UROLOGICAL DISEASES IN MIDDLE AGED MEN AND WOMEN
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Transcript of UROLOGICAL DISEASES IN MIDDLE AGED MEN AND WOMEN
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UROLOGICAL DISEASES IN MIDDLE AGED MEN AND WOMEN
Dr. BIOKU Muftau
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OUTLINE
• INTRODUCTION
• CLASSIFICATION OF UROLOGICAL DISEASES
• COMMON UROLOGICAL DISEASES IN MIDDLE AGED MALES AND FEMALES
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INTRODUCTION
• Urological dxs are pathological conditions of male genitourinary tract and female urinary tract.
• Account for about 1/3rd of all surgical admissions
• Many of the cases are not life threatening• MIDDLE AGE : 45 – 65 YEARS
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Male genitalia
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CLASSIFICATIONS
• URODYNAMIC• ONCOLOGIC• STONES• RECONSTRUCTIVE• ANDROLOGIC
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CONT’D
URODYNAMIC• BPH• NEUROGENIC DBLADDER• URINARY INCONTINENCE
ONCOLOGIC• PROSTATE CANCER• BLADDER TUMOUR• RENAL • TESTICULAR• PENILE
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CONT’D
STONE DISEASES• KIDNEYS• RENAL PELVIS• URETER• KIDNEYS• BLADDER• URETHRAL
ANDROLOGIC• ERECTILE DYSFUNCTION• MALE INFERTILITY• INTERSEX DISORDER
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CONT’D
CONGENITAL DXS• PUJ OBSTRUCTION• POLYCYSTIC KIDNEY• RENAL AGENESIS
OTHERS • UTI• EPIDIDYMO-ORCHITIS• URETHRAL STRICTURE• PENILE FRACTURE
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URINARY TRACT INFECTION
• Inflammatory response of urothelium to bacterial invasion
CLASSIFICATIONS• Urethritis• Prostatitis -Complicated UTI• Cystitis -Uncomplicated UTI• pyelonephritis
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Prevalence of UTIAge Female Male
Infants (<1 year) 1% 3%
School (<15 years old) 1-3% < 1%
Reproductive 4% <1%
Elderly 20- 30% 10%
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Risk Factors
1. Aging• a. Increased incidence of diabetes mellitus• b. Increased risk of urinary stasis• c. Impaired immune response
2. Females: short urethra, having sexual intercourse, use of contraceptives that alter normal bacteria flora of vagina and perineal tissues; with age increased incidence of cystocele, rectocele (incomplete emptying)
3. Males: prostatic hypertrophy, bacterial prostatitis, anal intercourse
4. Urinary tract obstruction: tumor or calculi, strictures
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Cystitis
- Most common UTI
General manifestations of cystitis a. Dysuria b. Frequency and urgency c. Nocturia d. Urine has foul odor, cloudy (pyuria),
bloody (hematuria) e. Suprapubic pain and tenderness
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Pyelonephritis
1. Inflammation of renal pelvis and parenchyma (functional kidney tissue)
Results from an infection that ascends to kidney from
lower urinary tract
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ManifestationsRapid onset with chills and feverMalaiseVomitingFlank painCostovertebral tendernessUrinary frequency, dysuria
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d. Urine culture and sensitivity
e. WBC with differential: leukocytosis and increased number of neutraphils
Diagnostic Tests for adults who have recurrent infections or persistent bacteriuria
a. Intravenous pyelography (IVP) or excretory urography
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b. Voiding cystourethrography c. Cystoscopy
d. Manual pelvic or prostate examinations to assess structural changes of genitourinary tract, such as prostatic enlargement, cystocele, rectocele
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TREATMENT
•Antibiotics used are; Beta lactams Tetracyclines Co- trimoxazole Quinolones Aminoglycosides Nitrofurantoin Phenazopyridine
•SURGERY :to correct anatomic abnormality
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Preventive measures
•Good personal hygiene.
•Drinking plenty of fluids (water).
