Disorders of male reproductive system

1. Congenital genital defects
Embryos of both sexes develop identically for approximately 6 weeks’ gestation, known as
the indifferent stage. At the 6th week, the urorectal septum begins to grow downward and
inward from the sides into the cloacal cavity, thereby separating the cloaca into the bladder
and rectum. Differentiated stage begins at the 7th week of intrauterine life many genes are
responsible for gonadal differentiation.
1. The tunica albuginea fascia envelops the corporal bodies tightly but is perforated by
an intercavernosal membranous septum that allows blood flow between the
corpora cavernosa. Buck fascia is a strong laminar structure that tightly surrounds
and binds the corpora cavernosa together and, in the case of the corpus spongiosum,
envelops these tissues into a single-functioning entity. The urethra and its overlying
corpus spongiosum are also protected proximally by surrounding muscles and by
their location within the intercorporal groove distally. The penile glans itself is a
vascular spongiosum containing unique sensory endings that are erogenous and
tactile. The glans epithelium is a unique uroepithelium that contains sensory cells,
particularly around the corona.
2. Cryptorchidism - absence of one or both testes from the scrotum. This includes
undescended testes. Hypospadias - an abnormally placed urinary meatus (opening).
Chordee - a condition in which the head of the penis curves downward (that is, in a
ventral direction) or upward, at the junction of the head and shaft of the penis.
Micropenis - an unusually small penis. Sometimes defined as being 2.5 times the
standard deviation smaller than the mean size. Aphallia - the phallus (penis or
clitoris) is congenitally absent. 75 cases are known worldwide as of 2005. Diphallia,
penile duplication (PD), Diphallic Terata, or Diphallasparatus, is a medical condition
in which a male infant is born with two penises. Bladder exstrophy exstrophy-
epispadias complex - a spectrum of anomalies of the lower abdominal wall, bladder,
anterior bony pelvis, and external genitalia. Most common male genitala defects
3. Exstrophy of the bladder is an uncommon condition that occurs in approximately 1
of every 30 000 live births, of which boys predominate in 3. The defining features of
epispadias and exstrophy are an open and protruding bladder, an open urethra, and
a foreshortened epispadiac penis. anomalies may extend to involve the
musculoskeletal structures and the gastrointestinal tract. Classic exstrophy –defined
by bladder exstrophy, epispadias (epispadias alone occurs in 30% of cases),
diastasis recti, absence of fusion of the pubic symphysis, and deformed pubic
escutcheon. The pubic rami are widely separated, and the inferior pubic rami are
consequently laterally rotated. This defect produces a widened and foreshortened
urethra and bladder neck. It also produces an incompletely formed penis that
remains rudimentary. The crural bodies are attached to the splayed pubic tubercles,
producing a penis that is short, wide, and with dorsal chordee. As they pass through
their post-adolescent period, many of these young men will benefit from further
lengthening procedures or even complete penile reconstruction. In some patients
correction of unaesthetic scars and further release of insufficiently released corpora
can help to gain length. Exstrophy and epispadias
4. Scar removal may help in gain lenth of penis ,some patient with no umblicus which
will need reconstruction (A)Bladder dystrophy with very small gentalia (B)Free
Radial forarm flap was done (C)Glans of the redimantry penis was left for sensation

2. 5. The reconstruction of a penis with a pedicled ALT flap used as a tube-within-a-tube
technique (only possible in thin ‘boys without a penis’ and after defatting). No real
urethra was reconstructed here since the patient had a urostomy. (A) Preoperative
view. (B) After flap dissection. (c) The flap is tunneled underneath the rectus
femoris muscle. (D) Suturing and nerve connection (ilioinguinal nerve to lateral
femoral cutaneous nerve).
6. The buried penis deformity is present in both the pediatric and adult populations. A
buried penis is defined as a penis that is of normal size for age but hidden within the
peripenile fat and subcutaneous tissues, buried penis must be differentiated from a
micropenis in this group of obese patient. In adults, the problem is almost always
associated with obesity and the development of pubic, scrotal, and peripubic ptosis,
Liposuction and lipectomy are part of the treatment. However in children the fat
resection is abandoned. With pubertal development the prepubic fat deposit often
decreases in size. The focus is on the release of the penis from the fibrotic dartos
tissue Many techniques are described but the most important steps include keeping
all available skin from the start of the procedure, to resect all dartos tissue and to
recover the released corpora with the skin. Buried penis
7. Typical buried penis in an infant. (B) Ventral incision of the skin with maximal
preservation of skin at the start of the procedure. (c) After complete resection of the
fibrotic dartos tissue the penis is released from its buried position and the skin is
extendable. (D) Coverage of the released corpora with the extended skin creating a
penis with normal length.
8. Chordee is a condition in which the head of the penis curves downward or upward,
at the junction of the head and shaft of the penis. The curvature is usually most
obvious during erection Chordee may be caused by disorder of sex development or
as a complication of circumcision though some medical professionals do not
consider it to be true chordee because the corporal bodies are normally formed.
Treatment:- The curvature of a chordee can involve (1)tethering of the skin with
urethra and corpora of normal size,(2)curvature induced by fibrosis and
contracture of the fascial tissue (Buck's fascia or dartos) ,(3)fibrotic urethra that
tethers the penis downward. The preferred method of surgical treatment is a z-
plasty,The preferred time for surgery is between the ages of 6 and 18 months .
Chordee
Hypospadias ppt
Definition:- Hypospadias is believed to result from arrested penile development, leaving a
proximal urethral meatus. Hypospadias can be defined as hypoplasia of the tissues forming
the ventral aspect of the penis beyond the division of the corpus spongiosum.
Symptoms:- Abnormal ventral opening of urethral meatus, Abnormal ventral curvature of
the penis, Abnormal distribution of foreskin with a dorsal hood Other abnormal findings:-
include downward glans tilt, deviation of the median penile raphe, scrotal encroachment
onto the penile shaft, midline scrotal cleft, and penoscrotal transposition.
Embryology of Penile Development:- The external genital enlage is initially indifferent
and develops the female phenotype unless exposed to androgens during the critical
gestational time period of 8 to 12 weeks. Dihydrotestoterone derived from 5ꭤ-reduced

