ANDROLOGY NMT13

MALE SEXUAL ANATOMY

Structure of the penis:
• The penis is formed of 2 dorsally placed corpora cavernosa and a ventral
corpus spongiosum containing the urethra.
• The glans penis is the expanded distal end of the corpus spongiosum.
• Erection is the function of the corpora cavernosa, which are covered by a
tough tunica albuginea. The cavernous spaces of the corpora cavernosa
are interconnected blood sinusoids lined by endothelial cells and
surrounded by smooth muscle fibres.
Arterial supply:
The penis is supplied by the internal pudendal artery, which has the following
terminal branches:

Dorsal artery: supplying the glans penis and skin

Spongiosal/ urethral artery: supplying the corpus spongiosum and
urethra.

Cavernosal artery: supplying the corpora cavernosa.

Bulbar artery: supplying the bulb.
Venous drainage:
The penis is drained at 3 venous levels:

Superficial system, which is formed by the superficial dorsal vein draining
the skin and subcutaneous tissue and terminating into the saphenous vein.

Intermediate system: Deep dorsal vein draining the distal corpora
cavernosa into the peri-prostatic venous plexus. It receives emissary
veins and circumflex veins.

Deep system: Cavernosal and bulbo-urethral veins drain proximal corpora
cavernosa and the corpus spongiosum into the internal pudendal vein.
Nerve supply:
1. Somatic: Pudendal nerve (S2, 3,4)

Sensory: skin of the penis.

Motor: Bulbocavernosus and ischiocavernosus muscles.
2. Autonomic

Sympathetic (T12 – L2)

Parasympathetic (S2,3,4)

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SEXUAL RESPONSE CYCLE

Sexual arousal can be initiated by a variety of sexual stimuli including visual,
auditory, olfactory, imaginative, memorizing and tactile. If such stimuli are
perceived as being sexual, they lead to the following changes:

In males In female
1- Genital Penile erection Vaginal transudation
Excitation changes: Bartholin gland secretion
phase Retraction of labia minora
Erection of clitoris
Extragenital increase in heart rate, blood pressure, respiratory rate
changes and depth and skeletal muscle tone. Additionally females
may also develop sexual flush and nipple erection.
2- Plateau phase: sexual excitation changes are maintained at their
maximum during intercourse. This phase lasts for about 2
- 5 minutes
Shorter Longer
3- Orgasmic phase the pleasure felt at the climax of sexual connection.
only one orgasm can be multi-orgasmic
per one sexual
response cycle
Ejaculation Rhythmic involuntary contraction of
pelvic floor, perineal and perivaginal
muscles (occasionally the uterus)
4- Resolution phase subsidence of all the changes that occurred during sexual
excitation.
Rapid Gradual
5- Refractory period In which whatever intense the sexual stimulus there can
never be similar response
present and its Absent
duration
depends on the
age,
psychological
state and
general health.

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PHYSIOLOGY OF ERECTION AND EJACULATION

A-Erection

From the neurological point, there are 2 type of erection:
a. Psychogenic erection: If visual, auditory, olfactory, memorizing or
imaginative stimuli are integrated in the limbic system as being
sexual, descending tracts pass through the sympathetic outflow of
T12-L2.
b. Reflexogenic erection: Tactile stimulation of the genital area sends
afferent impulses along the pudendal nerve, which reach the sacral
segments S2-4 the efferent impulses of which are parasympathetic.

The neurological impulses lead to erection by mediating the following
vascular response:
a. Maximum dilatation cavernosal artery.
b. Relaxation of smooth muscle fibres around the cavernous spaces of
the corpora cavernosa.
c. Passive venous occlusion results from compression of small venules
between the expanding cavernous spaces as well as the emissary
and sub-tunical veins under the tunica albuginea.

Phases of penile erection
a. Flaccid phase
b. Initial filling phase
c. Tumescence phase
d. Full erection phase
e. Rigid erection phase
f. Detumescence phase

Sequence of events during erection
Under resting conditions (flaccid):
• Sympathetic tone  Tonic contraction of smooth muscles of the
penis
• The diameter of the cavernosal artery = 0.5 mm
• The blood flow velocity = not more than 15 cm/seconds
During sexual stimulation:
• Release of endothelial factors & neurotransmitters  relaxation of
the smooth muscles of the cavernous tissue & arteries
• The diameter of the cavernosal artery = 1 mm
• The blood flow velocity = above 30 cm/seconds.
• This is the initial filling phase which will then lead to the
tumescence and the full erection phase afterwards
• Dilatation of the cavernous spaces  compression of the subtunical
venous plexus and the emissary veins being trapped between the

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two layers of the tunica albuginea  additional decrease in the

venous flow.
• These changes  a steady increase of the intracorporeal blood
pressure to reach above the diastolic blood pressure (Tumescence
phase) then to 90% of the systolic pressure (Full erection phase).
• Dorsal nerve stimulation during coitus  contraction of the
ischiocavernosus muscle  more venous compression and
consequently more rise of the intracavernosal pressure to above
the systolic blood pressure. This is the phase of rigid erection.
• During this phase there is no blood inflow and the penis becomes a
completely closed space. Its short duration due to muscle fatigue
prevents ischemia and tissue damage.
B-Ejaculation

Ejaculation is sympathetically mediated and involves 2 phases:
1. Emission phase: Contractions of the wall of the prostate, seminal vesicles,
cauda epididymis and vas deferens expel their contents into the prostatic
urethra (sympathetic T12, L 1,2,3).
2. Contraction of internal sphincter:
Antegrade ejaculation phase: Semen is expelled from the prostatic urethra to
the outside after bladder neck closure (sympathetic and somatic). It depends
on the contraction of the pelvic floor muscles in addition to the
ischiocavernosus & the bulbocavernosus muscles (each contraction is about 0.8s)

ERECTILE DYSFUNCTION

Definition: The persistent inability of the male to obtain and/or maintain a

quality of erection sufficient to permit coitus to be initiated and/or completed.
Etiology

ED is either due to psychogenic or organic disorders.

Psychogenic factors were previously thought to dominate (95%).

