MALE REPRODUCTIVE DISORDERS

                           Penis Diseases                  

A. Malformations of the urethral groove of the penis

1. Hypospadias
a. Abnormal opening on the ventral surface of the penis 
b. Most common malformation of urethral groove
c. Risk factors
(1) Father or previous male sibling with defect
(2) Monozygotic twins
• Insufficient production of human chorionic gonadotropin by single placenta
d. Frequently associated with ventral curvature of penis
• Called chordee
e. Pathogenesis
(1) Due to faulty closure of the urethral folds
(2) Possibly related to abnormal androgen production

2. Epispadias
a. Abnormal opening on the dorsal surface of the penis
b. Due to a defect in the genital tubercle

B. Phimosis of the penis
1. Orifice of the prepuce is too small to retract over the head of the penis
2. Commonly associated with infections

C. Balanoposthitis of the penis

1. Infection of the glans and prepuce
a. It usually occurs in uncircumcised males with poor hygiene.
b. Accumulation of smegma leads to infection.
• Candida, pyogenic bacteria, and anaerobes

2. Inflammatory scarring may produce an acquired phimosis.

D. Miscellaneous disorders of the penis

1. Peyronie disease
a. Type of fibromatosis 
b. Painful contractures of the penis
• Causes lateral curvature of the penis
c. May cause infertility

2. Priapism
a. Persistent and painful erection
b. Causes include sickle cell disease, penile trauma

E. Carcinoma in situ (CIS) of the penis

1. Bowen disease
a. Leukoplakia involving the shaft of the penis and scrotum
(1) Patients are usually >35 years old
(2) Association with human papillomavirus (HPV) type 16
b. Precursor for invasive SCC (~10% of cases)
c. Association with other types of visceral cancer

2. Erythroplasia of Queyrat
a. Erythroplakia located on the mucosal surface of the glans and prepuce
b. HPV type 16 association
c. Precursor for invasive SCC

3. Bowenoid papulosis
a. Multiple pigmented reddish brown papules on the external genitalia
b. Association with HPV type 16
c. Does not develop into invasive SCC
• Only CIS with no predisposition for invasion

F. SCC of the penis

1. Epidemiology
a. Circumcision protects against developing SCC of penis.
b. SCC is the most common cancer of the penis.
(1) Usually affects men 40 to 70 years old
(2) Most common sites
• Glans or mucosal surface of prepuce
c. Two-thirds of cases associated with HPV types 16 and 18
• Products from smoking tobacco may act as cocarcinogens with HPV.
d. Risk factors
(1) Lack of circumcision
• Greatest risk factor
(2) Bowen disease, erythroplasia of Queyrat

2. Metastasizes to inguinal and iliac nodes


  Testis, Scrotal Sac, and Epididymis Diseases

A. Cryptorchidism of the testes

1. Normal descent of testes
a. Transabdominal phase
(1) Testes descend to lower abdomen or pelvic brim
(2) Müllerian inhibitory substance (MIS) is responsible for this phase.
b. Inguinoscrotal phase
(1) Descent through the inguinal canal into the scrotum
(2) Androgen- and human chorionic gonadotropin (hCG)-dependent

2. Cryptorchidism
a. Epidemiology
(1) Incomplete or improper descent of the testis into the scrotal sac
(2) Most common genitourinary (GU) disorder in male children
(3) Occurs in 30% of premature males and 5% of full-term males
(4) Associations
• Androgen insensitivity syndrome, Kallmann syndrome, cystic fibrosis
(5) Locations
(a) Inguinal canal is the most common site (80% of cases)
• Palpable mass; majority are unilateral (90% of cases)
(b) Intra-abdominal (5%–10% of cases)
(6) Many will spontaneously descend by 3 months of age
(a) Due to combination of androgens and hCG
(b) Spontaneous descent is uncommon after 3 months.

b. Complications if uncorrected
(1) Potential for infertility
(a) Arrest in germ cell maturation
(b) Testicular atrophy
(c) Similar changes occur in the normally descended contralateral testis.
(d) Greatest risk if intra-abdominal or long duration in the inguinal canal
(2) Increased risk for developing a seminoma
(a) Risk for cancer in the cryptorchid testis increases by fivefold to tenfold.
(b) Risk also applies to the normally descended testicle.
(3) Increased risk for the undescended testis to undergo torsion (see later)

c. Treatment
(1) Orchiopexy may be done as early as 6 months; it should be performed by 2 years
of age.
(2) Hormonal therapy with hCG produces variable results.
(3) Administration of gonadotropin-releasing hormone (GnRH) before orchiopexy
may improve fertility in adult.