3. testosterone mediates the key steps in penis formation: elongation of the genital tubercle
and fusion of urethral folds. The urethral plate develops as an extension of endoderm from
the cloaca along the ventral midline of the genital tubercle.
Proliferating mesenchyme to either side creates urethral folds and establishes the urethral
groove. Fusion of the urethral folds begins proximally and continues distally at least to the
glans.
Two theories are proposed for glanular urethra development: ectodermal ingrowth
cannulating the glans to the urethral plate versus urethral plate tubularization to the tip of
the glans. Embryo studies suggest the penis initially exhibits ventral curvature during
formation, which can persist in hypospadias when normal development arrests.
ETIOLOGY :-The underlying cause for nonsyndromic hypospadias in most individual cases
is unknown. Based on knowledge of normal penis formation and the presumption that
hypospadias represents arrested development, several causes may exist.
1. Genetic Factors : Familial aggregation is found in 4% to 10% of hypospadias cases,
including first, second and third degree relatives • Brothers of affected individuals –
6-17% chance of being affected Incidence of hypospadias among fathers of affected
boys is increased five fold. 10-15% of patients have additional congenital
malformations particularly affecting the urogenital system.
2. Endocrinopathies:-The pivotal role of androgens in normal penis development
suggests endocrinopathies impacting hormone production or action may underlie
hypospadias. Defects in the testosterone biosynthetic pathway, specifically,
impaired 3ẞ-hydroxysteroid dehydrogenase alone or with impaired 17,20-lyase or
17ꭤ-hydroxylase activity,were reported in proximal hypospadias. Androgen
receptor gene mutations are considered a rare cause of hypospadias.
3. Gene Mutations:- Significantly associated with deletions of the chromosomal bands
1q42, 4p16, 7q34, 11p13 and duplications of bands 2q35, 8q12. Murine studies
indicating androgen receptor activity regulates Fgf8, Fgf10 and Fgfr2 involved in
urethral development have led to screening for defects in the candidate genes in
patients with hypospadias Several estrogen receptor genes are unregulated in
hypospadias patients, including ACT3, Cyr61, CTGF, and CADD45ẞ
4. Endocrine Disruptors :-A natural or synthetic compounds exerting estrogen-like,
androgen like effects could result in hypospadias An increased risk for hypospadias
has been identified in males after assissted reproduction , possibly attributable to
progesterone administered to mothers. Estrogen receptor influences androgen
activity, exposure to estrogen like compounds may explain abnormal masculization
in the absence of demonstrated defects in testosterone production, 5ꭤ reductase
type 2 activity, or the androgen receptor.
5. Syndromes with hypospadias:-Nearly 200 syndromes are associated with
hypospadias. Smith-Lemil-Opitz syndrome results from autosomal recessive
mutation of the DHCR7 gene on chromosome 11q13 coding for 7-
dehydrocholesterol reductase. Deletion in chromosome 11q13 results in WAGR
syndrome (Wilm’s tumor, Aniridia, Genital anomalies, mental retardation)
associated with hypospadias due to altered WT1 gene activity.
6. Hand-foot-genital syndrome is an extremely rare autosomal dominant condition due
to mutations in HOXA 13 on chromosome 7p14-15, resulting in bilateral thumb and

4. great toe hypoplasia. Opitz G syndrome occurs from X-linked mutations in midline 1
gene or autosomal dominant deletions in chrosome 22q11 Wolf-Hirschhorn
syndrome derives from deletions in chromosome 4p The critical region mediating
anorectal and genital anomalies has been localized to 13q33.1-34, containing 20
genes including EFNB2.
Epidemiology:- 1/250 male new borns , LBW and IUGR associated with hypospadias,
Prevalence appears to be increasing. Endocrine disrupting chemical (xeno estrogens) –
dioxins, organochlorine pesticides, dietary phtoestrogens (soy products). Rising
prevalence – result of improving fertility treatment increasing the number of children born
to subfertile men.
Diagnosis:- Physical examination, first suspected by the ventrally deficient prepuce and
confirmed by the proximal meatus. Other abnormal ventral findings potentially include
down- ward glans tilt, deviation of the median penile raphe, VC, scrotal encroachment onto
the penile shaft, midline scrotal cleft and penoscrotal transposition. • Megameatus intact
prepuce (MIP): Normally formed foreskin concealing a glanular to distal shaft hypospadias,
diagnosed after elective neonatal circumcision or in later childhood when the foreskin
retracts.
Associated anomalies:- Cryptorchidism: various studies shows that cryptorchidism is
associated with proximal hypospadias. Prostatic utricle: enlarged utricles are common in
penile shaft hypospadias, with increasing incidence as severity progresses from
penoscrotal to perineal cases. Incomplete androgen insensitivity, 5ꭤ-reductase type 2
deficiency, and testicular dysgenesis have been reported. The most frequent finding is
mixed gonadal dysgenesis, followed by ovotesticular disordered sexual differentiation. The
simultaneous occurence of hypospadias with cryptorchidism increases the likelihood for
DSD. Although hypospadias is considered arrested masculization, by convention it is
distinguished from DSD. Disorders of sex development, Malformation syndromes
Hypospadias most often occurs in infants without additional known medical conditions.
The finding of other anomalies increases the likelihood that hypospadias is part of a
malformation syndrome. Various syndromes include developmental delay, facial
dysmorphy, anorectal malformations and other genital anomalies, including penoscrotal
transposition and cryptorchidism.
Treatment:-
Indications for operation:-
Functional indications:-
1.Proximally located meatus
2.Ventrally deflected urinary stream
3.Meatal stenosis
4.Curved penis.
The cosmetic indications, which are strongly linked patient’s future psychology, are:
1.Abnormally located meatus
2.Cleft glans
3.Rotated penis with abnormal cutaneous raphe
4.Preputial hood
5.Penoscrotal transposition
6.Split scrotum.

