BIOS222 Pathology and Clinical Science 2 & 3

Transcription

1 BIOS222 Pathology and Clinical Science 2 & 3 Session 17 Male Reproductive Disorders Bioscience Department

2 Session Learning Outcomes At the end of the session, you should be able to: o Review the normal structure and functioning of male genital system. o Describe and discuss the clinical presentation, in male reproductive system. o Discuss the aetiology, clinical features, investigations and management of various prostatic disorders prostatitis, BPH and prostate cancer. o Outline and discuss various penile and testicular disorders. Endeavour College of Natural Health 2

3 Session Plan o Overview of the male reproductive system o Presenting problems in male reproductive disease: Hypogonadism Gynaecomastia Klinefelter s syndrome o Prostate disorders: Prostatitis Benign prostatic hyperplasia Carcinoma Endeavour College of Natural Health 3

4 Session Plan o Penile and testicular disorders: Congenital and acquired penile disorders Penile Infections and Inflammations Penile carcinoma Erectile dysfunction Testicular swellings Inguinal Hernia Cryptorchidism Testicular tumours Endeavour College of Natural Health 4

5 Overview of the Male Reproductive System Presenting Problems in Male Reproductive Disease Endeavour College of Natural Health 5

6 Male Reproductive System ORGANS MALE REPRODUCTIVE SYSTEM FUNCTION GONADS Testes Produce sperm and the male sex hormone testosterone DUCTS ACCESSORY SEX GLANDS SUPPORTING STRUCTURES Epididymis, Ductus Deference, Ejaculatory Duct, Urethra Seminal Vesicles, Prostate, Bulbourethral Glands Scrotum, Spermatic Cord, Penis Maturation of gametes Storage of gametes Delivery of gametes Producing Semen Scrotum supports and protects the testes as well as regulates the temperature of the testes. Tortora, GJ & Derrickson, B 2014, Principles of anatomy and physiology, 14th edn, John Wiley & Sons, Hoboken, NJ. Endeavour College of Natural Health 6

7 Presenting Problems in Male Reproductive Disease o Hypogonadism o Gynaecomastia o Klinefelter s syndrome o Male menopause o Prostatitis o Benign Prostatic Hypertrophy o Prostate cancer o Penile disorders o Infertility Endeavour College of Natural Health 7

8 Hypogonadism o Definition: Decreased function of the gonads. o Aetiology: Hypogonadotrophic hypogonadism Structural pituitary/ hypothalamic disease Functional gonadotrophin deficiency Isolated gonadotrophin deficiency Hypergonadotrophic hypogonadism Developmental/congenital gonadal disorders Acquired gonadal damage Endeavour College of Natural Health 8

9 Hypogonadism o Clinical features: Loss of libido Lethargy with muscle weakness Decreased frequency of shaving Gynaecomastia Infertility Delayed puberty Osteoporosis Anaemia of chronic disease Endeavour College of Natural Health 9

10 o Diagnosis: Hypogonadism Serum testosterone level Random LH and FSH, GnRH Investigations for ptuitary disease Testicular examination Karyotype analysis o Management: Testosterone replacement Regular measuring and monitoring prostate-specific antigen (PSA) and haemoglobin concentration Treatment for fertility Endeavour College of Natural Health 10

11 Gynaecomastia o Definition: It is the presence of glandular breast tissue in males resulting from an imbalance between androgen and oestrogen activity, which may reflect androgen deficiency or oestrogen excess. o Aetiology: Idiopathic Physiological Drug-induced Hypogonadism Androgen resistance syndromes Oestrogen excess Endeavour College of Natural Health 11

12 o Diagnosis: Clinical history Gynaecomastia Breast and testes examination Ultrasonography or mammography Random serum Testosterone, LH, FSH, oestradiol, Prolactin and hcg o Management: Self resolving in pubertal boys Androgen replacement Anti-oestrogen therapy Surgical excision for cosmetic reasons Endeavour College of Natural Health 12

13 Klinefelter s Syndrome o Definition: It is a genetic abnormality with mainly 47XXY karyotype, characterised by dysgenesis of the seminiferous tubules and impairment of Leydig cell function resulting in hypogonadism. o Clinical features: Gynaecomastia Failure to progress normally through puberty Infertility Small, firm testes. Tall stature increased risk of breast cancer and type 2 diabetes Endeavour College of Natural Health 13

