2021 進階男性學與泌尿學秋季論壇
Advanced Andrology and Urology Fall Forum
本次會議將以性功能障礙、不孕症等相關議題，由資深醫師做學術講演與討論。
這次會議同時也是台灣男性學醫學會每年為了泌專住院醫師甄審特別開辦的進階住
院醫師核心課程，會議中將提供住院醫師考前需要準備的核心知識，歡迎對進階男
性學有興趣的醫師與考生踴躍報名參加。
•
時 間：2021.9.4 (星期六)下午 13:00~17:05
•
地 點：張榮發基金會國際會議中心 10 樓 1003 室(台北市中山南路 11
號) (交通資訊)
•
主辦單位：台灣男性學醫學會、台大醫院泌尿部
•
協辦單位：台灣男性學醫學會不孕症委員會、台灣泌尿科醫學會男性學委
員會
•
教育積分：外科 5 分、泌尿科 2 分
2021/9/7
Outlines
Physiology of
Erectile Dysfunction
生理
病因
治療
2021-09-04
臺大醫院 曾啟新 醫師
2
解剖
解剖
內環外縱
type 1
collagen
3
解剖
4
解剖
Blood supply
• Internal pudendal artery, branch of the internal iliac artery
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6
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解剖
神經
• Flaccid
鈣上升
平滑肌收縮
血管縮小
7
神經
8
生理
軟
• 勃D1,4, 5HT2C
• 鈣高
• 平滑肌收縮
• 抑制勃 5HT1A
• 缺血
• 射D2, 5HT1A
• 促NE, NO, Oxy, Melan
(MCR4)
• 抑GABA, Opi, canna, pro
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生理
10
生理
硬
• 鈣低
• 平滑肌放鬆
• 充血
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12
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考古題
考古題
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考古題
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考古題
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考古題
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考古題
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考古題
考古題
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考古題
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考古題
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考古題
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考古題
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24
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考古題
考古題
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考古題
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考古題
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病生理
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病生理
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30
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病生理
病生理
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Epidemiology – Prevalence of ED
• All male (> 20 years old) : 10 ~ 20 %
• < 40 years old : 1~10 %
• 40~49 years old : 15 %
• 50~59 years old : 30 %
• 60~69 years old : 40 %
• 70~90 years old : 50~100%
• Prevalence of ED ∝ comorbid medical conditions
Evaluation and
Management of ED
台北榮總 泌尿部 陳威任
(T2DM; Obesity; CVA; HTN; dyslipidemia; depression; and
prostate disease/BPH)
2
Management principles
• Goal-Directed Management
• Their decisions accordingly follow individual preferences,
needs, and expectations regarding management options
• Partner interview
• women partners of men with ED are themselves more
likely to have sexual dysfunction or to cease sexual
activity entirely
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Cardiac risk assess
Diagnostic Evaluation
• High risk:
- unstable or refractory angina
- recent history of MI
- high-risk arrhythmia (exerciseinduced ventricular tachycardia,
implanted internal cardioverter
defibrillator with frequent shocks,
and poorly controlled Af)
- uncontrolled hypertension
- CHF (NYHA class IV)
- Obstructive hypertrophic
cardiomyopathy with severe
symptoms
- moderate to severe valve disease,
esp. aortic stenosis
The Princeton III Consensus
Mayo Clin Proc. 2012 Aug;87(8):766-78.
信心 進入 維持 完成 滿意
9
Diagnostic Evaluation — Lab
• Complete blood count
• Lipid profile
• Serum total testosterone: morning-time blood draw
• Prolactin
• Thyroid function tests
• Serum prostate-specific antigen (PSA)
• Urinalysis
• Fasting glucose or HbA1c
•
Severe: 5-7 Moderate: 8-11 Mild to moderate: 12-16 Mild: 17-21
•
No ED: 22-25
Special examination
>45msec
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Specialized evaluation and test
Intracavernosal injection
• Combined intracavernosal injection and stimulation
• Duplex ultrasonography
• Penile angiography
• Dynamic infusion cavernosometry and
cavernosography
• Bypass neurologic and hormonal influence.
• Evaluate the vascular status of the penis
PGE1
• Nocturnal penile tumescence (NPT) monitoring
Duplex Ultrasonography
Duplex Ultrasonography
Filling phase (<5 minutes)
sinusoidal resistance is low
•
intracavernous pressure ↑
→ diastolic velocities ↓
intracavernous pressure
> systemic DBP
2nd
line evaluation of
penile blood flow.
• most reliable and least
invasive
• Scan dorsal a. and
cavernous a.
16
Duplex ultrasonography
• PSV (peak systolic velocity) < 25 cm/sec :
Normal cavernous arterial inflow → PSV>35 cm/sec (consistently)
or Cavernous acceleration time (PSV/systolic rise time) > 122 ms
Penile Angiography
• 3rd-line evaluation of penile blood flow.
• Indications :
• Trauma
• For surgery
• RI(PSV – EDV)/PSV ,vascular resistive index<0.75:
• Normal: PSV > 35 cm/s, EDV < 3 cm/s, and
resistance index > 0.9
• From internal pudendal a.
• Survey the inferior epigastric
a. for use in surgical revascularization.
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Dynamic Infusion Cavernosometry and Cavernosography
Dynamic Infusion Cavernosometry and Cavernosography
Cavernosography follows cavernosometric evaluation and
is intended to show the site of venous leakage.
• 3rd-line evaluation of penile blood flow.
evaluates penile venous outflow
system
• Induction flow(IF) :
誘導勃起的灌流率
• Maintenance flow(MF) :
維持勃起的最低流速
正常3~5ml/min灌流速率可維持勃起時
intracavernous pressure在100mmHg
• Pressure loss(PL) :
停止灌流30秒內海綿體壓力下降梯度
正常人當intracavernous pressure為100
mmHg時，30秒內通常會下降<45mmHg
Dynamic Infusion Cavernosometry and Cavernosography
NPT monitoring, Rigiscan®
• Normal NPTR:
Indicated for select patients :
• Site-specific vasculogenic leak resulting from perineal or
pelvic trauma
• Lifelong ED (primary ED)
- 4-5 erectile episodes per night, mean duration >30mins
- increase in circumference >3cm at the base and >2cm at
the tip
- maximal rigidity >70% at both base and tip.
21
NPT monitoring, Rigiscan®
The RigiScan device has been designed to measure penile rigidity during home
nocturnal monitoring.
(A) A study in a patient with at least two episodes of well-sustained, completely rigid
nocturnal erections.
(B) A study with two episodes of poorly sustained, poorly rigid nocturnal erections.
Such home studies fail to document sleep quality.
• Limitations :
Can not identified the cause and severity of ED
The results may be poorly reproducible
False positive : multiple sclerosis
False negative : depression or anxiety, which may
conditionally affect the physiology of sleep-related
erectile phenomena
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Hormonal Evaluation - Testosterone
• 2~33 % ED patient had androgen deficiency
• Aging is the primary cause of androgen deficiency :
•
•
•
•
•
ADAM, Androgen deficiency of the aging male
PADAM, partial androgen deficiency of the aging male
Hypoandrogenism
SLOH, Symptomatic late-onset hypogonadism
Andropause
Hormonal Evaluation - Testosterone
• Total T = Free T(0.5~3%) + SHBG(30%) + Albumin or other
protein(67%)
• Bioavaible T = Free T(0.5~3%) + Albumin or other protein(67%)
• Decreased SHBG : obesity, nephrotic syndrome, hypothyroidism,
and the use of glucocorticoids, proges-tins, and androgenic steroids
• bio-available testosterone ↑
• Increased SHBG : aging, hepatic cirrhosis, hyperthyroidism, human
immunodeficiency virus infection, and the use of anticonvulsants
and estrogens
• bio-available testosterone ↓
• Free T(0.5~3%), SHBG(30%), Albumin or other
protein(67%)
• DM patient : variable SHBG levels
25
Hormonal Evaluation - Testosterone
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Hormonal Evaluation – Gonadotropin and
Prolactin
• blood draw be performed between 7:00 AM and
11:00 AM
• FSH and LH
• blood draw should be repeated for confirmation if T
level is low
• Prolactin
• To identified primary or secondary hypogonadism
• 30 % patient will return to normal
• Hyperprolactinemia causes hypogonadism by
suppression of GnRH, which impairs the pulsatile LH
secretion required for serum testos-terone production