Following the recent progress in diagnostic techniques, more than 60%
of ED cases have ED-related organic problems
Psychogenic ED
1. Developmental factors 2. Interpersonal factors
Gender identity conflict Divergent sexual preferences
Traumatic childhood experience Excessive hatred
Negative family attitude towards Dislike female figure
sex (religious or social) Distrust of the partner
Paternal & maternal dominance Marital relationship conflicts
Homosexuality
Oedipal complex

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3. Affective factors 4. Cognitive factors

Anxiety Sex ignorance
Depression Misinterpretation about articles, books
Guilt or talks about sex
Phobia e.g.pregnancy, STDs and Acceptance of cultural and religious
failure. orders
Organic ED
Vascular causes Neurogenic causes
Arterial disorder Atherosclerosis, Central:cerebro-vascular
Embolism, Trauma, Leriche Syndrome accident,multiplesclerosis, spinal cord
Venous disorder: venous leakage injury, etc
(failure of corporal veno-occlusive Peripheral:peripheral neuropathy
mechanism)
Cavernous space disorder: fibrosis
(post-priapism) & Peyronie’s disease
Endocrinal causes Drug-induced
1- Diabetes mellitus (due to Antihypertensives
neuropathy, atherosclerosis,micro- Psychoactive drugs: high dose of
angiopathyor psychogenic) major tranquilizers and
2- Hypogonadism e.g. Klinefelter antidepressants.
syndrome Addictive agents: alcohol, marijuana,
3- Hyperprolactinemia and heroin.
4- Myxedema Estrogen & antiandrogens
Systemic disorders
Liver, renal and heart failure
Diagnosis of ED
1- History Taking :to differentiate organic from psychogenic ED and to
determine the etiology and of organic ED.
PSYCHOGENIC ED ORGANIC ED
Onset Usually sudden Usually gradual
Course Usually intermittent Usually progressive
Duration Usually short Usually long
Morning erections Present & good quality Absent or weak
Erection at non-coital Present Absent
occasions
History of HTN, DM, etc Less frequent Usually positive

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2- Examination
GENERAL LOCAL
Endocrinal: Penis:
Secondary sex characters and Peyronie’s disease, penile size, pulse and
gynecomastia urethral orifice
Vascular: Scrotum:
BP and pulse Testis size and consistency
Neurological: PR:
Sensations and reflexes Prostate and seminal vesicles
Others: e.g. surgical scars Cremasteric reflex
Scrotal reflex
Bulbocavernosus reflex
3- Diagnostic Procedures For ED:
A) Laboratory Investigations
All ED patients must be subjected to:

Fasting and post-prandial blood sugar,

Serum testosterone and prolactin level.
According to clinical suspicion, some patients may need:

Liver function tests

Renal function tests

T3 - T4 - TSH level
B) Nocturnal Penile Tumescence (NPT) Monitoring
Normally, during rapid eye movement (REM) stage of sleep, penile erections
occur. In adolescents, this happens 4-5 times per night (duration of 15-20 min
each). It tends to decrease in duration and frequency with age.
Eliciting the occurrence of these erections during sleep helps to differentiate
organic from psychogenic ED. This can be done using:

Regiscan: This is the most precise method that detects the frequency,
degree of rigidity and the duration of nocturnal penile erections.
C) Penile Vascular Studies
 Intracavernous Injection (ICI) Test:

This is a screening test for vasogenic ED

Normally, injection of certain vasodilator agents (e.g. Prostaglandin E1,
papaverine or phentolamine) into the corpora cavernosa leads to full
rigid erection this erection starts within 10 min. and lasts for more
than 30 min.

The occurrence of this response is a good positive test that penile
haemodynamics are normal.

In arterial problems: Delay in the onset of erection occurs

In venous leak: Unsustained erection (< 30 min.) occurs.

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In neurogenic ED: prolonged erection and priapism occur even with the
smallest doses of vasoactive agents due to denervation
hypersensitivity.
 Confirmatory Tests For Penile Arteriogenic ED:

Evaluation of penile arteries is indicated if no or delayed erection
occurs in the ICI test.
A. Duplex ultrasonography: This is the method of choice
for evaluation of the penile arteries. It allows measurement
of diameter and blood velocity in the cavernosal artery
before and after injection of the vasoactive drugs.
• Normal cavernosal arteries show:
a. Peak systolic velocity more than 25 cm/sec.
b. Diameter increase after ICI by more than 75%
B. Selective internal pudendal angiography: This is an
invasive procedure performed only before arterial surgery.
 Confirmatory Tests For Venogenic ED:

These are indicated if a venous leak is suspected by:
• No or unsustained erection in the ICI test.
• Duplex shows normal cavernosal arteries with elevated end
diastolic velocity more than 5 cm/sec.

Cavernosometry: Saline is injected intracavernously (after ICI) at
a rate that induces and maintains a rigid erection (I.C. pressure =
150 mm Hg).
• Normally:
• Induction rate is less than 40 ml/min.
• Maintenance rate is less than 15 ml/min.
• The rate of drop in I.C. pressure after stopping
infusion is less than 40 mm Hg in the first half minute.
• In venous leak, there are higher figures especially the drop
of I.C. pressure.

Cavernosography: If cavernosometry shows venous leak,
intracorporal radio-opaque dye is injected and X-ray is done to
demonstrate the leaking veins.
 Neurological evaluation

Biothesiometry A biothesiometer is a vibration sense-measuring
apparatus that can be used for screening of sensory deficit.

Dorsal nerve somato-sensory evoked potential Electrical
stimulation of the dorsal nerve of the penis followed by recording
the evoked EEG waveforms over the sacral cord and cerebral
cortex helps to diagnose sacral and suprasacral sensory lesions.

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Treatment of ED
Choice Of Treatment Depends Upon

Etiology

Age of the patient / Spouse

Associating disease

Availability

Cost

Choice of the patient
Management of the cause e.g.

Specialized psychiatric treatment for deep psychic ED

Quit smoking, alcohol and addiction

Control DM, hypertension, etc

Testosterone or gonadotropins for hypogonadism

Bromocriptine for hyperprolactinemia

Switching to safe medications in drug-induced ED
Sex Therapy
Indications: Treatment of performance anxiety in psychogenic ED
Principles of sex therapy:

Sex education.

Mutual responsibility about any sexual disorders.

Establishment of proper physical and psychological stimulation.

Elimination of marital relationship difficulties.

Systemic desensitization “Master and Johnson's technique” “Sensate
focus” - stages
Medical Treatment

Empirical treatment
o Aphrodisiac
o Herbals and other forms of primitive medicine
o Androgens: Testosterone

Phosphodiesterase inhibitors
o selective cavernous tissue dilator
o contraindicated in cardiac patients receiving nitrates.
o Sildenafil (Viagra), Vardinafil (Levitra), Tadalafil (Cialis)

Alpha adrenergic blockers
o Yohmbine :presynaptic α2 blocker
o Phentolamine: α 1&2 blocker

K channel openers:Minoxidil

Opioid receptor antagonist: Naltrexone

Dopamine receptor agonists
o Trazodone
o Apomorphine

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Beta-adrenergic stimulant: Isoxupine

Intracavernous Injections (ICI) Therapy
The patient is trained at ICI self-injection that can be used before a desired
intercourse. Prostaglandin E1, papaverine and phentolamine can be used
separately or in combination.
Indications:

Psychogenic ED

Mild vascular ED
Complications:

Prolonged erection(2-6 h)

Priapism(>6h) treated by repeated aspiration of blood from the corpora±
ICI of sympathomimetic (ephidrine). If erection persists shunt operation
may be done