5. Preoperative evaluation – Intersex evaluation. Isolated anterior and middle hypospadias
– not indicated. Any degree of hypospadias + cryptoorchidism – indicated. Hypospadias
with developmental delay, dysmorphic facies, and/or anorectal or scrotal malformations –
indicated. Posterior hypospadias regardless of gonadal position or palpability –
controversial Ultrasound, gonadal (histology), chromosomal, biochemical and molecular
testing.
Evolution of hypospadias surgery:- The term ‘hypospadias’ is derived from the Greek
word Hypo – under; spadon – rent/fissure. Galen was the first physician to use the term
hypospadias. Quest for a surgical procedure that consistently results in a straight penis
with a normally placed glanular meatus has challenged surgeons for over 2 centuries.
Amputation beyond the orifice was also recommended by Paul of Aegina (625-690 A.D.).
They described partial resection of the glans penis to locate the orifice more centrally.
Heliodorus and Antyllus (2nd century A.D. ) were the pioneers who described, classified
and defined pathophysiology and treatment of hypospadias. Ancient Greece
Serafeddin (15TH century) was a surgeon from central Antolia during the Ottoman period.
In one of his books he describes the fine scalpel “mibza” used for the treatment of meatal
stenosis in hypospadias.
The Rennaissance Period, In 1556, Amatus Lusitanus from Portugal treated a 2 year old
boy with penoscrotal hypospadias. In 1861, Bouison suggested a ventral transverse
incision to straighten the penile shaft. He was the first to use a rotated local pedicle scrotal
flap in order to cover the ventral defect. The inner surface of this flap was used to create
the anterior aspect of the neourethra with a technique resembling the Mathieu operation.
Theophile Anger was the first to use local tubularized skin flaps to repair hypospadias He is
considered the real initiator of urethroplasty technique in hypospadias surgery. 1869- Van
Hook – first surgeon to use vascularized island flaps in hypospadias surgery. 1897 – Novve
Joserand – first to successfully use a free graft to create urethra.
MILESTONES IN MODERN HYPOSPADIAS SURGERY:- 1971 – Asopa used a tubularized
horizontal inner preputial flap to form the neourethra. Duckett furthered this technique by
describing a transverse preputial island flap (TPIF) repair in 1980. 1984 – double face
preputial flap 1989 – anatomical studies of Baskin proved that there are no neural
elements in the dorsal midline position of the penile shaft. 1994 – Snodgrass tubularized
incised plate urethroplasty
Perioperative considerations 1) Timing of surgery – • Ideal age for genital surgery is
between 6-12 months of age. Healing seems to occur more quickly and with fewer scars,
and young infants overcome the stress of surgery more easily. The highest incidence of
postoperative emotional disturbance has been noted at the ages of 1-3 yrs. The most
common problems are prolonged night terrors, negativism, hysterical reactions, phobias,
and anxiety reactions. A normal penis grows only about 0.8 cms between the ages of 1 and
3 yrs and hence the size of the phallus is not an important technical consideration.
Anaesthesia/ analgesia:
General anesthesia provides uninterrupted performance of the repair without concern for
patient movement or sensation of pain. Adjunctive analgesia in the form of long-acting
injectable agents, delivered via a caudal route or as a dorsal penile nerve block, has proven
safe and efficacious. A popular agent for adjunctive analgesia is bupivacaine (0.25%)
without epinephrine administered as either a caudal or dorsal penile nerve block.

6. Suture/ suture technique:- Stay sutures - to limit tissue handling. A subcuticular technique
is employed during longitudinal closure of the neourethra when performing a
tubularization procedure. The edge of the epithelial surface is inverted and the raw
surfaces of the subepithelial tissue are approximated. Healing then provides a “watertight”
anastomotic suture line that, at least theoretically, would decrease the risk of
urethrocutaneous fistula formation.
Hemostasis:- Use of electrocautery should be limited during hypospadias repair.
Bipolar electrocautery:- Injection of a vasoconstrictive agent (epinephrine diluted
1:200,000 with lidocaine) deep to proposed glanular incision. Intermittent compression
with gauze soaked in iced saline and/or epinephrine solution. Intermittent use of a
tourniquet at the base of the penis(50 min).
Optical Magnification:- Wacksman (1987) reported that a microscope compared
favorably with previous results with loupe magnification and allowed use of small sutures
with great accuracy. Shapiro (1989) compared the results of hypospadias repair using 3.5≥
magnification (loupes) and the Zeiss reconstruction microscope. The study did not show
any significant difference in outcome.
Neo urethral intubation:- Controversial:- No drainage is required for glanuloplasty repair
and for children who undergo meatal advancement. Most non–toilet-trained children who
undergo a meatal-based flap urethroplasty do not require diversion. Toilet-trained children
who undergo a meatal-based urethroplasty usually require urinary diversion, this is
performed with a 7 French soft Jackson-Pratt urethral ‘‘splent.’’
SPLINT + STENT = SPLENT acts as an effective conduit for the urine during voiding
decreases the accumulation of secretions given off by the traumatized urethra, which
predispose to infection elimination of external collection devices lessening of the bladder
spasms that are often seen with Foley catheters. The tube is well tolerated and the child no
longer requires restraints and complete bedrest 8-10 DAYS
Dressing:- In 1982, Oosterlinck described a soft, pliable foam dressing, the “silicone foam
elastomer” After mixture of elastomer and catalyst, the sterile foam is molded around the
penis. This dressing appears to be well tolerated and easily removed in 4 to 6 days. Recent
trials - there is little or no advantage to the application of a dressing to the operated
hypospadias. Judicious use of anticholinergic medication has been described for
postoperative bladder spasm in catheterized patients Hepatotoxicity Ketoconazole reduces
adrenal and testicular androgen production through the inhibition of 17,20-desmolase,
thereby preventing the conversion of cholesterol to testosterone.
8) Postoperative Penile Erection, Bladder Spasm
Koff and Jayanthi presented evidence that supports the use of hCG before the repair of
proximal hypospadias Increase in penile size and length, Decrease in hypospadias and
chordee severity, Increased vascularity and thickness of corpus spongiosum, Allowance of
more simple repairs, IM testosterone enanthate – 2mg/kg/dose given for a total of 2 or 3
doses before hypospadias repair is a reliable way of obtaining reliable penile growth in the
appropriate patient, Prepubertal exogenous testosterone administration does not seem to
impair ultimate penile growth. 9) Hormonal manipulation
GENERAL PRINCIPLES OF HYPOSPADIAS REPAIR ORTHOPLASTY URETHROPLASTY
MEATOPLASTY GLANULOPLASTY SKIN COVERAGE
Orthoplasty Intraoperative assessment of penile curvature by either artificial or
pharmacologic methods is a critical step in hypospadias repair. It is performed after