•Emptying the bladder as soon as urge is felt
• Vitamin C makes the urine acidic
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BENIGN PROSTATIC HYPERPLASIA
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Anatomy
PROSTATE
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EPIDEMIOLOGY
EXCLUSIVELY A MALE PHENOMENON
MOST COMMON BENIGN TUMOUR IN MEN
MOST COMMON DISEASE OF THE PROSTATE (80%)
INCIDENCE IS 1 IN EVERY 10 MEN, AFTER AGE 50 YRS (i.e. AGE-RELATED INCIDENCE)
PREVALENCE OF SYMPTOMATIC BPH @ AGE 55YRS = 25% @ AGE 75YRS = 50%
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RISK FACTORSPoorly understood; includes : AGING
POSITIVE FAMILIAL & GENETIC FACTORS 50% of men < 60yrs undergoing surgery for BPH,
have a heritable form of disease Most likely an autosomal dominant trait First-degree relatives of such pxs carry an
increased relative risk of ~ 4-fold
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AETIOLOGY
NOT COMPLETELY UNDERSTOOD
APPEARS TO BE MULTIFACTORIAL & ENDOCRINE-CONTROLLED
PROSTATE COMPOSED OF BOTH STROMAL & EPITHELIAL ELEMENTS
HISTOLOGIC & SYMPTOMATIC BPH CAN ARISE FROM EITHER ELEMENT : Singly, or in Combination
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CONTD.
THE DIFFERENTIAL REPRESENTATION OF THE HISTOLOGIC TYPES IN BPH, EXPLAINS IN PART, THE POTENTIAL FOR RESPONSIVENESS TO DIFFERENT MEDICAL THERAPIES Smooth muscle predominance = α1a – blockers sensitive
Epithelial cell predominance = 5-α reductase inhibitors sensitive
Mixed smooth muscle & epithelial cell predominance = Combination of above two (2) drugs effective
Fibrous tissue/Collagen predominance = No drug effective; an indication for surgery
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AETIOLOGICAL CONSIDERATIONS
PRESENCE OF FUNCTIONING TESTES Castration results in regression of established BPH &
improvement in urinary symptoms Rare occurrence in eunuchs
NORMAL ANDROGEN LEVELS
INCREASE IN 5-α REDUCTASE ACTIVITY
FREE TESTOSTERONE/OESTROGEN IMBALANCE May explain association b/w BPH & aging Suggests that increased oestrogen levels with aging causes
induction of androgen receptor Thereby sensitizing prostate to free testosterone No demonstrable elevated oestrogen receptor levels in human
BPH
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Training slides - Volume 1 - Document designed for internal use only . 26
The Lower Urinary Tract Symptoms (LUTS)
FILLING
Frequency & volume
Urgency
Nocturia
Dysuria
VOIDING
Hesitancy
Weak stream
Intermittency
Terminal dribbling
Feeling ofincomplete emptying
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Training slides - Volume 1 - Document designed for internal use only . 27
BPH and its treatments can provoke sexual dysfunction
BPH BPH treatments
LUTS Sexual dysfunction
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Training slides - Volume 1 - Document designed for internal use only . 28
The physical examination
1. Abdominal examination
rule out other possible urinary or rectal conditions
2. Digital Rectal Examination(DRE)
fundamental method for assessing the shape and the volume of the prostate
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Training slides - Volume 1 - Document designed for internal use only . 29
Urinalysis
Standard examination for the detection of:
- Haematuria,
- Proteinuria,
- Pyuria.
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Training slides - Volume 1 - Document designed for internal use only . 30
The I-PSS is based on the answers to 7 questions concerning urinary symptoms.
Each question is assigned points from 0 to 5 indicating increasing severity.
The total score can therefore range from 0 to 35 (asymptomatic to very symptomatic).
