Male Reproductive & Sexual Function:

The organs of the male reproductive system are specialized for the following functions:

 To produce, maintain and transport sperm (the male reproductive cells) and protective
fluid (semen)
 To discharge sperm within the female reproductive tract
 To produce and secrete male sex hormones

The male reproductive anatomy includes internal and external structures.

The external structures of the male reproductive system are the penis, the scrotum and the
testicles.
 Penis — The penis is the male organ for sexual intercourse. It has three parts: the root,
which attaches to the wall of the abdomen; the body, or shaft; and the glans, which is the
cone-shaped end of the penis. The glans, which also is called the head of the penis, is
covered with a loose layer of skin called foreskin. (This skin is sometimes removed in a
procedure called circumcision.) The opening of the urethra, the tube that transports semen
and urine, is at the tip of the glans penis. The penis also contains a number of sensitive
nerve endings.

The body of the penis is cylindrical in shape and consists of three internal chambers.
These chambers are made up of special, sponge-like erectile tissue. This tissue contains
thousands of large spaces that fill with blood when the man is sexually aroused. As the
penis fills with blood, it becomes rigid and erect, which allows for penetration during
sexual intercourse. The skin of the penis is loose and elastic to allow for changes in penis
size during an erection.

Semen, which contains sperm, is expelled (ejaculated) through the end of the penis when
the man reaches sexual climax (orgasm). When the penis is erect, the flow of urine is
blocked from the urethra, allowing only semen to be ejaculated at orgasm.

 Scrotum — The scrotum is the loose pouch-like sac of skin that hangs behind the penis.
It contains the testicles (also called testes), as well as many nerves and blood vessels. The
scrotum has a protective function and acts as a climate control system for the testes. For
normal sperm development, the testes must be at a temperature slightly cooler than the
body temperature. Special muscles in the wall of the scrotum allow it to contract (tighten)
and relax, moving the testicles closer to the body for warmth and protection or farther
away from the body to cool the temperature.
 Testicles (testes) — The testes are oval organs about the size of very large olives that lie
in the scrotum, secured at either end by a structure called the spermatic cord. Most men
have two testes. The testes are responsible for making testosterone, the primary male sex
 hormone, and for producing sperm. Within the testes are coiled masses of tubes called
seminiferous tubules. These tubules are responsible for producing the sperm cells through
a process called spermatogenesis.
 Epididymis — The epididymis is a long, coiled tube that rests on the backside of each
testicle. It functions in the carrying and storage of the sperm cells that are produced in the
testes. It also is the job of the epididymis to bring the sperm to maturity, since the sperm
that emerge from the testes are immature and incapable of fertilization. During sexual
arousal, contractions force the sperm into the vas deferens.

The internal organs of the male reproductive system, also called accessory organs, include the
following:

 Vas deferens — The vas deferens is a long, muscular tube that travels from the
epididymis into the pelvic cavity, to just behind the bladder. The vas deferens transports
mature sperm to the urethra in preparation for ejaculation.
 Ejaculatory ducts — These are formed by the fusion of the vas deferens and the seminal
vesicles. The ejaculatory ducts empty into the urethra.
 Urethra — The urethra is the tube that carries urine from the bladder to outside of the
body. In males, it has the additional function of expelling (ejaculating) semen when the
man reaches orgasm. When the penis is erect during sex, the flow of urine is blocked
from the urethra, allowing only semen to be ejaculated at orgasm.

Three types of accessory vesicles:

 Seminal vesicles — The seminal vesicles are sac-like pouches that attach to the vas
deferens near the base of the bladder. The seminal vesicles produce a sugar-rich fluid
(fructose) that provides sperm with a source of energy and helps with the sperms’
motility (ability to move). The fluid of the seminal vesicles makes up most of the volume
of a man’s ejaculatory fluid, or ejaculate.
 Prostate gland — The prostate gland is a walnut-sized structure that is located below the
urinary bladder in front of the rectum. The prostate gland contributes additional fluid to
the ejaculate. Prostate fluids also help to nourish the sperm. The urethra, which carries
the ejaculate to be expelled during orgasm, runs through the center of the prostate gland.
 Bulbourethral glands — The bulbourethral glands, or Cowper’s glands, are pea-sized
structures located on the sides of the urethra just below the prostate gland. These glands
produce a clear, slippery fluid that empties directly into the urethra. This fluid serves to
lubricate the urethra and to neutralize any acidity that may be present due to residual
drops of urine in the urethra.