B. Orchitis

1. Mumps
a. Infertility is uncommon.
b. Most cases are unilateral.
c. Orchitis is more likely to occur in an older child or adult.

2. Congenital or acquired syphilis
3. HIV
4. Extension of acute epididymitis

C. Epididymitis

1. Causes
a. Common pathogens in persons <35 years old
(1) N. gonorrhoeae
(2) C. trachomatis

b. Common pathogens in persons >35 years old
(1) E. coli
(2) Pseudomonas aeruginosa

c. Tuberculosis
(1) Begins in the epididymis
• Spreads to the seminal vesicles, prostate, and testicles
(2) Caseating granulomatous inflammation

d. AIDS
• Association with cytomegalovirus, Toxoplasma, Salmonella

2. Clinical findings in acute epididymitis
a. Usually unilateral scrotal pain with radiation into spermatic cord or flank
b. Scrotal swelling, epididymal tenderness
c. Urethral discharge
• If it is sexually transmitted
d. Prehn sign
• Elevation of the scrotum decreases pain.

3. Treatment
a. If <35 years old, ceftriaxone + doxycycline (STD treatment)
b. If >35 years old, ciprofloxacin extended release

D. Varicocele

1. Epidemiology
a. Occurs in 15% to 20% of all males
(1) Usually occurs between 15 and 25 years of age
(2) Rarely occurs after 40 years old
b. Occurs in 40% of infertile males
c. Most common cause of left-sided scrotal enlargement in adults
d. Left spermatic vein drains into the left renal vein
(1) Increased resistance to blood flow
(2) Blockage of left renal vein can also produce a varicocele.
• Examples—renal cell carcinoma invading renal vein; superior mesenteric artery
compressing the left renal vein
e. Right spermatic vein drains into the vena cava
(1) Blockage of right spermatic vein produces right-sided varicocele.
(2) Examples—retroperitoneal fibrosis; thrombosis of the inferior vena cava

2. Pathogenesis
• Incompetent valves in the left spermatic vein from increased pressure

3. Clinical findings
a. Aching pain in scrotum
b. Dragging sensation in testicle
c. Visible “bag of worms”
d. Infertility (controversial)
• Heat decreases spermatogenesis.

4. Diagnose by ultrasound

5. Treatment
a. Varicocelectomy
b. Embolization by an intervention radiologist

E. Torsion of the testicle

1. Epidemiology
a. Majority occur between 12 and 18 years old.
b. Predisposing factors
(1) Violent movement or physical trauma
• Most common causes
(2) Cryptorchid testis
(3) Atrophy of testis
c. Twisting of spermatic cord cuts off the venous/arterial blood supply.
• Danger for hemorrhagic infarction of the testicle 

2. Clinical findings
a. Sudden onset of testicular pain
b. Absent cremasteric reflex (key diagnostic finding)
• Stroking the inner thigh with a tongue blade normally causes the scrotum to retract.
c. Testicle is drawn up into the inguinal canal 

3. Diagnose with ultrasound

4. Treatment
a. One-third spontaneously remit.
b. Surgery is imperative within 12 hours for those that do not remit.

F. Hydrocele

1. Most common cause of scrotal enlargement in children 
a. The tunica vaginalis fails to close.
b. Fluid accumulates in serous space between the layers of the tunica vaginalis.
c. It is invariably associated with an indirect inguinal hernia.

2. Diagnosis
• Ultrasound distinguishes fluid versus a testicular mass causing scrotal enlargement.

3. Other fluid accumulations
a. Hematocele contains blood.
b. Spermatocele contains sperm.

4. Treatment is surgery.

URINARY TRACT DISORDERS

I. Common Ureteral Disorders

A. Congenital megaloureter

• May be associated with Hirschsprung disease

B. Ureteritis cystica

1. Disorder is a manifestation of chronic inflammation.

2. Smooth cysts project from the mucosa into the lumen.

• Similar findings may be present in the bladder.