Penile pain

Corporal fibrosis
Transurethral Alprostadil
Using a special applicator, PGE pellet can be introduced trans-urethrally to
induce penile erection. Although results are inferior to the intracavernous
injection therapy patients who are not happy with self-injection may prefer
this line of treatment.
External Vacuum & Constriction Devices
The idea of this type of treatment is to:

Induce erection using a vacuum device

Maintain erection using a rubber band applied to the base of the penis
Surgical Management
1- Penile Vascular surgery
In Arteriogenic ED:

Proximal arterial disease: internal iliac reconstruction

Distal arterial disease: anastomosing inferior epigastric artery to penile
arteries
In Venogenic ED:

Ligation of deep dorsal vein with its tributaries in addition to the
cavernosal and crural veins

Arterialization of the deep dorsal vein using the inferior epigastric
artery
2- Penile prosthesis
Artificial cylinders or rods are placed in the corpora cavernosa to induce an
erection-like state.
Indications: All intractable causes of ED in which other lines of treatment
failed or simply unavailable:
Advanced diabetic ED

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Venogenic ED

Neurogenic ED

Post-priapism ED

Peyronie’s disease

Longstanding resistant psychogenic ED
Types:

Rigid prosthesis (obsolete)

Malleable rods (popular)

Inflatable prosthesis
EJACULATORY DYSFUNCTION
PREMATURE EJACULATION RETARDED EJACULATION
Definition Inability of the male to Definition Inability of the male to
control his ejaculatory reflex so that reach orgasm intravaginally despite an
he can satisfy his wife in at least 50% adequate erection quality.
of their coital connections.

Incidence A very common condition Incidence Uncommon problem

affecting around 40% of patients

Etiology Etiology
Psychogenic causes (>90%) Psychogenic causes
1- Conditioned prematurity: This 1- Obsessive compulsive personality
occurs when the early sexual 2- Repressed hostility
experiences have been with 3- Phobias e.g.
prostitutes, through petting or chronic
Fear of pregnancy
heavy masturbation.
Religious guilt feelings
2- Subconscious hatred towards
Fear of soiling the partner with
females. semen
3- Anxiety and over concern about
Oedipal fears of retaliation
partner satisfaction.
4- Unresolved marital problems. Organic causes
Organic causes (<10%) 1. Drug-induced e.g. narcotics,
1. Chronic pelvic congestion e.g. sympatholytics and alcohol,
chronic prostatitis 2. Neurological disorders e.g.
2. Drug-induced e.g. neuropathies and spinal cord
sympathomimetics injury
3. Neurological disorders e.g.
hypersensitive glans penis, MS
and neuropathies

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Treatment Treatment
1- Minimizing penile receptivity: 1- Sex therapy

Condom
Sensate focus exercises.

Local anesthetics
Desensitization by allowing the

Distractive thinking patient to masturbate up to
2- Sex therapy ejaculation on his own first,

Squeeze technique: then with his wife, then outside
Wife stimulates the penis then the vagina to resolve his fear
squeezes the glans firmly when the of intravaginal ejaculation then
husband is about to ejaculate. The finally normal intravaginal
cycle is repeated several times. ejaculation is tried.

Start-stop technique: 2- Electro-vibratory stimulation:
Stimulation is stopped before This is done to obtain semen sample
ejaculation is inevitable and then to be used for artificial insemination
resumed once more. when fertility is desired.
3- Drugs:

SSRIs (selective serotonin
reuptake inhibitors)

Anafranil

Introduction

The testis has two functional compartments:
1. The seminiferous tubules containing the germ cell population and the
Sertoli cells.
2. The interstitial compartment containing Leydig cells

The hypothalamus secretes (GnRH) stimulating the pituitary gland to
secrete:
o FSH: stimulates Sertoli cells to produce androgen binding protein
(ABP) and inhibin.
o LH: stimulates Leydig cells to produce testosterone.

ABP carries testosterone to the seminiferous tubules to stimulate
spermatogenesis, which proceeds as follows:
 Spermatogonia (46 chromosomes) divide mitotically giving rise to
primary spermatocytes (46 chromosomes), which undergo meiosis
to be transformed into secondary spermatocytes (23
chromosomes) then to spermatids (23 chromosomes).
 Spermatids are round cells that undergo a process called
spermiogenesis, which is a metamorphosis to give rise to the

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spermatozoon, which have the characteristic shape (head, midpiece

and tail).

From the lumen of the seminiferous tubules, sperms pass to the rete
testis then along the vasa efferentia to the epididymis.

The epididymis is a single highly convoluted tubule, about 5-6 meters long.
Sperm transport in the epididymis takes 2-3 weeks, a period essential for
sperm maturation.

At ejaculation, spermatozoa stored in the tail of the epididymis are
expelled by the peristaltic waves along the vas deferens to the posterior
urethra.

Seminal plasma volume is mainly formed by the seminal vesicles (60%) and
the prostate (30%). The spermatozoa and the epididymal plasma form the
remaining 10%.
DEFINITION OF INFERTILITY

Infertility is defined as a childless marriage after at least one year of
regular unprotected sexual relation.

Infertility in males can be either:
o Primary: if the man has never been able to induce conception of his
wife.
o Secondary: if infertile man has previously been able to impregnate
his wife.
AETIOLOGY
Pre-testicular Hormonal Hypothalamus, pituitary, thyroid &
Causes disorders suprarenal
Systemic Hepatic,renal, malignancy, etc
disorders
Testicular Causes Congenital Klinefelter syndrome
Sertoli cell only syndrome
Cryptorchidism
Traumatic Excess heat exposure
Irradiation
gonadotoxins
Inflammatory Mumps orchitis
Neoplastic Testicular tumors
Vascular Varicocele
Testicular torsion
Post-testicular Mechanical infertility
Causes Obstructive infertility
Immunological infertility

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Male accessory sex gland infections

Another classification is to divide the causes of male infertility under 3
main headings: functional, obstructive and mechanical.
A. Functional infertility This includes causes of defective sperm production
and function.
a. Congenital: e.g.
o Klinefelter syndrome
o Sertoli cell only syndrome
o Undescended testis
b. Traumatic e.g. Torsion testis
c. Inflammatory e.g. mumps orchitis and prostato-vesiculitis
d. Endocrinal:
o Pituitary disorder e.g. hypogonadotropic hypogonadism and
hyperprolactinemia
o Thyroid disorder e.g. myxedema
o Adrenal disorder e.g. adrenogenital syndrome
e. Drugs and chemicals e.g.
o Anti-mitotic and cytotoxic drugs
o Hormones: estrogen, anti-androgens and testosterone
o Irradiation: Gamma rays, X-ray and large dose ultrasound .
o Excess heat exposure: occupational or pathological .
f. Immunological: Anti-sperm antibodies.
g. Varicocele.
Definition Varicocele is the dilatation, elongation and tortuousity of the
veins draining the testis (especially pampiniform plexus of
veins).
Types o Primary (affecting about 20 % of male population):
caused by congenital weakness of the smooth muscles in
the wall of veins and incompetence of their valves
o Secondary: varicocele is due to increased venous
pressure secondary to abdominal tumor
(hypernephroma)
Symptoms • Usually asymptomatic
• Infertility
• Testicular pain mostly related to sex congestion
Relation to Not all varicocele patients are infertile.
fertility Varicocele can affect semen picture and lead to infertility via:
1. Disturbance of testicular thermoregulation with
increased intra-testicular temperature
2. Reflux of the renal and suprarenal metabolites (e.g.