7. degloving of penile shaft skin. Gittes and McLaughlin introduced artificial method of
erection. The degree of curvature may vary with force of injection and/or the method used
to impede saline outflow. Intracorporal injection of the arterial vasodilator prostaglandin
E1 allows for a more accurate and continued assessment of penile curvature before, during,
and after its correction. Etiology of chordee:- Percent distribution Skin tethering 32%
Fibrotic fascia 33% Corporeal disproportion 28% Congenitally short urethra 7%.
Significant chordee is clinically defined as curvature greater than 200. Curvature of less
than 500 is best approached dorsally, while curvature of more than 500 should be
approached ventrally.
Excision of diamond shaped wedge/s at the point of maximum curvature and closing the
tunica transversely with absorbable sutures
1) Nesbit technique.
2) Heineke-Mikulicz principle Several transverse incisions in the tunica are closed
longitudinally to achieve lengthening of the concave aspect of the penis. The Nesbit and
Heineke- Mikulicz principle can be used simultaneously on opposing aspects of the
curvature.
3) Tunica albuginea placation
4)Dorsal midline placation:- It is impossible to lift the neurovascular bundle without
damaging some of the nerve branches that wrap around the penis The 12 o’clock position
is a nerve-free area and is also the thickest and thus strongest portion of the tunica • If two
parallel dorsal midline plication sutures do not staighten the penis, additional rows of
midline plication sutures can be placed along the area of curvature.
Nonabsorbable sutures are placed in the area of maximal convex curvature from the
dorsolateral aspect of one corpus cavernosum across the midline to the other side such that
the corpora are rotated toward the dorsal midline
5) Corporal rotation - KOFF and EAKINS The corporal rotation technique allows one-stage
reconstruction while achieving and/or maintaining maximal penile length.
Disadvantages of corporal rotation:- The suture lies on top of the nerves, potentially
causing a crush-type injury. When incising the septum there is a risk of cutting into the
corpora cavernosum.
Split and Roll technique Decter (1999) added midline ventral splitting and called it the split
and roll technique
6) Total penile disassembly- Perovic. Since there is no plication the procedure avoids penile
shortening. A major disadvantage of this procedure is the extensive dissection that is
required to separate the dorsal nerves off of the corpora, although theoretically a careful
dissection can be successful. In addition it might be unnecessary to separate the urethra as
the urethal plate is rarely the cause of curvature.
7) Dermal Graft – Devine and Horton
The best results appear to be obtained when one-layer SIS is used for management of
severe ventral penile curvature at the first stage of a two-stage repair for severe
hypospadias. Small intestinal submucosa (SIS) is an acellular collagen-based material
derived from porcine small intestine used as an interposition graft for severe penile
curvature. Useful in cases of severe curvature in which the necessary plication would lead
to shortening of the penis.
8) Urethroplasty Immediately adjacent tissue:- Least risky and least technically challenging
Eg. – simple tubularization of urethral plate Local tissue flaps Thin, non hirsute, reliably

8. tailored. Fasciocutaneous flaps – dartos fascia Local/ extra genital free grafts. Flaps are
preferred to grafts. Among free grafts, BMG is most commonly used
NEO URETHRAL COVERAGE – 2ND LAYER:- 2nd layer coverage of the neourethra with
various vascularized flaps. It has significantly decreased urethrocutaneous fistula. 1. Dartos
flap 2. Tunica vaginalis flap 3. Corpos Spongiosum
Dartos flap
TUNICA VAGIANLIS FLAP
Corpos Spongiosum:- Paraurethral (spongiosal) tissue approximation in the midline as a
second cover of the initial suture line was initially described by van Horn and Kass (1995)
as an adjunct to distal hypospadias repair. The distal wrap of corpus spongiosum appears
to avoid fistula formation without causing residual or recurrent curvature.
Various techniques have been employed for the purpose of completing hypospadias with
adequate skin coverage of the penis. These techniques have included
1. Ventral transfer of preputial skin either with a buttonhole through the skin for through-
passage of the glans penis
2. Midline longitudinal split of the prepuce or dorsal penile skin followed by lateral transfer
of the skin on either side of the penis for ventral coverage
3. Transverse outer preputial island flap.
Penile Shaft Skin Coverage
The level of the hypospadias, degree of penile curvature, and tissue availability and quality
dictate repair options. Distal hypospadias is typically amenable to advancement or
tubularization techniques. Middle hypospadias is typically amenable to tubularization or
vascularized flap techniques. Proximal defects are treated with tubularization, vascularized
flap, two-stage techniques, or the incorporation of extragenital skin for repair.
Introperative algorithm
DISTAL HYPOSPADIAS:-
1. Urethromeatoplasty
2. MAGPI
3. M lnverted V plasty
4. GAP 5. Urethral advancement procedure
6. Mathieu procedure
7. TIP
Epispadias
Definition:- An epispadias is a rare type of malformation of the penis in which the urethra
ends in an opening on the upper aspect of the penis.
Incidence:- 1 in 70 chance of the child being born with this type of congenital issue.
Causes and Risk factors:- Caucasian firstborn children are also more likely to be born
with this condition. Males are four times more likely to have epispadias than females.
Glanular epispadias: This is where the urinary meatus is found on the head of the penis,
but on the top rather than in the standard location at the tip.
Types:-