Mild 0-7Moderate 8-19Severe 20-35
The I-PSS - symptom assessment
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Training slides - Volume 1 - Document designed for internal use only . 31
Patient Name: Not at all Less than Less than About More than AlmostYourDate: 1 time half the half the half the always score
in 5 time time time
1. Incomplete emptyingOver the past month, how oftenhave you had a sensation of sensation of not emptying yourbladder completely after you finish urinating? 0 1 2 3 4 5
2. FrequencyOver the past month, how often have you had to urinate again lessthan two hours after you finishedurinating? 0 1 2 3 4 5
3. IntermittencyOver the past month, how often have you found you stopped andstarted again several times when you urinated? 0 1 2 3 4 5
The I-PSS Questionnaire
Not at all
0
0
0
Less than1 time in 5
1
1
1
Lessthan halfthe time
2
2
2
More than half the time
Almost always
Your score
About half the time
3
3
3
4
4
4
5
5
5
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Training slides - Volume 1 - Document designed for internal use only . 32
The I-PSS Questionnaire (2)
Patient Name: Not at all Less than Less than About More than` AlmostYour scoreDate: 1 time half the half the half the always
in 5 time time time
4. UrgencyOver the past month, how oftenhave you found it difficult topostpone urination? 0 1 2 3 4 5
5. Weak streamOver the pas month, how oftenhave you had a weak urinarystream? 0 1 2 3 4 5
6. StrainingOver the past month, how oftenhave you had to push or strain tobegin to urinate? 0 1 2 3 4 5
7. NocturiaOver the past month, how many None 1 time 2 times 3 times 4 times 5 timestimes did you most typically get or moreup to urinate from the time you went to bed until the time you gotup in the morning? 0 1 2 3 4 5
TOTAL I-PSS SCORE =
Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always
Your score
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
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Training slides - Volume 1 - Document designed for internal use only . 33
Other recommended tests
Renal function Creatinine
Prostate cancer PSA
Flow rate Uroflowmetry
PVR Transabdominal ultrasonography
Symptoms Voiding diary
Objective Test
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TREATMENT OPTIONSMILD SYMPTOMS
• WATCHFUL WAITING
MODERATE SYMPTOMS
• MEDICAL THERAPY
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SEVERE SYMPTOMS
• MINIMAL ACCESS SURGERY• OPEN SURGERY
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PROSTATE CANCER
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EPIDEMIOLOGY
• Most important malignancy in the male genitourinary tract.
• 95% of cancers are detected in men 45-89 years old. (median age 72 years.)
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EPIDEMIOLOGY.
• Eunuchs do not develop Cancer of the prostate gland.
• Highest incidence in African-Americans
• Most common cancer in men in Nigeria.
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EPIDEMIOLOGY.
Nigeria – 127/100,000 – 1997.
• 5-10% of cancers are inherited in autosomal dominant manner
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ETIOLOGY/RISK FACTORS
Risk factor Relative risk
Obesity 1.25
Dairy products 1.30
Animal fat 1.31
Number of sexual partners 1.21
Vasectomy 1.54
Family history 1.70
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PRESENTING SYMPTOMS.
• Asymptomatic
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PRESENTING SYMPTOMS.
IRRITATIVE SYMPTOMS.
URGENCY.
FREQUENCY.
NOCTURIA.
OBSTRUCTIVE SYMPTOMS.HESITANCY.
POOR URINARY STREAM.
URINARY RETENTION.
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PRESENTING SYMPTOMS.
SYMPTOMS OF METASTASES.
• EASY FATIGUABILITY.
• PARAPLEGIA.
• RESPIRATORY DIFFICULTIES.
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D.R.E FINDINGS.
• PROSTATE IS ENLARGED.
• HARD IN CONSISTENCY. • IRREGULAR.
• OBLITERATION OF SULCI.
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INVESTIGATIONS.
• ULTRASOUND: TRANSRECTAL / TRANSABDOMINAL
Heterogenous architecture
Hypoechoic areas
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INVESTIGATIONS.
PROSTATE SPECIFIC ANTIGEN (PSA).
HELPFUL IN DIAGNOSIS AND FOLLOW-UP OF CANCER OF PROSTATE.
52% reduction in diagnosis of stage D cases in the USA since use of PSA in diagnosis.
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P.S.A
• ELEVATED PSA IS HOWEVER NOT CANCER SPECIFIC.
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INVESTIGATIONS.
• BIOPSY
• BONE SCAN
• MRI
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TREATMENT OPTIONS.
