Failure of any of these processes impedes descent of the testis into the scrotum, resulting in cryptorchidism, which is widely known to be associated with impaired reproductive potential in later life (Sigman et al, 2009). However, because the inflammation involves the glans penis (which is not removed), the secondary inflammation may also involve the skin graft. The dorsal nerve of the clitoris is the principal somatic sensory innervation of the clitoris and surrounding tissues. The penile shaft is composed of three erectile bodies: the paired corpora cavernosa and the corpus spongiosum. The use of through-and-through skin closures, which give an unacceptable "railroad track" scar, should be avoided. The propionate-testosterone ester is not widely used because of its short-term formulation, requiring 2 or 3 fractionated doses weekly. In cases where adaptation fails, surgical intervention may be an option (Goldstein and Burrows, 2007). Histologic Features Most tumors of the penis are squamous cell carcinomas demonstrating keratinization, epithelial pearl formation, and various degrees of mitotic activity. Given the rarity of these tumors, they are often not suspected preoperatively, and most patients undergo radical orchiectomy. Noting the presence or absence of irrigant leakage from the meatus around the catheter can also help evaluate the possibility of urethral injury. Prevalence of testicular size discrepancy in infertile men with and without varicoceles. Although reversal of testicular growth failure has been documented with intentional testicular artery ligation at the time of retroperitoneal repair in children, the effect of artery ligation on subsequent spermatogenesis is uncertain. A second electroejaculation sequence can be immediately performed under the same anesthetic to obtain additional sperm. In a series of 90 women undergo ing diverticulectomy, 5 (6%) were found to have invasive adenocar cinoma. In addition, this has implications for the diagnosis of ejaculatory duct disorders because "static" anatomic imaging, such as transrectal ultrasonography, may not be sufficient to differentiate between these disorders, and medications and conditions (such as diabetes) might predispose the system to seminal vesicle dysfunction (Smith et al, 2008). Pure septal plaques have also been reported and may result in narrowing, shortening, or no recognized deformity at all (Bella et al, 2007). Thoracic metastasis in the absence of retroperitoneal disease and/or elevated serum tumor markers is uncommon, particularly for seminomas. The patient is positioned with the involved thigh slightly abducted and externally rotated with cushioned support under the flexed knee. Four grafts that have been successfully used for primary urethral reconstruction are the full-thickness skin graft, bladder epithelial graft, oral mucosal graft, and rectal mucosal graft. In the bulky cauda epididymis, the tubule diameter enlarges substantially and acquires an irregular shape. This test in concept extends from pudendal nerve function reflex testing and involves electrophysiologic stimulation with two stimulating electrodes placed at the glans and the base of the penis for obtaining two bulbocavernosus reflex latency measurements. In that series, 67 patients were described, all with follow-up exceeding 5 years and some with 10 years of follow-up. The septum is correctly illustrated as strands that interweave with the tunica albuginea ventrally anddorsally. Variability in these percentages is likely a function of patient selection and the specific template used. Multi-institutional long-term experience with conservative surgery for invasive penile carcinoma. Prevalence of masturbation and associated factors in a British national probability survey. They may be transferred as free flaps but are usually transferred locally, left attached to the vascular pedicle. Gonadal hormones in long-term survivors 10 years after treatment for unilateral testicular cancer. Functional alterations may derive from direct effects of the infectious organism on sperm or through induction of immunologic responses in any male reproductive organ, leading to sperm dysfunction (La Vignera et al, 2011). Metastatic tumors to the penis: a report of 17 cases and review of the literature.
