2v2 Smo,ing cigarettes' high saturated fat diet
2. &athogenesis
o DH-9dependent
2. =ross and microscopic findings
a. De$elops in the peripheral 6one
22 &alpable by D"#
222 2bstructi$e uropathy is not an early finding.
b. &rostate intraepithelial neoplasia (&3;*
22 5oci of atypia?dysplasia
222 May be a precursor lesion for prostate cancer
c. 3n$asi$e cancer has a firm' gritty yellow appearance
d. Hallmar,s of malignancy
22 3n$asion of the capsule around the prostate
222 +lood $essel?lymphatic in$asion
2222 &erineural in$asion
2v2 #1tension into the seminal $esicles or base of the bladder
2. Clinical findings in symptomatic prostate cancer
a. 2bstructi$e uropathy implies e1tension into the bladder base
b. 4ow bac,?pel$ic pain
22 &ortends bony metastases to $ertebra and pel$ic bones
Due to spread $ia the +atson $enous ple1us
222 %l,aline phosphatase is increased.
Due to osteoblastic metastases
c. Compression of the spinal cord
2. Diagnosis of prostate cancer
a. Screening
22 D"#?&S% annually beginning at @0 years of age
222 &S% is sensiti$e but not specific for cancer.
+&H and prostatic infarcts can increase &S%D hence' lowering its
specificity by increasing false positi$es.
2222 &S% o$er 10 ng?m4 is highly predicti$e of cancer.
C0: positi$e predicti$e $alue
2v2 &S% between . and 10 ng?m4 is a gray 6one.
2$erlap between early cancer and +&H
v2 2ther more sensiti$e methods of reporting &S%
"ate of change of &S% $alues with time (&S% $elocity*
"atio between serum &S% and $olume of the prostate gland
(prostate density*
Measurement of free $ersus bound forms of circulating &S%
b. Confirmatory test
22 ;eedle biopsies of suspicious sites if screening tests are abnormal
2. Spread of prostate cancer
a. &erineural in$asion
b. 4ymphatic spread to regional lymph nodes
c. Hematogenous spread
22 +one is the most common e1tranodal site
3n descending order9lumbar spine' pro1imal femur' and pel$is
222 4ungs and li$er
2. &rognosis
a. >ith treatment' o$er /0: li$e for more than 1@ years.
Male .ypo'onadism
;ormal male reproducti$e physiology
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1. 5ollicle9stimulating hormone (5SH*
a. Stimulates spermatogenesis in the seminiferous tubules
b. ;egati$e feedbac, relationship with inhibin
i. 3nhibin is synthesi6ed in Sertoli cells in seminiferous tubules.
ii. Decreased inhibin causes an increase in 5SH.
2. 4uteini6ing hormone (4H*
a. -estosterone synthesis occurs in the 4eydig cells.
b. -estosterone has a negati$e feedbac, with 4H.
Decreased testosterone causes an increase in 4H.
22 &rolactin
a. &rolactin enhances testosterone synthesis and spermatogenesis.
b. 3ncreased prolactin inhibits gonadotropin9releasing hormone (=n"H*
Decreases 4H and 5SH
22 -estosterone
a. Maintains male secondary se1 characteristics
b. #nhances spermatogenesis in the seminiferous tubules
c. 3ncreases libido (se1ual desire*
d. Decreased testosterone causes male hypogonadism and infertility.
22 Se1 hormone9binding globulin (SH+= or androgen9binding globulin*
a. +inding protein for testosterone and estrogen
i. 3n both men and women' SH+= is mainly synthesi6ed in the li$er.
ii. 3n men' the Sertoli cells also synthesi6es SH+=.
iii. #strogen increases synthesis of SH+= in the li$er.
i$. %ndrogens' insulin' obesity' and hypothyroidism all cause decreased
synthesis of SH+=.
b. SH+= has a higher binding affinity for testosterone than estrogen.
7#strogen amplifier7
i. 3ncreased SH+= decreases free testosterone le$els.
ii. Decreased SH+= increases free testosterone le$els.
&athogenesis of male hypogonadism
1. Decreased production of testosterone
o #1amples9hypopituitarism' 4eydig cell dysfunction
2. "esistance to testosterone
o #1ample9androgen receptor deficiency in testicular femini6ation
Clinical presentations
-estosterone' per se' does not ha$e any role in producing an erection
(parasympathetic response* or eaculation (sympathetic response*. Howe$er'
decreased testosterone decreases libido' which decreases psychic desire.
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1. 3mpotence
a. Most common manifestation
b. 5ailure to sustain an erection during attempted intercourse or during intercourse
2. 4oss of male secondary se1 characteristics
a. #strogen acti$ity is unopposed.
b. 5indings include female hair distribution' gynecomastia
!. 2steoporosis
o -estosterone normally inhibits osteoclastic acti$ity and increases osteoblastic
acti$ity.
2. 3nfertility
o Decreased spermatogenesis
Classification of male hypogonadism
1. &rimary hypogonadism
o Due to 4eydig cell dysfunction
a. 4uteini6ing hormone (4H* is increased.