14 Klinefelter s Syndrome o Diagnosis: Clinical presentation Karyotype analysis o Management: Androgen replacement Grossman SC & Porth CM 2014, Porth s Pathophysiology- Concepts of Altered Health States, 9th edn. Wolters Kluwer Health - Lippincott, Williams & Wilkins Endeavour College of Natural Health 14

15 Male Menopause o Definition: A progressive decline in gonadal functions in male around age of 40 years but not complete cessation. o Aetiology: Decrease in testosterone Alcohol excess Malnutrition Stress Lack of sleep Certain medications o Clinical features: Erectile dysfunction, Depression, anxiety, fatigue Reduced libido Reduced cognitive functions and memory o Management: Androgen replacement Endeavour College of Natural Health 15

16 Prostate Disorders Endeavour College of Natural Health 16

17 Prostatitis o Definition: It is an infection or inflammation of the prostate gland. o Aetiology: Acute bacterial: E. coli, Gram-negative bacteria (Proteus, Klebsiella, Pseudomonas) and enterococci Chronic Bacterial Prostatitis: Gram-negative enterobacteria Chronic non-bacterial (Chronic Pelvic Pain Syndrome): Autoimmune. functional obstruction of the bladder neck, Prolonged tension of the pelvic floor muscles Endeavour College of Natural Health 17

18 Prostatitis o Clinical features: Frequent urination, dysuria, difficulty passing urine Painful ejaculation, perineal or groin pain Systemic disturbance (in acute disease) o Diagnosis: Digital rectal examination Microbial culture of urine or urethral discharge o Management: Antibiotics Combination of α-blockers, NSAIDs and amitriptyline Endeavour College of Natural Health 18

19 Benign Prostatic Hyperplasia o Definition: It is an age-related, non-malignant enlargement of the prostate gland that occurs due to increase in cell number of both the glandular and stromal components giving rise to large nodules. o Aetiology: unknown o Risk factors: Age Family history Race, ethnicity Dietary fat and meat consumption Hormonal factors: Testosterone and dihydrotestosterone Oestrogens Endeavour College of Natural Health 19

20 Benign Prostatic Hyperplasia 60 SIZE (mm) Marked enlargement 80 gram Moderate enlargement 25 gram gram 8 gram 15 gram NEWBORN AGE (years) Endeavour College of Natural Health 20

21 Benign Prostatic Hyperplasia o Clinical features: Difficulty in voiding urine: Hesitancy, poor urinary flow and a sensation of incomplete emptying Urinary frequency, urgency of micturition and urge incontinence Acute urinary retention with a painful distended bladder o Complications: Bladder hypertrophy and hyperplasia Bladder calculi Bladder diverticulum Increased predisposition to UTI s and prostatitis Hydroureter Hydronephrosis Renal damage Endeavour College of Natural Health 21

22 Benign Prostatic Hyperplasia o Complications: Hydronephrosis Infection Hydroureter Trabeculation Bladder wall hypertrophy and hyperplasia Diverticulum formation Calculus formation Compression of urethra, obstruction Vardaxis, N A, 2010, a Textbook of Pathology, 2nd edn, Elsevier, Australia Endeavour College of Natural Health 22

23 Benign Prostatic Hyperplasia o Diagnosis: Digital rectal examination Urinalysis Test for urine flow rate Blood tests for prostate-specific antigen (PSA) o Management: Medical Prostate < 30 g: α- adrenoceptor blockers Prostate > 30 g: 5αreductase inhibitors +/- α adrenoceptor blockers Surgical Transurethral resection of prostate (TURP) Holmium laser enucleation Open prostatectomy Endeavour College of Natural Health 23

24 Prostate Carcinoma o Definition: Carcinoma of the prostate that predominately affect peripheral zones of the gland. o Aetiology: Unknown o Risk factors: Age Race Heredity A high-fat diet Male hormone o Clinical features: Asymptomatic Lower urinary tract symptoms as BPH Metastases S/S: Back pain, weight loss, anaemia and obstruction of the ureters. Endeavour College of Natural Health 24

25 Prostate Carcinoma o Diagnosis: Digital rectal examination Blood tests for prostate-specific antigen (PSA) Transrectal ultrasound-guided prostate biopsies o Management: Surgery Androgen-suppressing drugs Androgen receptor blockers Gonadotrophin-releasing hormone (GnRH) analogues Endeavour College of Natural Health 25

