urological diseases in middle aged men and women

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

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The Lower Urinary Tract Symptoms (LUTS)

FILLING

Frequency & volume

Urgency

Nocturia

Dysuria

VOIDING

Hesitancy

Weak stream

Intermittency

Terminal dribbling

Feeling ofincomplete emptying

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BPH and its treatments can provoke sexual dysfunction

BPH BPH treatments

LUTS Sexual dysfunction

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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

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Urinalysis

Standard examination for the detection of:

- Haematuria,

- Proteinuria,

- Pyuria.

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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

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Investigations

• Urinalysis, urine m/c/s.• Plain abdominal X-ray(KUB)• IVU• Abdominal ultrasound• CT Scan• MRI• Urethrocystoscopy and retrograde

pyelography

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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.

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TREATMENT.

Observation for spontaneous passage Indication –stones < 5mm

Measures –• Adequate pain control• Liberal fluid intake aiming at urine output of 2-

3L/ day

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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