• WATCHFUL WAITING.
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TREATMENT OPTIONS.
SURGERY.
RADICAL PROSTATECTOMY
RADIOTHERAPY.
RADICAL:
TELETHERAPY
BRACHYTHERAPY
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TREATMENT OPTIONS.
HORMONAL MANIPULATION.
ORCHIDECTOMY.
LHRH ANALOGUES.
MAXIMUM ANDROGEN BLOCKADE.
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TREATMENT OPTIONS.
CHEMOTHERAPY.
ESTRAMUSTINE PHOSPHATE SODIUM.
MITOXANTRONE + STEROID.
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TREATMENT OPTIONS.
• Biphosphonates.
• Epidermal Growth-factor inhibitors.• Platelet derived Growth-factor
inhibitors.
• Docetaxel.
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SUPPORTIVE CARE.
PAIN CONTROL.
ANALGESICS.
RADIOTHERAPY.
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SUPPORTIVE CARE.
PAIN CONTROL.
RADIO-ISOTOPES.
Phosphorous 32
Strontum 89
Samarium 153(haematological complications)
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SUPPORTIVE CARE.
• CONTINENCE CONTROL
• ANAEMIA
• PARAPLEGIA
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UROLITHIASIS
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epidemiology
It has a worldwide distribution. India,Pakistan,M/East > W/E Africa
Incidence(Nig): 7—34/100 000M/F ratio-3:1.Race : Whites>BlacksPeak incidence: 3rd –5th decades.Recurrence :15%..........3ys
30%..........15ysRecurrence time: 9ys(average)
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Type of stone
CALCIUM OXALATE(60%) Hard, irregular, spiculated Usually single. Yellow– red. Formed in acid urine. Pure or mixed wt CaPO4. Radio-opaque
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Types ctd
PHOSPHATE STONE(30%)CaPo4, NH4MgPo4 or
CaNH4MgPo4(triple phosphate)White or greenish yellowCrumbly & radio-opaqueFormed in alkaline urineCommon sec vesical calculus
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TYPES CTD
URIC ACID & URATE STONE(5—10%) Multiple & hard Yellow to purple Radioluscent Related to high standard Found more in the bladder OTHERS:TRIAMPTERENE;XANTHINE;
MATRIX
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Types ctd
CYSTINE STONE(1—3%) Multiple( may aggregate 2 form stag
horn) Soft Yellow changes to green on exposure
to light radioopaque
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AETIOLOGY/PATHOGENESIS CTDRISK FACTORS Family hx: +ve in 25% of pts wt recurrent
dx Geography: high temp/humidity Urine pH OccupationINFECTION Urea splitting organisms leads to the
alkalinization of urine==CaPo4AFFLUENCE
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PATHOLOGICAL EFFECTSSEC HYDRONEPHROSIS INFECTIONMETAPLASIAANURIAPERIURETHRAL ABSCESS
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AETIOLOGY/PATHOGENESIS CTDRISK FACTORS Family hx: +ve in 25% of pts wt recurrent
dx Geography: high temp/humidity Urine pH OccupationINFECTION Urea splitting organisms leads to the
alkalinization of urine==CaPo4AFFLUENCE
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PATHOLOGICAL EFFECTSSEC HYDRONEPHROSIS INFECTIONMETAPLASIAANURIAPERIURETHRAL ABSCESS
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CLINICAL PRESENTATION
• Pain caused by obstruction• Haematuria• Nausea and vomiting• Irritative/Obstructive voiding symptoms
• Physical examination
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Investigations
• Urinalysis, urine m/c/s.• Plain abdominal X-ray(KUB)• IVU• Abdominal ultrasound• CT Scan• MRI• Urethrocystoscopy and retrograde
pyelography
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Investigations
• Serum urea, electrolytes and creatinine• Serum calcium, phosphate and albumin• Serum uric acid• 24 hour urine calcium estimation• *Chemical analysis of stone that is passed
spontaneously or removed surgically.
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TREATMENT.
