Andrology M.hassan & M.A.Wadood

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Andrology M.hassan & M.A.Wadood

  1. 1. Urology Department Under-graduate courses AndrologyBy Moh.Hassan, MBBcH Revised by M.A.Wadood , MD, MRCS
  2. 2. Erectile Dysfunction ©
  3. 3. Blood supply of penisArterial supply by the internal pudendal artery,Venous drainage1. Intracavernosal drainageinto subtunical venules.2. Extracavernosal drainage. (a) deep dorsal veins. (b) cavernosal and crural veins. (c) superficial dorsal vein. ©
  4. 4. Vascular Physiology of Erection 1. Nitric oxide • Following sexual stimulation, Nitric oxide diffuses into the corporal smooth muscle and induces smooth-muscle relaxation. 2. Venous outflow resistance • Filling of the lacunar spaces stretches the subtunical venules to create venous outflow resistance and a further increase in intracavernosal pressure. ©
  5. 5. Vascular Physiology of Erection ©
  6. 6. Erectile Dysfunction• Erectile dysfunction is the persistent inability to obtain and maintain an erection sufficient for sexual intercourse• Infertility is the inability to produce offspring, which is usually not caused by impotence. ©
  7. 7. Causes of EDVasculogenic impotence 1. Arterial disease: Atherosclerosis is a common cause of organic impotence. 2. Venogenic impotence : an increase in corporal smooth-muscle tone during stress or anxiety induce a functional venous leak.Diabetes mellitus in up to 75% of diabetic patients .Renal failure 50% of dialysis-dependent uremicpatients. ©
  8. 8. Causes of EDNeurologic lesions affect erectile function atmany levels: 1. Intracerebral 2. Spinal cord 3. Peripheral nervesEndocrine disorders less than 5%. 1. Hypogonadotropic hypogonadism 2. Hypergonadotropic hypogonadism 3. Hyperprolactinemia ©
  9. 9. Causes of EDTrauma 1. Pelvic. 2. Perineal trauma.Postoperative or iatrogenic impotence. 1. Aortic or peripheral vascular surgery. 2. Renal transplantation 3. Pelvic suergery or irradiation. 4. Cavernosal-spongiosal shunts 5. Neurosurgical procedures.Drugs. ©
  10. 10. Evaluation of EDSexual history The onset, duration, andcircumstances of the erection problem.• Psychogenic cause: sudden onset of impotence or impotence under some circumstances.• Organic cause: gradual deterioration of erectile quality with preservation of libidoMedical history DM, hypertension, smoking, andhyperlipidemia, liver, renal, vascular, neurologic,psychiatric, or endocrine disease. ©
  11. 11. Evaluation of ED• Physical examination of body habitus and secondary sexual characteristics (Gynecomastia, the penile length, fibrotic region, or deformity of the corporal bodies).• Laboratory tests Hormonal status is adequately assessed by serum serum testosterone, LH & prolactin.• Specialized tests Vascular testing Duplex ultrasonography to assess cavernosal artery diameter and flow velocity. Cavernosography and cavernosometry. ©
  12. 12. Treatment of EDSex therapy For Patients with psychogenic impotence .Oral therapy1. Oral phosphodiesterase inhibitors (sildenafil, Tadelafil, Vardenafil) increase intracellular concentration of cGMP causing corporal smooth-muscle relaxation and erection. Side effects headaches, dyspepsia & visual color changes Contraindications: nitrate therapy, severe uncontrolled hypertension, severe cardiac malfunction2. Androgen replacement: for patients with androgendeficiency ©
  13. 13. PDE5 inhibition with sildenafil Sexualstimulation Corpus cavernosum Erection NANC NO Smooth GTP cGMP muscle relaxation of the GMP cavernosal PDE5 arteries & the corporaNO=nitric oxide; NANC=nonadrenergic-noncholinergic neurons;PDE5=phosphodiesterase type 5
  14. 14. Treatment of EDNonsurgical therapyIntracavernous pharmacotherapy Alprostadil alone or incombination with papaverine and/or phentolamine mesylatemay be injected intracavernosally.Transurethral alprostadil ©
  15. 15. Treatment of EDSurgical therapyInflatable prostheses: consist of a pair of inflatablecylinders, a reservoir, a pump, and tubing to connect thesecomponents.Noninflatable prostheses: a pair of silicone rods ©
  16. 16. Male Infertility ©