9. 1) Penile epispadias: The urinary meatus is found on the shaft of the penis, anywhere
before the head of the penis but above the base where the shaft meets the body.
2) Penopubic epispadias: This is where the urinary meatus is found close to the body,
potentially not on the penis but near the pubic bone at the base of the penis.
3) Urgency and frequecny
Signs and symptoms:- Hematuria, Painful urination, UTI, Dribbling of urine
Imaging studies including ultrasound or CT scans, X- rays,
Diagnostic Tests:- urine tests, Physical examination, History collection
The Mitchell technique involves taking the penis apart completely, then putting it back
together. This is done so the urethra is in the most functional and normal position, and
dorsal bend (chordee) is corrected.
Surgical Management:- The Modified Cantwell Ransley Repair. The modified Cantwell
technique involves "rebuilding" the penis. It takes some of the penis apart to move the
urethra to a more normal position. The Mitchell Technique
MALE REPRODUCTIVE SYSTEM INFECTIONS
Reproductive tract infection are the infection that affects the reproductive tract which is a
part of reproductive system. For females infection can be in upper reproductive tract which
includes(fallopian tubes, uterus) and lower reproductive tract which includes (vagina,
cervix and vulva). For male these infections are at penis, testicles and urethra.
Prostate Cancer
Prostate cancer is the most common cancer in men in the UK, with over 40,000 new cases
diagnosed every year. Prostate cancer usually develops slowly, so there may be no signs
you have it for many years.
Causes:- Age , Ethnic group, Family history, Environmental, Smoking, Diet
Symptoms:- Urinate more frequently, often during the night, Needing to rush to the toilet,
Difficulty in starting to urinate, Straining long time while urinating, Feeling that your
bladder has not emptied fully, bone and back pain, a loss of appetite, pain in the testicles,
unexplained weight loss.
Diagnosis:- Ask for a urine sample to check for infection, Prostate-specific antigen (PSA)
test, Digital rectal examination (DRA), Biopsy, Transrectal ultrasound-guided biopsy
(TRUS), Gleason score – MRI – CT scan
Treatment :- Surgery , Radiotherapy, Good prostate cancer care, Multidisciplinary team
(MDT)
Watermelon, Pink grapefruit and oranges, Berries -- especially blueberries, Beans, Spinach,
Tomatoes -- both raw and cooked
PREVENTION:- Limiting high-fat foods, Cutting back on red meats, Healthy food choices
bread, cereals, rice, pasta, Antioxidants in foods (Lycopene)
Chlamydia Infection:-
Chlamydia trachomatis is a bacteria, which is found in the semen and vaginal fluids of men
and women who have the infection. Chlamydia is easily passed from one person to another
through sexual contact. Anyone who is sexually active can get it and pass it on.
Symptoms (for women):- Abnormal vaginal discharge that may have an odor, Bleeding
between periods Painful periods , Abdominal pain with fever, Pain when having sex, Itching
or burning in or around the vagina Pain when urinating

10. Symptoms(men):- Small amounts of clear or cloudy discharge from the tip of the penis,
Painful urination, Burning and itching around the opening of the penis, Pain and swelling
around the testicles
Diagnosis:- Patient will probably use a swab to take a sample from the urethra in men or
from the cervix in women and then will send the specimen to a laboratory to be analyzed.
There are also other tests which check a urine sample for the presence of the bacteria.
TREATMENT:- Antibiotics are very effective for treating Chlamydia. The two most
commonly prescribed antibiotics to treat Chlamydia are: 1. azithromycin (single dose) 2.
doxycycline (a longer course, usually 2 capsules a day for a week)
Testis and adjacent structure
Orchitis ( Orchitis is an inflammation of the testes)
Epididymitis ( is an infection or Inflammation of the Epididymis)
Hydrocele ( is a condition of collection of fluid in the tunica Vaginails of the testes)
Varicocele ( is a condition an abnormal dilation of the veins in the scrotum)
Testicular cancer
ORCHITIS:-
Orchitis is an inflammation of the one or both testes, caused by bactrial, viral, spirochetal,
parasitic, traumatic, chemical or unknown factors.
Causes:- The more common cause of isolated orchitis is mumps.
Bactrial causes usually spread from an associated Epididymitis in sexually active men.
Causative orginsms include:- Neisseria gonorrhea, chlamydia trachomatis, E. Coli •
Klebsiella, Pseudomonas, staphylococcus species and streptococcus species.
RISK FACTORS:- Not being immunized against mumps, Having recurrent UTI, Any surgery
involving the genitals or urinary tract, Multiple sexual partners, History of STDs
Clinical manifestations:- Acute scrtoal pain and edema and tender. Pain ranging from
mild to severe (the term testicle pain also called “ groin pain” in some cases fever and
nausea and vomiting.
Complications:- Testicular atrophy, Scrtoal abscess, Recurrent Epididymitis, Infertility
Assessment and diagnostic findings:-
History and physical examination
Testicular examination
STDs screening
Ultra sound
Treatment:- If Bactrial orchitis antibiotics are the first line treatment. NSAIDSs or
analgesics for reducing pain and anti inflammatory drugs. Bed rest and scrotum elevated
Cold packs
Penile disorders
Balinitis:-
Definition: It is an inflammation of the glans or head of the penis.
Incidence: It is a common condition affecting 1 in every 25 boys.

11. Causes: Candida albicans infections. It is a most common cause, Sexually transmitted
infections (STIs), Skin conditions can also trigger the conditions includes Lichen planus ,
Eczema , Dermatitis and Psoriasis. Irritants includes Chemicals used in condoms, lubricants
and spermicides lead to inflammation of the glans, Phimosis. Diabetes, Unprotected sex,
Poor hygiene. Having a urinary catheter.
Symptoms:- Sores on the glans, Painful urination, Tight foreskin that cannot be pulled
back, An unpleasant smell, A thick, lumpy discharge under the foreskin, Inflammation,
soreness, itchiness, or irritation of the glans, Tight, shiny skin on the glans
Diagnostic evaluation:- A urine test if diabetes is suspected. A swab test to test for any
infection. A blood test to determine blood glucose level.
Physical examination: Inspection of the penile area, History collection.
Treatment:- Yeast infection: Antifungal cream such as Clotrimazole, Miconazole. The
patient’s sex partner should also be treated. Allergic reaction: Mild steroid cream such as
1% hydrocortisone.
Sitz bath .
Bacterial infection: If there is a bacterial infection, an antibiotic such as penicillin,
Erythromycin.
Phimosis:-
Phimosis is defined as inability to retract the foreskin or prepuce of the penis.
Types:- There are two types of Phimosis:
A. Congenital Phimosis.
B. Acquired Phimosis.
Phimosis is normal for the uncircumcised infant/child and usually resolves around 5-7
years of age. Children are born with tight foreskin at birth and separation occurs naturally
over time
Phimosis that occurs due to scarring, infection or inflammation.
Forceful retraction of the foreskin over the glanspenis.
Causes:- Due to loss of skin elasticity and infrequent urination. Genetic. Poor hygiene. Yeast
infection, Congenital defect.
Symptoms:- Pain during sexual intercourse, Painful erections, Hematuria, Pain during
urination, Scarring of the foreskin and bleeding, Skin irritation, Inability to fully retract the
foreskin over the glans
Diagnostic evaluation:- Blood test, Urine test, A swab from the foreskin area to rule out
bacterial infection, Physical examination, History collection.
Treatment:- Consists of Gentle daily manual retraction, Congenital Phimosis may be
successfully treated by gentle repeated stretching of the foreskin over the glans. It is an
effective treatment in most males. Topical corticosteroid ointment includes hydrocortisone
etc. ointment is recommended for children with Phimosis.
It is done to prevent recurrence of Paraphimosis. It may be done for religious, culture or
hygienic reasons.
Circumcision: Circumcision is the surgical removal of the foreskin of the penis.
Prepuce is retracted over the glans and forms a constriction at the base of the glans.
It is rare condition in which the foreskin gets stuck in the retracted position. When
health care professional forgets to pull back the foreskin after a medical
intervention or procedure.