The entire male reproductive system is dependent on hormones, which are chemicals that
stimulate or regulate the activity of cells or organs. The primary hormones involved in the
functioning of the male reproductive system are follicle-stimulating hormone (FSH), luteinizing
hormone (LH) and testosterone.

FSH and LH are produced by the pituitary gland located at the base of the brain. FSH is
necessary for sperm production (spermatogenesis), and LH stimulates the production of
testosterone, which is necessary to continue the process of spermatogenesis. Testosterone also is
important in the development of male characteristics, including muscle mass and strength, fat
distribution, bone mass and sex drive.

Sex Function:
1. sexual desire or libido
2. erectile function
3. orgasm and ejaculation

SEXUAL DESIRE OR LIBIDO

Sexual desire, libido and sex drive are all essentially a man’s desire for sex.
There are a number of factors that can affect sexual desire, both physical and emotional. These
can include:
• stress
• anxiety or depression
• relationship problems
• erectile dysfunction
• premature ejaculation
• pain
• certain types of medication.
The hormone testosterone is produced mainly in the testes and is the main driver of sexual
desire. When the testosterone levels drop, sex drive will diminish. Testosterone levels decrease
with age or as a result of illness or treatment, and in particular after hormone therapy for prostate
cancer.
Conditions particularly likely to decrease libido include hypogonadism, chronic kidney disease,
and depression; up to 25% of men with diabetes may meet the definition of hypogonadism.

Drugs that potentially decrease libido include weak androgen receptor antagonists
(eg, spironolactone, cimetidine), luteinizing hormone-releasing hormone (LHRH) agonists
(eg, leuprolide, goserelin, buserelin) and antagonists (eg, degarelix) used to treat prostate cancer,
antiandrogens used to treat prostate cancer (eg, flutamide, bicalutamide), 5-alpha-reductase
inhibitors (eg, finasteride, dutasteride) used to treat benign prostatic hyperplasia, some
antihypertensives, and virtually all drugs that are active in the CNS (eg, SSRIs, tricyclic
antidepressants, antipsychotics)..

ERECTILE FUNCTION
There are two cylinders of spongy tissues that run either side of the penis (corpus cavernosum).
The third cylinder (corpus spongiosum) runs along the underside of the penis and surrounds the
urethra (urine tube).
 CROSS SECTION OF A PENIS

During an erection, a man first becomes sexually aroused. The brain sends messages down the
spinal cord and through nerves located near the prostate to tell the blood vessels to let more
blood into the spongy cylinders. As these cylinders expand and fill with blood, an erection
occurs

ORGASM AND EJACULATION

After continued sexual stimulation, men usually experience orgasm. Orgasm is the pleasurable
sensation that occurs in the brain generally simultaneously with ejaculation. Sexual pleasure
peaks, accompanied by rhythmic pelvic muscle contractions followed by ejaculation of semen.
Ejaculation is controlled by the sympathetic nervous system. Neural stimulation of the alpha-
adrenergic receptors in the male adnexa (eg, penis, testes, perineum, prostate, seminal vesicles)
causes contractions of the epididymis, vas deferens, seminal vesicles, and prostate that transport
semen to the posterior urethra.

Note: Before ejaculation, sperm is mixed with fluid from the seminal vesicles and the prostate.
Sperm and seminal fluid together make semen.
UROLOGICAL TRAUMA

Mode of injury

4.1.1.2.1 Blunt renal injuries

Blunt mechanisms include motor vehicle collision, falls, vehicle-associated pedestrian accidents and assault [29]. A direct blow
to the flank or abdomen during sports activities is another cause. Sudden deceleration
or a crush injury may result in contusion or laceration of the parenchyma or the renal hilum. In general, renal vascular injuries
occur in less than 5% of blunt abdominal trauma, while isolated renal artery injury is very rare (0.05-0.08%) [14] and renal artery
occlusion is associated with rapid deceleration injuries.