3. Cysts may undergo glandular metaplasia and predispose to adenocarcinoma.

C. Ureteral stones

• Ureters are the most common site for stones to cause obstruction.

D. Retroperitoneal fibrosis

1. Causes

a. Most cases are idiopathic.

b. Known causes/associations include:

(1) Ergot derivatives used in the treatment of migraines

(2) Retroperitoneal malignant lymphoma

(3) Association with other sclerosing conditions

(a) Primary sclerosing cholangitis (PSC)

(b) Sclerosing mediastinitis, Reidel fibrosing thyroiditis

2. Complications

a. Hydronephrosis is the most common complication.

b. It may cause a right scrotal varicocele (see section V).

• Blocks the drainage of the right spermatic vein into the vena cava

E. Ureteral cancers

• Transitional cell carcinoma (TCC) is the most common cancer.

II. Urinary Bladder Diseases

A. Congenital diseases of the urinary bladder

1. Exstrophy of the bladder 

a. Developmental failure of the anterior abdominal wall and bladder

(1) Bladder mucosa is exposed to the body surface.

(2) It is often associated with epispadias (see section IV).

b. Complications

(1) Inflammation predisposes to glandular metaplasia.

(2) The likelihood of developing adenocarcinoma of the bladder is high.

2. Urachal cyst remnants

a. Usually the embryonic allantois (part of the yolk sac) is obliterated to form the fibrous

urachus connecting the apex of the bladder with the umbilicus (called the median

umbilical ligament in adults).

• If the lumen remains patent in the newborn, fistulas may develop between

the bladder and the umbilicus; midline cysts may persist that may drain

urine.

b. Cyst remnants predispose to adenocarcinoma of the bladder

• Most common cause of bladder adenocarcinoma

B. Acute and chronic cystitis

1. Risk factors for lower urinary tract (LUT) infection

a. Female sex

(1) Short urethra

(2) Ascending infection (refer to Chapter 20)

b. Indwelling urinary catheter

(1) Most common cause of sepsis in hospitalized patients

(2) Account for 50% of nosocomial urinary tract infections (UTIs)

c. Sexual intercourse

(1) “Honeymoon cystitis” occurs from trauma to the urethra.

(2) Voiding after intercourse reduces the risk for infection by washing out bacteria in

the urethra.

d. Diabetes mellitus, neurogenic bladder

e. Cyclophosphamide

(1) Produces hemorrhagic cystitis

(2) Prevented with mesna

f. Schistosoma haematobium

(1) Transmission

(a) The fork-tailed cercariae penetrate the skin.

(b) Larvae enter veins in the urinary bladder wall.

(c) Larvae develop into adult worms that deposit eggs.

(d) Host develops an intense inflammatory response consisting of

eosinophils that surround the eggs.

(e) Inflammation causes squamous metaplasia of the bladder

epithelium.

(2) Eggs have a large terminal spine (see Fig. 21-1B).

(3) Treatment is praziquantel.

2. Causes of acute cystitis

a. Escherichia coli

(1) Most common uropathogen (80%–90% of cases)

(2) Gram-negative rod (see Fig. 21-1C)

(3) UTIs account for 40% of hospital-acquired (nosocomial) infections.

(4) Most common cause of sepsis in a hospitalized patient

(5) Treatment is double-strength trimethoprim-sulfamethoxazole.

b. Adenovirus

• Causes hemorrhagic cystitis

c. Staphylococcus saprophyticus

(1) Causes acute cystitis in young, sexually active women

• Accounts for ~10% to 20% of LUT infections

(2) Coagulase negative

(3) Treatment is oral cephalosporin or amoxicillin-clavulanate.

d. Acute urethral syndrome in women

(1) Female counterpart to nonspecific urethritis (NSU) in men

(2) Chlamydia trachomatis is the most common cause of acute urethral syndrome.

