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Urinary Tract and Male Reproductive Disorders

Ureteritis cystica:
Due to inflammation.

Retroperitoneal fibrosis:
Idiopathic. Due to: Ergot derivatives, sclerosing preconditions, lymphoma. Complications: hydronephrosis.

Congenital disorders: exstrophy of bladder:


Developmental failure of anterior abdominal wall and bladder.

Complications:
Glandular metaplasia, adenocarcinoma.

Cystitis:
UTIs. Common in females due to: short urethra, ascending infection. Catherization. Diabetes mellitus, cyclophosphamide, Schistosoma hematobium. Acute cystitis: E. coli, adenovirus, S. saprophyticus, acute urethral syndrome in women due to C. Trachomatis.

Findings:
Dysuria, urgency, suprapubic discomfort, hematuria.

Lab:
Pyuria, bacteriuria, hematuria; + dipstick for leukocyte esterase and nitrite.

Asymptomatic bacteriuria in women:


Pregnancy, elderly, diabetes mellitus.

Sterile pyuria:
C. trachomatis, renal TB, acute tubulointerstitial nephritis.

Malacoplakia:
E. coli.

Findings:

Michaelis-Gutmann bodies (foamy macrophages), defective phagosomes.

Bladder tumors:
Bladder papilloma:
Uncommon, benign.

Transitional cell carcinoma:


Male dominant. Most common. Smoking, aniline dyes, cyclophosphamide, S. hematobium. Painless hematuria, dysuria.

Squamous cell carcinoma:


S. hematobium. Common in Egypt. Type II hypersensitivity reaction related to S. hematobium eggs.

Embryonal rhabdomyosarcoma:
AKA sarcoma botryoides. Common in children. Grape-like mass in urethra of boys.

Infections:
Chlamydial and gonococcal infections.

Reiter's syndrome in men:


Chlamydial urethritis, conjunctivitis, HLA-B27-associated arthritis.

Carcinoma in situ:
Bowen's disease:
Penis shaft and scrotum.

Erythroplasia of Queyart:
Erythroplakia on glans and prepuce; HPV type 16 association.

Bowenoid papulosis:
Multiple pigmented reddish-brown papules on external genitalia; HPV type 16 association.

Squamous cell carcinoma:


Most common penile cancer. HPV type 16, 18 association in most cases; smoking. Risk: lack of circumcision.

Epididymitis:
Causes:

TB.

Infection in younger than 35 years old:


N. gonorrhoeae, C. trachomatis.

Infection in older than 35 years old:


E. coli, P. aeruginosa.

Findings:
Scrotal pain, swelling, tenderness. Discharge, Prehn's sign.

Varicocele:
Blocked right renal vein; blocked left spermatic vein.

Testicular tumors:
Risk factors:
Cryptorchid testicle, testicular feminization, Klinefelter's symdrome (XXY).

Findings:
Unilateral painless enlargement of testes. Increased: AFP, hCG, lactate dehydrogenase.

Prostatitis:
Acute:
Urinary reflux from urethra to bladder. E. coli, K. pneumoniae.

Chronic:
Abacterial.

Findings:
Fever (acute), lower back pain, painful/swollen gland on rectal examination, dysuria, hematuira.

Diagnosis:
More than 20 WBCs/HPF; increased bacterial count.

Benign prostatic hyperplasia:


Digital rectal exam 50% sensitive. DHT is mediator. Estrogen is co-mediator.

Findings:
Obstruction, hematuria, PSA.

Complications:

Obstructive uropathy, bladder infections, prostatic infarcts.

Prostate cancer:
Most common cancer in adult males. Risk: age, familial, black, smoking, high saturated fats in diet. DHT is mediator.

Findings:
Obstructive uropathy, back pain, alkaline phosphatase is increased, spinal cord compression.

Diagnosis:
Screening (DRE/PSA).

Confirmation:
Needle biopsy.

Spreads to:
Lungs, liver.

Normal physiology:
FSH: stimulates spermatogenesis; inhibited by inhibin. LH: testosterone synthesis in Leydig cells. Prolactin: enhances testosterone function and spermatogenesis; increases GnRH; decreases LH and FSH. Testosterone: maintains male secondary characteristics, libido, enhances spermatogenesis. SHBG: synthesized in liver; decreased by androgens, obesity, hypothyroidism, insulin.

Male hypogonadism:
Decreased testosterone; resistance to testosterone.

Findings:
Impotency, loss of secondary male characteristics, osteoporosis, infertility.

Primary:
Ledig cell dysfunction.

Causes:
Liver disease, renal failure.

Findings:
Decreased testosterone; increased LH, sperm count; normal FSH.

Secondary: hypothalamic/pituitary dysfunction:


Causes:
Delayed puberty, Kallmann's syndrome, hypopituitarism.

Findings:

Decreased testosterone; decreased LH, sperm count; decreased FSH.

Male infertility:
Decreased sperm count due to:
Testicular dysfunction: Leydig cell and/or seminiferous tubule dysfunction. Secondary hypogonadism: pituitary and hypothalamic dysfunction. End-organ dysfunction.

Erectile dysfunction:
Psychogenic, decreased testosterone, vascular insufficiency, neurologic disease (defect in parasympathetic S2-S4 (erection) or sympathetic T12-L1 (ejaculation)), drugs, endocrine disease, penis disorders.

Treatment:
Sildenafil (Viagra); Yohimbe.