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catecholamines) into the testis through incompetent

valve between left internal spermatic and renal veins
3. Hypoxia of testicular tissue
4. Epididymal dysfunction
Examination Varicocele can be bilateral but it usually occurs more on left
side due to:

Left testis is more dependent

Left testicular veins opens into the left renal vein
perpendicularly, while the right one opens in the inferior
vena cava obliquely

Compression of the left renal vein between left renal
artery and superior mesenteric artery
Grades Grade I: Palpable thrill with Valsalva's maneuver
Grade II: Palpable dilated veins feel like a "bag of worms”
Grade III: Veins are dilated to the degree that makes them
visible.
Investigations  Doppler and Duplex ultrasound
 Scrotal thermography
 Venography
 Scrotal Scientigraphy
Conservative: No treatment is required if the patient is
Treatment asymptomatic and varicocele is not affecting semen picture or
testicular size
Surgery:
• Varicocelectomy is indicated if the patient presents
with orchalgia or infertility.
• Surgical ligation of the varicocele is performed via a
high retro peritoneal, inguinal or subinguinal approach.
• Improvement in semen parameters and pregnancy rate
occur within 2 years postoperative in about two thirds
of patients
B. Obstructive infertility This refers to defective sperm transport due to
one of the following causes:
a. Congenital e.g.
o Bilateral absent vas deferens
o Ejaculatory duct obstruction
b. Traumatic e.g.
o Vasectomy for male contraception
o Accidental during hernia operation in childhood
c. Post-inflammatory e.g. Post-epididymitis fibrosis

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C. Mechanical infertility This refers to normal sperm production, function

and transport but the problem is failure of sperm deposition in the
posterior vaginal fornix and its transport along the cervical canal .
Sexual disorders Anatomical disorders
Erectile dysfunction Perineal hypospadias
Severe premature or retarded ejaculation
Another classification based on clinical approch based on semen
• Azoospermia
o Obstructive
o Non-obstructive
• OAT oligoasthenoteratozoospermia
o Milder forms of defective sperm production
o Partial / unilat obstruction
o Common causes
Varicocele
Genital tract infection
• Normal semen
o Idiopathic infertility
o Female factors
• Isolated defects
o Low semen volume
o Necrospermia and immotile sperm
o Absolute isolated Teratozoospermia
o Hyperviscosity
DIAGNOSIS OF MALE INFERTILITY
HISTORY TAKING
Personal history

Type of infertility: primary or secondary (consider date of the last
childbirth or abortion)

Duration of infertility (consider previous use of contraceptives and long
periods without sexual relation)

Occupation (heat, irradiation or chemical exposure)

Residence (endemic diseases)

Special habits (smoking, alcoholism and addiction)
Sexual history

Age of puberty

Frequency of sexual intercourse

ED and severe premature ejaculation (mechanical infertility)

Previous use of contraceptives or postcoital antiseptics

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Past history

Drugs related to infertility e.g. Antimitotics, estrogen, androgen,
antiandrogen, colchicine, cimitidine, nitrofurantoin, propranolol, etc

Operations related to infertility:
1) Retroperitoneal surgery may lead to anejaculation.
2) Inguinal herniotomy may lead to injury of the vas.
3) Bladder neck operations may cause anejaculation

History of diseases & conditions related to infertility:

Bilharziasis (epididymal obstruction)

Epididymo-orchitis (epididymal obstruction)

Tuberculosis (multiple epididymal and vasal obstruction)

Mump orchitis (destroy the germ cells)

Undescended testis (functional infertility)
EXAMINATION
General examination:

Male secondary sexual characters (hair distribution, voice, muscle
development, fat distribution, height : span ratio)

Gynecomastia
Local examination:

Penis: urethral orifice (hypospadias and epispadias may cause mechanical
infertility)

Testis: if palpable or not, its size and consistency

Epididymis: epididymal nodules denote obstruction

Vas deferens: if present or absent and if it is beaded (T.B)

Spermatic cord: for the presence of varicocele

PR examination: for prostate (size, consistency and surface regularity)
and seminal vesicles (normally not felt)
INVESTIGATIONS
A-Semen analysis
Normal semen Parameters
1. Physical characters

Color: grayish-white

Volume: 2-5ml

PH: Alkaline

Liquefaction time: normally semen forms a coagulum at ejaculation and
liquefies in less than 30 minutes
2. Microscopic examination:

Sperm count: more than 20 millions/ml and less than 250 millions/ml

Sperm motility: 50% or more of the spermatozoa show active forward
progression after 2 hours of ejaculation

Sperm morphology: abnormal forms is less than 35%

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3.Biochemical markers (not routine): Determination of some semen markers

may be of help in some clinical conditions e.g.

Fructose estimation (seminal vesicle marker) may be requested if
bilateral congenital absence of the vas deferens is suspected.

L-Carnitine estimation (epididymal marker) may help differentiating pre
from post-epididymal obstruction

Abnormalities of Semen Analysis

1. Abnormal Physical Parameters:
a. Color disorders:

Deep yellow (infection, jaundice)

Red or brown (hemospermia)
b. Volume disorders:

Aspermia: absence of the semen at ejaculation

Hypospermia: low semen volume (less than 2 ml)
c. Non-liquefied or delayed liquifaction: due to prostatic dysfunction.
2. Abnormal Microscopic Parameters:
a. Azoospermia: absence of sperm in semen
b. Oligozoospermia: sperm count less than 20 million /ml
c. Polyzoospermia: sperm count more than 250 million / ml (usually
associated with poor sperm motility)
d. Asthenozoospermia: sperm motility less than 50% after 2 hours
e. Teratozoospermia: abnormal sperms more than 35%
Advanced semen analysis

Computer aided semen analysis ( CASA )
Advantages objective - new parameters (velocity)

Staining for pus cells ( leukocytospermia ) Culture for pathogenic bacteria

Supravital staining for vitality

Electron Microscopy

Sperm Function Tests
■ Hypo osmotic swelling test (HOS)
■ Acrosome reaction
■ Zona free hamster ova penetration assay
■ Chromatin decondensation
Causes of Azoospermia:

Functional azoospermia: failure of sperm production by the testis.
Treatment is directed towards the cause but usually ICSI is required.

