MEN’S HEALTH

Systems III

Dr. Alex Alexander

WTR 2013

MALE REPRODUCTIVE ANATOMY

• Immature sperm are formed in the testes (formation depends on cooler temps)

• Sperm mature as they pass thru 20 ft long epididymis (a 20 day cruise), a coiled tube that sits on top of each testicle

• Sperm then travel thru the vas deferens to the seminal vesicle where they are stored and mix with mucous that is made here.

• Upon demand, sperm pass thru the ejaculatory duct into the prostate gland where it meets up with the urethra. Cowper’s gland contributes more mucous for easy passage thru the urethra

• Sperm then travel in what is now called semen out the urethra. Urine cannot pass when semen is exiting.

MALE SEXUAL DEVELOPMENT

• At age 10-14, boys begin puberty, which lasts until 15-17 years old

• The signs that the testes are maturing are the production of testosterone (secondary sexual characteristics) and sperm (ejaculation).

• First ejaculation often involuntary and at nighttime (“wet dream”) which is normal.

• LHRH (leutinizing hormone releasing hormone) produced by the hypothalamus and tells the pituitary to secrete LH and FSH.

• LH triggers the production of testosterone • FSH triggers the production and development of sperm

TESTOSTERONE

• Male sex drive• Growth of penis, testes, and scrotum• Growth of larynx and deepening of voice• Rugae in scrotal skin• Growth of seminal vesicles and secretion of fluids rich in

fructose• Growth of prostate gland• Secretion of prostatic fluid• Stimulation of sperm production• Maintenance of erectile function• Fusion of bone growth plates• Maintenance of muscle bulk

DIHYDRO-TESTOSTERONEVIA 5-ALPHA REDUCTASE IN PROSTATE AND HAIR FOLLICLES

• Growth of hair on face, in armpits, and on extremities

• Male pattern pubic hair growth• Male pattern baldness• Acne• Benign enlargement of the prostate gland

WHAT IS CIRCUMCISION?• Surgical removal of all or part of the foreskin of the penis• Advocates for circumcision that it provides important health

advantages which outweigh the risks, has no substantial effects on sexual function, has a low complication rate when carried out by an experienced physician, and is best performed during the neonatal period

• Opponents of circumcision argue, for example, that it is a practice which has historically been, and continues to be, defended through the use of various myths; that it interferes with normal sexual function; is extremely painful; and when performed on infants and children violates the individual's human rights.

• The AMA stated in 1999: "Virtually all current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision, and support the provision of accurate and unbiased information to parents to inform their choice."

ERECTILE FUNCTION

ERECTILE DYSFUNCTION

• The inability to achieve or maintain an erection sufficient for sexual intercourse at least 25% of the time.

• Can indicate an underlying medical problem; no longer thought of as “normal with aging”.

• Under-diagnosed due to the embarrassment factor, but being talked about more since the marketing of Viagra

• Often is psychological, although there are many physical reasons for it too. Often multi-factorial.

• If men awaken with an erection or are able to achieve/maintain erection during masturbation, suggests psychological causes

CAUSES OF ED• Athersclerosis• Heart, lung, kidney, liver disease• High blood pressure• Diabetes• Obesity• Medications (antidepressants, antihistamines, high blood pressure

meds, pain meds)• Tobacco, alcohol, drug use• Neuro problems: Parkinson’s, MS, spinal cord or nerve injury, stroke• Low testosterone levels• Treatments for prostate issues• Depression, anxiety, stress, fatigue• Communication problems or conflict with partner• Cycling

TREATMENT FOR ED

• Address underlying cause as best as possible• Phosphodiesterase inhibitors (Viagra, Cialis,

Levitra)– Should NOT take if you are on some other meds

(nitrates, coumadin), if blood pressure is very low or uncontrolled high, out of control diabetes, heart disease, or if you’ve had a stroke

• Prostaglandin E• Testosterone replacement if low• Penis pumps and implants• Counseling, sex therapy