After the patient is correctly positioned, the perineal approach to reconstruction begins with an incision and dissection anterior to the transverse perinei musculature (anterior perineal triangle). Both in vivo animal models and in vitro models provided evidence that testosterone induces coronary vasodilation by modulating the activity of ion channels. EjaculatoryDucts the left and right ejaculatory ducts enter the prostatic urethra at the level of the utricle. The median age at diagnosis is 45 years, but rare cases in boys have been reported. Pressing a valve mechanism in the pump transfers the solution from the reservoirs into the distal, inflatable portion of each cylinder. In these situations, it is comforting to be able to palpate the bladder neck and the properly placed sound before embarking on a dissection beneath the pubis. In the absence of bowel repair/anastomoses, patients are given sips of ice chips on the evening of surgery. Several technical modifications of sonographic evaluation of the penis have been described. Primary lymphatic metastatic spread in testicular cancer occurs ventral to the lumbar vessels. Reliability and safety of current dynamic sentinel node biopsy for penile carcinoma. The cord is then dissected and all the internal spermatic veins are ligated (Dubin and Amelar, 1977). Surgical and behavioral treatments for vestibulodynia: two-and-one-half year follow-up and predictors of outcome. Female sexual dysfunction in a healthy Austrian cohort: prevalence and risk factors. The spermatic cord is grasped with a Babcock clamp and delivered through the wound. For very proximal short-length bulbous strictures, tension-free anastomosis can be facilitated by the dissection of the membranous urethra. In the absence of randomization, these outcomes were likely heavily influenced by selection bias. Androgens modulate endothelial function and endothelial progenitor cells in erectile physiology. Grossly, they are well-circumscribed, unilocular cystic masses filled with keratinized debris that may have a laminated appearance, which gives them the characteristic "onion peel" appearance on ultrasound scan. Proponents posit that draining the scrotum can decrease edema, increase comfort, and decrease the time to initiation of device cycling. Testicular cancer is also one of the most curable solidorgan neoplasms, owing in large part to an excellent multimodal treatment paradigm that includes effective platinum-based chemotherapy and surgery (Einhorn, 1981). Varicocele is found in approximately 15% of the general population, 35% of men with primary infertility, and 75% to 81% of men with secondary infertility. Other authors have found vascular abnormalities, including hypoplasia of the cavernous arteries (Montague et al, 1995) or venoocclusive dysfunction owing to aberrant cavernous venous drainage (Lue, 1999). These agents work by stimulating the release of noradrenaline from the nerve axon terminals but also may directly stimulate both - and -adrenergic receptors. Although the production of prostaglandins and the expression of prostaglandin receptors in the erectile tissue have been clearly demonstrated, their roles in physiologic erection are still undefined. Table 24-1 enumerates percentages of final diagnoses made in one infertility clinic (Sigman et al, 2009). Thus this study failed to confirm the initial high response rate of single-agent methotrexate; the response rate was not significantly higher than that of single-agent cisplatin, and bleomycin pulmonary toxicity was significant (Haas et al, 1999). In some instances patients have been given prolonged courses of antibiotics or topical antifungal preparations before being referred for biopsy. In the "tubewithin-a-tube" design, the inner tube allowed the placement of a baculum during intercourse, and the outer tube provided skin coverage. These studies yielded conflicting results: Shirai and associates (1978) concluded that penile venous flow is increased during erection, but markedly increased arterial flow compensates for this; Wagner (1981) also demonstrated increased arterial flow but concluded that venous drainage is decreased during erection. Regression/resorption of the labia minora is an important and often overlooked anomaly that is most commonly observed in women who are hormonally deficient (Goldstein and Burrows, 2008).
Diseases
Because structures such as the sperm tail share similar microtubular construction with cilia, conditions that affect this architecture frequently result in a variety of other clinical manifestations such as immotile sperm, congenital heart disease, chronic respiratory and otolaryngologic infections, and laterality defects (Ferkol and Leigh, 2012). A 12-Fr or 14-Fr Silastic catheter lubricated with a small amount of mineral oil is used because common lubricants are spermicidal. At the lower dose used to treat male-pattern alopecia (1 mg daily), no sexual dysfunction was seen (Tosti et al, 2001). In adults, circumcision can be done with local anesthesia, by blocking the dorsal nerves at the base of the penis and circumferentially infiltrating the superficial layers of the penile base. When combined, these observations suggest that spermatozoa are able to develop motility based on contact time with the proximal epididymal epithelium. An oral narcotic is often required the first week, followed by nonsteroidal anti-inflammatory medication as needed. Eligible patients had stage Tx, N2 or N3 lymph node metastases, no evidence of distant metastases (M0), and no prior chemotherapy. Pathologic findings and clinical outcome of patients undergoing retroperitoneal lymph node dissection after multiple chemotherapy regimens for metastatic testicular germ cell tumors. The meatus should be examined; if lesions are present, urethroscopy should be performed (Culp et al, 1944; Barrasso et al, 1987). Likewise, the difference between varicoceles that can be seen and those that can only be felt is clinically obvious, and a reasonable grading system would differentiate the two (Niederberger, 2011). Long-term results of laparoscopic retroperitoneal lymph node dissection: a single-center 10-year experience. Although electrofulguration has been reported as a possible treatment of urethral hemangioma, it should be used only to control an acute episode. Skin is one of those tissues, and its properties vary from individual to individual and from place to place on the same individual. To evaluate proximal perforation during surgery, a dilator can be placed in each crura, and their heights can be compared to confirm that one has penetrated too deeply inside the perineum. These disparate