(3) Identification of Chlamydia

• Polymerase chain reaction (PCR) testing of voided urine

(4) Treatment is azithromycin

e. Other uropathogens

• Mycoplasma hominis, Ureaplasma urealyticum, Neisseria gonorrhoeae

3. Clinical findings in LUT infections

a. Dysuria (painful urination)

b. Increased frequency, urgency, nocturia

c. Suprapubic discomfort

d. Gross hematuria

4. Laboratory findings in LUT infections

a. Pyuria ≥10 white blood cells (WBCs) per high-power field (HPF) in a

centrifuged specimen

• More than 2 WBCs/HPF in an uncentrifuged specimen

b. Bacteriuria, hematuria

c. Positive dipstick for leukocyte esterase and nitrite (refer to Chapter 20)

d. Culture showing at or above 105 colony-forming units (CFUs)/mL

• Gold standard criterion of infection

5. Asymptomatic bacteriuria in women

a. Two successive cultures with 105 or more CFUs/mL in an asymptomatic

patient

b. Causes

(1) Pregnancy

• Acute pyelonephritis may occur in 1% to 2% of cases.

(2) Elderly women in nursing homes

c. Treatment

(1) Pregnant women

• Amoxicillin

(2) Asymptomatic, healthy elderly women

• No treatment necessary

6. Sterile pyuria

a. Neutrophils in the urine and negative standard culture after 24 hours

• Positive leukocyte esterase, negative nitrite

b. Causes

(1) C. trachomatis

(2) Renal tuberculosis (TB)

(3) Acute tubulointerstitial nephritis (TIN; refer to Chapter 20)

7. Malacoplakia

a. Associated with a chronic E. coli infection of the bladder

b. Microscopic findings

(1) Yellow, raised mucosal plaques

(2) Foamy macrophages filled with laminated mineralized concretions

• Called Michaelis-Gutmann bodies, which are defective phagosomes that cannot

degrade bacterial products

C. Miscellaneous diseases of the urinary bladder

1. Acquired diverticula

a. Most are due to benign prostatic hyperplasia (BPH)

b. BPH causes obstruction of urine outflow and increased intravesical pressure,

predisposing to diverticula formation through areas of weakness.

c. Diverticulitis and stone formation are common complications.

2. Cystocele

a. Common in middle-aged to elderly women

b. Mechanism

(1) Relaxation of pelvic support causes descent of the uterus

(2) Bladder wall protrudes into the vagina

• Creates a pouch that collects residual urine

3. Cystitis cystica and glandularis

a. Bladder analog of ureteritis cystica

b. Increased risk for developing bladder adenocarcinoma

III. Urethral Diseases

A. Infections of the urethra

1. Chlamydial and gonococcal infections in men and women

• Urethra is the most common site for these sexually transmitted diseases (STDs).

2. Nonvenereal diseases causing urethritis

a. Most commonly due to E. coli

b. Complications

(1) Cystitis in women

(2) Prostatitis in men

3. Chlamydial urethritis is a common component of Reiter syndrome in men.

a. Urethritis

b. Sterile conjunctivitis

c. Human leukocyte antigen (HLA)-B27–associated arthritis (refer to Chapter 24)

B. Urethral caruncle

1. Female dominant disease

2. Friable, red, painful mass is present at the urethral orifice.

3. Chronically inflamed granulation tissue causes bleeding.

C. Squamous cell carcinoma of the urethra

• Most common cancer of the urethra

SAVE YOURSELF FROM " ROAD ACCIDENTS"

THINGS ARE AT FAULT:-

1.Drivers - Over speeding, rash driving, violation of rules, failure to understand sign and fatigue

2.Pedestrian - Carelessness, illiteracy, crossing at wrong places, moving on carriage way

3.Passengers - Projecting their body outside vehicle, by talking to drivers, alighting & boarding vehicle from side travelling on footboards, catching a running bus etc

4.Road Users - Excessive speed and rash driving, violation of traffic rules, failure to perceive traffic situation or sign or signal in adequate time, carelessness, fatigue, alcohol,sleep etc.

5.Vehicle - Defects such as failure of brakes, steering system, tyre burst, lighting system,overloading, projecting etc.

6.Road Condition - Skidding road surface, pot holes, ruts, merging of rural roads with highways, diversion etc.

7.Road design - Defective geometric design like inadequate sight distance, inadequate width of shoulders, improper curve design, improper traffic control devices and improper lighting,.

8.Weather conditions - Fog, snow, heavy rainfall, wind storms, hail storms etc.