THE PROSTATE GLAND

• The main function of the prostate is to store and secrete a clear, slightly alkaline (pH 7.29) fluid that constitutes 10-30% of the volume of the seminal fluid that, along with sperm, constitutes semen. The rest of the seminal fluid is produced by the two seminal vesicles. The alkalinity of seminal fluid helps neutralize the acidity of the vaginal tract, prolonging the lifespan of sperm

THE PROSTATE GLAND

• A healthy human prostate is slightly larger than a walnut. It surrounds the urethra just below the urinary bladder and can be felt during a rectal exam

BENIGN PROSTATIC HYPERPLASIA

• Enlargement of the prostate gland that occurs naturally with age (50% by age 50, 75% by age 80)

• Symptoms can include frequency of urination (may be noticed more at nighttime), trouble starting to urinate, decreased stream, or urinary retention (can’t urinate!)

• Can be confused as cancer because of the enlargement and an increased blood concentration of PSA (prostate-specific antigen)

BPH TREATMENT

• As long as it is benign and not an infection, it doesn’t require treatment unless the symptoms are bad enough

• Initially, cutting back on fluid consumption, esp at bedtime, as well as caffeine and alcohol, can help

• Herbal: Saw palmetto, stinging nettles• Medication options include

– 5-alpha reductase inhibitors (Proscar & Avodart): blocks testosterone to prevent its enlarging effect ED

– Alpha blockers (Flomax, Hytrin, Cardura): relax smooth muscles of the prostate and bladder neck HA, lightheadedness, fatigue

• Surgery– Transurethral resection of the prostate (TURP) may lead to

ED– Laser surgery is less invasive but may not last as long as TURP

PROSTATITIS

• Acute or chronic inflammation of the prostate gland• Usually caused by bacterial infection• Acute: onset of dysuria, frequency, urgency, hematuria,

fever/chills, pain in low back or groin, painful ejaculation. Caused by bacteria in the prostate which may be from bladder or urethral infection (UTI or STD)

• Chronic: many of these symptoms (usu not fever) with a gradual onset and symptoms come and go/wax and wane. Unclear what causes. Maybe bacteria brought from elsewhere in the body or an incompletely treated acute episode.

• Treatment: antibiotics and anti-inflammatories

PROSTATE CANCER

• The Prostate Specific Antigen (PSA) Debate• It is the most common non-skin cancer in America,

affecting 1 in 6 men. A non-smoking man is more likely to develop prostate cancer than he is to develop colon, bladder, melanoma, lymphoma and kidney cancers combined. In fact, a man is 35% more likely to be diagnosed with prostate cancer than a woman is to be diagnosed with breast cancer.

• In 2008, more than 186,000 men will be diagnosed with prostate cancer, and more than 28,000 men will die from the disease. One new case occurs every 2.5 minutes and a man dies from prostate cancer every 19 minutes.

• Risk factors: African American, family history, diet and lifestyle factors

SX’S OF PROSTATE CANCER

• Nocturia and/or daytime frequency• Difficulty starting or holding back urine• Weak or interrupted flow of urine• Dysuria• Erectile difficulty• Painful ejaculation• Blood in urine or semen

PROSTATE CANCER

• Because approximately 90% of all prostate cancers are detected in the local and regional stages, the cure rate for prostate cancer is very high—nearly 100% of men diagnosed at this stage will be disease-free after five years.

• Generally a slow-growing cancer, and often men die of other causes before the cancer affects them.

• If it spreads, it tends to go to the bones.

PROSTATE CANCER

• Treatment for prostate cancer may involve watchful waiting, surgery, radiation therapy including brachytherapy and external beam radiation, High Intensity Focused Ultrasound (HIFU), chemotherapy, cryosurgery, hormonal therapy, or some combination. Important factors are the man's age, his general health, and his feelings about potential treatments and their possible side effects. Because all treatments can have significant side effects, such as erectile dysfunction and urinary incontinence, treatment discussions often focus on balancing the goals of therapy with the risks of lifestyle alterations.

EPIDIDYMIS

• The place where sperm are stored, and when called upon, mature into swimmers and are carried into the vas deferens for transport.