by the gonads.
• Hyperprolactinemia can cause loss of libido
• Prolactin interfere of peripheral conversion of T to DHT
27
Magnetic Resonance Imaging Scans
• Indications for pituitary imaging
• Severe central hypogonadism (testosterone <150 ng/dL)
• Suspicion of pituitary disease (i.e., panhypopituitarism,
persistent hyperprolactinemia, or symptoms of tumor
mass effect).
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28
Hormonal Evaluation - Thyroid
• Hyperthyroidism is associated with ED
increasing aromatization of testosterone into
estrogen (which raises levels of SHBG) increasing
adrenergic tone (which causes smooth muscle
contraction or exerts psychobehavioral effects)
• Hypothyroidism
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Treatment
Treatment
• ED can be treated successfully with current
treatment options, but it cannot be cured.
• The only exceptions are psychogenic ED, posttraumatic arteriogenic ED in young patients, and
hormonal causes (e.g.,hypogonadism), which
potentially can be cured with specific treatments.
• Lifestyle Modification
• Stop the drugs that may cause ED
• Hormonal therapy
Hormonal Therapy
Hormonal Therapy
Alternative Hormone Treatments
• Hyperprolactinemia Treatments
Human chorionic gonadotropin
Aromatase inhibitors
Selective androgen receptor modulators
• Stop drugs that may cause hyperprolactinemia (estrogens,
morphine, sedatives, and neuroleptics)
• Bromocriptine (dopamine agonist)
• Consider surgery if there were prolactin-secreting adenoma
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PDE5 inhibitor
PDE6 (Retina)
Cross-react
Controlled and postmarketing
studies have shown that they do
not cause an increase in
myocardial infarction or death
rates
Vardenafil is not recommended
for pt under
-
type 1A antiarrhythmics (e.g.,
quinidine or procainamide)
-
type 3 antiarrhythmics (e.g.,
PDE5 inhibitors
• Caution is advised for the use of PDE5 inhibitors in
patients with:
- aortic stenosis
- left ventricular outflow obstruction
- Hypotension
- Hypovolemia
• Nitrate use in any form represents an absolute
contraindication.
sotalol or amiodarone)
-
congenital prolonged QT
syndrome.
PDE5i side effects
• Side effects observed with PDE5 inhibitor therapy
include:
- headache (7% to 16%)
- dyspepsia (4% to 10%)
- flushing (4% to 10%) → Sildenafil
- myalgia/back pain (0 to 3%) → Tadalafil
- nasal congestion (3% to 4%)
- visual disturbances (e.g., photophobia, blur vision)
(0 to 3%) → Sildenafil
- nonarteritic anterior optic neuropathy (NAION) (?)
Trazodone
• Serotonin-receptor effectors
• “off-label”
• work at the spinal-cord level with multiple
serotonergic effects
• affinity for the 5-HT2A receptor
• Agonist of the proerectile 5-HT2C receptor through
reuptake inhibition
• antagonist of antierectile 5-HT1A receptors
• With strong side effect and minimal therapeutic
effect
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Intracavernosal injection (ICI)
Intraurethral
Suppositories
• Alprostadil: The only FDA-approved injectable
medication for ED
• A synthetic formulation of prostaglandin E1 was
developed and the FDA approved it in November
1996 as MUSE (Medicated Urethral System for
Erection)
• A suppository inserted into the urethral opening
that dispenses a semisolid pellet (1 × 3 mm) of
alprostadil (125-, 250-, 500-, and 1000-μg doses)
into the distal urethra (3 cm from the external
urethral meatus).
Surgery
Vacuum erection device therapy
• Penile Prosthesis Surgery
• Malleable (semirigid) device
• inflatable (hydraulic) device
Efficacy rates : 90%
Satisfaction rates : 30~70%
• Penile Revascularization Surgery
Complications : penile pain
and numbness, difficult
ejaculation, ecchymosis,
petechiae, penile skin necrosis,
urethral varicosities, and
Fournier gangrene.
• Arterial Revascularization
• Creat anastomosis of inferior epigastric
artery to corpus cavenosum, dorsal artery, or
deep dorsal vein with venous ligation
• Venous Reconstruction (under investigation)
• Ligating or embolizing penile veins (e.g.,
superficial dorsal vein, deep dorsal vein,
crural vein) or surgically compressing the
penile crura (e.g., crural plication/ligation,
pericavernoplasty)
the ring should not be left in place for longer than 30 minutes
45
46
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Thank you
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睪固酮:16
生理：9
病因：3
治療：4
高雄醫學大學
錢祖明
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2
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3
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European Association of Urology guideline on Sexual and Reproductive Health, 2020
European Association of Urology guideline on Sexual and Reproductive Health, 2020
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Normal Ejaculation
Organs
Ejaculatory Dysfunction
輔大附醫泌尿科 藍祺昀
Ejaculatory Dysfunction
Epididymis, vas deferens, seminal vesicles ,
prostate, bladder neck, post. urethra
Neural control
Hormones
Interplay with CNS, PNS and Neurotransmitter
(mainly serotonergic and dopaminergic neurons)
Oxytocin, Prolactin, TSH, Testosterone,etc
Neurophysiology of Ejaculation
Organs
absent ejaculate
Epididymis, vas deferens, seminal vesicles ,
premature ejaculation
(retrograde ejaculation and aspermia)
prostate, bladder neck, post. urethra
Neural control
delayed ejaculation
(DE) / anorgasmia
Interplay with CNS, PNS and Neurotransmitter
(mainly serotonergic and dopaminergic neurons)
Coordinated activation of autonomic and somatic
spinal nuclei is controlled by a group of lumbar
spinal interneurons (L3-L5) described as the spinal
generator of ejaculation.
unsatisfactory Hormones
sensation of ejaculation
(painful ejaculation and ejaculatory anhedonia)
Oxytocin, Prolactin, TSH, Testosterone,etc
Neurophysiology of Ejaculation
epididymis, vas deferens, seminal
vesicles, prostate gland, prostatic urethra
and bladder neck
Sympathetics (spinal level T10 ‐ L2)
* synergic activation of sympathetic and parasympathetic pathways
• Emission : Sympathetics (spinal level T10 ‐ L2)
• Bladder neck closure : Sympathetics (spinal level T10 ‐ L2)
• Antegrade Ejaculation : Somatics (spinal level S2 ‐ S4)
Emission
release of oxytocin , neuropeptide Y , vasoactive
intestinal polypeptide, and nitric oxide
• Integrated Reflex Control Center : Spinal level T12 ‐ L1
Smooth muscle contraction, release excretions
into post. urethra
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Central control of ejaculation
Somatic nervous
from S2–4 nerve roots
Sympathetic spinal cord reflex
• Many neurotransmitters have been found to be involved, including dopamine,
norepinephrine, serotonin, acetylcholine, oxytocin, GABA, and nitric oxide
Expulsion
• Dopamine and serotonin have emerged as the essential neurochemical
•Rhythmic contractions of the bulbospongiosus and
ischiocavernosus muscles
•External urinary sphincter relaxes
•Bladder neck closes
factors, with dopamine facilitating ejaculation and serotonin primarily playing
an inhibitory role .
Dopamine
Facilitate ejaculation
( D2 receptor enhances emission )
Serotonin (5-HT)
Inhibit ejaculation
( 5-HT2C inhibit ejaculation, 5-HT1A enhance ejaculation )
考題
Central
Neurotransmitters
and their function
考題
考題
D2 receptor—>emission
A—> + ejaculation
C—> - ejaculation
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考題
考題
考題
Premature Ejaculation
2014年國際性醫學醫學會ISSM定義早洩常見三項要素
1) 陰道內射精延遲時間(IELT)較短 (L-PE < 30-60secs; A-PE <3mins)
2) 無法控制、或不能延遲射精
3) 造成個人和/或伴侶不適、人際關係障礙
Types of Premature Ejaculation
Type
Lifelong PE
Acquired PE
• 非常短
陰道內射精延遲時間
• 30~60秒(80%病人)、1~2 (非常)短
(IELT)
分鐘(20%病人)
症狀
發病時間
幾乎每次性交都過早射精
從第一次性交開始
Types of Premature Ejaculation
Premature-like
ejaculatory
dysfunction
Natural variable PE
正常
• 正常/長
• 3~6分鐘/5~25分鐘
• 射精有時過早，有時正常
• 在發病前，男性通常射精正
•
，沒有規律性
常
• 射精控制能力不佳，IELT
• PE可能突然發生，或IELT漸
•
可能過短(<1.5分鐘)或正
進性縮短
常(≥1.5分鐘)
主觀性認為性交時一直、
或有時過早射精
猜想自己過早射精、或無
法控制射精，而感到擔憂
Type
Lifelong PE
射精控制能力
• 一生都過早射精(70%病人)