Obstructive azoospermia: failure of sperm transport due to bilateral
obstruction of epididymis, vas deferens or ejaculatory ducts. Treatment
is designed to by pass the obstructed part

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How to differentiate obstructive from functional azoospermia ?

Functional Obstructive
Testis size Small or normal Normal size
FSH level Elevated (testicular cause) Normal level
Reduced (pre-testicular cause)
Testis biopsy Abnormal spermatogenic Normal spermatogenesis
picture e.g.

Maturation arrest

SCO picture

Tubular hyalinization
Causes of Oligozoospermia

Idiopathic
Small doses of radiation and

Varicocele gonadotoxins

Unilateral undescended testis
Unilateral obstruction

Heat exposure
Bilateral partial obstruction
Causes of Asthenozoospermia
• Asthenozoospermia is usually associated with oligozoospermia when it
shares the same causes.
• Isolated asthenozoospermia:
a) Immotile cilia syndrome
b) Chronic prostatitis
c) Antisperm antibody
Causes of teratozoospermia
• Idiopathic • Varicocele • Gonadotoxins
Causes of Aspermia (absence of seminal fluid at orgasm)
1) Retrograde ejaculation: Instead of going out of the urethral orifice, semen
passes backwards to the bladder due to a bladder neck disorder that may
occur after prostatectomy or advanced diabetic neuropathy.
2) Secretory aspermia: lack of seminal fluid formation may be due to
hypogonadism or post-inflammatory fibrosis of the prostate and seminal
vesicles.
3) Non-emission and anejaculation: failure of the contraction of the prostate,
seminal vesicles and vas at orgasm may occur due to sympathetic denervation
after radical pelvic surgery.
Causes of Hemospermia (blood in semen)

Bilharzial seminal vesiculitis

Prostatic Calculi and cancer prostate

Blood diseases and coagulation defects

Hypertension
B-Hormonal Profile

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C-Testicular biopsy
■ Open biopsy - Needle biopsy
■ Differentiate obstructive from non-obstructive azoosperma
■ Histopathological types
■ Normal
■ Haylinization
■ Sertoli cell only syndrome
■ Spermatogenic arrest
■ Hypospermatogenesis
D-Antisperm antibodies
o When to test for antibodies

Idiopathic infertility

Poor post coital test

Semen : athenospermia - auto agglutination – hypervicosity
E-Imaging
o Scrotal US

Scrotal swellings (size and echogenecity of testis - hydrocele)

Varicocele (subclinical varicocele - confirmatory)
o Transrectal US

Low semen volume (Ejaculatory duct obstruction - CAV)
o Abdominal US

Undescended testis ( may help in localisation ) - CT / MRI
o Vasography
o Venography
TREATMENT OF MALE INFERTILITY
PROPHYLAXIS

Early surgery for undescended testis (before the age of 2 years).

Early correction of testicular torsion (before 4 hours).

Early management of urogenital infections.

Avoidance of gonadotoxins e.g. irradiation, and gonadotoxic drugs.

Cryopreservation of semen before cancer chemotherapy and
radiotherapy.
THERAPEUTIC STRATEGIES
Medical treatment
Specific Treatment Non-specific Treatment
(for specific disorders) e.g. (for idiopathic causes) e.g.
Bromocriptine (for
Androgen therapy
hyperprolactinemia)
Anti-estrogen therapy
Corticosteroids (for immune
Human chorionic gonadotropin
infertility)
Human menopausal gonadotropin
Antibiotics (for infection)

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Surgical treatment

Indication Operation
Varicocele Varicocelectomy
Epididymal tail obstruction Epididymo-vasostomy
Vasal obstruction Vasovasostomy
Undescended testis Orchiopexy
Torsion testis Detorsion and orchiopexy
Assisted Reproductive Technology (ART)

ART refers to all procedures that help to bypass barriers for successful
fertilization. It is a last step in managing resistant and unexplained infertile
males but sometimes it can be a first line especially in azoospermic cases.
1) Artificial insemination husband
Male Indications:
a) Functional infertility:Oligozoospermia ,Asthenozoospermia,
Teratozoospermia, Low semen volume, Immune infertility,
Retrograde ejaculation
b) Mechanical infertility
• Sexual problems (ED, retarded and severe premature
ejaculation)
• Anatomical problems (hypospadias)
c) Unexplained infertility
Steps of AIH:
1) Induction and monitoring of ovulation
2) Semen processing e.g. by the “swim-up technique”
3) Methods of Insemination:
d) Intracervical insemination: for mechanical infertility and cases with low
semen volume
e) Intrauterine insemination: In cervical hostility and immunological
infertility.
f) Intra vaginal insemination (in cases of deposition failure)
2) In-vitro fertilization & embryo transfer (IVF-ET)
Mature oocytes are incubated into culture medium with processed sperms and
after spontaneous fertilization embryos are transferred into the uterus. This
method was mainly performed for cases with tubal obstruction with normal
semen or mild semen parameter disorder.
NB: Gamete Intrafallopian Transfer (GIFT) and zygote Intrafallopian
Transfer (ZIFT) are now considered as obsolete techniques.
3) Gamete micromanipulation
Gamete micromanipulation involves microscopic handling of sperms and ova to
facilitate fertilization with the main advantage of reducing the number of
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sperms needed to fertilize oocyte up to single sperm. These techniques

include:

Partial zona dissection (PZD) and Drilling (ZD): old methods involving
interruption of zona pellucida to facilitate sperm entry.

Subzonal insemination (SUZI): old method entailing placement of few
sperms in the perivitelline space.

Intracytoplasmic Sperm Injection (ICSI): This is most popular method
in ART. As it requires only one viable sperm to inseminate one oocyte, it
can be used in the severe semen parameter disorders up to azoospermia
where sperms may be retrieved from the testis or epididymis.

Sexually transmitted diseases (STDs) refer to the group of infectious diseases,

which predominantly spread through sexual contact.
EPIDEMIOLOGICAL ASPECTS OF STDs

By epidemiology is meant the study of various factors that affect the incidence
and prevalence of a disease in a community.
Factors affecting prevalence and incidence of STDs include:
Host factors

Age: STDs occur among the sexually active 15-35 years age group.

Sex: Males tend to present to STDs clinics more than females.

Marital status: Single people are more vulnerable than married.

Special habits: STDs are more common among alcoholics and drug
addicts.

Occupation: Certain occupations are associated with STDs more than
others e.g. barmen, night club workers, sailors, hairdressers, actors,
taxi-drivers, etc

Socioeconomic standard: STDs are less prevalent among moderate
socioeconomic class people compared to very low and high ones.

Medical condition: Patients having medical conditions that require
repeated injections or blood transfusion (e.g. hemophilia) have a higher
chance to develop blood-born STDs.

Religious attitude: Religious persons are less prone to develop STDs
than others.