findings point to at least three problems with respect to grading and prognosis, including (1) lack of a uniform system, (2) reproducibility of interpretation, and (3) intratumoral heterogeneity of tumor components. Presently, this role remains unclear, owing to limited welldesigned and conducted. The prevalence of sexual dysfunction and/or decreased sexual activity in women with lower urinary tract symptoms varies between 19% and 50% depending on population and means of assessment. Regulation of the differentiated functions of Leydig tumor cells by epidermal growth factor. In a rabbit model of vasculogenic impotence, Azadzoi and colleagues (1997) demonstrated that veno-occlusive dysfunction could be induced by cavernous ischemia. Any additional length loss as a result of the implant may be distressing to the patient and should be addressed preoperatively. Fortunately, laboratory testing to evaluate the presence of leukocytes is not difficult. This practice may be carried out in a variety of settings, from surgical suites using sterile technique or in traditional village ceremonies using crude instruments from the environment. Reproductive parameters of community-dwelling men from 2 regions in Flanders are associated with the consumption of self-grown vegetables. An important concept is that the absence of teratoma in the primary tumor does not reliably exclude its presence in the retroperitoneum (Toner et al, 1990; Beck et al, 2002). In the past, complications related to radical ilioinguinal lymphadenectomy have been significant. Chapter22 MaleReproductivePhysiology 533 changes may influence subsequent sperm transport processes, and hence procedural success, after vasectomy reversal (Dixon et al, 1998). Magnetic resonance imaging and the female sexual response: overview of techniques, results, and future directions. Randomized, doubleblind, placebo-controlled study of postoperative nightly sildenafil citrate for the prevention of erectile dysfunction after bilateral nerve-sparing radical prostatectomy. Patient had a series of penile shunt procedures in attempts to reverse ischemic priapism: Winter, Al-Ghorab, bilateral corpora cavernosa to spongiosum. Laparoscopic retroperitoneal lymphnode dissection with the waterjet is technically feasible and safe in testiscancer patient. Spontaneous contractile activity of cavernous smooth muscle has been recorded in vitro and in vivo. Hypospadias appears to have both genetic and environmental causes, with genetic polymorphisms playing a predominant role rather than isolated gene defects (Macedo et al, 2012).
Early cavernous arterial branching or the presence of multiple such branches may affect blood-flow velocity determinations of the main cavernous artery. Transurethral resection of ejaculatory ducts in the treatment of complete ejaculatory duct obstruction. Laparoscopic retroperitoneal lymph node dissection in a patient with stage 1 testicular carcinoma. In my opinion, the reservoir should always be placed through a separate incision (if the implant is performed via a penoscrotal approach) and placed in a submuscular position. If hematuria if present at this point, it could potentially indicate injury to the bladder wall, which must be ruled out before closing. Effects of medical therapy, alcohol, smoking, and endocrine disruptors on male infertility. Sympathetic fibers to the clitoris are derived from the hypogastric nerve, which is in turn derived from the paravertebral sympathetic chain ganglia (Giuliano et al, 2002). Age-related increase of reactive oxygen species in neat semen in healthy fertile men. The end of the vas toward the seminal vesicles is then cannulated with a 24-gauge angiocatheter sheath and is injected with 1 mL of lactated Ringer solution with a 1-mL tuberculin syringe to confirm its patency. A special case arises in peripubertal boys undergoing cytotoxic chemotherapy for cancer. In contrast to a ventral curvature, with a lateral curvature, the entire dorsal neurovascular bundle does not need to be reflected; it is seldom required and it is not considered beneficial to excise the deep dorsal vein in approaching the dorsum of the penis. Intraoperative ultrasonography is useful during surgical exploration of the testis to locate the lesion. Neuropathy is a common complication of end-stage kidney disease, typically manifesting as a distal symmetrical process with insidious onset progressing over months. Monofilament 10-0 nylon sutures, double-armed with 70-micron diameter taper-point needles bent into a fish hook configuration (available from Sharpoint and Ethicon), are used. It is critical that all instruments are thoroughly scrubbed of all potential debris before undergoing final sterilization. Inguinal Incision An inguinal incision is the preferred approach in men when obstruction of the inguinal vas deferens from prior herniorrhaphy or orchiopexy is strongly suspected. In a survey of childhood cancer survivors, chances of having future offspring were lessened by radiation doses to the testes of 7. Communicating the 5th percentile value as one that likely represents infertility and the 50th percentile as typical for a man conceiving with his wife within 1 year is reasonable practice for clinical urology. Use of magnification to identify and preserve lymphatics can virtually eliminate the risk of hydrocele formation after varicocelectomy (Goldstein et al, 1992; Marmar and Kim, 1994; Glassberg et al, 2008). Balanitis xerotica obliterans: effective treatment with topical and sublesional steroids. These procedures allow for a more thorough assessment of the superficial inguinal nodal basin, do not require specialized equipment, and are associated with less morbidity than standard inguinal lymphadenectomy. The sensitivity of lymphangiography was only 31%, but there were no false-positive results. The next branch of the abdominal aorta is the celiac artery (celiac trunk or truncus coeliacus) which is a short, unpaired artery that arises anteriorly at the midline at the level of T12. These authority-based definitions are discussed in detail on the Expert Consult website. This suggests a glandular source potentially analogous to the male prostate and argues against female ejaculate as urine (Goldberg et al, 1983; Davidson et al, 1989). It is slow growing, and delay in diagnosis in one series ranged from 2 months to 50 years (Kim et al, 1994). The hips have been rotated into position by elevation of the buttocks portion of a specially modified table. This concern is particularly so for autonomic function tests, distinct from somatic function testing, which has been shown to be reproducible and valid.