Observation for spontaneous passage Indication –stones < 5mm
Measures –• Adequate pain control• Liberal fluid intake aiming at urine output of 2-
3L/ day
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TREATMENT.• Surgical procedures
*The minimally invasive procedures for renal and ureteral
stones are• Extracorporeal shock wave lithotripsy (ESWL)• Percutanous nephrolithotomy(PNL)• Retrograde ureteroscopic intrarenal surgery(RIRS)• Laparoscopic stone surgery *Open surgery
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TREATMENT.
Bladder stones• Cystolitholopaxy• Cystolithotripsy
– Electrohydraulic– Ultrasonic– Pneumatic lithotripsy– Holmium Yag laser
• ESWL• Percutaneous cystolithotomy
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TREATMENT.
Indications for stone removal• Intractable pain• Non-progressing calculus(impacted)• Infection• Prolonged obstruction• Stones >5mm
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TREATMENT.
• Complications of ESWL.– Bleeding– Perinephric haematoma– Stein straisse
• Contraindications - Bleeding disorders - Acute infections - Pregnancy
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PREVENTION OF RECURRENCE
General measures– Hydration: aim at urine output >2L/24hrs– Dietary restriction
• Decrease protein intake• Decrease sodium intake• Decrease oxalate intake• Avoid excess vitamin c• Decrease phosphate
Increase dietary fibre
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PREVENTION OF RECURRENCE.
Specific measures– Thiazide diuretics i.e. for calcium oxalate stones– Orthophosphates– Sodium cellulose phosphates: this tends to bind to calcium
thereby inhibiting the intestinal absorption of calcium– Allopurinol:→ decreases the production of uric acid.– Citrates e.g. sodium potassium citrate, potassium citrate.– Magnesium
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ERECTILE DYSFUNCTION
• Inability to have penile erection sufficient for satisfactory sexual intercourse
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EPIDEMIOLOGY• ED is highly prevalent affecting 30-52% of
men 40-70yrs of age (MMA-Study).• PREVALENCE: Nigeria= 57.4% (Afolayan AJ,
Yakubu MT,Sex Med 2009 Apr;6{4}).» EGYPT= 63.6%» PAKISTAN= 80.8%
• Both severity and prevalence increase consistently with age.
• World-wide prevalence predicted to rise from 152 million (1995) to 322 million(2025).
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EPIDEMIOLOGY
• Major predictors of ED:• DM (A Adegbite et al, Jos; society of endocrinology 2009)
• Heart disease• Hypertension• Dyslipidemia.
• High prevalence in men who had undergone pelvic surgery or irradiation for CAP.
• Psychological correlates: depression, anger .
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ERECTILE DYSFUNCTION: Increases with Age
40 45 50 55 60 6570 Age
Pre
vale
nce.
%
25
0
50
75
Feldman, H.A. et al. Impotence and its medical and psychosocial correlates: Results of the Massachusetts Male Aging Study. Journal of Urology
Complete Moderate Minimal
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CLASSIFICATIONS
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BASIC TESTING FOR ED
• FBS [& in diabetics GLYCOSYLATED Hb (HbA1c)]
• LIPID PROFILE – Cholesterol & TG
• TESTOSTERONE – Morning collection; calculated free Testosterone more reliable to establish Hypogonadism
• FBC AND URINALYSIS
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ADDITIONAL ENDOCRINE TESTING
• PROLACTIN
• LH & FSH
• OESTROGEN
• DHEA – DihydroepiandosteroneOTHER OPTIONAL TESTS• PSA• TFT• Serum Cr• Scrotal USS
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Treatment fo ED - General
• Life syle changes• Psychotherapy• Stopping offending drugs• Hormonal teratment
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Treatment fo ED - Specific• First line therapy
– Phosphodiesterase-5 inhibitors• Sildenafil• Vardenafil• Tadalafil
– Apomorphine– Vacuum device– Phychosexual therapy
• Second line therapy– Intracavernosal injection
• Alprostadil (caverjet)• Alprostadil, paperverine phentolamine combination
– Intraurethral therapy• PGE1
• Third line therapy– Penile prosthesis
• Malleable (semirigid)• Inflatable
– Two piece– Three piece
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Semi-rigid (malleable) penile prosthesis
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3-piece inflatable penile prosthesis in place
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MALE INFERTILITY
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DEFINITION
» Inability to achieve a pregnancy after 1 year of unprotected and adequate sexual
intercourse» Primary/Secondary
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INTRODUCTION
Background » 25% of women become pregnant
after 1 month » 80% of women become pregnant
after 1 year » Male factor alone(40% of couples),
both male/female factor(20%). Thus, both couples should be
evaluated.