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Sex education and cultural level: Lack of knowledge and preventive

methods of STDs, particularly among ignorant people, make them easy
victims for STDs.

Sexual orientation and preferences: Oro-genital sexual practice,
homosexuality and other sexual preferences alter the classic
presentation of most STDs.
Environmental factors
General community factors that favor the higher incidence and prevalence of
STDs are:

Lack of legislation against illegitimate sexual practice

Poverty

Development of new communities

Modernization and industrialization

Illegal prostitution

Tourism
Agent factors
The prevalence of STDs in a community is affected by certain factors related
to the causative agent e.g.

Virulence of the organism (recently, there is increased prevalence of
highly virulent strains)

Rate of organism multiplication

Susceptibility to chemotherapeutic agents (lack of effective antiviral
agents)

Antibiotic resistant strains (bacterial mutation and penicillinase
production)

Nutritional requirements of certain bacterial strains.
Prevention and control of STDs

Aim to : complete elimination or reduce incidence to low endemic levels

Methods:
1- Reduce exposure: delay sex exposure / reduce partners
2- Reduce transmission efficiency: Safe sex
3- Reduce duration of infectiousness: early detection and treatment of
cases
4- Sex education - Contact Tracing
CLASSIFICATION OF STDs
According to the causative agent

Bacterial Viral
Syphilis AIDS
Chancroid Herpes progenitalis
Lymphogranuloma venerum Condyloma accuminata

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Granuloma inguinale Molluscum contagiosum

Gonorrhea Viral hepatitis B (and may be HCV)
Non-gonococcal urethritis
Protozoal Parasitic
Trichomonas vaginalis Genital scabies

According to the clinical presentation

Ulcer syndrome Urethral discharge syndrome

Syphilis
Gonorrhea

Chancroid
Non-gonococcal urethritis

Lymphogranuloma
venerum

Granuloma inguinale

Herpes progenitalis
Other local presentations Systemically presenting STDs

Condyloma accuminata
AIDS

Molluscum contagiosum
Viral hepatitis B and C

Genital scabies

STDs Causing an ulcer

STDs presenting by genital ulcers include:
1. Syphilis
2. Chancroid
3. Lymphogranuloma venerum
4. Granuloma inguinale
5. Herpes progenitalis
I. Syphalis
Caused by Treponema pallidum.
 Spirochete
 Spiral organism with regular coils.
 Moves in a "cork-screw" fashion.
 Cannot be grown on ordinary culture media.
Modes of transmission
(1) Sexual contact:
• In normal heterosexual relation: chancre develops on the genitals
• In orogenital sex: it develops on the lips or oral mucosa
• In homosexuals: it develops on the anus or within the anal canal
(2) Asexual contact: Chancre may develop on:
• Fingers of physicians examining lesions without gloves

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• Breast of a woman lactating a congenitally syphilitic child

(3) Trans-placental: from an infected pregnant mother to her fetus
(4) Blood transfusion: Contaminated needles and blood transfusion introduces
Treponema directly to the blood stream. The clinical presentation in such
case will be by secondary stage lesions without a primary stage, a condition
known as “Syphilis d’emblée”.

Classification

ACQUIRED SYPHILIS

Early infectious phase Late non-infectious phase

First 2 years of infection After 2 years of infection
stage
1. Primary stage 1. Late latent stage
2. Secondary stage 2. Benign tertiary stage
3. Early latent stage 3. Malignant tertiary stage:
• Cardiovascular syphilis
• Neuro-syphilis

CONGENITAL SYPHILIS
Early infectious phase Late non-infectious phase Stigmata:
Scars & deformities left
after early and late
lesions
First 2 years of life From third year of life Persist for life
1. No primary 1. Late latent
2. Secondary 2. Benign 3ry
3. Early latent 3. Malignant 3ry
• Cardiovascular
• Neurosyphilis

Acquired Syphilis
Primary : chancre
 Genital (95%) or extra-genital (5%)
 starts as a macule  papule  ulcer (highly infectious)
 Single
 Painless
 Rounded, well defined
 Indurated base
 Dull red floor with grayish scab
 Spontaneous healing in 3-10 weeks  thin atrophic scar
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Secondary
 Appears after few weeks
 Skin rash
 Mucous patches
 Condyloma lata
 Generalized lymphadenopathy
 Constitutional symptoms
 Others: Hepatitis, periostitis, meningitis,….etc.
Latenet stage serologicaly positive clinically free
 This is the period from the end of the secondary stage up to the end of
the second year from the appearance of primary stage.
 Patients are clinically free but serologically positive.
 In this stage clinical and/or serological “relapses” may occur.
 Despite absence of clinical signs, this stage is infective (mainly by
blood).
o Early Latent: infective
o Late Latent: non infective
Benign tertiary: (Gumma)
 Skin, M.M.
 Bones
 Viscera e.g. testis, liver, stomach
Diagnosis of syphilis

1. Dark ground microscopy: Exudate from the floor of chancre, from

condyloma lata or lymph node puncture is examined under the dark ground
microscope. Treponema pallidum appear luminescent with corck-screw
motility.
2. Serological tests: These become positive only late in primary stage (50%
are positive during the chancre stage and 100% are positive in the
secondary stage). Serological tests are of two types:

Non-specific tests Specific tests

1. Venereal disease research 1. Treponema pallidum
laboratory (VDRL) test hemagglutination antibody
2. Rapid plasma reagin (RPR) (TPHA)
test 2. Fluorescent Treponema
antibody (FTA)
3. Treponema pallidum
immobilization (TPI)

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These are used as screening tests. These are used as confirmatory

tests if the patient has positive
non-specific test.
The patient’s serum is tested The patient’s serum is tested
against cardiolipin antigen against Treponemal antigens.

They give false positive results (e.g. They give positive results only in
in collagen diseases, leprosy, drug Treponemal diseases
addicts, pregnancy, etc)

Treatment of syphilis

One of the following drugs can be used in the treatment of syphilis:

I- Procaine penicillin: 600,000 IU/day IM

For 10 days (in early acquired syphilis)

For 20 days (in late cases)

II- Benzathin penicillin: 2.4 million units IM

For primary stage: single injection.

For secondary stage: two injections separated by one-week interval.

For tertiary stage: three injections separated by one-week interval.

III- Other antibiotics: if the patient is allergic to penicillin, we may give:

Erythromycin: 500mg/6 hours for 15 days in early cases and for 30 days
in late cases.

Tetracycline: can be used in the same dose schedule (never in pregnant
syphilitic women).

IV- Treatment of Congenital Syphilis: Procaine penicillin in a total dose of

50,000 IU/Kgm divided on 10 daily injections.
II. CHANCROID
Causative organism: Hemophilus ducreyii

Clinical presentation:
• IP: 2-5 days.
• Genital ulcer: Multiple small shallow painful ulcers that bleed easily on
touch.
• Regional lymph nodes: Inguinal nodes are usually unilaterally affected,
become acutely inflamed, swollen, tender and later get matted, suppurate

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“abscess-like” and break down forming a sinus oozing pus “inflammatory

bubo”.
Diagnosis: Gram stained smear (gram negative bacilli) and culture.