AndroGel (testosterone 1% gel) is a topical gel pack that contains 50, 75, or 100 mg of testosterone, with only 10% of the drug being absorbed during a 24-hour period. Use of radia tion therapy has increased compared to men treated for urethral carcinoma. Some systems differentiate varicoceles that can be palpated only during the Valsalva maneuver (Nagler and Grotas, 2009). Other nonciliated cells have microvilli suggestive of resorptive activity and predominate in the distal ductuli efferentes. Researchers have investigated a large number of potential male reproductive environmental toxicants. These observations show novel pathways in the etiology of urologic diseases, underscore the links of urologic conditions with overall health, and suggest new interventions for their prevention and treatment. Additional sutures are placed between the mucosal sutures,completingtheanastomosis. The vessels traverse the penis beneath Buck fascia, terminating mostly in the deep inguinal lymph nodes of the femoral triangle. Penile curvature was significantly improved in both the active drug and placebo groups without significant difference. Metabolic syndrome as a precursor of cardiovascular disease and type 2 diabetes mellitus. Acute testicular pain is less common and is caused by rapid expansion of the testis secondary to intratumor hemorrhage or infarction caused by rapid tumor growth. Azoospermia due to aperistalsis of the vas deferens: successful treatment with pseudoephedrine. In many cases (anterior urethral reconstruction), we have found that retrograde urethrography is more confusing than helpful. The urine is reconstituted by centrifugation and the number of sperm in the pellet is counted (Sigman et al, 2009). Given the impact of treatments for testis cancer on fertility, men who are undecided or are planning future paternity are recommended to undergo sperm cryopreservation before treatment is initiated. Chromic suture is rarely used now because the choices of other absorbable sutures seem superior in virtually all cases. The mentor alpha 1 penile prosthesis with reservoir lock-out valve: effective prevention of auto-inflation with improved capability for ectopic reservoir placement. Finally, during contrast-enhanced urethrography, more than one projection may be necessary to visualize the stricture. Risk of bladder cancer in patients with diabetes mellitus: an updated meta-analysis of 36 observational studies. For primary anastomosis of the corpus spongiosum or for a posterior urethral reconstruction, 3-0 suture may be appropriate because of tying concerns. Duplex Doppler ultrasonography: noninvasive assessment of penile anatomy and function. Some men have ectopic testis, in which instead of the testes being side by side, one testis is behind the other. Etiology Any process that injures the urethral epithelium or the underlying corpus spongiosum to the point that healing results in a scar can cause an anterior urethral stricture. These procedures using skin islands oriented on the penile dartos fascia have also been useful for reconstruction of the fossa navicularis (Cohney, 1963; Blandy and Tresidder, 1967; Brannen, 1976; De Sy, 1984; Jordan, 1987; Armenakas et al, 1998). In this section, we review the contemporary treatments and focus on placebocontrolled studies when possible. Fistulae associated with inflammatory strictures occur as periurethral tracts and develop secondary to high-pressure voiding of infected urine. Given this finding and the chemoresistance of teratoma, adjuvant chemotherapy is not recommended in these patients. It would seem intuitively obvious that knowing the length of distraction would be helpful in determining the precise approach and steps necessary for reconstruction. These were mainly infectious in nature and were managed with intravenous antibiotics or incision and drainage. Examination of fresh, unfixed tissue for the presence of sperm with tails and possible motility, and examination of multiple samples if sperm are not found initially, is now recommended.