、或隨著年齡增長射精越
來越快(30%病人)
• 缺乏射精控制能力、或變
弱
病因
Acquired PE
Natural variable PE
Premature-like
ejaculatory
dysfunction
缺乏射精控制能力、或變弱
• 神經生物學因素
• 基因
• 健康因素[泌尿系統功能
異常，例如勃起功能障
• 正常變異
礙(ED)、攝護腺炎]
• 心理、或伴侶關係問題
• 心理因素
低(2.3%)
低(3.9%)
高(5.1%)
在男性人生中某個時間點發生
盛行率
高(8.5%)
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Etiology of PE
分類
心理因素
神經性因素
基因因素
Diagnosis and evaluation of PE
Etiology
• Validated tool :
• Problem of relationship
• Hypersensitivity of 5-HT1A receptor
• Hyposensitivity of 5-HT2Creceptor
• Glans hypersensitivity
Genetic polymorphism of serotonin and dopamine transport protein
(5-HTTLPR) / (DAT-1)
男性學因素
Erectile dysfunction
泌尿道因素
• Prostatitis or urethritis
內分泌因素
Hyperthyroidism
藥物因素
• Mainly by History. Laboratory or imaging studies are routinely required
• Sexual performance anxiety
‣ Index of Premature Ejaculation(IPE)
‣ Premature Ejaculation Profile (PEP)
‣ Premature Ejaculation Diagnostic Tool (PEDT)
• About 30 percent of men with PE have concurrent ED
• Chronic pelvic pain syndrome
DSetoxification of withdraw from recreational medication
Management of PE
Management of PE
Management of PE
Management of PE
Treatment Options
• Psychotherapy and behavioral
modification ( psychosexual CBT )
• Medication
‣ SSRI
‣ Topical anesthetic agent
‣ Other off-label medication
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Management of PE
Treatment Options
• Psychotherapy and behavioral
modification ( psychosexual CBT )
• Medication
‣ SSRI
‣ Topical anesthetic agent
‣ Other off-label medication
Management of PE
First-line treatment
Treatment Options
• Psychotherapy and behavioral
• Lifelong PE : Pharmacotherapy
modification ( psychosexual CBT )
• Acquired PE : Behavioral
therapy or combination treatment
• Medication
‣ SSRI
‣ Topical anesthetic agent
‣ Other off-label medication
First-line treatment
• Lifelong PE : Pharmacotherapy
• Acquired PE : Behavioral
therapy or combination treatment
Psychosexual CBT
• Limited role as first-line therapy,
especially in lifelong PE.
• But important as an adjunct to
pharmacotherapy
Medication of PE
SSRI
Medication of PE
SSRI
Not FDA approved
Topical
Anesthetics
考題
考題
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考題
考題
考題
3.2%
2.3%
4.8%
3.9%
6.4%
5.1%
11.4%
8.5%
考題
?
考題
?
考題
?
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考題
考題
考題
考題
Delayed ejaculation
Causes of delayed ejaculation
• The estimated prevalence of DE is 1–4% of the male population
• psychogenic inhibited ejaculation,
• Use an IELT greater than two standard deviations above average (5.4 minutes),
• degeneration of penile afferent nerves
which is roughly 22–25 minutes
• hypogonadism/hypothyroidism
• diabetic autonomic neuropathy
• treatment with SSRI antidepressants and major
tranquilizers
• radical prostatectomy or other major pelvic
surgery
• radiotherapy
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Drug Therapy for DE
•
• The causes of DE and anejaculation are manifold.
All have limited evidence
• Failure of ejaculation can be a lifelong problem (25%) or an acquired problem
(75%). It may be global and occur in every sexual encounter or be intermittent
or situational.
• Treatment of men with DE should address the issue of infertility in men of
reproductive age.
• Drug treatment of men with DE or anejaculation has limited success.
考題
考題
考題
考題
Hyperprolactinemia-> low T
比較容易造成DE
Hypothyroidism跟DE比較有關
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考題
考題
Retrograde ejaculation
• TURP and diabetic autonomic neuropathy are the most common
causes of retrograde ejaculation.
• RE and failure of emission can be distinguished by examination of a
postmasturbatory specimen of urine for the presence of spermatozoa
and fructose.
• Pharmacotherapy is associated with variable degrees of success and
includes agents such as pseudoephedrine, midocrine, and imipramine.
Thank You
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Evaluation for infertile men
•
•
•
•
Guideline in Male Infertility
Complete medical and reproductive history
Physical examination
At least 2 semen analyses
Additional tests:
–
–
–
–
–
YU-SHENG CHENG
鄭裕生主任
Orchidometer
endocrine evaluation
genetic screening
ultrasonography
post-ejaculatory urinalysis
specialized tests on semen and sperm
Presence of varicocele
W
L
Prader orchidometer
L x W x W x 0.52 (prolate spheroid)
橢圓球體的三軸長的長度為a,b,c
則橢圓球體的體積為(4/3)*π*abc
• 4/3 * 3.14* (L/2)*(W/2)*(H/2)
= 4/3*3.14*1/8*L*W*H
= 0.523 * LWH
L x W x H x 0.52 (ellipsoid)
L × W × H × 0.71 (Lambert)
WHO lower reference limits (5th centiles and
their 95% C.I.) for semen characteristics(2010)
參數
Parameter
低参考值
Lower reference limit
精液量 (毫升)
Semen volume (ml)
1.5 (1.4-1.7)
精蟲總數 (百萬/每次射精)
Total sperm number (106 per ejaculate)
39 (33-46)
精蟲濃度 (百萬/毫升)
Sperm concentration (106 per ml)
15 (12-16)
總活動力 (前進運動＋非前進運動，%)
Total motility (PR＋NR, %)
40 (38-42)
前進運動 (%)
Progressive motility (PR, %)
32 (31-34)
存活率 (活精蟲，%)
Vitality (live spermatozoa, %)
58 (55-63)
精蟲型態 (正常，%)
Sperm morphology (normal forms, %)
4 (3.0-4.0)
Nomenclature of Semen characteristics
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Aspermia
無精液
Azoospermia
精液中無精蟲
Oligozoospermia
精液中精蟲數量低於低參考值
Cryptozoospermia
新鮮精液中無精蟲，但在離心後之粒狀物檢查有精蟲
Asthenozoospermia
精蟲前進泳動之比率低於低参考值(low reference limit)
Teratozoospermia
型態正常精蟲之比率低於低参考值
Necrozoospermia
精液中活精蟲比率低，且大部份的精蟲不會活動
Normozoospermia
精液中精蟲數量、前進運動之精蟲比率、型態正常之精蟲比率相等或
高於低參考值
1
7/9/2021
Hormonal profile: FSH, LH, T, PRL
(Sertoli cell)
2020 TUA泌尿科治療指引 男性不孕症
Genetic disorders in infertility
• Chromosomal anomalies resulting in impaired
testicular function
• Y chromosome gene deletions associated
isolated spermatogenic failure
• Cystic fibrosis gene (CFTR) mutations
associated with congenital absence of vasa
deferntia
Klinefelter syndrome (47, XXY)
• Most frequent sex chromosome aneuploidy in human
males
• One in 500 to 800 live male births (estimated 15,000
~25,000 males in Taiwan)
• During early puberty, the spermatogonia appear to
undergo massive apoptosis due to failure in meiosis.
• Low T in 50% of KS (not all)
• 50~60% sperm retrieval rate
• 50~85% fertilization rate
• 15~45% live birth rate
• The eariler in life (<35 Y/O) TESE is performed, the
better the chance of finding sperm.
Y Chromosome deletions
• Testing for Yq deletion:
– < 5 million spermatozoa/mL (EAU 2012).
– Non-obstructive azoospermia (AUA 2010)
• Azoospermia factor, AZFa, b, c
• AZFc (DAZ gene) is the most common deletion, with SRR
of 70%.
• Poor sperm retrieval rate in complete AZFa or AZFb
microdeletions
Vernaeve et al., Hum Reprod, 2004; Schiff et al., J Clin Endocrinol Metab.
2005; Friedler et al., Hum Reprod, 2001; Okada et al., Fertil Steril. 2005;
Raman et al., J Urol, 2002
2
7/9/2021
TRUS for low ejaculate (< 1ml)
(seminal vesicles, vas and EjD)
2020 TUA泌尿科治療指引 男性不孕症
Normal transrectal ultrasound of the ampulla of the vas deferens
(V) and seminal vesicles (SV) in transverse section.
Sperm DNA fragmentation testing: Summary evidence and
clinical practice recommendations
Primary spermatogenic failure
Oligozoospermia
Azoospermia (NOA)
Esteves et al. Andrologia, Volume: 53, Issue: 2, 2020
Diagnostic evaluation of primary
spermatogenic failure
• Routine investigations
– Usually small testis, semen analysis &
hormonal determination
• Oligozoospermia
• In non-obstructive azoospermia (NOA), semen
analysis shows normal ejaculate volume and
azoospermia after centrifugation (3000 g for 15
minutes).
Sperm retrieval techniques
Epididymal
(MESA, PESA)
Vasal
(MVSA, PVSA)
Testicular
(TESA, TESE, microTESE)
Turek PJ, Nature Reviews Urology, 2013
3
7/9/2021
TESE outcomes by diagnosis
`
2020 TUA泌尿科治
療指引 男性不孕症
Diagnostic evaluation of obstructive
azoospermia
Obstructive azoospermia
Obstruction in primary infertile men is frequently
present at the epididymal level.
Congenital Bilateral Absence of the Vas
Deferens (CBAVD)
CFTR mutations in CBAVD
• 95% of male patients with cystic fibrosis had CBAVD.
• Most infertile men (2/3) with CBAVD carry mutations in