12. Causes:- It is most common causes of Paraphimosis. More Tighter foreskin that normal.
Physical trauma to genitalia. Infection.
Symptoms:- Swollen and painful foreskin. The main symptom of Paraphimosis is the
inability to return the foreskin back to its normal position over the tip of the penis.
Physical examination: Inspection of the penis, Ask about symptoms, History collection,
The first step in management of Paraphimosis is to reduce swelling .
Steps includes: 1. apply ice to the area, use needles to drain pus or blood, inject
hyaluronidase, Pain Killer is given at that time.
Second step : After reducing swelling doctor gently move the foreskin back into
position. A complete circumcision is necessary in severe cases of Paraphimosis. It is painful
medical emergency. It occurs in the absence of both physical and psychological
stimulation, within four hours.
Priapism:- Priapism a medical condition in which the erect penis does not return to its
flaccid state.
Types:- There are two types of Priapism .
1. Low flow (ischemic) Priapism: blood not adequately returning to the body from the
penis. 80 – 90 % are low flow types.
2. High flow ( Non ischemic) Priapism : a short-circuit of the vascular system pathway
along the penis.
Causes:- The exact cause of Priapism is not fully understood yet .
1. Hematological disorders such as sickle cell anemia, leukemia and thalesemia ETC.
2. neurologic disorders such as spinal cord lesions and spinal cord trauma.
3. Intra-cavernous injections for treatment of erectile dysfunction (papaverine,
alprostadil).
4. Others are antihypertensive, antipsychotics.
Diagnostic tests:- includes Blood tests, Blood gas analysis, Doppler ultrasonography.
Physical examination. History collection.
Treatment for Low flow Priapism : 1. Excess blood is drained from penis by using needle
and syringe (Aspiration).
2. Medications: Phenylephrine.
3. Surgeon: As a last resort surgery is performed.
Peyronie’s disease:-
Definition: Peyronie’s disease, also known as chronic inflammation of the tunica Albuginea
(CITA).
Precipitating factors are: Trauma or injury to the penis through physical activity, Trauma
and injury through sexual intercourse, Exact cause is unknown.
Symptoms:-Plaques formation, Painful sexual intercourse, Abnormal curvature of the
penis.
Treatment:- It is an FDA approved injectable drug for treatment of Peyronie's disease.
Medications: Collagenase clostridium histolyticum .The Nesbit operation, first used for
Peyronie’s disease in 1977, is still the most common operation performed to correct a
penile curvature.Nesbit operation- is considered a last resort .
Penile Cancer:-
Penile cancer is a malignant growth found on the skin or in the tissues of the penis.

13. Incidence:- Around 95% of penile cancers are squamous cell carcinoma.
Types:-1. Merkel cell carcinoma. 2. small cell carcinoma. 3. Melanoma.
Causative agents:- HIV infection, Human papilloma virus, Genital warts, Poor hygiene,
Phimosis, Smegma: It is a white substance that can accumulate beneath the foreskin,
Tobacco.
Etiology:- Phimosis, Change in color of the penis, Bleeding from the penis, Warts or ulcer
formation, Pain in the penis, Foul smelling discharge from the penis, Redness of the penis.
Treatment:- It includes surgery, radiation therapy, chemotherapy, biological therapy.
Amputation (penectomy), Circumcision, Laser surgery, Microsurgery: surgery
performed with a microscope is used to remove the tumor .
Wide local excision : the tumor and some surrounding healthy tissue are removed
Erectile Dysfunction:-
ED or impotence is the inability to attain or maintain an erect penis that allows satisfactory
sexual intercourse.
Definition: Impotence or Erectile dysfunction is the inability of a man to have an erection
firm enough or sustain an erection long enough for sexual intercourse.
The two fundamental causes of impotence are physiological and psychological
Causes:- Smoking, alcoholism and substance abuse, including cocaine use, Multiple
sclerosis, Parkinson's disease, Obesity and metabolic syndrome, High cholesterol, High
blood pressure, Diabetes, Heart disease and narrowing of blood vessels, Other relationship
problems such as pressure from a sex partner, Poor communication with a sex partners,
Stress can include work, financial, and emotional problems, Stress , fear, anxiety, or anger,
Depression .
Symptoms:- Inability to have an erection firm enough for penetration, Inability to sustain
an erection, Inability to have an erection.
Diagnostic evaluation:- Psychological test, Arteriogram: Dye is injected to study blood
flow, Hormonal studies, Fasting blood sugar, BUN, Urinalysis, CBC, Physical examination,
History collection regarding sexual history.
Treatment of Erectile dysfunction:- includes Medications and Physical therapy,
counseling, sexual therapy.
Vasodialators are Papaverine and pentolamine.Topical Agents are occasionally used to
enhance venous congestion of the penis e.g. Nitroglycerin ointments- topical vasodilator,
Sildenafil (Viagra).
Testosterone is used as hormonal therapy . It induce libido.
External vacuum devices are used to achieve an erection for short time.
Counseling and sexual therapy classes may be suggested for patients who have identified
impotence.
1. Vascular reconstructive surgery. 2. Inflatable prosthesis. 3. semi rigid prosthesis.
Prostate disorders
Prostate Enlargement:- Prostate enlargement, also known as benign prostatic
hyperplasia, is a common condition that affects older men. It is usually not a serious threat
to health.