Syndromes
In infertile men with low serum testosterone levels, microsurgical varicocelectomy alone results in substantial improvement in serum testosterone levels (Su et al, 1995; Cayan et al, 1999; Younes, 2003; Rosoff et al, 2009; Tanrikut et al, 2011). Metastatic carcinoma to the testis: a clinicopathologic analysis of 26 nonincidental cases with emphasis on deceptive features. Pharmacoangiographic evidence of the presence and anatomical dominance of accessory pudendal artery(s). However, the use of this test has been questioned, and it has been shown that a full battery of electrophysiologic tests evaluating limb nerve function is more sensitive in diagnosing neuropathy than such tests specific to pudendal nerve function alone (Vodusek et al, 1993; Ho et al, 1996). Almost all of the reports showed high prevalence rates for men in their 70s and 80s, ranging from 50% to 75%. The bulbous urethra is lined distally with squamous epithelium that gradually changes to the transitional epithelium found in the membranous urethra as it swings upward (Devine and Horton, 1977). The wounds are covered with Bacitracin ointment and a fluff-type dressing secured with a snug scrotal support. Penile length in the flaccid and erect states: guidelines for penile augmentation. The role of prolactin levels in the sexual activity of married men with erectile dysfunction. The tunica vaginalis is opened and the operating microscope is brought into the field. The decision for en bloc caval resection was justified by the adverse nodal pathology, which included active cancer in 63% and teratoma in 31% of the specimens. Systemic and cavernous plasma levels of neuropeptide Y during sexual arousal in healthy males. The microsurgical approach with delivery of the testis lowers the incidence of varicocele recurrence to less than 1% compared with 9% with use of conventional inguinal techniques (Goldstein et al, 1992; Marmar and Kim, 1994). Cancerspecific survival at 5 and 10 years was estimated at 53% and 46%, respectively. The glans clitoris is attached to the symphysis pubis by the suspensory ligament (Rees et al, 2000). The authors concluded that in patients with normal penile hemodynamics but without adequate rigidity, structural causes should be investigated (Udelson et al, 1998). The arousal phase is characterized by vulvar and clitoral swelling, vaginal lubrication and lengthening, nipple erection, increased genital sensitivity, tachycardia, tachypnea, and subjective pleasure and excitement (Masters and Johnson, 1966; Basson et al, 2010b). In cases in which vesicourethral anastomosis is impossible, a urachal-peritoneal flap combined with a rectus abdominis muscle flap is used to bolster the closed bladder neck and to keep the closed bladder neck from sticking to the back of the pubis. Increased osteocalcin-positive endothelial progenitor cells in hypogonadal male patients. This stimulation may take the form of external stimulation of the anus or anal penetration with a penis, finger, or other object. At our center, we perform neonatal circumcision with a penile block for anesthesia. Nevertheless, D4 receptors seem to play only a modest role in the pro-erectile effect (Melis and Argiolas, 2011). Second, the inner triangleshaped suspensory ligament is attached to the anterior aspect of the symphysis pubis and blends with the dartos fascia of the penis below it. Rhythmic contraction and compression of the bulbocavernosus muscle on the proximal corpus spongiosum helps semen expulsion, provided that the external sphincter is relaxed and the urethral lumen is compressed by the engorged spongiosum. The external iliac lymph nodes receive drainage from the deep inguinal, obturator, and hypogastric groups. These include an increased capacity for glycolysis (Hoskins et al, 1975), changes in intracellular pH and calcium content, modification of adenylate cyclase activity (Casillas et al, 1980), and alterations in cellular phospholipid and phospholipid-like fatty acid content (Voglmayr, 1975). Neuropeptide Y in the human female genital tract: localization and biological action. The conditions of the problem are often Patient complaining of erectile dysfunction Sexual, psychosocial, and medical assessment Sexual function assessment Psychosocial assessment Focused physical examination Basic lab tests Basic evaluation Medical history Findings support initiation of treatment Findings necessitate further evaluation Problem with orgasm, ejaculation, genital pain, or libido Reversible risk factors Unstable C.