  17. 17. Normal Hypothalamic Pituitary Gonadal Axis• Hypothalamus site of production of GnRH, which reaches the anterior pituitary via the portal system.• Pituitary: anterior pituitary secretes 2 hormones (gonadotropins)  Luteinizing hormone (LH) released into systemic circulation in a pulsatile fashion. LH is the major stimulus to testosterone production by Leydigs cells. testosterone exerts a -ve feedback on pituitary LH release.  Follicle-stimulating hormone (FSH) is responsible for initiation and maintenance of spermatogenesis (Sertolis cells ©
  18. 18. Normal Hypothalamic Pituitary Gonadal Axis ©
  19. 19. Male Infertility• Definition : the inability to achieve a pregnancy resulting in live birth after 1 year of unprotected intercourse (primary infertility).• Incidence : male factor can be identified in nearly 50% of these couples ©
  20. 20. Evaluation of the Infertile maleHistory• The duration of the marriage and attempts to conceive• if either partner has been previously married.• History of undescended testicles, hypospadias, gynecomastia, mumps, herniorrhaphy or scrotal surgery.• Retrograde or absent ejaculation is most often caused by diabetic autonomic neuropathy, sympatholytic drugs, or retroperitoneal surgery.Physical examination 1. Testes. The size and consistency. 2. Spermatic cord. Any asymmetry, the presence of varicoceles, gynecomastia or galactorrhea. ©
  21. 21. Evaluation of the Infertile male - Laboratory evaluationSemen analysis is the single most important.• collected after 3 days of abstinence from ejaculation.• On at least two occasions. Parameter Normal range Ejaculate volume 1.5-5.0 mL Sperm denisty > 20 million/mL Motility > 60% Forward progression > 2 (scale 0-4) Morphology > 60% normal Agglutination No Pyospermia No ©
  22. 22. Evaluation of the Infertile maleHormonal assays (In severely oligospermic or azoospermic)• FSH, LH, testosterone and prolactinGenetic assessment (karyotyping) for Azoospermiachromosome number (e.g, Klinefelters syndrome, 47XXY).chromosome structure (e.g., abnormal Y translocations).Radiologic evaluationTransrectal ultrasonography (TRUS) is now the initialdiagnostic modality for documenting ejaculatory ductobstruction and seminal vesicle/vasal absence or aplasia ©
  23. 23. Male Reproductive Abnormalities• Low-volume azoospermia 1. Ejaculatory duct obstruction (acquired or congenital). 2. Congenital bilateral absence of the vas deferens (CBAVD)• Normal-volume azoospermia 1. Vasal or epididymal occlusion may be congenital or acquired. 2. Spermatogenic failure Clinical clues to this diagnosis include small testes ©
  24. 24. Male Reproductive Abnormalities• Hypergonadotropic hypogonadism 1. Klinefelters syndrome: karyotype (47,XXY). Testes are small and firm. Gynecomastia. Hormonal evaluation shows elevated LH and FSH, testosterone may be low. 2. XX male syndrome is seen in 1 in 10,000 3. Bilateral mumps or viral orchitis, radiation, chemotherapy, and other toxic/inflammatory insults suppress spermatogenesis.• Oligoasthenospermia Low sperm density and poor sperm motility often coexist. Due to varicocele, toxins or idiopathic. ©
  25. 25. Varicocele• the most common cause of oligospermia.• unilateral (on the left) in 80% of patients.• bilateral in 18% of patients.• Varicocele have been reported in about 15% of the fertile male population.• varicocele is seen in 40% of infertile males. ©
  26. 26. Treatment of EDLow-semen-volume azoospermia (<1.0 mL) 1. Ejaculatory duct obstruction is diagnosed with TRUS. • Transurethral resection if TRUS has defined a midline cystic structure. 2. Vasal aplasia sperm retrival and ICSI.Normal-semen-volume azoospermia cause isPrimary spermatogenic failure (FSH levels are elevated).• Testicular sperm extraction (TESE) may retrieve sperms and ICSI is done. ©
  27. 27. Treatment of EDEjaculatory dysfunction• Treated by either:  Penile vibratory stimulation or  Rectal probe electroejaculationRetrograde ejaculation• use post-ejaculate urine specimen and sperm retrieval and ICSI. ©
  28. 28. Treatment of ED• Oligoasthenoteratospermia 1. Elimination of spermatotoxin. 2. Medical therapy. Clomiphene citrate, hCG, tamoxifen citrate, oral kallikrein, pentoxifylline, and folinic acid. 3. Surgical therapy. (varicocelectomy) improves SA in 40 - 70% of patients. • Pregnancy occurs in 40% of couples within 1 year of treatment. 4. Assisted reproductive techniques (ARTs) a. Intrauterine insemination (IUI). b. Intracytoplasmic sperm injection (ICSI) ©
  29. 29. Thank You

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