4.1.1.2.2 Penetrating renal injuries

Gunshot and stab wounds represent the most common causes of penetrating injuries and tend to be more severe and less
predictable than blunt trauma. In urban settings, the percentage of penetrating injuries can be as high as 20% or higher [30, 31].
Bullets have the potential for greater parenchymal destruction and are most often associated with multiple-organ injuries [32].
Penetrating injury produces direct tissue disruption of the parenchyma, vascular pedicles, or collecting system.

Recommendations for patient history and physical examination

G
Recommendations
R
Assess haemodynamic stability upon admission. A*
Obtain a history from conscious patients, witnesses and rescue team personnel with regard to the time and setting of the
A*
incident.
Record past renal surgery, and known pre-existing renal abnormalities (UPJ obstruction, large cysts, lithiasis). A*
Perform a thorough physical examination to rule out penetrating injury. Flank pain, flank abrasions and bruising
ecchymoses, fractured ribs, abdominal tenderness, distension or mass, could indicate possible renal involvement.

Urinalysis, haematocrit and baseline creatinine are the most important tests.

indications for renal imaging in blunt trauma are rapid deceleration injury, direct flank trauma, flank contusions, fracture of the
lower ribs and fracture of the thoracolumbar spine, regardless of presence or absence of haematuria

Grade* Description of injury

1 Contusion or non-expanding subcapsular haematoma No laceration
Non-expanding peri-renal haematoma
2
Cortical laceration < 1 cm deep without extravasation
3 Cortical laceration > 1 cm without urinary extravasation
Laceration: through corticomedullary junction into collecting system

or
4

Vascular: segmental renal artery or vein injury with contained haematoma, or partial vessel laceration, or vessel
thrombosis
Laceration: shattered kidney

5 or

Vascular: renal pedicle or avulsion

Blunt renal injuries

All grade 1 and 2 injuries, either due to blunt or penetrating trauma, can be managed non-operatively. For the treatment of grade
3 injuries, most studies support expectant treatment [66-68].

Most patients with grade 4 and 5 injuries present with major associated injuries, and consequently often undergo exploration and
nephrectomy rates

Penetrating Renal injuries

If the site of penetration by the stab wound is posterior to the anterior axillary line, 88% of such injuries can be managed non-
operatively

Following blunt renal trauma, manage stable patients conservatively with close monitoring of vital signs. B
Manage isolated grade 1-3 stab and low-velocity gunshot wounds in stable patients, expectantly. B
Indications for renal exploration include:

 haemodynamic instability;
 exploration for associated injuries; B
 expanding or pulsatile peri-renal haematoma identified during laparotomy;
 grade 5 vascular injury.

Treat patients with active bleeding from renal injury, but without other indications for immediate abdominal operation, with
B
angio-embolisation.
Attempt renal reconstruction if haemorrhage is controlled and there is sufficient viable renal parenchyma. B

4.1.4 Follow-up

Bladder Trauma

4.3.1 Classification
The AAST proposes a classification of bladder trauma, based on the extent and location of the injury [189]. Practically the
location of the bladder injury is important as it will guide further management (Table 4.3.1):

 Intraperitoneal;
 Extraperitoneal;
 Combined intra-extraperitoneal.

Table 4.3.1: Classification of bladder trauma based on mode of action

Non-iatrogenic trauma
• blunt
• penetrating
Iatrogenic trauma
• external
• internal
• foreign body

Epidemiology, aetiology and pathophysiology

4.3.2.1 Non-iatrogenic trauma
Motor vehicle traffic collisions are the most common cause of blunt bladder injury, followed by falls, industrial trauma/pelvic
crush injuries and blows to the lower abdomen
 1. Clinical signs and symptoms of bladder injury

Diagnostic evaluation

4.3.3
4.3.3.1 General evaluation
The cardinal sign of bladder injury is visible haematuria [190, 191].