Predictors of poorer survival outcomes include viable malignancy or somatic-type malignancy at late relapse, prior chemotherapy, and incomplete resection (Baniel et al, 1995a; George et al, 2003; Sharp et al, 2008). With cautery, the electrical charge is grounded either to a pad (monopolar) or to the opposite tong of the forceps (bipolar). This will cause a decrease in the countertraction of the transversalis fascia, making it more difficult to puncture the floor of the inguinal canal and access the space of Retzius. Studies on models of sexual response are discussed in more detail on the Expert Consult website. In male newborns, simple tactile stimulation such as diaper changing, bathing, and urethral catheterization may result in erection; the erection quickly subsides after cessation of stimuli. It is interesting to note that spermatotoxic effects of tetracycline may be paternally transmitted to male offspring (Zeh et al, 2012). Prognostic parameters in adult impalpable ultrasonographic lesions of the testicle. Nonetheless, *Grades of recommendation: A: At least one meta-analysis, systematic review, or randomized controlled trial with a low level of bias and directly applicable to the target population. The middle lobe may become hyperplastic and may extend into the bladder neck with age. However, most patients experience a differential elasticity between the dorsal and the ventral aspects of the corporeal bodies, and although the curvature may have been lessened, it persists unless further procedures are done to straighten the penis. Adherence to the following principles will enable anastomosis in the convoluted vas to succeed as often as those in the straight portion. In studies in which biopsy of the testis was performed in these cases, intratubular germ cell neoplasia was seen in 42% of patients (Daugaard et al, 1992). NonischemicPriapism(Arterial,High-Flow) Nonischemic priapism is a persistent erection caused by unregulated cavernous arterial inflow. The air-filled balloon also identifies the location of the bladder neck relative to any obstruction. In general, the vascularity of the bowel mucosa is based on the vascularity of the underlying muscle, with the mucosa carried on perforators. Our choice in managing the acute injury is exploration and attempted immediate anatomic repair, perhaps placing a suprapubic tube should extensive urethral reconstruction be required. Treatment options include orchiectomy, low-dose radiotherapy, and close observation. Until more recently, late relapse was associated with a worse prognosis than early relapses, although contemporary data suggest these patients may have a similar probability of cure. In vitro studies demonstrated that prostanoids are responsible for the tone and spontaneous activity of isolated trabecular muscle (Christ et al, 1990). If not meticulously performed, vasography can cause stricture or even obstruction at the vasography site, which can complicate subsequent reconstruction (Howards et al, 1975b; Poore et al, 1997). Proper cryopreservation of sperm results in long-term potential for reproductive success, and patients may be assured that should they store sperm in this way, it will be available when they need it (Rofeim and Gilbert, 2005). DeCastro and associates (2002) reported an interesting variant of excision with anastomosis for anterior stricture. Antibiotics are often administered preoperatively to reduce the inflammatory component of the regional adenopathy. There is evidence of pelvic floor denervation and loss of pelvic floor strength in as many as 80% of women giving birth (Allen et al, 1990). Sexual function: a comparison between male renal transplant recipients and hemodialysis patients. A new combination of testosterone and nestorone transdermal gels for male hormonal contraception. In the initial Crook series, prophylactic lymph node dissections were not routinely performed, and as one would expect, 50% of moderately or poorly differentiated tumors recurred regionally or distally (Crook et al, 2002). Consequently, the most rational approach based on whether identification of a varicocele is likely to affect treatment outcomes is not to rely on ultrasound as a necessary diagnostic tool.
PhysicalExamination A general physical examination including vital signs is required. If microscopic examination of this fluid reveals the absence of sperm, the diagnosis of epididymal obstruction is confirmed. In these men, the accessory pudendal was the dominant blood supply in 54% and the only corporeal blood supply in 11%. Position statement: utility, limitations, and pitfalls in measuring testosterone: an Endocrine Society position statement. Human cadaveric dissection has revealed medial and lateral branches of the cavernous nerves (the former accompanying the urethra and the latter piercing the urogenital diaphragm 4 to 7 mm lateral to the sphincter) and multiple communications between the cavernous and dorsal nerves (Paick et al, 1993). The sexual arousal phase is followed by the plateau phase during which sexual excitement/ arousal continues (Masters and Johnson, 1966). Preliminary data have suggested that arginase inhibitors may enhance genital responses in vitro but in vivo studies are scant (Cama et al, 2003). Much attention has been focused on this issue, but despite this, many boys in the United States are circumcised. Drug therapy and prevalence of erectile dysfunction in the Massachusetts male ageing study cohort. The epididymal tunica is incised over a dilated tubule as described previously for vasoepididymostomy. The stricture process usually involves the fossa navicularis to some extent as well. There was no indication of an increased risk for suicidal ideation or suicide attempts and little indication of withdrawal symptoms with abrupt dapoxetine cessation (Levine, 2006). Reproductive hormones in the early menopausal transition: relationship to ethnicity, body size, and menopausal status. Prevalence of sexual dysfunction among postmenopausal women with and without metabolic syndrome. When orchiopexy is performed in adults, regular self-examination and yearly sonography are mandatory. A compared two cohorts of patients undergoing penile implant for refractory ischemic priapism. Anatomy and physiology of the clitoris, vestibular bulbs, and labia minora with a review of the female orgasm and the prevention of female sexual dysfunction. The role of thoracotomy in managing postchemotherapy residual thoracic masses in patients with nonseminomatous germ cell tumours. Suadicani and colleagues (2009) reported a significant decrease of gap junction protein connexin 43 in the corpus cavernosum in aged and streptozotocin-induced diabetic rats. Dye permeability and alkaline phosphatase activity of testicular capillaries in the postnatal rat. In humans and rats, inhibition of norepinephrine release by clonidine, an 2-adrenergic agonist, is associated with a decrease in sexual behavior, and yohimbine, an 2-receptor antagonist, has been shown to increase sexual activity (Clark et al, 1985). Improved clinical outcome for men with fibrosis at post chemotherapy retroperitoneal lymph node dissection for metastatic non-seminomatous germ cell tumors. TranspositionoftheTestis Occasionally when vasal length is critically short, a tension-free crossed anastomosis can best be accomplished by testicular transposition. The two main blood supplies to the epididymis, running superiorly and inferiorly, form an extensive interconnection such that if the vasal artery is ligated from previous vasectomy, the blood supply to the epididymis from the testicular artery is more than adequate. Medical treatment of hypercalcemia includes aggressive saline hydration to restore the extracellular fluid volume and to promote both sodium and calcium excretion. Although it would appear that for more severe curvature more advanced techniques are necessary, published experience has suggested that manual modeling may be used as first-line therapy for correction of curvature after prosthesis implantation (Levine et al, 2010; Chung et al, 2012c). Testicular causes of male reproductive dysfunction may consequently be considered to derive from pathology in the production of sperm in the seminiferous epithelium or in the synthesis of testosterone by Leydig cells, or obstruction in the microductal system transporting sperm toward the ejaculatory ducts. Combined post-chemotherapy retroperitoneal lymph node dissection and resection of chest tumor under the same anesthetic is appropriate based on morbidity and tumor pathology. In addition, as a consequence of chromosomal recombination, each daughter cell contains different genetic information.