the CFTR (cystic fibrosis transmembrane conductance
regulator) gene in Caucasians.
• 1/29 Caucasians are carriers
• Over 2/3 of mutant alleles are ΔF508 (in-frame
deletion of phenylalanine at residue 508) and R117H .
• When a man has structural abnormalities of the vas
deferens (unilateral or bilateral absence), he and his
partner should be tested for CF gene mutations.
• At least one testis with a volume > 15 mL,
(although a smaller volume may be found in
some patients with OA and concomitant partial
testicular failure)
• Enlarged and dilated epididymis
• Nodules in the epididymis or vas deferens
• Absence or partial atresia of the vas
• Serum FSH and Inhibin B levels may be normal,
(but do not exclude a testicular cause of
azoospermia (e.g. spermatogenic arrest)).
Surgery of OA
2020 TUA泌尿科治療指引 男性不孕症
4
7/9/2021
Varicocele
pros and cons of various methods of
varicocele repair
• Andrological conditions:
– failure of ipsilateral testicular growth and
development(>2cc or 20%)
– symptoms of pain and discomfort;
– male sub-fertility
– Hypogonadism
• Diagnostic evaluation:
– clinical examination and should be confirmed
by colour Duplex analysis.
EAU guideline 2020
2020 TUA泌尿科治療指引 男性不孕症
Campbell Urology 12th , chapter 67
根據目前最新版的教科書，NOA是可以建議開刀的，對將來的testicular
function也有好處
Campbell Urology 12th , chapter 67
5
7/9/2021
Hypogonadotrophic hypogonadism
• Medical treatment of male infertility is recommended
only for cases of hypogonadotrophic
hypogonadism.
– hCG (1500-3000 IU), 3 times/week for 8-12 week
– Recombinant or highly purified human FSH is added at a dose of
75 IU 3 times/week, if no effect to hCG.
– Onset of spermatogenesis: 3-6 months
– Take up 1-2 years to maximize effect on sperm production
• Androgens are strictly contraindicated. (EAU guideline
on male infertility, 2012)
– Androgen replacement inhibits gonadotropin production,
decrease intratesticular T levels, and suppress spermatogenesis.
J Urol 2006; 176:1307-12
Asian J Androl 2012;14: 57-60
Eur Urol 2012; 62:324-32
Hypogonadotrophic hypogonadism
2020 TUA泌尿科治療指引 男性不孕症
Microlithiasis and testicular tumor
Kallmann Syndrome
• 1/10000
• X-linked (KAL1 gene)
mutation
• Failure of GnRH secretion
by the hypothalamus
• Anosmia or hyposmia
• Cleft palate, hearing defect,
colorblindness
• Cryptorchidism,
micropenis, gynecomastia,
delay pubertal development
隱睪症 (Cryptorchidism)
2020 TUA泌尿科治療指引 男性不孕症
Testicular Microlithiasis (TM)
Impalpable testicular tumor and
microlithiasis
2020 TUA泌尿科
治療指引 男性不
孕症
6
7/9/2021
Germ cell malignancy and male infertility
2020 TUA泌尿科治療指引 男性不孕症
Idiopathic male infertility
Oligo-astheno-teratozoospermia (OAT)
2020 TUA泌尿科治療指引 男性不孕症
male accessory gland infections and infertility
2020 TUA泌尿科治療指引 男性不孕症
Idiopathic male infertility
2020 TUA泌尿科治療指引 男性不孕症
敬祝 金榜題名
7
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Anatomy and Etiology
催促寫paper的主任
全院缺床跑來護理
站咆嘯的病人
In Male Infertility
又要請假的PGY
09.04.21 張榮發基金會國際會議中心
賴俊佑 醫師 中國附醫
小孩又出生的R1
怕爆的CR
催促寫paper的主任
全院缺床跑來護理
站咆嘯的病人
109+110考題解析
考古題數
勃起功能障礙：生理
10
勃起功能障礙：病因，治療
10
性腺功能低下：睪固酮生理，病因，治療
9
7
射精功能障礙：早洩，逆行，遲射
不孕症精液分析/解剖/結紮/精索靜脈曲張
不孕症評估/手術
又要請假的PGY
小孩又出生的R1
不知道會不會因為
疫情取消的泌專考
試大魔王
無精症
Priapism & Peyronie’s disease
不孕症: 28
7
5
14
7
7
12
4
4
男性學課本範圍
• Male reproductive physiology：chapter 21-23
• Male infertility：chapter 24,25
• Erectile dysfunction: chapter 26,27,30
• Priapism: chapter 28
• Premature ejaculation: chapter 29
• Peyronie disease: chapter 31
• Female sexual dysfunction: chapter 32
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2021/9/7
15-30 mins
2
2021/9/7
15-30 mins
2010 WHO lower reference limits (5th centiles) for
semen characteristics
30 mins
3
40%
32%
參數
Parameter
低参考值
Lower reference limit
精液量 (毫升)
Semen volume (ml)
1.5 (1.4-1.7)
精蟲總數 (百萬/每次射精)
Total sperm number (106 per ejaculate)
39 (33-46)
精蟲濃度 (百萬/毫升)
Sperm concentration (106 per ml)
15 (12-16)
總活動力 (前進運動＋非前進運動，%)
Total motility (PR＋NR, %)
40 (38-42)
前進運動 (%)
Progressive motility (PR, %)
32 (31-34)
存活率 (活精蟲，%)
Vitality (live spermatozoa, %)
58 (55-63)
精蟲型態 (正常，%)
Sperm morphology (normal forms, %)
4 (3.0-4.0)
Nomenclature of Semen characteristics
其他閥值 Other consensus threshold values
pH值
≧7.2
過氧化酶陽性之白血球 (百萬/毫升)
Peroxidase-positive leukocytes (106 per ml)
＜1.0
混合抗球蛋白反應 (%)
MAR test (motile spermatozoa with bound particles, %)
﹤50
免疫念珠試驗 (%)
Immunobead test (motile spermatozoa with bound beads, %)
﹤50
精液鋅濃度 (微摩爾/每次射精)
Seminal zinc (μmol/ejaculate)
≧2.4
精液果糖濃度 (微摩爾/每次射精)
Seminal fructose (μmol/ejaculate)
≧13
精液中性葡糖苷酶 (毫單位/每次射精)
Seminal neutral glucosidase (mU/ejaculate) …epi function marker used
≧20
•
•
•
•
•
•
•
•
Aspermia → 無精液
Azoospermia → 無精症(精液中無精蟲)
Oligozoospermia → 寡精症(精液中精蟲數量低於1,500萬)
Cryptozoospermia → 隱精症(新鮮精液中無精蟲，但在離心後之粒狀物檢查有精蟲)
Asthenozoospermia → 弱精症(精蟲前進泳動之比率低於32%)
Teratozoospermia → 畸精症(型態正常精蟲之比率低於4% (Kruger), 30% (1992 WHO))
Necrozoospermia → 死精症(精液中活精蟲比率低於58%，且大部份的精蟲不會活動)
Normozoospermia → 精液中精蟲數量、前進運動之精蟲比率、型態正常之精蟲比率相等或高於
低參考值
for diagnosis of obstruction
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2021/9/7
30 mins內要液化
1. PR
2. NR
3. Immotility
PR: 32%
Total: 40%
4
2021/9/7
Testicular artery
Internal iliac artery
5
2021/9/7
口訣
可幫助快速記憶!!!
干拎肏森沒?
Q. Stone recurrent的risk factor?
GDGDA→IFEBUS
2-12 days
G: general → IFEBUS…
D: disease
G: genetic
D: drug
A: anatomy
口訣很重要!!!
6
2021/9/7
短臂
7
2021/9/7
• Postvasectomy pain syndrome has no
association with immediate postoperative
complications such as hematoma or infection.
• Several theories:
• Epididymal duct dilation with obstruction
• Extravasation of spermatozoa…
精索靜脈曲張:4
8
2021/9/7
DNA fragmentation
9
2021/9/7
• AUA update: 可以念!!!! 一年大概35章update，一章約莫五題!!!!
而且老師會覺得這個很新，通常考生不一定拿得到AUA update
series，可以考慮投資
筆試
口試
筆試分數計算
• 共150題 (非劃卡，需寫答案到答案卷)
• 60分及格
• 20分：考古題=> 30題(30x 2/3=20)
=> 答錯倒扣2/3分(等於扣4/3分)
• 泌尿科醫學會約考前兩周至一個月公佈
分數計算
• 所以如果要60分
• 後面20分一定要拿到！
• 前面120題，你必須答對
60題(60x2/3=40)，而且不能寫錯!
• 80分：120題(120x 2/3=80)，由近三年題庫出題
=> 答錯倒扣1/3分(等於扣一分)
10
2021/9/7
CMUH GU
This is MORE than a test…
11
2021/9/7
Outline
• Algorithm of male infertility
Management
of Male
Infertility
林口長庚醫院泌尿科
黃靖崴 醫師
2021/9/4 15:40
gonadotoxin
• Surgical role in male infertility
•
•
•
•
•
Testicular biopsy
Vasography
Vasovasostomy/Vasoepididymostomy
Mesa
TESE
• Lesson learned of history: Examples
Initial Evaluation of Male Infertility
Algorithm of Male Infertility
Sperm+
• Initial evaluation of infertility
Varicocele
Scrotal
exploration
Varicocelectomy
VV/VE
obstructive
Azoospermia
Sperm
retrieval
MESA/TESE
Male infertility
Non-obstructive
Endocrinopathy
SCOS
MA
HypoS
47XXY
AZFc del
S/p C/T
Mumps
UDT
Hypo-hypo
MD-TESE
Detailed History Taking
Physical Examination
Toxin
Infection
Childhood
Sex
Bilateral consistency of vas
Size of testis
Surgical scar
Varicocele
MD-TESE
Surgical Evaluation of Male Infertility
Overall Final
Diagnosis of Male
Infertility
⚫Testicular Biopsy
• To distinguish obstructive from nonobstructive
azoospermia
⚫Vasography
• To confirm the site of obstruction
1
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Indication of Testicular Biopsy
Risk of Testicular Biopsy
⚫Normal testis size and consistency
⚫ Accidental damage to the testicular artery: 5%
⚫Palpable vasa deferentia
⚫ Epididymitis
⚫Normal serum follicle-stimulating hormone (FSH) levels
⚫ Hematoma
⚫Negative serum antisperm antibody assay
Biopsy Site:
Upper Pole
Indication of Vasography
Indication of Vasography
Absolute indication:
Relative indication
⚫Severe oligospermia with normal testis biopsy
⚫High level of sperm-bound antibodies, which indicates
unilateral, bilateral, or partial obstruction
⚫Low semen volume and very poor sperm motility (partial
ejaculatory duct obstruction)
⚫Azoospermia, plus
⚫Complete spermatogenesis with many mature spermatids
on testis biopsy, plus
⚫At least one palpable vas deferentia
Typical
Methodology
for Vasography
Vasography
Image
2
2021/9/7
Key points for Vasography
Risk of Vasography
⚫Only perform under the impression of obstructive
azoospermia