14. Symptoms:-Changes in hormone levels in a man’s body due to ageing, Difficult for you to
start urination, Weaken the flow of urine, Strain to pass urine, Frequently need to urinate,
Wake up frequently during the night to urinate, Sudden urge to urinate, Blood in the urine
(haematuria)
Diagnotic evaluation:- International Prostate Symptoms Score (IPSS), Urine tests, Rectal
examination, Prostate-specific antigen (PSA) test
Treatment:- Finasteride or dutasteride, Alpha blockers, Surgery
Dietary Management:- Eggs, Milk, Soya, Fish, Cheese, Chicken
Prostatitis
Prostatitis:- It is a general term that refers to inflammation (swelling) of the prostate
gland, which is caused by an infection.
Etiology:- A bacterial infection is only sometimes responsible. In many cases of chronic
(long-term) prostatitis, doctors can't find any infection in the prostate gland, In these cases,
the cause is poorly understood. Chronic prostatitis is thought to be caused by a number of
suggested factors, including partial blockage of the flow of urine and underlying problems
with the immune system, pelvic floor or nervous system.
Symptoms:- Pain in the pelvis, genitals, lower back and buttocks, Pain when urinating,
Frequent need to urinate, Difficulty urinating, such as problems starting or 'stop- start'
urination, Pain when ejaculating, which may contribute to erectile dysfunction, Discomfort
in the perineal area (the area between the scrotum and the anus)
Diagnosis:- Acute Prostatitis :-Rectal examination.
Chronic Prostatitis:- Blood tests, Ultrasound scan or CTscan, Cytoscope
Treatment:- Acute Prostatitis:- Antibiotic tablets (Paracetamol and/or
ibuprofen),Codeine
Chronic Prostatitis:- Antibiotics, Alpha blockers
DISORDER OF EJACULATION:-
Pre mature ejaculation occurs when a man cannot control the ejaculatory reflex and once
aroused, reaches orgasm beforeor shortly after intromission.
Causes:- are including for premature ejaculation, Neurological disorder (spinal cord injury,
Multiple sclerosis, Neuropathy secondary to diabetes mellitus.
Surgery:- Surgery (prostatectomy) & medications are the most common causes of
inhibited ejaculation.
Behavioral therapies may be indicated for treatment of Premature ejaculation. These
therapies involves both the man and his sexual partner.
Treatment modalities depend on the nature and severity of the ejaculation problem.
MALE INFERTILITY:-
FECUNDITY - probability of achieving live birth within a cycle.
SUBFERTILITY- couples who exhibit decreased reproductive efficiency
INFERTILITY - one year of unprotected intercourse without conception
INTRODUCTION
SPERMATOGENSIS:-During embryogensis, there are approximately 300 thousand
spermatogonia in each gonad. Each undergoes mitotic division, and by puberty 600 million
in each testis.
Transport of sperms – vas deferens

15. Maturation of sperms takes place in epididymis. Leydig cells produce testosterone (which
along with FSH, stimulates spermatogenesis). Adult males produce 100-200 million sperm
each day. Spermatogenesis takes about 70 days Sperm production takes place in
seminiferous tubules within testis.
Physiology of Semen after Ejaculation:-
1. Liquefaction 2. Capacitation 3. Acrosome reaction 4. Cortical reaction 7
Relative prevalence of the etiologies of infertility Percentage Male Factor 20-30 Both male
& Female 10-40 Female Factor 40-55 Unexplained Infertility 10-20 8
Diagnostic evaluation:- SEMEN ANALYSIS:- Abstinence for 2-3 days (Not less than 2 days
& not more than 7 days) Abnormal sperm count - analysis at least after 4 weeks. 9
Semen sample should be examined within an hour after collection. Semen can also be
collected in a silastic condom, which does not contain any antispermicidal agents. Semen
specimen should be collected in a clean container. Longer abstinence intervals - increase in
the proportion of dead, immotile and morphologically abnormal sperms. Short intervals of
abstinence- decreases the sperm density and semen volume.
Parameters Normal Reference Values, Lower Reference Limits Volume 1.5-5.0 mL 1.5 (1.4-
1.7) mL
P H >7.2 Viscosity <3 Sperm Concentration >20 million/mL 15 (12-16) million/mL
Total sperm number >40 million/ejaculate 39 (33-46) million/ejaculate Percent motility
>50% 40 (38-42)% Forward progression >2 (scale 0-4) 32 (31-34)%
Normal morphology >15,30,50% normal 4(3-4)% Round cells <5 million/mL Sperm
agglutination <2 (Scale 0-3) 12
Semen analysis Ejaculate volume and pH:-Low or absent – CBAVD, ejaculatory duct
obstruction, hypogonadism, retrograde ejaculation. High volume (> EDO- semen is acidic
(prostrate secretions), and has no sperm or fructose. Seminal vesicle secretions are alkaline
and contains fructose. 5ml)- Inflammation of accessory gland
Sperm concentration and total sperm count: 1. Azoospermia, Oligospermia
Types:-
OBSTRUCTIVE: blockage in ductal system ( CBAVD, scrotal or inguinal surgery)
NON OBSTRUCTIVE: primary testicular failure, endocrinopathies that suppress
spermatogenesis.
Endocrine and genetic evaluation indicated in men with severe oligospermia.
Total sperm count is the product of multiplying semen volume and sperm
concentration.
Necrozoospermia – all sperms are Leucocytospermia – increased WBC, Aspermia – no
ejaculate Azoospermia- no sperm in semen, Oligoasthenoteratozoospermia – sperm
variables are subnormal Teratozoospermia- increased abnormal sperms
Asthenozoospermia – reduced sperm motility Oligozoospermia - reduced sperm count,
Abnormalities of sperm
Causes:- Idiopathic (40-50%), Disorders of sperm transport (10-20%), Primary gonadal
disorders (30-40%) Hypothalamic pitutary disorders (1- 2%) Causes of Male Infertility,
Obesity, Infections, Chronic systemic illness and malnutrition, Drugs:- Hyperprolactinemia,
Infiltrative disease, Hypothalamic and pitutary tumours Single gene mutations Kallmann
syndrome, Idiopathic isolated gonadotropin deficiency, Hypothalamic pitutary disorders
Treatment:- To identify the individuals whose infertility can neither be corrected or
overcome with ART, in whom adoption or donor sperm are considered. To identify any