• During ejaculation, sperm flow from the lower portion of the epididymis (which functions as a storage reservoir). They are packed so tightly that they are unable to swim, but are transported via the peristaltic action of muscle layers within the vas deferens, and are mixed with the diluting fluids of the seminal vesicles and other accessory glands prior to ejaculation (forming semen).

EPIDIDYMITIS

Epididymitis is inflammation of the epidydymis, usually caused by infection. Usually an STD (chlamydia and gonorrhea) but can be UTI critters.

Epididymitis usually has a gradual onset. On physical examination, the testicle is usually found to be in its normal vertical position, of equal size compared to its counterpart, and not high-riding. Typical findings are redness, warmth and swelling of the scrotum, with tenderness behind the testicle, away from the middle (this is the normal position of the epididymis relative to the testicle)

Treatment is antibiotics for the infection. If left untreated, can cause chronic epididymitis which can cause infertility.

Epididymitis

VARICOCELE

• Varicocele is an abnormal enlargement of the veins in the scrotum draining the testicles. The testicular blood vessels originate in the abdomen and course down through the inguinal canal as part of the spermatic cord on their way to the testis. Up-ward flow of blood in the veins is ensured by small one-way valves that prevent backflow. Defective valves, or compression of the vein by a nearby structure, can cause dilatation of the veins near the testis, leading to the formation of a varicocele.

• There are most frequently diagnosed when a patient is 15-25 years of age, and rarely develop after the age of 40. They occur in 15-20% of all males, and in 40% of infertile males.

VARICOCELE

• Symptoms of varicocele may include:– Dragging and aching pain in the scrotum. – Feeling of heaviness in the testicle(s) – Infertility – Atrophy (shrinking) of the testicle(s) – Visible or palpable (able to be felt) enlarged

vein (bag of worms)

• Treatment is scrotal support, ligation of the vein surgically, or venous embolization

Varicocele

VASECTOMY

• Tying off of the vas deferens for the purpose of sterilization

• Ejaculate maintains 90% of volume• Does NOT affect libido or erectile function (except

sometimes affects men psychologically)• Can be done in a doctor’s office in 10-15 minutes! $350-

500, often subsidized by insurance. No needle/no scalpel technique

• >99% efficacy in the first year, almost 100% after that• Reversal procedures are $7000+ and work about 50% of

the time.

Vasectomy

MALE INFERTILITY

• The most common causes of male infertility include abnormal sperm production or function, impaired delivery of sperm, general health and lifestyle issues, and overexposure to certain environmental elements.

Impaired Production or Function of Sperm

• Impaired shape and/or movement• Low sperm concentration (nl>20million/mL

of semen)• Varicocele (heatlow sperm count/mobility)• Undescended testicle• Low testosterone• Genetic defects• Infections (STDsscarring, mumps)

Impaired delivery of sperm

• ED, premature ejaculation, low libido• Retrograde ejaculation (semen enters bladder,

due to diabetes, medications, or h/o surgery)• Blockage of vas deferens, epididymis, or

ejaculatory ducts• Hypospadia (abnl location of urethral opening)• Antisperm antibodies after vasectomy• Cystic fibrosis (obstructed vas deferens)

General Health and Lifestyle

• Stress low sperm counts• Malnutrition• Obesity• Cancer treatments• Alcohol and drug use• Age• Cycling nerve damage

Environmental Factors

• Pesticide exposure• Overheating testicles• Drugs, esp cocaine and marijuana• Tobacco use

STDs

• Chlamydia• Gonorrhea• Herpes• HPV

INGUINAL HERNIA

• Protrusion of abdominal cavity contents through the inguinal canal

• Direct or Indirect• 7% of population will have one – common• Occur more often in men due to the passage for the

descent of the testicles• Hernias present as bulges in the groin area that can

become more prominent when coughing, straining, or standing up. They are often painful, and the bulge commonly disappears on lying down

• Complication is strangulation of intestines• Recommended is surgical repair to prevent emergency

surgery sometime later

THE END