urological diseases in middle aged men and women
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UROLOGICAL DISEASES IN MIDDLE AGED MEN AND WOMEN
Dr. BIOKU Muftau
OUTLINE
• INTRODUCTION
• CLASSIFICATION OF UROLOGICAL DISEASES
• COMMON UROLOGICAL DISEASES IN MIDDLE AGED MALES AND FEMALES
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
Male genitalia
CLASSIFICATIONS
• URODYNAMIC• ONCOLOGIC• STONES• RECONSTRUCTIVE• ANDROLOGIC
CONT’D
URODYNAMIC• BPH• NEUROGENIC DBLADDER• URINARY INCONTINENCE
ONCOLOGIC• PROSTATE CANCER• BLADDER TUMOUR• RENAL • TESTICULAR• PENILE
CONT’D
STONE DISEASES• KIDNEYS• RENAL PELVIS• URETER• KIDNEYS• BLADDER• URETHRAL
ANDROLOGIC• ERECTILE DYSFUNCTION• MALE INFERTILITY• INTERSEX DISORDER
CONT’D
CONGENITAL DXS• PUJ OBSTRUCTION• POLYCYSTIC KIDNEY• RENAL AGENESIS
OTHERS • UTI• EPIDIDYMO-ORCHITIS• URETHRAL STRICTURE• PENILE FRACTURE
URINARY TRACT INFECTION
• Inflammatory response of urothelium to bacterial invasion
CLASSIFICATIONS• Urethritis• Prostatitis -Complicated UTI• Cystitis -Uncomplicated UTI• pyelonephritis
Prevalence of UTIAge Female Male
Infants (<1 year) 1% 3%
School (<15 years old) 1-3% < 1%
Reproductive 4% <1%
Elderly 20- 30% 10%
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
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
Pyelonephritis
1. Inflammation of renal pelvis and parenchyma (functional kidney tissue)
Results from an infection that ascends to kidney from
lower urinary tract
ManifestationsRapid onset with chills and feverMalaiseVomitingFlank painCostovertebral tendernessUrinary frequency, dysuria
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
b. Voiding cystourethrography c. Cystoscopy
d. Manual pelvic or prostate examinations to assess structural changes of genitourinary tract, such as prostatic enlargement, cystocele, rectocele
TREATMENT
•Antibiotics used are; Beta lactams Tetracyclines Co- trimoxazole Quinolones Aminoglycosides Nitrofurantoin Phenazopyridine
•SURGERY :to correct anatomic abnormality
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
BENIGN PROSTATIC HYPERPLASIA
Anatomy
PROSTATE
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%
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
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
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
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
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
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
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
Training slides - Volume 1 - Document designed for internal use only . 29
Urinalysis
Standard examination for the detection of:
- Haematuria,
- Proteinuria,
- Pyuria.
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
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
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
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
TREATMENT OPTIONSMILD SYMPTOMS
• WATCHFUL WAITING
MODERATE SYMPTOMS
• MEDICAL THERAPY
SEVERE SYMPTOMS
• MINIMAL ACCESS SURGERY• OPEN SURGERY
PROSTATE CANCER
EPIDEMIOLOGY
• Most important malignancy in the male genitourinary tract.
• 95% of cancers are detected in men 45-89 years old. (median age 72 years.)
EPIDEMIOLOGY.
• Eunuchs do not develop Cancer of the prostate gland.
• Highest incidence in African-Americans
• Most common cancer in men in Nigeria.
EPIDEMIOLOGY.
Nigeria – 127/100,000 – 1997.
• 5-10% of cancers are inherited in autosomal dominant manner
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
PRESENTING SYMPTOMS.
• Asymptomatic
PRESENTING SYMPTOMS.
IRRITATIVE SYMPTOMS.
URGENCY.
FREQUENCY.
NOCTURIA.
OBSTRUCTIVE SYMPTOMS.HESITANCY.
POOR URINARY STREAM.
URINARY RETENTION.
PRESENTING SYMPTOMS.
SYMPTOMS OF METASTASES.
• EASY FATIGUABILITY.
• PARAPLEGIA.
• RESPIRATORY DIFFICULTIES.
D.R.E FINDINGS.
• PROSTATE IS ENLARGED.
• HARD IN CONSISTENCY. • IRREGULAR.
• OBLITERATION OF SULCI.
INVESTIGATIONS.
• ULTRASOUND: TRANSRECTAL / TRANSABDOMINAL
Heterogenous architecture
Hypoechoic areas
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.
P.S.A
• ELEVATED PSA IS HOWEVER NOT CANCER SPECIFIC.
INVESTIGATIONS.
• BIOPSY
• BONE SCAN
• MRI
TREATMENT OPTIONS.
• WATCHFUL WAITING.
TREATMENT OPTIONS.
SURGERY.
RADICAL PROSTATECTOMY
RADIOTHERAPY.
RADICAL:
TELETHERAPY
BRACHYTHERAPY
TREATMENT OPTIONS.
HORMONAL MANIPULATION.
ORCHIDECTOMY.
LHRH ANALOGUES.
MAXIMUM ANDROGEN BLOCKADE.
TREATMENT OPTIONS.
CHEMOTHERAPY.
ESTRAMUSTINE PHOSPHATE SODIUM.
MITOXANTRONE + STEROID.
TREATMENT OPTIONS.
• Biphosphonates.
• Epidermal Growth-factor inhibitors.• Platelet derived Growth-factor
inhibitors.
• Docetaxel.
SUPPORTIVE CARE.
PAIN CONTROL.
ANALGESICS.
RADIOTHERAPY.