9.Environmental factors -Unfavourable weather conditions like mist, snow, smoke and heavy rainfall which restrict normal visibility and makes driving unsafe

10. Other causes - Improper location of advertisement boards, gate of level crossing notclosed when required etc

Measure taken to prevent road accident

  Adapting the environment

    Changes to the road environment to reduce traffic volumes and speeds, separate cyclists from other vehicles and improve safety for pedestrians can have a positive impact on levels of RTAs and injuries. 

    Area-wide traffic calming measures (e.g. speed humps, narrowing roads, 20mph zones or road closures) have been found to reduce traffic speeds and injuries, particularly among children (12-15).

•         The average speed within the zones was 17mph

•         Mean traffic speeds had reduced by an average of 9mph

•          The use of red light cameras (these identify vehicles crossing a junction after a traffic light has turned red). There is some evidence that they can reduce right-angled collisions, but rear-end collisions have been found to increase, suggesting they may not be a successful safety measure

•         Marked pathways for cyclists on roads. Clearly marked lanes for cyclists on the road can reduce injury rates when compared to unmarked roads ;

•         The use of school crossing patrols.an evaluation of their use in the late 1980s suggested that they can reduce the number of accidents occurring to child pedestrians at, or near, crossing sites ;

•         Safe routes to school initiatives. These combine different measures to create safer routes to school for children, including: better pavements; traffic calming measures; safe crossings for pedestrians and cyclists;

•         By-passes that divert traffic out of towns and villages;

•         Improving rural routes for walkers and cyclists;

•         Reviewing and reducing traffic speeds on country lanes;

•         Reducing speeds at problematic junctions or locations (e.g. through the use of vehicle activated signs or rough road surfaces);

•         Removing road markings (e.g. central white lines) from narrow roads;

  Safety education and skills training

•        Promoting the use of safety equipmen

    A range of educational and promotional methods have been used to encourage the use of safety equipment, often with the provision of free or discounted equipment. These have included: information and lessons targeting parents and/or children; media campaigns highlighting the importance of their use; and health promotion counselling by clinicians.demonstrations of helmet protection and information about how to wear a helmet properly. Helmets were offered to children at a low cost.

                    2.2 Safety education programmes for pedestrians

                      Education programmes have been used to increase an individual’s ability to cope with traffic environments and so reduce pedestrian injuries.

                    2.3 Driver training / education programmes

                    Driver education programmes aim to increase the safety behaviours of drivers and reduce driver errors.

                    2.4 Media education campaigns

                      In the UK, media education campaigns have been used to increase knowledge, and change attitudes towards, a range of road safety behaviours using television, radio, and printed materials such as newspapers, posters and magazines. For instance, in England and Wales the Government’s THINK! campaigns have promoted: road safety among children and older people; reducing driving speeds in both rural and urban areas; wearing seat belts; and using child restraints.

                    3.Addressing drink driving

                    Addressing drink driving is  implemented to reduce levels of drink driving in the community. These include bar server training programmes and designated driver programmes.

                    3.1 Bar server training programmes

Bar server training programmes train bar staff how to serve alcohol responsibly, with the intention of slowing patron drinking and preventing customers from becoming intoxicated.

3.2 Designated driver programmes

                      Designated driver programmes promote the use of one person (within a group of friends) abstaining from alcohol during a night out and driving the other individuals home safely. Information on designated driver programmes are either disseminated through media campaigns or through initiatives based in nightlife settings that offer incentives (e.g. free soft drinks).

  4. Multi-component community interventions

    Comprehensive interventions that engage the community at large and combine strategies such as education programmes and traffic calming measures can be effective in reducing the incidence of childhood pedestrian injury

  5. Enforcement of legislation      

    There is a wide range of legislation relating to roads, vehicles and drivers that protect road users and pedestrians against accidents (see box on road safety legislation).

  5.1 Speed enforcement detection devices

    Speed enforcement detection devices (e.g. speed cameras and laser and radar devices) can be effective in reducing traffic speeds and reducing the level of road traffic crashes, injuries and deaths in the vicinity of device sites

  5.2 Increased policing for drink and drug driving

  The presence of police on the roads (and the threat of arrest) can act as a deterrent for people considering driving after drinking alcohol or taking drugs.