Treatment: One of the following may be used:

Tetracycline:
• Oxytetracyclin 500mg/6 hours for 21 days.
• Doxycycline 100mg/12 hours for 21 days.
• Minocyclin 100mg/12 hours for 21 days.
Macrolides
• Erythromycin 500mg/6 hours for 21 days.
• Rulid 300mg/12 hours for 21 days.
• Zithromax

III. LYMPHOGRANULOMA VENERUM

Causative organism: Chlamydia trachomatis (serotype L1,2,3)

Clinical presentation:
• IP: 7-15 days.
• Genital ulcer: An initial papule or vesicle breaks down to an ulcer, which is
usually transient disappearing in few days.
• Regional lymph nodes: Chlamydia spreads along lymph vessels leading to
inguinal lymphadenopathy (usually bilateral). The enlarged lymph nodes get
matted forming a sausage-shaped swelling below and above the inguinal
ligament leaving a characteristic “sign of a groove” in between. When the
nodes break down they open by multiple sinuses discharging semi-caseous
material.
• Urethral discharge.
• Systemic symptoms: fever, headache, arthralgia, erythema nodosum and
sometimes meningism.
Diagnosis: being an obligatory intracellular organism, chlamydia is diagnosed by:

Giemsa-stained swab examination.

Tissue culture on McCoy’s medium.

Direct immunofluorescence, PCR, ELISA.

Frie’s intradermal test
Treatment

Erythromycin: 500mg/6 hours for 21 days.

Tetracycline: 500mg/6 hours for 21 days.

Doxycycline: 100mg/12 hours for 21 days.

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IV. GRANULOMA INGUINALE

Causative organism: Calymmatobacterium granulomatis or donovanis (gram
negative bacilli).

Clinical presentation:
 IP: 2-6 weeks.
 Genital ulcer: Granulomatous lesions develop on the genitals breaking down
into ulcers with velvety appearance and raised everted edges clinically
resembling malignant ulcers.
 Regional lymph nodes are not affected but subcutaneous granulomas in the
inguinal region can be mistaken for enlarged lymph nodes “pseudo-bubo”.

Diagnosis: Biopsy reveals the characteristic bacilli within the histeocytes

“Donovani bodies”.

Treatment:
 Tetracycline: 500mg/6 hours for 21 days.
 Erythromycin: 500mg/6 hours for 21 days.

V. HERPES PROGENITALIS
Causative organism:
 Herpes simplex virus type-2 (HSV-2) causes more than 90% of
cases
 HSV-1 is responsible for less than 10% probably related to
orogenital sex.
Clinical presentation:
 IP: 2-7 days.
 Genital lesion: Lesion can occur anywhere on the genital with
tendency to be peri-orificial i.e. around urethral orifice and anal
orifice. Burning sensation usually precedes the appearance of
grouped vesicles on an erythematous base. These vesicles either
rupture forming superficial erosions or get secondary infected
leading to pustule formation. Dryness of the contents of the
vesicle or pustule leads to the formation of crusts. Spontaneous
healing takes 1-2 weeks but recurrences are common and
precipitated by friction (sexual intercourse), psychic stress, etc.
 Regional lymph nodes: usually enlarged and tender.
 Systemic manifestation: The primary attack is associated with
constitutional symptoms but recurrences are not.

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Complications:
 Recurrences are the most troublesome complication in sexual life.
 Secondary infection.
 Sacral radiculitis.
 Herpes in pregnancy may lead to abortion, congenital and neonatal
herpes in the fetus.
 Cancer cervix.
 Systemic dissemination in immuno-compromised patients.
 Diagnosis: tissue culture for virus, PCR, DNA probe, etc

Treatment: Acyclovir local (cream) and systemic (tablets).

STDs Causing urethral discharge

Physiological • Prosemen: 1-2 drops of mucoid discharge are secreted from

Cowper and Littre glands during sexual excitation to lubricate
the urethra and neutralize remnants of acidic urine.
• Prostatorrhea: In unmarried males and in those without regular
sexual outlet, the prostate may be congested and full of
secretion. This may be expelled during straining at the end of
micturition or during defecation.
Pathological • Gonorrhea
• Non-gonococcal urethritis

GONORRHEA
Causative organism;-
 Diplococci (pairs)
 Gram negative
 kidney shaped
 Non-motile
 Non-spore forming
Mode of transmission:

1) Sexual contact:
Primary Site Of Infection

Heterosexuals Urethra in males Urethra & cervix in females

Homosexuals Urethra in active homo Rectum in passive homo

Orogenital sex Urethra Pharynx

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2) Asexual transmission e.g.

Contaminated towels and instruments

Contaminated hands.
Clinical Picture:
 Genital affection in males
 Genital affection in females
 Extra-genital gonorrhea
 Gonorrhea in children
 Metastatic gonorrhea
Male Female
Primary site The anterior urethra (penile Urethra and cervix.
urethra). Extension to the
posterior urethra (pelvic
urethra) is considered as a
complication.

Symptoms Gonococcal anterior 50 % of the cases are

urethritis presents with: asymptomatic. Others may

Urethral discharge: have:
Profuse purulent greenish
Mild soreness of the
yellow vulva.

Urethral discomfort
Mild dysuria and

Hyperemia and edema of frequency
urethral orifice
Scanty mucopurulent
If infection extends to discharge.
posterior urethra, there
Low back pain or lower
will be: abdominal pain.

Dysuria

Frequency of micturition

Hematuria, urgency and
constitutional symptoms
Complications 1. Cystitis
Complications of anterior
2. Skenitis
urethritis:
3. Bartholinitis, which may
1. Tysonitis proceed to abscess or cyst
2. Littritis formation.
3. Paraurethral gland 4. Salpingitis, oophoritis.
infection 5. Tubo-ovarian abscess.
4. Periurethral abscess 6. Pelvic peritonitis.
5. Cowperitis 7. Pelvic Inflammatory disease

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6. Balano-posthitis: (PID)
inflammation of the glans 8. Fitz-Hugh-Curtis Syndrome:
penis and prepuce in Perihepatitis (inflammation
uncircumcised patients of liver capsule) may follow
7. Urethral stricture gonococcal or chlamydial
Complications of posterior PID. Organisms spread
urethritis: along lymphatics or along
1. Acute prostatitis and peritoneum.
prostatic abscess.
2. Seminal vesiculitis.
3. Epididymitis (obstructive
infertility follows
bilateral cases).
4. Cystitis.
Extra-genital gonorrhea
 Proctitis.
 Pharyngitis.
 Conjunctivitis.
Disseminated gonococcal infection;- It is a rare complication of neglected
gonorrhea occurring mainly in women and manifested clinically by:
1. Dermatitis.
2. Arthritis.
3. Endometritis.
4. Meningitis.
5. Hepatitis.
Diagnosis of gonorrhea

1- Gram stained smear:

Gram stained smear >> gram-negative diplococci intra and
extracellular (within PNLs).

