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Male Infertility: 60% couples conceive w/in 3mos 90% w/in 1 yr if not using protection

Infertility: 40% strictly male problem.  Another 20% male contributing to problem

Eval: illnesses(mumps), surgery, delayed puberty, meds, toxing, cigs, pot, lubricants

Phys: genitals, Klinefelters habitus, visual field defects, olfactory (hypothalamus), gynecomastia, varicocele

Semen – 3 samples after abstinence for 24 hours

o

low volume, decreased testosterone, retrograde ejaculation, duct obstruction

Tx:

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Retrograde ejac: sympathommimetrics or retrieve sperm from bladder for in vitro

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Obstruction: fructose test (should be fructose in ejac) TRUS

Tx w/ transurethral resection

o

Azoospermia:

Rule out CF

Atrophic testicles, increased FSH --> counsel for adoption

Normal findings – scrotal exploration

Varicocele – it’s possible to repair… may help

Impotency: 85% causes are organic

Vasculogenic – most common cause impotency: arterial insufficiency

o

HTN, hyperlipidemia, DM, cigs, pelvic trauma

Endocrinologic: low testosterone low libido

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Hypogonadotropic hypogonadism + pituitary adenoma possible etiology

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Serum testosterone level if low get Gn + prolactin levels then get MRI pituitary

Psychogenic: anywhere from minor component to entirely responsible

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REM sleep erections: if no erections while sleeping; cause = organic

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Neurogenic – spinal cord injury, MS, alocohol, DM, Surgery

Eval:

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Nocturnal tumescence, duplex US after pharmacologic erection, carvenosometry, pudendal arteriography

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Usually not performd except in young men who have had pelvic trauma (in older men it’s irreversible)

Tx:

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Vaccum for erection; restrictive band for maintaining

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Urethral suppository (alprostadil)

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Prosthesis – LAST RESORT

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PDE inhibitor Viagra – Smooth muscle relaxation (contraindicated in nitrates used)

Bladder Catherterization: procedure on page 461

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Clean w/ iodine, lube it up, insert (as far as possible on males), wait for urine output, inflate balloon

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Probs: resistance – DON’T FORCE!!

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More lube

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Coude cath – larger upward point sheath to get around prostate

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If stricture – consult urology

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