26 Penile and Testicular Disorders Endeavour College of Natural Health 26

27 Congenital and Acquired Penile Disorders o Micropenis: Very small penis usually due to prenatal androgen production, defective testosterone synthesis or pituitary gonadotrophin defect. o Epispadiasis: Urethra opens on dorsal aspect of penis. Urethral opening on ventral surface o Hypospadiasis: Urethra opens on ventral aspect of penis. Urethral opening on dorsal surface Grossman SC & Porth CM 2014, Porth s Pathophysiology- Concepts of Altered Health States, 9th edn. Wolters Kluwer Health - Lippincott, Williams & Wilkins Endeavour College of Natural Health 27

28 Micropenis Epispadias Hypospadias Normal testes, fertile man Urethra opens on dorsal aspect (upper surface) of penis Urethra opens on ventral aspect (under surface) of penis Image courtesy of Prof. Vardaxis. Endeavour College Endeavour College of Natural Health 28

29 Congenital and Acquired Penile Disorders o Phimosis: It refers to a tightening of the prepuce or penile foreskin that prevents its retraction over the glans (congenital or acquired) Foreskin covering the glans o Paraphimosis: The foreskin is so tight and constricted that it cannot cover the glans. A tight foreskin can constrict the blood supply to the glans and lead to ischemia and necrosis.. Retracted foreskin Endeavour College of Natural Health 29

30 Penile Infections and Inflammations o Balanitis: It is an acute or chronic inflammation of the glans penis. Men with poor hygiene, immunosuppression, or diabetes are more prone to balanitis o Balanoposthitis: It refers to inflammation of the glans and prepuce. It is usually encountered in men with phimosis or a large, redundant prepuce that interferes with cleanliness and predisposes to bacterial growth Endeavour College of Natural Health 30

31 Penile Carcinoma o Aetiology: Unknown o Risk factors: Increasing age Poor hygiene Smoking HPV types 16 and 18 infections Ultraviolet Radiation exposure Immunodeficiency states o Clinical features: Small lump or ulcer Painful swelling Purulent drainage Difficulty urinating Palpable lymph nodes in the inguinal region o Management: Surgery 5-year survival >95% Endeavour College of Natural Health 31

32 Erectile Dysfunction o Definition: It is defined as the inability to achieve and maintain an erection sufficient to permit satisfactory sexual intercourse. o Aetiology: Psychogenic: Performance anxiety, A strained relationship with a sexual partner, depression Overt psychotic disorders. Organic: Neurogenic disorders Hormonal disorders Vascular disorders drug-induced penile-related aetiologies Endeavour College of Natural Health 32

33 Erectile Dysfunction o Diagnosis: Careful history (medical, sexual, and psychosocial), Physical examination Investigations for underlying organic causes o Management: Psychosexual counseling, Androgen replacement therapy, Oral and intracavernous drug therapy, Vacuum constriction devices, and Surgical implants Endeavour College of Natural Health 33

34 Testicular Swellings o Hydrocele: A collection of excessive fluid between the layers of the tunica vaginalis. o Hematocele: It is an accumulation of blood in the tunica vaginalis, which causes the scrotal skin to become dark red or purple. o Varicocele: It is characterized by varicosities of the pampiniform plexus, a network of veins supplying the testes. o Spermatocele: It is a painless, sperm-containing cyst that forms at the end of the epididymis. Endeavour College of Natural Health 34

35 Testicular Swellings Grossman SC & Porth CM 2014, Porth s Pathophysiology- Concepts of Altered Health States, 9th edn. Wolters Kluwer Health - Lippincott, Williams & Wilkins Endeavour College of Natural Health 35

36 Testicular Swellings Hydrocele Varicocoele AF7E8D7281E3A972DC08672B11E489584CFF825E&first=391&FORM=ID FRIR Image courtesy of Prof. Vardaxis. Endeavour College Endeavour College of Natural Health

37 Inguinal Hernia o Definition: It is a protrusion of the parietal peritoneum and part of the intestine through an abnormal opening from the abdominal cavity. o Aetiology: Congenital: Patent vaginal process ( 1% of paediatric disorders) Acquired: When obliterated vaginal process opens due to excessive stress being placed upon it o Management: Immediate Surgery o Complications: Intestinal obstruction, compression of veins, infarction and gangrene due to strangulated hernia Endeavour College of Natural Health 37

38 Inguinal Hernia Vaginal process Normal Hernia Vardaxis, N A, 2010, a Textbook of Pathology, 2nd edn, Elsevier, Australia Endeavour College of Natural Health 38

39 Cryptorchidism o Definition: It occurs when one or both of the testicles fail to move down into the scrotal sac (undescended testes). The undescended testes may remain in the lower abdomen, at a point of descent in the inguinal canal, or in the upper scrotum. o Clinical features: Absence of one or both testes from the scrotum Increased risk of Infertility, Malignancy, Testicular torsion Endeavour College of Natural Health 39