⚫Perform vasography only at time of reconstruction
⚫Always sample vasal fluid for cryopreservation
⚫ Stricture
⚫ Injury to the Vasal Blood Supply
⚫ Hematoma
⚫ Sperm granuloma
Possible Site of Obstruction
After the vasography
⚫ Ejaculatory duct obstruction
⚫ Vas deferens obstruction
⚫ Long segment loss of vas
Ejaculatory Duct
Obstruction
⚫ Vasal agnesis
Vas deferens Obstruction
⚫ Vasovasostomy
⚫ Vasoepididymostomy
Vasovasostomy
3
2021/9/7
Key to Successful Vaso-vasostomy
⚫ Accurate mucosa-to-mucosa approximation
⚫ Tension-free anastomosis
⚫ Good blood supply
⚫ Leakproof anastomosis
Robotic Assisted
Vaso-vasostomy
⚫ Healthy mucosa and muscularis
⚫ Good atraumatic anastomotic technique
⚫ SHORTER OPERATIVE TIMES
⚫ BETTER MEAN SPERM COUNT
Parekattil, Sijo & Atalah, Hany & S Cohen, Marc. (2009). Video Technique for Human Robot-Assisted
Microsurgical Vasovasostomy. Journal of endourology / Endourological Society. 24. 511-4. 10.1089/end.2009.0235.
Choice between VV and VE
Vasoepididymostomy
If Reconstruction not Feasible
Sperm retrieval with microsurgical open method
⚫ MESA: microsurgical epididymal sperm aspiration
MESA
⚫ Caput(Head)
⚫ Corpus(Body)
⚫ Cauda(Tail): preferred
⚫ mTESE: testicular sperm extraction
4
2021/9/7
TESE
Time for Archaeology
What Has History Told Us?
• Male infertility and general health condition
• Certain disease condition
• Klinefelter‘s syndrome
• Kallmann syndrome
• Y-chromosome microdeletion
Klinefelter
Syndrome
• Interpretation of semen analysis and hormone profile
• Sperm retrieval successful rate and indication
• Medical treatment for male infertility
Kallmann Syndrome
Y-Chromosome Microdeletion
5
2021/9/7
Example 1
Example 2
• TESE/MESA sperm retrieval rate
• Possible Etiology of this
Vasography Image?
Mid-line ejaculatory duct cyst
Example 3
Example 4
• Medical Tx for Male Infertility
• Vaso-vaso/Vaso-epididyostomy- Surgical procedures,
intra-OP findings and indication
•
•
•
•
Clomiphere Citrate
Bromocriptine
hCG
FSH
• Exogenous testosterone is contraindicated
Example 4(Cont.)
Example 5
• YES or NO?
• Testicular end of vas deference如果發現vasal fluid呈現copious thick
white, toothpaste-like water insoluble液體，此時vasal fluid大部份都有
sperm，可以進行vasovasostomy X
• Vasoepididymostomy應該同時做副睪丸抽吸並做冷凍精子保存 O
• 執行腹腔鏡精索靜脈截斷手術(laparoscopic varicocelectomy)時，最容
易傷到的神經為 genitofemoral nerve，執行腹股溝精索靜脈截斷手術
(inguinal approach varicocelectomy)時，最容易傷到的則為ilioinguinal
nerve X
• 執行vasovasostomy時，vas長度不足可剝離vas與epididymis之間的
connective tissue，額外得到4-6cm的長度 O
• Miscellaneous
• Anti-sperm antibody
• Azoospermia evaluation algorithm
• Autonomic dysreflexia during rectal electrode neuro-stimulation
for aejaculation
6
2021/9/7
Azoospermia
考前衝刺
考古題
Campbell, EAU Guideline, AUA Guideline
高雄長庚 劉惠瑛
Liu,Hui-Ying, M.D.
2
1.
Introduction
Liu, Hui-Ying M.D.
Liu, Hui-Ying M.D.
WHO / EAU
1-3% of male population
✓Centrifugation
3,000 g for 15 min
10-15% of infertile males
✓Microscopic exam
× 200 magnification
Liu, Hui-Ying M.D.
Liu, Hui-Ying M.D.
1
2021/9/7
History
PE
Semen
Endocrine
Normal adult testis:
• AP 3 cm
• Width 2–4 cm
• Length 3–5 cm 4.6cm
• Weighs 12.5-19 mL
Genetic testing
Sonography
Evaluation
Hypothalamic–pituitary–gonadal axis
•
•
Radiographics. 27 (5): 1239-53. doi:10.1148/rg.275065172
https://radiopaedia.org/articles/testis-1
P
Hypothalamic–pituitary–gonadal axis
P
L F
L F
T E
T E
Karyotyping (chromosomal analysis)
•
Azoospermia
•
Sperm count <10× 106/mL
Y chromosome microdeletion analysis
•
Azoospermia
•
Severe oligozoospermia <5× 106/mL
Campbell 11th edition
Liu, Hui-Ying M.D.
EAU guideline 2020
Liu, Hui-Ying M.D.
Int. J. Mol. Sci. 2021, 22(6), 3264
2
2021/9/7
NOA
Congenital Hypogonadotropic Hypogonadism (CHH)
• 50% Unknown
Primary testicular failure
• 73% Unknown
• 15% Karyotype
✓47,XXY Klinefelter syndrome
✓46,XX male syndrome
• 7% Y chromosome microdeletion
✓AZF a/ b / c
Congenital Bilateral Absence of
Vas Deferens (CBAVD)
• 75-85% CFTR
2.
Classification
OA
Liu, Hui-Ying M.D.
Int. J. Mol. Sci. 2021, 22(6), 3264
Liu, Hui-Ying M.D.
Pretesticular
Pretesticular
NOA
Testicular
Post-testicular
Liu, Hui-Ying M.D.
Testicular
OA
Pre-testicular
Pre-testicular
✓ Hypothalamus / Pituitary abnormality
✓ Endocrinopathy
✓ Secondary testicular failure
✓ FSH ↓, LH ↓, Testosterone ↓
✓ Hypogonadotropic hypogonadism
- Congenital:
‣ Kallmann syndrome
‣ Idiopathic Hypo-Hypo (IHH)
- Acquired: tumor, drugs
✓ Hyperprolactinemia
✓ Androgen insensitivity
✓ Tumor, Trauma, Infection, Drugs,
Radiation, …
Liu, Hui-Ying M.D.
Post-testicular
Liu, Hui-Ying M.D.
Hypogonadotropic Hypogonadism
✓ FSH ↓, LH ↓, Testosterone ↓
✓ Kallmann syndrome
- Pituitary function ↓
- Anosmia
- 10% mutations in GNRHR or KAL1
gene
✓ Treatment: Medicine
- Replacement of
‣ LH with hCG
‣ FSH with rFSH or hMG
- Gonadotropin therapy for 1-2 years
before sperm becomes evident in the
ejaculate
Liu, Hui-Ying M.D.
3
2021/9/7
✓ Primary testicular failure
✓ Testosterone ↓/↔︎, FSH ↑, LH ↑
✓ Small testis, collapsed epididymis
Testicula
r
✓ Primary testicular failure
✓ Testosterone ↓/↔︎, FSH ↑, LH ↑
Testicula
r
✓ Chromosomal abnormality:
- Klinefelter’s syndrome (47 XXY)
- Y chromosome microdeletions
- 46 XX male syndrome
‣ Absence of AZF region
‣ No spermatogenesis
- 47 XYY (Superman syndrome)
- Mixed gonadal dysgenesis
- Genetic disorders of spermatogenesis
(complete absence or reduced)
Liu, Hui-Ying M.D.
✓ Local conditions:
- Varicocele
- Cryptorchidism, Orchitis, Torsion
- Trauma, Radiation, Chemotherapy
✓ Alcohol, smoke, heat, toxin
Liu, Hui-Ying M.D.
Klinefelter’s syndrome
✓ Primary testicular failure
✓ Testosterone ↓/↔︎, FSH ↑, LH ↑
Testicula
r
✓Spermatogenic Dysfunction
- FSH ↑ (> 7.6IU/L), Testis < 4.6cm
Testicula
r
✓Steroidogenic Dysfunction
- LH ↑, Testosterone ↓
- Leydig cell dysfunction
✓Microductal Obstruction
Liu, Hui-Ying M.D.
Liu, Hui-Ying M.D.
Klinefelter’s syndrome
Testicula
r
Liu, Hui-Ying M.D.
✓ 47 XXY, 10-20% mosaic
✓ Observed in 1/500 - 1/1000 live births
✓ Increased height, small firm testes,
gynecomastia
✓ NOA, Testosterone ↓, FSH ↑, LH ↑
(Hyper-Hypo)
✓ High risk for breast cancer (50x), nonHodgkin lymphoma and extragonadal
mediastinal germ cell tumors
✓ Sperm retrieval rate：68%
✓ Treatment:
- Surgical extraction of sperm at early
to mid puberty
✓ 47 XXY, 10-20% mosaic
✓ Observed in 1/500 - 1/1000 live births
✓ Increased height, small firm testes,
gynecomastia
✓ NOA, Testosterone ↓, FSH ↑, LH ↑
(Hyper-Hypo)
✓ High risk for breast cancer (50x), nonHodgkin lymphoma and extragonadal
mediastinal germ cell tumors
✓ Sperm retrieval rate：68%
✓ Treatment:
- Surgical extraction of sperm at early
to mid puberty
•
Testosterone replacement therapy for symptomatic
primary / secondary hypogonadism not considering
parenthood.
•
Do not use testosterone replacement for male infertility
Liu, Hui-Ying M.D.
4
2021/9/7
Y chromosome microdeletions
Testicula
r
✓ Regions of Y chromosome:
- Necessary for spermatogenesis
✓ AZFa and AZFb microdeletions
- Absence of retrievable sperm from the
testis
✓ Microdeletions of AZFc currently have
unclear clinical significance
✓ AZF deletions will be transmitted to the
son.
Liu, Hui-Ying M.D.
Liu, Hui-Ying M.D.
Hypospermatogenesis > Maturation arrest > Sertoli cell-only
Klinefelter
AZFc
68%
70%
AZFa, AZFb
0%
Spermatocytogenesis
Spermiogenesis
Liu, Hui-Ying M.D.
Liu, Hui-Ying M.D.
Varicocele
Testicula
r
Liu, Hui-Ying M.D.
✓ 11.7% of men & 25.4% of men with
abnormal semen analysis
✓ Surgical varicocelectomy significantly
improves semen parameters
- Clinical varicoceles
(Subclinical X)
- Abnormal semen parameters including
NOA
(Normal semen analysis X)
✓ After varicocele repair for men with NOA
- 36% at least one non-motile sperm in the
ejaculate
✓ Clinical features:
- 15-20% of men with azoospermia
- Normal FSH, normal size testes
- Epididymal enlargement
Post-testicular
Liu, Hui-Ying M.D.
Ejaculatory dysfunction
✓ Anejaculation
✓ Retrograde ejaculation
Obstruction of sperm delivery
✓ Intratesticular obstruction
✓ Epididymal obstruction
✓ Vas deferens obstruction