16. medical condition that requires specific attention. To identify- Genetic abnormality To
identify the individuals whose fertility cannot be corrected but could be over come by IUI
and ART. To Identify and correct specific cause Evaluation of male infertility
Occupational exposure to tobacco, alcohol and other drugs, Current medications and
allergies, Exposure to environmental toxins, History of exposure to STD, Previous surgery
and its outcome, systemic medical illness Childhood illness and developmental history Any
previous evaluation or treatment of infertility Coital frequency and sexual dysfunction
Duration of infertility and previous infertility.
Diagnostic evaluation:-Digital rectal examination, Secondary sexual characteristics, hair
distribution, and breast development, Presence of any varicocele, Presence and consistency
of both vasa and epididymides Palpation of testes and measurement of their size
Examination of penis, Physical examinations, Vasography Testis bio psy- azoospermia
Renal ultrasonography, Transurethral or transcrotal USG, Endocrine evaluation - FSH, LH,
Testosterone. Urologic evaluation, Semen culture (If pus cells in microscopy) Other
investigations Absence of fructose: Congenital absence of seminal vesicle, Partial duct
obstruction.
Abnormal spermatogenesis- FSH normal/increased, LH, Hypogonadotropic gonadism-
FSH,LH,testosterone low Endocrine evaluation:
Indications: Abnormal semen analysis Serum FSH,LH and testosterone & Testicular failure-
high FSH and LH, low /normal testosterone, testosterone normal Genetic evaluation 1)
Mutations within cystic fibrosis transmembrane conductance regualtor (CTFR gene) 2)
Chromosomal anomalies resulting testicular dysfunction – klinefelter syndrome 3) Y
chromosome deletions associated with abnormalities of spermatogeneis. 26
Trans scrotal ultrasonography: To confirm physical findings. Detect non palpable
varicocele.
Renal ultrasonography: unilateral or bilateral vasal agenesis.
Transrectal ultrasonography: less invasive indicated in diagnosis severe oligospermia or
azoospermia.
Testis biopsy : diagnostic purpose in azoospermic men when the testicular biopsy shows
normal spermatogenesis obstruction to the vas deferens is suspected.
Drugs that impair male infertility
Hypergonadotropic hypogonadism: 1. IVF/ICSE, Donor sperm, Adaptation 2. Androgen,
FSH, Clomiphen 3. Hyperprolactinemia-Dopamine agonists 4. Strict control of DM,
Hypothyroid, Hypogonadotropic hypogonadism: Pulsatile GnRh, hCG, hMG, Testosterone,
Clomiphen citrate, Tamoxifen
Treatment:- Retrograde ejaculation, Neurogenic impotence, Severe Hypospadias
Intrauterine insemination (IUI) 31 For ejaculatory problems(Retrograde ejaculation):
Imipramine , Pseudoephedrine/Ephedrine , Phenylpropalamine, Erectile dysfunction-
PDE5 Inhibitor (Sildenafil), Pretesticular
Contraceptive methods in males
The deliberate prevention of conception or impregnation by any of techniques, drugs or
devices (Birth control)
Contraceptive methods in males:- 1. Conventional method 2. Coitus interruptus 3. Male pill
4. Vasectomy 5. Injection

17. Provide protection against sexually transmitted diseases (STD)Free from side-effects
Easy to use Prevent live sperm from meeting the secondary oocyte Made up from latex
or polyurethane 1) Conventional method • Requires at the time of coiter
CONDOM (failure: 3.6%)
Coitus interruptus
Definition: Withdraw the penis from the vagina and away from a woman's external genitals
before ejaculation to prevent pregnancy
ADVANTAGES AND DISADVANTAGES:- Free Slightest mistake in timing can cause
pregnancy, Readily available, Some amount of sperms might present in pre-ejaculation
liquid, No side effect, Withdrawal disrupts sexual pleasure, Doesn’t need fitting, Doesn’t
need prescription
Precautions: -Properly time withdrawal, Take precautions before coiter again
Male Pill Gossypol:- A chemical found in the seeds of cotton plants-15-20 mg is used daily
for 12-16 weeks, followed by a maintenance dose of 7.5-10 mg per day, Starve the cells –
Low to zero sperm count
ADVANTAGES AND DISADVANTAGES:- Does not affect libido, Hypokalemia, Incomplete
reversibility
Vasectomy
Definition: A minor surgical procedure to cut, clamp or seal the vas deferens (right & left)
to prevent sperms going into the semen
DIFFERENT WAYS IN VASECTOMY a. No-Scalpel Vasectomy; Key-Hole Vasectomy. The
surgeon locates the vas deferens by sensing the scrotum. A numbing medication is given to
the patient. The surgeon makes a tiny hole in the scrotum using a sharp hemostat instead
of a scalpel. The surgeon may pull the vas deferens through the small hole to tie it or cut it.
Stitches are not required, and the incision heals quickly.
Open-Ended Vasectomy:- The patient’s scrotum is shaved and cleaned. A numbing
medication is given into the area. A small surgical cut is made in the upper part of the
scrotum. The vas deferens is tied and cut. The testicular end of the vas deferens is not
sealed. This allows sperm to stream continuously into the scrotum.
The incision is closed using stitches or skin glue. – Open-ended vasectomy may prevent
pressure in the epididymis and testicular pain caused by back pressure.
Vas-Clip Vasectomy – The patient’s scrotum is shaved and cleaned. A numbing
medication is given into the area. A small surgical cut is made in the upper part of the
scrotum. The vas deferens is squeezed shut with a clip to stop the flow of sperm. The
incision is closed using stitches or skin glue.
ADVANTAGES AND DISADVANTAGES:- Safe and convenient method, Reversible but
success rate only 50% to rejoin the vas deferens, Cheap for long term, Does not protect
against ST, Have to wait for few months to confirm zero sperm count in semen, Injection,
Reversible inhibition of sperm under guidance (RISUG), Synthetic polymer styrene maleic
anhydride (SMA), Injection into the vas deferens, Anhydride and hydrolizes in the
presence of water in the spermatic fluid becomes a hydride and has a positive charge.
This disturbs the negative charge of the sperm membrane on contact, Membranes of the
sperm to burst, Still in clinical trials

18. Vasalgel – Injecting the non-hormonal polymer into the vas deferens, Polymer hyrogel that
blocks sperm from coming out of the body, Reversible. Another injection of a different
substance to flush out the polymer. Less invasive than a vasectomy. Still in clinical trials
Male breast cancer
Modified radical mastectomy. The dotted line shows where the entire breast and some
lymph nodes are removed. Part of the chest wall muscle may also be removed.
Breast-conserving surgery. Dotted lines show the area containing the tumor that is
removed and some of the lymph nodes that may be removed.