40 Cryptorchidism o Management: Spontaneous descent Hormone therapy Orchiopexy Lifelong follow-up Testicular selfexamination Possible locations of undescended testes. Grossman SC & Porth CM 2014, Porth s Pathophysiology- Concepts of Altered Health States, 9th edn. Wolters Kluwer Health - Lippincott, Williams & Wilkins Endeavour College of Natural Health 40

41 Orchitis and Epididymoörchitis o Definition: It is an Infection or inflammation of the testis or of testis and epididymis. o Aetiology: Associated with other infections of the genitourinatry tract such as cystitis, prostatitis and urethritis Chlamydia trachomatis and Neisseria gonorrhoeae. Mumps (Mumps orchitis). o Clinical features: Unilateral pain and swelling, Erythema and oedema of the overlying scrotal skin Scarring, atrophy, infertility or sterility Endeavour College of Natural Health 41

42 Torsion of the Testis o Definition: It is a is a condition in which there is twisting of the testis on itself. o Aetiology: Violent movements, trauma (sportsmen) Abnormalities of situation or attachment of the epididymis, a long spermatic cord or testicular atrophy o Clinical features: Distress within hours of onset and often have nausea, vomiting, and tachycardia. Affected testis is large and tender, with pain radiating to the inguinal area o Management: Immediate Surgery Endeavour College of Natural Health 42

43 o Aetiology: Unknown Testicular Tumours o Risk factors: Genetic predisposition Disorders of testicular development: Klinefelter syndrome and testicular feminization, Cryptorchidism HIV o Clinical features: scrotal mass painless or mild dull pain o Diagnosis: Biopsy, USG, CT scan for metastasis o Managemen: Orchidectomy, Radiotherapy, chemotherapy Endeavour College of Natural Health 43

44 Testicular Self-Examination (TSE) o 12% of cancer deaths between 16 and 36 years due to testicular tumours o Monthly, three minute testicular self-examination after a shower or bath o Discovery of changes in size, consistency of the testis, presence of hard lumps, pain or tenderness should be followed by a doctor s examination Endeavour College of Natural Health 44

45 Reading and Resources o o o o o o o Crowley LV, 2012, An Introduction to Human Diseases Pathology and Pathophysiology Correlations, 9th edn, Jones and Bartlett Learning Grossman SC & Porth CM 2014, Porth s Pathophysiology- Concepts of Altered Health States, 9th edn. Wolters Kluwer Health - Lippincott, Williams & Wilkins Hinson, J, Raven, P & Chew, S 2010, The endocrine system: basic science and clinical conditions, 2nd edn, Churchill Livingstone Elsevier, Edinburgh Jamison, JR 2006, Differential diagnosis for primary care: a handbook for health care practitioners, 2nd edn, Churchill Livingstone Elsevier, Edinburgh. Jarvis, C, 2012 Physical Examination & Health Assessment, 6th ed., Elsevier Saunders, Philadelphia. Kumar, P & Clark, M 2012, Kumar and Clark s clinical medicine, 8th edn, Saunders Elsevier, Edinburgh. Kumar, V, Abbas, AK & Aster, JC 2015, Robbins & Cotran pathologic basis of disease, 9th edn, Elsevier Saunders, Philadelphia. Endeavour College of Natural Health 45

46 Reading and Resources o Lee, G & Bishop, P 2009, Microbiology and infection control for health professionals, 4th edn, Pearson Education, Frenchs Forest, NSW. o McCance, KL, Heuther, SE, & Brashers, VL 2014, Pathophysiology: the biologic basis for disease in adults and children, 7th edn, Elsevier. o Michael-Titus, A, Revest, P & Shortland, P 2010, The nervous system: basic science and clinical conditions, 2nd edn, Churchill Livingstone Elsevier, Edinburgh o Mosby s dictionary of medicine, nursing and health professions 2013, 9th edn, Elsevier, St. Louis, MO. o Tortora, GJ & Derrickson, B 2014, Principles of anatomy and physiology, 14th edn, John Wiley & Sons, Hoboken, NJ. o VanMeter, KC & Hubert, RJ 2014, Gould's pathophysiology for the health professions, 5th edn, Elsevier, St Louis, MO. o Vardaxis, N A, 2010, a Textbook of Pathology, 2nd edn, Elsevier, Australia o Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh. Endeavour College of Natural Health 46

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