✓ Ejaculatory duct obstruction
✓ Functional obstruction of distal seminal
ducts
5
2021/9/7
Anejaculation
✓ Clinical features:
- 15-20% of men with azoospermia
- Normal FSH, normal size testes
- Epididymal enlargement
✓ Involves
- Complete absence of antegrade
- Retrograde ejaculation
✓ Associate
- Central or peripheral nervous system
dysfunction
- Drugs
Ejaculatory dysfunction
Post-testicular
Liu, Hui-Ying M.D.
✓ Anejaculation
✓ Retrograde ejaculation
Obstruction of sperm delivery
✓ Intratesticular obstruction
✓ Epididymal obstruction
✓ Vas deferens obstruction
✓ Ejaculatory duct obstruction
✓ Functional obstruction of distal seminal
ducts
Post-testicular
Liu, Hui-Ying M.D.
Retrograde ejaculation
Post-testicular
✓ Sperms in the post ejaculatory urine
✓ Causes
- Neurogenic
‣ Spinal cord injury
‣ Multiple sclerosis
‣ DM
- Pharmacological
‣ α1-adrenoceptor antagonists
- Urethral
- Bladder neck incompetence
‣ Bladder neck resection
‣ Prostatectomy
Liu, Hui-Ying M.D.
Liu, Hui-Ying M.D.
Retrograde ejaculation
Retrograde ejaculation
✓ Treatment
✓ Treatment
Ephedrine
Pseudoephedrine
Imipramine
Post-testicular
Liu, Hui-Ying M.D.
Post-testicular
Liu, Hui-Ying M.D.
6
2021/9/7
Intratesticular Obstruction
✓ Clinical features:
- 15-20% of men with azoospermia
- Normal FSH, normal size testes
- Epididymal enlargement
✓ 15% of men with OA
✓ Congenital forms are less common
✓ Acquired forms
- Post-inflammatory
- Post-traumatic
Ejaculatory dysfunction
✓ Anejaculation
✓ Retrograde ejaculation
Post-testicular
Liu, Hui-Ying M.D.
Post-testicular
Obstruction of sperm delivery
✓ Intratesticular obstruction
✓ Epididymal obstruction
✓ Vas deferens obstruction
✓ Ejaculatory duct obstruction
✓ Functional obstruction of distal seminal
ducts
Post-testicular
Liu, Hui-Ying M.D.
Epididymal Obstruction
Vas deferens Obstruction
✓ Most common cause of OA
✓ 30-67% of azoospermic men
✓ Congenital forms
- Young’s syndrome
‣ Chronic sinopulmonary infections
‣ Triad: bronchiectasis, sinusitis,
obstructive azoospermia
✓ Acquired forms
- Infection (gonococcal, chlamydial)
- Trauma
- Surgical intervention
✓ Congenital forms
- CBAVD (Bilateral)
- CUAVD (Unilateral)
‣ Unilateral agenesis or a partial defect is
associated with 80% contralateral
seminal duct anomalies or 26% renal
agenesis
✓ Acquired forms
- s/p vasectomy=> Vasectomy reversal
- s/p hernia repair
Liu, Hui-Ying M.D.
Post-testicular
Liu, Hui-Ying M.D.
CBAVD
Ejaculatory duct Obstruction
Congenital Bilateral Absence of the Vas Deferens
Post-testicular
Liu, Hui-Ying M.D.
✓ 1% infertile men, 6% of azoospermic
✓ 65-80% Mutations in the CFTR gene
responsible for Cystic fibrosis
✓ Gene encodes a chloride ion channel
✓ Clinical features:
- Normal testis size and volume
- Semen volume < 1.5 mL
- pH < 7.0 (acidic)
- Spermatogenesis is typically normal
- Caput of epididymis always present BUT
cauda and corpus usually absent
- 10% also exhibit renal genesis
✓ Treatment:
- Sperm extraction and IVF/ICSI
✓ 1-3% of OA
✓ Semen volume ↓, seminal fructose ↓,
pH ↓ (acidic)
✓ Dilated seminal vesicles (> 15 mm)
Post-testicular
✓ Cystic obstructions
- Usually congenital (eg, Mullerian duct
cyst or ejaculatory duct cysts)
- Typically midline
✓ Post-inflammatory
- Usually secondary to urethroprostatitis
(Infection)
- Trauma
- Urethral surgery
Liu, Hui-Ying M.D.
7
2021/9/7
Functional Obstruction
Post-testicular
✓ Functional obstruction of the distal seminal
ducts might be attributed to local
neuropathy
✓ Often associated with urodynamic
dysfunction
✓ Impaired sperm transport
- Idiopathic
- Associated with selective serotonin reuptake inhibitor (SSRI) medication
Low volume
Low fructose
Low pH
Characteristics of ejaculatory duct
obstruction
Liu, Hui-Ying M.D.
Liu, Hui-Ying M.D.
Obstruction
Incomplete
Functional
Low volume-Normal
Absent-Low-Normal
Absent-Low-Normal
Low pH-Normal
Post-testicular
Characteristics of ejaculatory duct
obstruction
Liu, Hui-Ying M.D.
Liu, Hui-Ying M.D.
Transurethral resection of the
ejaculatory ducts
Obstruction
Post-testicular
Liu, Hui-Ying M.D.
✓ TRUS
- Midline cyst
- Dilated ejaculatory duct
- Dilated seminal vesicle (> 1.5cm)
✓ Treatment: Surgery
- Microsurgical vasovasostomy or
tubulovasostomy
‣ Recanalisation require 3-18 months
‣ Patency rates 60-87%
- TURED (Transurethral resection of the
ejaculatory ducts)
- Sperm retrieval techniques
✓ Clinical features:
- Testis: Normal in size and volume
- Hormonal profiles: Normal
- Sperm count: variant
- Seminal vesicles: Dilated
- Epididymis: Full
- Semen:
‣ Low volume
‣ Low pH (acidic)
‣ Low fructose
•
Cold knife incision alone leads to re-obstruction
•
Resection of the verumontanum will often reveal the
dilated ejaculatory duct orifice or cyst cavity.
•
Avoid excessive coagulation
•
Foley catheter left overnight
•
7 days of oral antibiotics
Liu, Hui-Ying M.D.
8
2021/9/7
3.
•
•
•
考古題
(A) 先天性的射精管阻塞,與先天性無輸精管的構造變異都是相同的輸送管路
的發育缺陷。
(B) 若精液檢查顯示有少數精子出現於精液中,為極度寡精症時,即可以排除是
射精管阻塞。
•
(C) 射精管阻塞的病因包括攝護腺及儲精囊的囊腫壓迫所致。
•
(D) 關鍵的診斷工具是經直腸超音波。
•
Liu, Hui-Ying M.D.
1. 射精管阻塞會引起阻塞性無精症,是男性不孕症中可以針對病因治療的其
中一項。以下描述何者為非:
(E) 射精管出口阻塞可以接受經尿道射精管切除手術 (TUR of the ejaculatory
duct),為了避免切口再開合,應該使用電刀切除,避免只使用 cold Knife 切開。
Liu, Hui-Ying M.D.
Transurethral resection of the
ejaculatory ducts
Incomplete
Functional
Low volume-Normal
Absent-Low-Normal
•
Cold knife incision alone leads to re-obstruction
•
Resection of the verumontanum will often reveal the
dilated ejaculatory duct orifice or cyst cavity.
•
Avoid excessive coagulation
•
Foley catheter left overnight
•
7 days of oral antibiotics
Absent-Low-Normal
Low pH-Normal
Characteristics of ejaculatory duct
obstruction
Liu, Hui-Ying M.D.
Liu, Hui-Ying M.D.
1. 射精管阻塞會引起阻塞性無精症,是男性不孕症中可以針對病因治療的其
中一項。以下描述何者為非:
•
2. 下列哪一些症狀與病徵,與先天性雙側無輸精管無關?
(A) 先天性的射精管阻塞,與先天性無輸精管的構造變異都是相同的輸送管路
的發育缺陷。
•
(A) 精液酸鹼度小於7
(B) 若精液檢查顯示有少數精子出現於精液中,為極度寡精症時,即可以排除是
射精管阻塞。
•
(B) 單次射精的量小於1.5m
•
(C) 射精管阻塞的病因包括攝護腺及儲精囊的囊腫壓迫所致。
•
(C) 伴隨 Pulmonary fibrosis 的先天遺傳疾病
•
(D) 關鍵的診斷工具是經直腸超音波。
•
(D) 陰囊觸診摸不到輸精管或部分副睾
(E) 射精管出口阻塞可以接受經尿道射精管切除手術 (TUR of the ejaculatory
duct),為了避免切口再開合,應該使用電刀切除,避免只使用 cold Knife 切開。
•
(E) 異常之基因突變與 chloride ion channel 有關
•
•
•
•
Liu, Hui-Ying M.D.
Liu, Hui-Ying M.D.
9
2021/9/7
CBAVD:
CFTR gene, Cystic fibrosis
Chloride ion channel
Semen volume < 1.5 mL, pH < 7.0 (acidic)
•
2. 下列哪一些症狀與病徵,與先天性雙側無輸精管無關?
•
(A) 精液酸鹼度小於7
•
(B) 單次射精的量小於1.5m
•
(C) 伴隨 Pulmonary fibrosis 的先天遺傳疾病
•
(D) 陰囊觸診摸不到輸精管或部分副睾
•
(E) 異常之基因突變與 chloride ion channel 有關
Liu, Hui-Ying M.D.
•
•
3. 30 歲男性不孕症患者,兩套精液分析顯示無精蟲,精液量2.5ml,可
摸到兩側輸精管;睾丸大小:右側 12ml,左側8ml,下列處置何者不適當
?
•
(A) 可做Y染色體缺損檢測
•
(B) 可做 FSH, LH, Testosterone 檢測
•
(C) 可做陰囊超音波檢查
•
(D) 可做睾丸切片檢查
•
(E) 可做睾丸取精手術
Liu, Hui-Ying M.D.
3. 30 歲男性不孕症患者,兩套精液分析顯示無精蟲,精液量2.5ml,可
摸到兩側輸精管;睾丸大小:右側 12ml,左側8ml,下列處置何者不適當
?
•
(A) 可做Y染色體缺損檢測
•
(B) 可做 FSH, LH, Testosterone 檢測
•
(C) 可做陰囊超音波檢查
•
(D) 可做睾丸切片檢查
•
(E) 可做睾丸取精手術
Liu, Hui-Ying M.D.
Biopsy indication:
Normal testis size
Palpable vas
Normal FSH
Negative antisperm antibody
•
4. 35 歲男性因原發性男性不孕症求診,檢查發現無精蟲,無重大病史,理學
檢查可摸到兩側輸精管;睾丸大小: 右側 10 ml,左側 8ml; 有兩側精索靜脈
曲張 (Gr II),血清FSH: 26 mIU /mL; LH: 14 mlU/mL; Testosterone: 2.2
ng/mL; 染色體檢查:46, XY; 無Y染色體缺損,下列何者不正確?
•
(A) 可建議患者接受兩者精索靜脈曲張結紮手術
•
(B) 可建議患者接受睾丸取精手術
•
(C) 兩者精索靜脈曲張結紮手術後,精液出現精子的機率為15-20%
•
(D) 睾丸取精手術中找到精子的機率為50%
•
(E) 若有精子,該夫妻最終的懷孕率及活產率為 30-50%
Liu, Hui-Ying M.D.
After varicocele repair for men with NOA
36% at least one non-motile sperm in the ejaculate
•
4. 35 歲男性因原發性男性不孕症求診,檢查發現無精蟲,無重大病史,理學
檢查可摸到兩側輸精管;睾丸大小: 右側 10 ml,左側 8ml; 有兩側精索靜脈
曲張 (Gr II),血清FSH: 26 mIU /mL; LH: 14 mlU/mL; Testosterone: 2.2
ng/mL; 染色體檢查:46, XY; 無Y染色體缺損,下列何者不正確?
•
5. 31 歲男性,無精子症患者,理學檢查發現睾丸大小: 右側9ml、左側8ml,左側有
Grade III精索靜脈曲張,賀爾蒙檢查: FSH:18.1 mlU/mL、LH:8.5 mlU/mL、
Testosterone:2.12 ng/mL,染色體檢查:46, XY,無Y 染色體顯微缺損,陰囊超音波檢查
顯示左侧精索靜脈曲張及兩側睾丸微鈣化(testicular microlithiasis),以下那一項處置
最不適當:
•
(A) 可建議患者接受兩者精索靜脈曲張結紮手術
•
(A) 睾丸取精手術
•
(B) 可建議患者接受睾丸取精手術
•
(B) 睾丸切片手術
•
(C) 兩者精索靜脈曲張結紮手術後,精液出現精子的機率為15-20%
•
(C) 左側精索靜脈曲張結紮手術
(D) 睾丸取精手術中找到精子的機率為50%
•
(D) 若患者沒有生育考量,可以使用睾固酮治療
•
•
(E) 若有精子,該夫妻最終的懷孕率及活產率為 30-50%