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AETIOLOGY
a) Pre-testicularb) Testicularc) Post-testicular
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Pre-testicular Causes
1) Genetic disorders – Klinefelter’s Syndrome(47 XXY), Nooman’s sndrome
(46 XY), intersex, cystic fibrosis, Prune- belly syndrome, Prader-willi syndrome, Moon Bardet-Biedl syndrome, Down’s
syndrome.2) Endocrine – Hypopituitarism,
Hypogonadotrophic hypogonadism, Hypothyroidism, hyperthyroidism, DM.
3) Autoimmune diseases
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4) Systemic disorders- Liver diseases, Renal dxs, Amyloidosis, SCD, Kartagener’s syndrome, Leukaemia, Lymphoma, Inflammatory bowel dx.
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TESTICULAR CAUSES
1) Varicoele2) Infections-
STDs,Epididymitis,Schistosomiasis,Tb,Mumps, Leprosy, Brucellosis.
3) Cryptorchidism4) Testicular Failure- germinal cell aplasia (sertoli
cells only syndrome), testicular atrophy, spermatogenic maturation arrest, spermatotoxins(alcohol,marijuana,smoking,irradiation)
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5) Drugs- Cytotoxics(cyclophosphamide), Nitrofurantoin, Steroids, Antihypertensives,
Cimetidine.6) Torsion7) Neoplasm - Testicular
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POST TESTICULAR
1) Obstruction- ejaculatory duct, vas deferens, epididymis, urethra (stricture).
2) Infection – prostatitis, vesiculitis(seminal)
3) Neoplasm- Prostatic Ca, Urethral Ca.4) Iatrogenic- Prostatectomy, bladder
neck reconstruction, herniorrhaphy
(ejaculatory duct), scrotal exploration, RPLN dissection,
orchidectomy.
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5) Neurological disorder- Spinal cord injury, xle sclerosis.6) Abnormalities of penis – hypospadias,
epispadias, impotence, micropenis.
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CLINICAL EVALUATION
FERTILITY Hx1) Relationship hx -present relationship -previous relationship » Present relationship hx • Duration of infertility • Use of contraceptives • Number of pregnancies (plus
miscarriages/abortions)
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» Previous relationship hx • Number of pregnancies in past
relationships if any. • Divorcements2) Sexual Hx » Frequency of intercourse/masturbation, relationship to ovulation. » Libido, potency, sexual technique, NPT
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» Premature ejaculation » Proper deposition of semen (deep
penetration, hypospadias) » Dyspareunia/lubrication3) Genitourinary hx » Testicular descent –unilateral, bilateral. » Onset of puberty, 2° Sexual
characteristics.
