This document provides an overview of common male reproductive system problems, including the prostate, hernias, and erectile dysfunction. It discusses the normal anatomy and histology of the prostate, as well as common prostate issues like benign prostatic hyperplasia (BPH) and prostate cancer. BPH causes urinary symptoms and is treated medically or surgically. Prostate cancer risk increases with age and can metastasize. Erectile dysfunction has many potential causes and treatments like PDE5 inhibitors. Other issues addressed include varicocele, testicular torsion, and testicular cancer.

1. Problems of the Male
Reproductive System
Prostate, Hernias and ED

2. We will cover
1) Normal structure and function of the
prostate
2) Benign Prostatic Hyperplasia
3) Prostate Cancer
4) Erectile Dysfunction

3. Prostate: Key Facts- Histology
1) It’s a glandular organ- tubuloalveolar gland
2) Has a fibromuscular stroma
3) Surrounds the prostatic urethra

4. Cross- section of normal prostate

6. Prostate: Key Facts- Anatomy
1) Relations: a) Superiorly- Bladder neck
b)Inferiorly- External sphincter
c) Anteriorly- Pubic symphysis
d) Posteriorly- Rectum
e) Laterally- Levator Ani

9. Prostate: Key Facts- Anatomy
1) Most of its blood supply comes from the
inferior vesical arteries
2) Dual innervation from parasympathetic and
sympathetic nerves

10. The 3 Zones of the Prostate (McNeal)
1) Transition Zone- around urethra (BPH)
2) Central Zone- Around the ejaculatory ducts
3) Peripheral Zone- Around the other two
areas!(Cancer)
(Plus anterior fibromuscular zone)
Only way to properly understand them is 3-D
visualization

12. And again

14. What the prostate does:
• Proteolytic secretions- liquefaction of semen
• Nutritional secretion- eg citric acid
• PSA- ‘unknown’ function but important
clinically!

15. Prostate Pathology
3 Processes:
1) BPH
2) Carcinoma
3) Inflammation (not covered today)

16. Benign Prostatic Hyperplasia
• Weighs 20grms
• 3 long x 4 wide x 2 AP
• Increases with increasing age:
• Half over 40 have histologic hyperplasia, half
of them get symptoms, and only a few suffer
from significant complications
• STILL A VERY COMMON PROBLEM!!!

17. BPH- What is it?
• Hyperplasia of both the glands and the stroma
• Almost invariably in the transitional zone
• Symptoms progressive- spectrum from mild to
complete urethral obstruction

19. Aetiology
• Decreased rate of cell death in the prostate
• Castration- prostate shrinks
• DHT(dihydrotestosterone) makes it grow
• Converted from Testosterone by Type 2 5a-
reductase (type 1 important for effects on
skin).
• This enzyme present in stromal cells

21. Summary on BPH pathology
• Aetiology: Increased age and increased DHT
(plus oestrogen levels, other growth factors)
• DHT from stromal cells but increased size of
both stromal and epithelial cells
• Increase in size because of decreased cell
death
• Mainly in transitional zone around the
prostatic urethra

23. Clinical BPH- LUTs (Prostatism)
• Voiding= SHITE
• Storage= FUN
• Complications: Recurrent UTIs, Urethral
obstruction and post- renal failure, Occasional
haematuria.

24. Voiding
• Slow stream
• Hesitancy
• Intermittent flow
• Terminal dribbling
• Emptying is incomplete

25. Storage
• Frequency
• Urgency
• Nocturia

26. Diagnosing BPH
1) History/symptom score/examination
2) DRE
3) Urinalysis
4) ?PSA
5) Others(depends on case, eg TRUB)

27. PSA Test
Normal ranges:
40 - 49 yrs 0 - 2.5 ng/ml
50 -59 yrs 0 – 3 ng/ml
60 - 69 yrs 0 – 4 ng/ml
> 70 yrs 0 – 5 ng/ml
Less than 10ng/ml is usually due to BHP
BUT raised PSA also because of prostatitis, recent
ejaculation, DRE, etc etc

29. Management- medical
1) Watchful waiting
2) Alpha- blockers eg tamsulosin
3) Competitive inhibitors of T2 5a- reductase eg
finasteride
4) If there is deteriorating renal function or
upper renal tract dilatation -> Surgery?