SUPPORTIVE CARE.
PAIN CONTROL.
RADIO-ISOTOPES.
Phosphorous 32
Strontum 89
Samarium 153(haematological complications)
SUPPORTIVE CARE.
• CONTINENCE CONTROL
• ANAEMIA
• PARAPLEGIA
UROLITHIASIS
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)
Type of stone
CALCIUM OXALATE(60%) Hard, irregular, spiculated Usually single. Yellow– red. Formed in acid urine. Pure or mixed wt CaPO4. Radio-opaque
Types ctd
PHOSPHATE STONE(30%)CaPo4, NH4MgPo4 or
CaNH4MgPo4(triple phosphate)White or greenish yellowCrumbly & radio-opaqueFormed in alkaline urineCommon sec vesical calculus
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
Types ctd
CYSTINE STONE(1—3%) Multiple( may aggregate 2 form stag
horn) Soft Yellow changes to green on exposure
to light radioopaque
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
PATHOLOGICAL EFFECTSSEC HYDRONEPHROSIS INFECTIONMETAPLASIAANURIAPERIURETHRAL ABSCESS
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
PATHOLOGICAL EFFECTSSEC HYDRONEPHROSIS INFECTIONMETAPLASIAANURIAPERIURETHRAL ABSCESS
CLINICAL PRESENTATION
• Pain caused by obstruction• Haematuria• Nausea and vomiting• Irritative/Obstructive voiding symptoms
• Physical examination
4/3/2008 69
Investigations
• Urinalysis, urine m/c/s.• Plain abdominal X-ray(KUB)• IVU• Abdominal ultrasound• CT Scan• MRI• Urethrocystoscopy and retrograde
pyelography
4/3/2008 70
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.
4/3/2008 71
TREATMENT.
Observation for spontaneous passage Indication –stones < 5mm
Measures –• Adequate pain control• Liberal fluid intake aiming at urine output of 2-
3L/ day
4/3/2008 72
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
4/3/2008 73
TREATMENT.
Bladder stones• Cystolitholopaxy• Cystolithotripsy
– Electrohydraulic– Ultrasonic– Pneumatic lithotripsy– Holmium Yag laser
• ESWL• Percutaneous cystolithotomy
4/3/2008 74
TREATMENT.
Indications for stone removal• Intractable pain• Non-progressing calculus(impacted)• Infection• Prolonged obstruction• Stones >5mm
4/3/2008 75
TREATMENT.
• Complications of ESWL.– Bleeding– Perinephric haematoma– Stein straisse
• Contraindications - Bleeding disorders - Acute infections - Pregnancy
4/3/2008 76
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
4/3/2008 77
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
4/3/2008 78
ERECTILE DYSFUNCTION
• Inability to have penile erection sufficient for satisfactory sexual intercourse
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).
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 .
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
CLASSIFICATIONS
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
ADDITIONAL ENDOCRINE TESTING
• PROLACTIN
• LH & FSH
• OESTROGEN
• DHEA – DihydroepiandosteroneOTHER OPTIONAL TESTS• PSA• TFT• Serum Cr• Scrotal USS
Treatment fo ED - General
• Life syle changes• Psychotherapy• Stopping offending drugs• Hormonal teratment
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
Semi-rigid (malleable) penile prosthesis
3-piece inflatable penile prosthesis in place
MALE INFERTILITY
DEFINITION
» Inability to achieve a pregnancy after 1 year of unprotected and adequate sexual
intercourse» Primary/Secondary
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.
AETIOLOGY
a) Pre-testicularb) Testicularc) Post-testicular
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
4) Systemic disorders- Liver diseases, Renal dxs, Amyloidosis, SCD, Kartagener’s syndrome, Leukaemia, Lymphoma, Inflammatory bowel dx.
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)
5) Drugs- Cytotoxics(cyclophosphamide), Nitrofurantoin, Steroids, Antihypertensives,
Cimetidine.6) Torsion7) Neoplasm - Testicular
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.
5) Neurological disorder- Spinal cord injury, xle sclerosis.6) Abnormalities of penis – hypospadias,
epispadias, impotence, micropenis.
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)
» 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
» Premature ejaculation » Proper deposition of semen (deep
penetration, hypospadias) » Dyspareunia/lubrication3) Genitourinary hx » Testicular descent –unilateral, bilateral. » Onset of puberty, 2° Sexual
characteristics.
» 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
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
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
3) DRE – prostate, seminal vesicles (present or absent, not usually palpable)
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
» 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
» Physical Semen parameters • Colour – grayish • pH - 7.2 – 8.0 • Fructose – in case of azoospermia &
volume < 1ml » Interpretations • Aspermia • Oligospermia • Azoospermia • Asthenospermia • Teratospermia
2) Urinalysis (m/c/s) » r/o infection3) Endocrine evaluation » Serum LH, FSH, testosterone,
prolactin4) Others – Thyroid and Adrenal function5) Genetic testing » Karyotype
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
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
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
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
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
» -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
» Varicoceles – do varicocelectomy • Transvenous angiographic
embolisation /balloons/stainless steel sclerosis agent introduction
• Surgical ligation • Laparoscopic ligation
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
(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
» tx • stimulation of production • artificial insemination- IUI, IVF,
ICSI(e) Abnormal morphology » Unusual, transient, self-limiting » No known tx
» ART (a) IUI – Male factor infertility Cervical mucus problem Anatomical cervical difficulty (sperm
deposition) (b) IVF (c) GIFT (d) ZIFT
(e) ICSI – poor fertilizing capacity of
sperm - IVF & ICSI should not be done
without prior karyotyping» Adoption
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