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» STI/UTI , Torsion » Heat exposure (hot baths, steam rooms) » Chemical /Irradiation exposure4) Previous infertility evaluation » Previous SFA, surgical px, medical tx » Spouse – evaluation so far -completed before invasive
procedure
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GENERAL MEDICAL Hx
1) Medical illness (DM, HTN, CLD, CRD) & Tx leading to infertility2) Use of cytotoxics3) Occupation/Stress » SFA parameters4) Habits – recreational drugs, herbs5) Family hx » Sibling fertility status- cystic fibrosis, CAH » Exposure to DES in pregnancy
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PHYSICAL EXAMINATION1) General PE- habitus, 2⁰ sexual
characteristics, gynaecomastia.2) Genitalia » Penis – meatal location, size » Testes – location, size, consistency » Epididymides – size, consistency,
smoothness » Vas deferentia - absence » Spermatic cord – size, consistency,
valsava » Inguinal region – hernia, scars
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3) DRE – prostate, seminal vesicles (present or absent, not usually palpable)
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INVESTIGATIONS1) SFA + M/C/S » Collection • 2-3 specimens • Abstinence for 2-3 days • Masturbation method • Analysed within 2-3 hours • Specimen kept near body temperature
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» Minimal Standards of Adequacy (WHO) • Ejaculatory volume 1.5 - 5.0 ml • Density > 20 million/ml • Motility > 60% motile • Forward progression > 2.0 (scale 0-4) • Morphology > 30% normal
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» Physical Semen parameters • Colour – grayish • pH - 7.2 – 8.0 • Fructose – in case of azoospermia &
volume < 1ml » Interpretations • Aspermia • Oligospermia • Azoospermia • Asthenospermia • Teratospermia
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2) Urinalysis (m/c/s) » r/o infection3) Endocrine evaluation » Serum LH, FSH, testosterone,
prolactin4) Others – Thyroid and Adrenal function5) Genetic testing » Karyotype
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6) Sperm function tests» Mucus penetration test (post-coital test)-
ovulatory » Hamster egg penetration test –
capacitation7) Antisperm antibodies » ELISA »Immunobead binding assay 8)TRUS »Low Vol ejaculate(<1.5ml) »Ejaculatory duct obstruction- seminal
vesicle > 1.5 cm diameter » EDO, hypoplastic seminal vesicle,
absent seminal vesicle, cyst, stones, persistent utricle
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9) Vasography10) Scrotal USS » Indication- impalpable testes (from
hydrocele), varicocele, scrotal masses11) Testicular biopsy » Indications • Azoospermia with normal or low
FSH • Suitable side for microsurgical
anastomosis in obstructive azoospermia
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Chromosomal & meiotic studies(chromosomal disorders)
Testicular abnormality – diagnose disease process
Azoospermia + normal hormones, normal sized testes, normal fructose.
12) Miscellaneous - FBC, E,U&Cr, LFT, RBS
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TREATMENT (BY CATEGORIES)
1) All Parameters normal (SFA) » 2 SFA normal » Hx & PE non-conclusive » Further female evaluation » If partner evaluation is normal, do
sperm function test » Tx – IUI, IVF
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2) Azoospermia » r/o collection error, retrograde
ejaculation(RE) » Tx RE • Oral alkalization • Sympathomimetic agent • Centrifuge urine then IUI » LH/FSH, atrophic testes • TESE for IVF/ICSI
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» -ve fructose + azoospermia + normal hormonal studies (CAVD, bilateral ejaculatory duct obstruction, retrograde+scanty anterograde ejaculation)
• MESA + IVF/ICSI • Transurethral resection of ejaculatory
duct • Unroofing midline cysts • Testicular biopsy + cryopreservation of
sperm→ normal fructose,testicular size,hormones
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» Varicoceles – do varicocelectomy • Transvenous angiographic
embolisation /balloons/stainless steel sclerosis agent introduction
• Surgical ligation • Laparoscopic ligation
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4) Isolated abnormal parameters (a) Abnormal semen volume » Large ejaculate vol (>5.5ml) • result in dilution of spermatozoa, poor
cervical placement • Tx – mechanical sperm concentration, artificial insemination » Absent or low ejaculate vol- testosterone
may be low • r/o retrograde ejaculation • tx endocrine abnormality
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(b) Hyperviscosity » tx mechanical distruption of sample(c) Decreased motility » from endocrine dysfunction,infection,
varicocele, epididymal dysfunction,antisperm absence
» Specific tx – sperm washing, steroids(d) Oligospermia » Endocrine
dysfunction,genetic,idiopathic
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» tx • stimulation of production • artificial insemination- IUI, IVF,
ICSI(e) Abnormal morphology » Unusual, transient, self-limiting » No known tx
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» ART (a) IUI – Male factor infertility Cervical mucus problem Anatomical cervical difficulty (sperm
deposition) (b) IVF (c) GIFT (d) ZIFT
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(e) ICSI – poor fertilizing capacity of
sperm - IVF & ICSI should not be done
without prior karyotyping» Adoption
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