Signs and symptoms Remarks

Haematuria [190, 191] Visible = cardinal sign
Inability to void [190, 218]
Abdominal tenderness [191]
Suprapubic bruising [190, 218]
Abdominal distension [190, 218] In the case of urinary ascites
Swelling of scrotum, perineum,
abdominal wall and/or thighs [190]
Intraperitoneal rupture => reabsorption of urea nitrogen
Uraemia and elevated creatinine level [190]
and creatinine
Entrance/exit wounds at lower abdomen, perineum or
In penetrating injuries
buttocks [194, 218]

Disease management
4.3.4.1 Conservative management
Conservative treatment comprises clinical observation, continuous bladder drainage and antibiotic prophylaxis [190, 213]. This is
the standard treatment for an uncomplicated extraperitoneal injury due to blunt trauma

Surgical management

a. Blunt non-iatrogenic trauma

Intraperitoneal ruptures should always be managed by formal surgical repair [190, 218] because intraperitoneal urine
extravasation can lead to peritonitis, intra-abdominal sepsis and death [192] (LE: 3).

b.Penetrating non-iatrogenic trauma

The standard treatment is emergency exploration, debridement of devitalised bladder muscle and primary bladder repair (LE: 3)
[194, 195]. A midline exploratory cystotomy is advised to inspect the bladder wall and the distal ureters [190, 194]. In gunshot
wounds, there is a strong association with intestinal and rectal injuries, requiring faecal diversion [194]. Most gunshot wounds
are associated with two transmural injuries (entry and

exit wounds) and the bladder should be carefully checked for those two lesions [194]. As the penetrating agent (bullet, knife) is
not sterile, concomitant antibiotic treatment is advised

Urethral Trauma

4.4.1 Epidemiology, aetiology and pathophysiology

4.4.1.1 Iatrogenic urethral trauma
The most common type of urethral trauma seen in urological practice is iatrogenic, due to catheterisation, instrumentation, or
surgery

Cause Example
 Vehicular accidents
Blunt trauma Fall astride (‘straddle’) e.g. on bicycle, fences, inspection covers
Kicks in the perineum
Penile fractures
Sexual intercourse
Urethral intraluminal stimulation
Gunshot wounds
Stab wounds
Penetrating trauma Dog bites
External impalement
Penile amputations
Constriction bands Paraplegia
Endoscopic instruments
Iatrogenic injuries
Urethral catheters/dilators

TREATMENT
Use retrograde urethrography to evaluate urethral injuries. B
Manage posterior urethral defects with delayed formal urethroplasty. B
Treat partial posterior urethral ruptures by urethral or suprapubic catheterisation. C
Treat blunt anterior urethral injuries by suprapubic diversion.

TREATMENT OF RENAL CELL CARCINOMA

Treatment :

Localized disease

Radical nephrectomy (en bloc removal of the kidney and its enveloping fascia (gerota’s)
including the adrenal, proximal one-half ureter and lymph nodes up to the area transection of
renal vessels) is the primary treatment

Preoperative renal artery embolization limited to patients with extra large tumors and may be
useful to meringankan patients with tumor yg sulit dioperasi and memiliki significant symptoms
(hemorrhage, flank pain or paraneoplastic syndrome)

Radiation therapy as a neoadjuvant or adjuvant methode to radical nephrectomy : no evidence to

prolonged survival
Partial nephrectomy as indication for : solitary kidney, bilateral tumor, poorly functioning
contralateral kidney, small peripheral lession,incidentally detected tumor or malignancy
uncertain preoperatively

Laparoscopic radical nephrectomy : prosedur terkini dengan lebih cepat

pemulihan dengan kemanjuran yang sebanding dengan nefrektomi radikal terbuka

Disseminated disease :

Surgery : historically used as palliative procedure ; some studie show there is median survival of
pts undergoing nephrectomy followed by interferon alpha (IFN-α) versus interferon alone

Radiation therapy : effective palliation to metastatic disese is limited espite the belief that RCC is
a relatively radioresistant tumor

Newer biologic agents : antiangiogenic agents and inhibitors of tyrosine kinase and other cell
cycle activators in RCC

Bevacizumab and Sunitinib can specially inhibit receptor for VEGF (vascular endothelial growth
factor) and PDGF(platelet-derived growth factor) thereby menghambat tumor angiogensis and
tumor progression

Sorefenib is another agent can inhibit VEGF and PDGF and demonstrated progression free
survival for 5 months compare to the 2.8 months progresssion-free survival wiyh placebo

Temsirolimus is an agent which inhibits mTOR, to inhibit angiogenesis

Sunitinib and Sorefenib have been FDA-approved for use in patients with stage lanjut renal cell
cancer