Serious adverse events included corporeal rupture in three patients and penile hematoma in three patients. Improvement in penile curvature and plaque volume was significantly greater in patients treated with Tamoxifen Tamoxifen is a selective estrogen receptor modulator that has both agonist and antagonist effects on target tissues depending on tissuespecific estrogen receptor expression. With gentle traction on the cord, fibrous attachments and scar are incised until the suture on the spermatic cord is identified. The average risk for inguinal metastasis among 225 patients in seven different series was 59% (Table 37-7). Sexual dysfunction related to antihypertensive agents: results from the animal model. Case reports, however, suggest that this complication may be more common than realized. Minimizing target volume and dose has been investigated to reduce the toxicity of radiotherapy. Patients typically awaken with an erection that persists up to 4 hours and becomes progressively painful secondary to ischemia. Evidence based physiotherapy for the pelvic floor: bridging the research and clinical practice. However, in vivo cases and cadaveric injection studies demonstrated that the perirenal space has a conelike shape that is open at its inferior extent in the extraperitoneal pelvis (Lim et al, 1998). Most relapses occur within 2 years of completing initial treatment, and these are classified as early relapse (de Wit et al, 1998; Nichols et al, 1998; Michael et al, 2000; Culine et al, 2007; Motzer et al, 2007). Dysfunction of certain of these genes may result primarily in arresting the mechanical journey of the germ cells, whereas aberrant expression of others may be involved in the processes of both spermatogenesis and descent, causing infertility in ways beyond the thermal toxicity to which undescended testes are subject in later reproductive life. At this level, only one or two large veins are present, and in addition the testicular artery has not yet branched and is often distinctly separate from the internal spermatic veins. Once the testicular artery has been identified, it is dissected free of all surrounding tissue, tiny veins, and lymphatics, using a fine-tipped nonlocking micro needle holder and microforceps. Ultrastructural comparison of penile cavernous tissue between hypertensive and normotensive rats. Unlike with many other genitourinary tumors, which mandate systemic therapeutic strategies once metastasis has occurred, lymphadenectomy alone can be curative and should be performed. Topical application avoids the pain and trauma of intralesional injection therapy. Pelvic dissection in the setting of a patient with no palpable adenopathy who is discovered to have positive inguinal metastasis at frozen section is optional and based on pathologic findings (Lont et al, 2007; Zhu et al, 2008). During residence in the female reproductive tract, sperm must undergo capacitation before oocyte fertilization. Recanalisation of embolised cavernosal artery: restoring potency in a patient with high-flow priapism. Women who received treatment reported greater levels of sexual arousal in response to sexually explicit material compared to women receiving placebo; there was no significant difference in genital arousal response (Diamond et al, 2006). Examples include L-arginine with yohimbine (Meston and Worcel, 2002) and Korean red ginseng (Oh et al, 2010). Briefly, ejaculatory duct obstruction is suspected in azoospermic or severely oligospermic and/or asthenospermic men with at least one palpable vas deferens, a low semen volume, acidic semen pH, and negative, equivocal, or low semen fructose levels. Affected individuals have delayed puberty or infertility owing to lack of testosterone production. Short-term systemic recombinant interferon-gamma treatment is ineffective in recalcitrant condylomata acuminata. Consistent with the idea that principal cells carry out both absorptive and secretive processes, their cellular apices have numerous coated pits, micropinocytotic vesicles, multivesicular bodies, irregularly shaped membranous vesicles, and an extensive Golgi apparatus. After the decision has been made to proceed with excisions of ellipses of dorsal tunica, Buck fascia can be elevated, in concert with the dorsal neurovascular structures, by beginning just lateral to the corpus spongiosum and carrying the dissection dorsally across the midline. Urethral fistulae may be a complication of urethral surgery or develop secondary to periurethral infection associated with inflammatory strictures or treatment of a urethral growth (condyloma or papillary tumor). Most of these boys could undergo reconstruction in such a manner as to preserve reproductive function. Analysis of surface proteins of rat spermatozoa during epididymal transit and identification of antigens common to spermatozoa, rete testis fluid and cauda epididymal plasma. Large number of sperm can be harvested for cryopreservation of multiple vials in a single procedure. This marks the beginning of the thoracic duct, which runs cephalad posterior to the aorta and empties into the left innominate vein.