Liu, Hui-Ying M.D.
•
(E) 先使用 Clomiphene citrate 或 HCG 治療3-6個月, 若精液分析結果仍然無精子,再
使用 FSH治療 3-6 個月,若仍然無精子,再做睾丸取精手術
Liu, Hui-Ying M.D.
10
2021/9/7
Normal: FSH (1.5-12.4), LH (1.7-8.6), Testosterone (2.49-8.36)
Hypo-Hypo: hCG, rFSH or hMG
Hyper-Hypo: sperm retrieval
•
5. 31 歲男性,無精子症患者,理學檢查發現睾丸大小: 右側9ml、左側8ml,左側有
Grade III精索靜脈曲張,賀爾蒙檢查: FSH:18.1 mlU/mL、LH:8.5 mlU/mL、
Testosterone:2.12 ng/mL,染色體檢查:46, XY,無Y 染色體顯微缺損,陰囊超音波檢查
顯示左侧精索靜脈曲張及兩側睾丸微鈣化(testicular microlithiasis),以下那一項處置
最不適當:
•
(A) 睾丸取精手術
•
(B) 睾丸切片手術
•
(C) 左側精索靜脈曲張結紮手術
•
(D) 若患者沒有生育考量,可以使用睾固酮治療
•
•
•
•
•
•
(E) 先使用 Clomiphene citrate 或 HCG 治療3-6個月, 若精液分析結果仍然無精子,
再使用 FSH治療 3-6 個月,若仍然無精子,再做睾丸取精手術
Liu, Hui-Ying M.D.
•
•
6. 男性不孕症患者,精液檢查發現無精症(azoospermia),下列敘述何者錯誤?
(A) 抽血發現 testosterone 2.1 ng/ml, LH 38 mlU/ml, FSH 20 mlU/ml,(正常值 FSH:
1-8 mlU/mL LH: 0.6-12mlU/mL; Testosterone: 2.3-9.9 ng/mL),若患者想生育,建議手
術取精(surgical sperm extraction)。
(B) 若患者有 anosmia 且陰莖與睾丸發育不良,需安排基因檢測看是否有KALI 或
GNRHR gene 異常。
(C) 若雙輸精管觸診正常,測量睾丸長軸約4.8cm,精液量約1.8m,抽血 testosterone
3.5ng/ml, FSH 為6mIU/ml,則患者有九成以上的機會有精道(seminal tract)阻塞問題
。
•
(D) 約35%無精症有射精管阻塞的問題,尤其精液量小於1ml的患者。
•
(E) 以上敘述皆正確。
Liu, Hui-Ying M.D.
7. 以下何種NOA(non-obstructive azoospermia)的診斷是
一定取不到精子的？
6. 男性不孕症患者,精液檢查發現無精症(azoospermia),下列敘述何者錯誤?
•
(A) 抽血發現 testosterone 2.1 ng/ml, LH 38 mlU/ml, FSH 20 mlU/ml,(正常值 FSH:
1-8 mlU/mL LH: 0.6-12mlU/mL; Testosterone: 2.3-9.9 ng/mL),若患者想生育,建議手
術取精(surgical sperm extraction)。
•
(A) AZFc microdeletion
(B) 若患者有 anosmia 且陰莖與睾丸發育不良,需安排基因檢測看是否有KALI 或
GNRHR gene 異常。
•
(B) Klinefelter's syndrome
(C) 若雙輸精管觸診正常,測量睾丸長軸約4.8cm,精液量約1.8m,抽血 testosterone
3.5ng/ml, FSH 為6mIU/ml,則患者有九成以上的機會有精道(seminal tract)阻塞問題
。
•
(C) XX male syndrome
•
(D) 約35%無精症有射精管阻塞的問題,尤其精液量小於1ml的患者。
•
(D) Sertoli cell-only syndrome
•
(E) 以上敘述皆正確。
•
(E) Mumps orchitis history
•
OA: 15-20% of azoospermia
EDO: 1-3% of OA
Liu, Hui-Ying M.D.
Liu, Hui-Ying M.D.
46 XX male syndrome
✓Lack of Y chromosome linked AZF regions
✓Sperm retrieval rate: 0
•
7. 以下何種NOA(non-obstructive azoospermia)的診斷是
一定取不到精子的？
•
8. 以下何種NOA (non-obstructive azoospermia)情況是
可以靠藥物來矯正的?
•
(A) AZFc microdeletion
•
(A) Hypogonadotropic hypogonadism
•
(B) Klinefelter's syndrome
•
(B) Sertoli cell-only
•
(C) XX male syndrome
•
(C) Early maturation arrest
•
(D) Sertoli cell-only syndrome
•
(D) Hypospermatogenesis
•
(E) Mumps orchitis history
•
(E) AZF b+c microdeletion
Liu, Hui-Ying M.D.
Int. J. Mol. Sci. 2021, 22, 3264.
Liu, Hui-Ying M.D.
11
2021/9/7
Pretesticular: medicine
•
8. 以下何種NOA (non-obstructive azoospermia)情況是
可以靠藥物來矯正的?
•
9. 以下何種NOA (non-obstructive azoospermia) 是不可
能矯正的 (never correctable)?
•
(A) Hypogonadotropic hypogonadism
•
(A) Varicocele
•
(B) Sertoli cell-only
•
(B) Klinefelter's syndrome
•
(C) Early maturation arrest
•
(C) Kallmann's syndrome
•
(D) Hypospermatogenesis
•
(D) Idiopathic hypogonadotropic hypogonadism
•
(E) AZF b+c microdeletion
•
(E) Late maturation arrest
Liu, Hui-Ying M.D.
Liu, Hui-Ying M.D.
9. 以下何種NOA (non-obstructive azoospermia) 是不可
能矯正的 (never correctable)?
•
10. 下列有關非阻塞性無精子症(non-obstructive azoospermia)之敘
述何者不正確?
•
(A) Varicocele
•
(A) 非阻塞性無精子症之診斷無需做睾丸切片
•
(B) Klinefelter's syndrome
•
(B) 精母細胞停滯(spermatocytic arrest)通常伴隨正常FSH值
•
(C) 非阻塞性無精子症可能因精索靜脈曲張引起
•
(D) 應建議接受染色體核型分析及Y染色體顯微缺失檢測
•
Testicular
•
(C) Kallmann's syndrome
•
(D) Idiopathic hypogonadotropic hypogonadism
•
•
(E) Late maturation arrest
Liu, Hui-Ying M.D.
(E) 可以睾丸取精手術治療,惟該夫婦之最終活產率(live delivery
rate)約為40~50%
Liu, Hui-Ying M.D.
NOA: when sperm are found
Pregnancy rate: 45%
Live delivery rate: ~40%
•
10. 下列有關非阻塞性無精子症(non-obstructive azoospermia)之敘
述何者不正確?
•
(A) 非阻塞性無精子症之診斷無需做睾丸切片
•
(B) 精母細胞停滯(spermatocytic arrest)通常伴隨正常FSH值
•
(C) 非阻塞性無精子症可能因精索靜脈曲張引起
•
(D) 應建議接受染色體核型分析及Y染色體顯微缺失檢測
•
(E) 可以睾丸取精手術治療,惟該夫婦之最終活產率(live delivery
rate)約為40~50%
Liu, Hui-Ying M.D.
•
11. 一個無精症(azoospermia)的男性被轉介來你的門診,以下何種情況
不符合做睾丸切片(testis biopsy)的適應症之一？
•
(A) 正常的陰囊大小及一致性(consistency)
•
(B) 觸摸得到輸精管(vasa deferentia)
•
(C) 正常的血清促卵泡激素(serum follicle-stimulating hormone)數值
•
(D) 升高的血清促卵泡激素(serum follicle-stimulating hormone)數值
•
(E) 血清抗精子抗體檢測(serum antisperm antibody assay)為陰性
Liu, Hui-Ying M.D.
12
2021/9/7
Biopsy indication:
Normal testis size
Palpable vas
Normal FSH
Negative antisperm antibody
•
11. 一個無精症(azoospermia)的男性被轉介來你的門診,以下何種情況
不符合做睾丸切片(testis biopsy)的適應症之一？
•
(A) 正常的陰囊大小及一致性(consistency)
•
(B) 觸摸得到輸精管(vasa deferentia)
•
(C) 正常的血清促卵泡激素(serum follicle-stimulating hormone)數值
•
(D) 升高的血清促卵泡激素(serum follicle-stimulating hormone)數值
•
(E) 血清抗精子抗體檢測(serum antisperm antibody assay)為陰性
•
12. 輸精管攝影(vasography)在無精症(azoospermia)且睾丸切片有看到complete
spermatogenesis with many |mature spermatids及至少有一邊輸精管摸的到的病人是
個可考慮的診斷工具。以下為進行單側輸精管顯影劑注入後看到的景象,發現兩側輸精
管皆有顯影,何者為最可能的診斷?
•
(A) 可能是中線射精管囊腫(midline ejaculatory duct cyst)
•
(B) 可能是在疝氣手術後腹股溝有截斷
•
(C) 可能是射精管阻塞(ejaculatory duct obstruction),需做經尿道射精管切開術
(transurethral ejaculatory duct resection)
•
(D) 應是單側輸精管有盲端(blind end of vas deferens)
•
(E) 先天性兩側無輸精管(Congenital bilateral absence of the vas deferens)的病患
Liu, Hui-Ying M.D.
Liu, Hui-Ying M.D.
Liu, Hui-Ying M.D.
Liu, Hui-Ying M.D.
•
•
12. 輸精管攝影(vasography)在無精症(azoospermia)且睾丸切片有看到
complete spermatogenesis with many |mature spermatids及至少有一邊輸
精管摸的到的病人是個可考慮的診斷工具。以下為進行單側輸精管顯影劑
注入後看到的景象,發現兩側輸精管皆有顯影,何者為最可能的診斷?
(A) 可能是中線射精管囊腫(midline ejaculatory duct cyst)
Midline ejaculatory duct
cyst with contrast filling
Liu, Hui-Ying M.D.
4.
Summary
Liu, Hui-Ying M.D.
13
2021/9/7
OA
Azoospermia: NOA / OA
Liu, Hui-Ying M.D.
OA
三低：
Low volume
Low pH
Low fructose
OA
三低：
Low volume
Low pH
Low fructose
Liu, Hui-Ying M.D.
三低：
Low volume
Low pH
Low fructose
Liu, Hui-Ying M.D.
三低：
Low volume
Low pH
Low fructose
Liu, Hui-Ying M.D.
Liu, Hui-Ying M.D.
OA
NOA
NOA
•
Testis of normal size
•
Palpable vasa deferentia
•
Normal serum follicle-stimulating hormone (FSH)
•
Negative serum antisperm antibody assay
Liu, Hui-Ying M.D.
Testis biopsy indication
14
2021/9/7
Varicocele
Male infertility causes and associated factors
Liu, Hui-Ying M.D.
EAU guideline 2020
14.8%
10.9%
Hypogonadism 10.1%
16.4%
Klinefelter
13.7%
2.6%
Male infertility causes and associated factors
Liu, Hui-Ying M.D.
EAU guideline 2020
Pretesticular
✓ Secondary testicular failure
✓ FSH ↓, LH ↓, Testosterone ↓
✓ Kallmann syndrome (Hypo-hypo)
NOA
Obstruction
2.2%
10.3%
Vasectomy
0.9%
5.3%
CBAVD
0.5%
3.0%
Male infertility causes and associated factors
Liu, Hui-Ying M.D.
Pre-testicular
EAU guideline 2020
Pre-renal
Testicular
✓ Primary testicular failure
✓ Testosterone ↓, FSH ↑, LH ↑
✓ Small testis TLA ≤4.6cm OR ≤12.5-19mL
✓ Klinefelter’s syndrome (Hyper-Hypo)
Post-testicular
✓ Semen三低: volume ↓, pH ↓, fructose ↓
✓ Normal FSH/LH/T, Normal size testes
✓ Epididymal / S.V enlargement
✓ Ejaculatory duct obstruction / CBAVD
OA
Liu, Hui-Ying M.D.
Pre-testicular
Pre-renal
Testicular
Renal
Medical treatment
Testicular
Renal
Replacement therapy
Post-testicular
Liu, Hui-Ying M.D.
Post-renal
Post-testicular
Post-renal
Liu, Hui-Ying M.D.
15
2021/9/7
Pre-testicular
Pre-renal
Testicular
Renal
Post-testicular
Post-renal
NOA
✓ Testicular sperm extraction (TESE) is
the technique of choice (NOA)
✓ No role for epididymal sperm retrieval
in NOA
✓ 50% Spermatozoa are found by TESE
✓ Sperm+ in TESE:
- Pregnancy rate 45%
- Live delivery rate ~40%
Obstruction, Surgery
Liu, Hui-Ying M.D.
Liu, Hui-Ying M.D.
Pretesticular
✓ Medicine correction
NOA
Testicular
✓ Surgical extraction of sperm
✓ Surgical varicocelectomy
Post-testicular
Sperm Retrieval Techniques
Liu, Hui-Ying M.D.
Transl Androl Urol. 2014 Mar;3(1):94-101.
OA
Liu, Hui-Ying M.D.
✓ Retrograde ejaculation: medicine
✓ CBAVD: Sperm extraction
✓ Vasectomy reversal surgery
✓ Vaso-vasostomy, Vaso-epididymostomy
✓ TURED
Pretesticular
✓ Medicine correction
NOA
Testicular
✓ Surgical extraction of sperm
✓ Surgical varicocelectomy
Post-testicular
OA
Liu, Hui-Ying M.D.
✓ Retrograde ejaculation: medicine
✓ CBAVD: Sperm extraction
✓ Vasectomy reversal surgery
✓ Vaso-vasostomy, Vaso-epididymostomy
✓ TURED
高雄長庚 劉惠瑛
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2021/9/7
Priapism disease