30. Management- surgical
• TURP
• Open
• Laser ablation
• Transurethral microwave
• High energy ultrasound therapy

31. Prostate carcinoma
• 6th most common ca in the world
• Greatest risk factor= AGE (80% of 80 year olds
have some foci of malignancy)
• Most common= adenocarcinoma
• Unheard of in eunuchs and low incidence in
cirrhosis of the liver!

32. Prostatic adenocarcinoma
1) Most commonly in the PERIPHERAL zone
(Accounts for delayed presentation)
2) Can arise in many foci at once and each focus
might have varied degrees of dysplasia
3) Has a recognized PIN stage
4) PSA >10 plus symptoms likely to have cancer

33. Natural History
• Once again die with it not from it!
• Spread:
a) In the gland
b) To local strucutres- eg bladder
c) Lymph nodes
d) Retrograde venous mets to spine
e) Blood borne to liver lung and bone

36. Symptoms
1) Symtpoms of local disease: BPH- like
symptoms
2) Metastatic symptoms (back pain, weight loss,
anaemia)

37. Diagnosis
1) History and examination PLUS DRE
2) PSA Levels
3) TRUB- confirm a histological diagnosis and
allows for Gleason gradeing
4) Bone scan for mets
5) Further imaging for stageing

38. Management
1) Expectant management if small- die with not
from it
2) Radical prostatectomy- regional disease
3) Radiotherapy- locally advanced
4) Androgen depletion- most are androgen
dependant eg finasteride
5) LHRH analogues for metastatic disease eg
goserelin
6) Abiraterone- CYP17A1 inhibitor for castration
resistant

39. Putting it all together
Incidence
Age
Sex
Gender
Predisposing Factors
Macro
Micro
Spread
Progress

40. Erectile Dysfunction
Definition: Complete inability, inconsistent ability
or short- term erections only
Extremely common with increasing age
Causes a great deal of psychological morbidity,
might be a presenting symptom!!!

41. Erectile Dysfunction is a feature of
many diseases:

42. Anatomy of the Penis

43. Anatomy of the Penis

44. Physiology of erection
1) Flaccid state: SmM of CC arteries/oles is
tonically contracted. Blood flow at minimal
levels
2) Erect state: Vasodilatation with trapping of
blood in the sinusoidal spaces and
compression of the sub-tunical vein plexus.

45. How is vasodilatation achieved?
1) Integration of stimuli: Visual, imaginative,
olfactory, tactile.
2) Activation of ANS, increased parasympathetic
and decreased sympathetic outflow
3) At the molecular level vasodilation achieved
by Nitric Oxide release

46. Role of Nitric Oxide in ED
Sexual
Stimulation
nNOS eNOS
L-Arginine L-Arginine
Nitric
Oxide
Guanylate Cyclase
GTP
GMP
cGMP
PDE-5
cGK I
Erection
GTP, guanosine triphosphate; GMP, guanosine monophosphate;
cGMP, cyclic GMP; nNOS, neuronal nitric oxide synthase;
eNOS endothelial nitric oxide synthase. Burnett AL. Int J Impot Res. 2004;16:S15-S19.

47. Management
1) Is there a cause? Psychogenic or Functional
(neurogenic, vascular, endocrine)
2) PDE-5 Inhibitors eg Viagra
3) Mechanical devices/ Prostheses

48. Other common problems of male
reproductive system
1) Varicocele- usually on the left. Can be
secondary.
2) Testicular torsion- a urological emergency
3) Testicular cancers

49. Any questions you moustache?