4oss of negati$e feedbac, imposed by testosterone
b. Hypergonadotropic (increased 4H* hypogonadism
2. Secondary hypogonadism
o Due to hypothalamic?pituitary dysfunction
a. Decreased 4H
b. Hypogonadotropic (decreased 4H* hypogonadism
&rimary hypogonadismE 4eydig cell dysfunction
1. Causes
a. Chronic alcoholic li$er disease
3nhibits binding of 4H to 4eydig cells (N mechanism*
b. Chronic renal failure
-o1ins ha$e a direct to1ic effect on 4eydig cell
c. 3rradiation' orchitis' trauma
2. 4aboratory findings in 4eydig cell dysfunction
a. Decreased testosterone
Due to destruction of 4eydig cells
b. 3ncreased 4H
Due to decreased testosterone
c. Decreased sperm count
Due to testosterone deficiency
d. ;ormal 5SH
3nhibin is present in Sertoli cells.
&rimary hypogonadismE 4eydig cell and seminiferous tubule dysfunction
1. Causes
o Same causes as 4eydig cell dysfunction
2. 4aboratory findings
a. Decreased testosterone
Due to destruction of 4eydig cells
b. 3ncreased 4H
Due to decreased testosterone
c. Decreased sperm count
Due to testosterone deficiency and seminiferous tubule dysfunction
d. 3ncreased 5SH
Due to decrease in inhibin
Causes of secondary hypogonadism
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1. Constitutional delay in puberty
o % testicular $olume greater than . m4 indicates puberty has begun.
2. Iallmann's syndrome
a. %utosomal dominant disorder
b. Malde$elopment of the olfactory bulbs and =n"H9producing cells
c. Clinical findings
i. Delayed puberty
ii. %nosmia' color blindness
d. 4aboratory findings
Decreased 5SH' 4H' testosterone' and sperm count
2. Hypopituitarism
22 Causes
i. Craniopharyngioma in children
ii. ;onfunctioning pituitary adenoma in adults
b. 4aboratory findings
Decreased 5SH' 4H' testosterone' and sperm count
Summary of causes of male hypogonadism
Ta"le 20#2% ummary o/ Causes o/ Male .ypo'onadism
Dys/unction Testosterone perm Count L. ,.
Primary
4eydig dysfunction ;
4eydig cell and seminiferous tubule dysfunction
econdary
Hypopituitarism
5SH' follicle9stimulating hormoneD 4H' luteini6ing hormoneD ;' normal.
Male 0n/ertility
#pidemiology and pathogenesis
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1. Decreased sperm count
a. &rimary testicular dysfunction
i. 4eydig cell dysfunction
ii. Seminiferous tubule dysfunction
Causes
)aricocele (see section )*' Ilinefelter's syndrome
orchitis
;ormal testosterone and 4H
4eydig cells are intact
Decreased sperm count
4oss of seminiferous tubules and decreased testosterone
3ncreased 5SH
3nhibin is decreased
b. Secondary hypogonadism
&ituitary and hypothalamic dysfunction
22 #nd9organ dysfunction
a. Causes
i. 2bstruction of $as deferens
ii. Disorders in$ol$ing accessory se1 organs or eaculation
b. ;ormal testosterone' 5SH' 4H' prolactin
c. Sperm count $ariable
4aboratory tests for male infertility
1. Semen analysis
a. =old standard test for infertility
b. Components of semen
i. Spermato6oa deri$e from the seminiferous tubules.
ii. Coagulant deri$es from the seminal $esicles
iii. #n6ymes to li<uefy semen deri$e from the prostate gland.
c. Components e$aluated in a standard semen analysis
i. )olume
)olume does not correlate with the number of sperm.
ii. Sperm count
;ormal is 20 to 1@0 million sperm?m4.
iii. Sperm morphology
Morphology is $ery abnormal in reconnections of a $asectomy.
i$. Sperm motility
2. Serum gonadotropins' testosterone' prolactin
Male 0mpotence
5ailure to sustain an erection during attempted intercourse or during intercourse
Causes of impotence
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1. &sychogenic
a. Most common cause of impotence in young men
b. Stress at wor,' marital conflicts' performance an1iety
c. ;octurnal penile tumescence (;&-*
i. %$erage male has @ erections while sleeping at night.
ii. ;&- is preser$ed in impotence that is due to psychogenic causes.
iii. %ll other causes of impotence ha$e a loss of ;&-.
2. Decreased testosterone
o Decreased libido
2. )ascular insufficiency
a. Most common cause of impotence in men o$er @0 years old
b. #1ample94eriche syndrome
i. 3mpotence due to $ascular insufficiency
ii. %ortoiliac atherosclerosis in$ol$ing hypogastric arteries
iii. Calf claudication with atrophy
i$. Diminished femoral pulse
!. ;eurologic disease
c. &arasympathetic system (S29S.* is necessary for erection.
d. Sympathetic system (-12941* is necessary for eaculation.
e. ;eurogenic causes of impotence
i. Multiple sclerosis
ii. %utonomic neuropathy due to diabetes mellitus
iii. "adical prostatectomy
.. Drug effectsD e1amplesE
f. 4euprolide (=n"H agonist*
g. Methyldopa' psychotropics
@. #ndocrine disease
h. Diabetes mellitus
%utonomic neuropathy O $ascular insufficiency
22 &rimary hypothyroidism
3ncreased prolactin inhibits =n"H release
22 &rolactinoma
2. &enis disorders
22 &eyronie's disease (fibromatosis*
22 &riapism
Drugs used in erectile dysfunction
1. Sildenafil ()iagra*
a. Most common drug used for the treatment of erectile dysfunction
b. Mechanism
i. 3nhibits the brea,down of cyclic guanosine monophosphate (c=M&* by type
@ phosphodiesterase
ii. 3ncreases le$els of c=M& causes $asodilation in the corpus ca$ernosum
and the penis.
2. Aohimbe
o Herb that produces $asodilatation of $essels