Prognostic features of teratomas with malignant transformation: a clinicopathological study of 21 cases. Follicle-stimulating hormone ligand and receptor mutations, and gonadal dysfunction. Acceptance of and discontinuation rate from paroxetine treatment in patients with lifelong premature ejaculation. Great care is taken to separate the lymph nodes from the sympathetic chain and postganglionic nerve fibers. E: 360 refers to an etoposide dose of 360 mg/m2/cycle; E: 500 refers to an etoposide dose of 500 mg/m2/cycle. Previously, excision with primary anastomosis was thought to be a relatively limited procedure and applicable only for strictures less than 1. Effect of diltiazem and methylene blue on human sperm motility, viability and cervical mucus penetration: potential use as vas irrigants at the time of vasectomy. In this study, a semiquantitative system that estimated the amount of high-grade cancer. In most patients, the penis remains curved because of the inelasticity of the ventral aspect of the corpora cavernosa themselves. Legal and psychological implications in the assessment of sexual consent in the cognitively impaired population. There is evidence that T plays a role in sexual appetitive behavior, maintenance of genital tissue integrity, and sexual arousal responses in women (Van Goozen et al, 1997; Riley and Riley, 2000; Traish et al, 2010). The highly protective effect of newborn circumcision against invasive penile cancer. Closed-suction drains are placed under the subcutaneous tissue and brought out inferiorly. For most lesions, however, the bulk of the symphysis can be preserved with resection of the subsymphyseal arch. A systematic review of overweight and obesity as risk factors and targets for clinical intervention for urinary incontinence in women. At least two clinical issues remain unresolved with respect to MetS and the care of the urology patient. The left testis drains to the left para-aortic nodes with some drainage to the interaortocaval nodes. Successful palliative treatment may occasionally be possible in the case of solitary nodules or localized distal penile involvement if complete excision by partial amputation succeeds in removing the entire area of malignant infiltration (Spaulding and Whitmore, 1978). The bulbospongiosus muscle (midline fusion of the ischiocavernosus muscle) is fixed to the perineal body by its most posterior fibers. Considering the current treatment recommendations for bilateral inguinal staging procedures in men at high risk for metastasis and the definition of low-risk groups for metastasis by use of available prognostic markers, this scenario should rarely occur. When large vasal gaps are present, a gauze-wrapped index finger is used to bluntly separate the cord structures from the vas. The specimen must be sequentially passed through the web of postganglionic fibers as it is released from the body wall. The penile lesion is assessed with regard to size, location, fixation, and involvement of the corporeal bodies. The series included 20 patients treated with five different regimens including (1) single-agent bleomycin; (2) bleomycin, vincristine, and methotrexate; (3) cisplatin and 5-fluorouracil; (4) bleomycin, cisplatin, and methotrexate; and (5) cisplatin and irinotecan. Four to six 9-0 nylon interrupted sutures are placed between each muscular suture. On average, histology of resected specimens demonstrates necrosis, teratoma, and viable malignancy (with or without teratoma) in 40%, 45%, and 15% of cases (Table 34-6) (Toner et al, 1990; Gerl et al, 1995; Steyerberg et al, 1995; de Wit et al, 1997; Debono et al, 1997; Hartmann et al, 1997b; Sonneveld et al, 1998; Stenning et al, 1998; Steyerberg et al, 1998; Hendry et al, 2002; Albers et al, 2004; Spiess et al, 2006b; Carver et al, 2007a). For distal strictures of the anterior urethra, including the fossa and meatus and the pendulous urethra, the islands can be advanced to reconstruct to the level of the meatus by either developing glans wings or elevating the ventral glans. Thus sperm fertility maturation is, for the most part, achieved at the level of the late corpus or early cauda epididymis. Since the early 1990s, retroperitoneal laparoscopic surgery has been used with proven benefits related to reducing perioperative morbidity, improving cosmesis, and shortening convalescence without compromising oncologic efficacy (Cadeddu et al, 1998; Allaf et al, 2004; Permpongkosol et al, 2005).
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