 Definition：full or partial erection that continues more than 4 hours
beyond sexual stimulation and orgasm or is unrelated to sexual
stimulation.
 Classifying Priapism
 Ischemic Priapism (Veno-occlusive, Low-Flow)
三軍總醫院 泌尿外科
卓育慶醫師
2021-09-04
 Persistent erection, rigidity of the corpora cavernosa, little or no
cavernous arterial inflow.
 Untreat → severe corporal fibrosis and ED (emergency)
 Non-ischemic Priapism (Arterial, High Flow)
 Unregulated cavernous arterial inflow → persistent erection
 Corpora are tumescent but not rigid；the penis is not painful
 Stuttering Priapism (Intermittent, Recurrent Ischemic Priapism)
 Recurrent unwanted and painful erections in men with sickle cell disease
Etiology of Ischemic Priapism
(Veno-occlusive, Low-Flow)

Etiology of Non-ischemic and
Stuttering Priapism

 Nonischemic
Prolonged erection is more common than priapism after IC injection
Alprostadil Study Group: prolonged erection(5%); priapism(1%)
Evaluation and diagnosis
of priapism

 Key finding in priapism
 Stuttering
 Much rarer than ischemic
priapism.
 Laceration or disruption of
a cavernous artery.
 Trauma: straddle injury(most
common cause), pelvic
fractures, birth canal trauma.
 Iatrogenic trauma: cold-knife
urethrotomy, corporoplasty,
and penile revascularization.
 Sickle cell hemoglobinopathy
accounts for at least a third of
all cases of ischemic priapism.
 Increased blood viscosity is
responsible for painful crises.
 SCD patients may experience
stuttering priapism from
childhood.

 Typical Blood Gas Values
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2021/9/7
Treatment for Ischemic Priapism
Treatment for Non-ischemic Priapism


Oral agents are not recommended for acute ischemic priapism
Relieve priapism of case
Aspiration alone: 24%
Combine with cold saline: 66%
Phenylephrine: α 1 -adrenergic receptor actions
(AUA and EAU guidelines)
When aspiration and ICI of α-adrenergics has failed
The first choice: distal cavernoglanular shunt
 Arterial priapism is not an emergency.
 Spontaneous resolution or response to conservative
therapy has been reported in up to 62%.
 Cavernous aspiration has only a diagnostic role in HFP.
 Success rates with selective pudendal artery
catheterization followed by embolization are high
(89%~100%)
 Surgical ligation: when angioembolization fails or is
contraindicated.
A phenomenon of conversion from ischemic priapism to HFP has been described
Treatment for Stuttering Priapism


 Increasing frequency or duration of stuttering episodes
may herald a major ischemic priapism.
 Goals of manage: prevention of future episodes,
preservation of erectile function, and balancing the risks
versus benefits of various treatment options.
 Trials of daily




Oral α-adrenergic therapy
Oral sildenafil/tadalafil(PDE5 inhibitor)
Oral ketoconazole/prednisone(5 α-reductase inhibitor)
GnRH agonists or antiandrogens
Peyronie’s disease

 General consideration:

 Wound-healing disorder of the tunica albuginea.
 Results in penile deformity including curvature, indentation,
hinge effect, and shortening (accompanied by ED).
 Active (acute) phase: associated with painful erections and
changing deformity of the penis.
 Stable (chronic) phase: characterized by stabilization of the
deformity and disappearance of painful erections.
 Less than 13% of patients will have some improvement of
their deformity over the first 12 to 18 months after onset
of the disease process when not treated.
 The most frequent presenting symptoms of PD: penile
pain, erect deformity, palpable plaque and ED.
2
2021/9/7
Associated Conditions

 Aging
 Increase in prevalence: from 30 to 49 years of age
 Exponential increase in prevalence: at 50 years of age.
 Diabetes: the prevalence of diabetes with PD (33.2%)
 ED: the prevalence of ED with PD (37% to 58%)
 Psychological distress
 Not only a physically deforming but also a psychologically
devastating disorder
 Radical prostatectomy
 Hypogonadism
 Collagen disorders
Anatomy and Peyronie’s Disease

 The tunica albuginea: multilayered
structure predominantly composed of
type 1 collagen that is oriented with an
inner circular and outer longitudinal
layer interlaced with elastin fibers.
 Longitudinal layer of the tunica albuginea
is completely absent between the 5 and 7
o’clock positions.
 Most PD patients exhibit dorsal curvature.
 Antecedent trauma: 16% to 40%
 Some injurious stimulus is necessary to
trigger a cascade of events that lead to PD
 Dupuytren disease, plantar fascia (Ledderhose disease) and
tympanosclerosis
Evaluation
Non-surgical treatment

 Onset of symptoms, vascular risk factors for ED, patientestimated degree of deformity, and patient assessment of
quality of erection.
 Validated questionnaires include the PDQ to document the
degree of effect associated with PD.
 Calcification grading system

 AUA 2015 Guideline on Peyronie’s Disease: in-office
intracorporeal injection therapy should be performed in
every patient before invasive intervention.
 Grade 3: calcification (>1.5 cm or multiple plaques ≥1.0 cm)
 Grade 2: 0.3 to 1.5 cm
 Grade 1: <0.3 cm
 Duplex ultrasound:
 Identification of calcification, assessment of penile vascular flow
and observation of the erectile response
Oral Agents for Peyronie’s Disease

Intralesional Agents for
Peyronie’s Disease

 Only oral medication recommended by the AUA guideline
on PD is NSAIDs to reduce pain.
First FDA-approved drug for the treatment of PD
3
2021/9/7
External Force Application for
Peyronie’s Disease
Surgical treatment


Algorithm for the surgical
management of Peyronie’s disease
1


Testis torsion


 For males 25 years old and younger, testis torsion is more
than three times more common than testis cancer, with an
estimated incidence of 4.5 cases per 100,000 per year.
 Contralateral testicular biopsy findings are abnormal in
57% to 88% of males when torsion occurs.
 Approximately half of men with torsion develop adverse
spermatogenic effects.
Testis biopsy
The most serious complication: inadvertent biopsy of the epididymis.
The most common complication: hematoma.
 36% ~ 39% of men will have sperm concentrations below 20
million/mL.
 11% of men develop antisperm antibodies after torsion.
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Thanks for your attention


5