It is a simple test but useful only in acute gonorrhea in males.

False negative results are common in females and in chronic
gonorrhea in males.
2- Culture: modified Thayer and Martin medium
Indications: Culture is essential for definite diagnosis particularly in:

Gonorrhea in females.

Chronic gonorrhea in males.

Extra genital and metastatic gonorrhea.

Medico-legal proof.
Colonies confirmatory tests:

Gram stained smear examination from colonies.
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Oxidase test: Oxidase reagent turns gonococcal colonies black.

Sugar fermentation test (gonococcus ferments glucose only).

4- Gonozyme test: This is an enzyme immunoassay test designed for detection

of gonococcal antigens.

5- Direct immunofluorescence test (most specific and most sensitive test).

6- Serological tests e.g. Complement fixation test.

7- Two-glass urine test: To differentiate anterior from posterior urethritis,

the patient is asked to void the first few drops in a flask and the remainder of
urine in another one. In anterior urethritis the first glass contains more pus
cells than the second glass, while in case of posterior urethritis the two glasses
are almost indifferent.

First line therapy for A single dose of Procaine penicillin 4.8

uncomplicated gonorrhea million units IM is given with1 gm probenecid
orally to delay renal excretion of penicillin.
Patients refusing injection can be
Ampicillin single dose of 3.5 gm orally
given: with 1 gm oral probenecid.

Amoxicillin single dose of 3 gm orally
with 1gm oral probenecid.
Patients sensitive to penicillin can
Erythromycin: 500mg/6 hours for 5
be treated with: days.

Azithromycin 1gm single oral dose.

Tetracycline: 500mg/6 hours for 5
days.

Doxycycline: 200mg single oral dose.
Patients not responding to
Spectinomycin 2gm IM.
penicillin therapy may be having
Kanamycin 2gm IM.
Penicillinase producing gonococci
Cefotriaxone 250 mg IM.
and can be treated with:
Quinolone: single dose of
ciprofloxacin, norlfloxacin, or
ofloxacin
Disseminated and complicated
Hospitalization.
gonococcal infection:
Treatment for 1-2 weeks with higher
dose of the previously mentioned
drugs.
Non-gonococcal urethritis
1. Chlamydia trachomatis: Serovar D-K
2. Mycoplasma

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- Ureaplasma urealyticum
- Mycoplasma hominis
3. Trichomonas vaginalis
4. Intrameatal lesions e.g.
- Herpes progenitalis
- Chancre
- Lymphogranuloma venerum
- Condyloma accuminata
5. Others
- Uro-pathogens
- Stone urethra
- Oxaluria, etc.
GONORRHEA NON-GONOCOCCAL
URETHRITIS
Was previously a more common Now more common than gonorrhea
Prevalence cause of STDs urethritis It contributes to 15-20 % of patients
attending STDs clinics.
Causative Neisseria gonorrhea 1- Chlamydia trachomatis:
agent Serovar D,E,F,G,H,I,J,K
2- Mycoplasma:

Mycoplasma hominis

Ureaplasma urealyticum
3- Trichomonas vaginalis
4- Intrameatal lesions: e.g.

Herpes progenitalis

Chancre

Condyloma accuminata

Lymphogranuloma venerum
5- Others

Uro-pathogens

Stone urethra

Oxaluria, etc
IP 2-5 days Longer IP (1-5 weeks)
Symptoms Profuse purulent greenish-yellow
Scanty mucoid U.D
U.D with dysuria
Urethral discomfort

Frequently asymptomatic
Signs U.D & hyperemic urethral orifice Scanty mucoid U.D on urethral
milking
Local Complications rate is less than Complications are more common as
complications that of NGU as patients usually the mild symptoms usually lead to
seek treatment early but in neglect or delay of treatment
neglected cases they are severe
Systemic
DGI
Reiter’s syndrome
complications
Peri-hepatitis (Triad of urethritis, conjunctivitis
and arthritis)

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Peri-hepatitis

Gram-stained Gram negative diplococci Negative

smear
Culture Modified Thayer and Martin Tissue culture for chlamydia e.g.
medium McCoy cells
Gene detection by PCR
Treatment of Penicillin Tetracycline
choice Cephalosporin Macrolides
Quinolones Quinolones

OTHER LOCALLY PRESENTING STDs

CONDYLOMA ACCUMINATA
“Venereal Warts”

Causative organism: Human papilloma virus (HPV).

Clinical presentation: Condyloma accuminata are warty outgrowths that

have the following characters:
 Multiple (rarely single).
 Cauliflower-like (usually for penile or external vulval lesions) or flat
(usually on mucous membranes of cervix).
 Dry non-oozing.
 Skin-colored or hyperpigmented.
 Variable in size from pinhead-size to large tumor “Buschke
Lowvenstein Tumor”.

Sites

In males: penile shaft, pubic area, glans penis, intrameatal, perianal,
groin, etc

In females: Cervix, vagina, vulva, pubic area, perianal, etc

Aggravating factors: Immuno-suppression causes marked increase in the

size and number of the lesion as in:

Pregnancy

Diabetes

AIDS

Immunosuppressive drugs
Complications:
a. Cancer cervix
b. Laryngeal papillomatosis: infants may acquire the virus from the
maternal passage during labor and develop papilloma in the larynx

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Differential diagnosis: condyloma lata (see table).

Diagnosis:

CONDYLOMA CONDYLOMA LATA

ACCUMINATA
Etiology HPV Treponema pallidum
Sites Any part of genital may be Sites of friction mainly
intrameatal perianal
Infectivity Infective Highly infective
Surface Cauliflower-like Flat-topped
Skin-colored or Grayish-white surface
Color
hyperpigmented
Aspect Moist and oozing Dry
Base Pedunculated Sessile
Treatment Local podophyllin Penicillin injection

Cytology: characteristic koilocytes.

Biopsy.

Treatment:

Repeated careful painting of the lesions with 25% podophyllin resin in
alcohol or in liquid paraffin. This is contraindicated in pregnancy.

Other chemical cauterizing agents e.g. trichloro-acetic acid.

Electrocautery and surgical removal are less preferred.

Intralesional or systemic Alpha-interferon.

MOLLUSCUM CONTAGIOSUM

Causative organism: Poxvirus.

Clinical presentation: this dermatological viral disease can be seen in the

hands, face and trunk of children being transmitted by direct contact. In
adults, multiple pearly-white papules with characteristic central
umbilication develop on the external genital skin and pubic region being
transmitted sexually.

Treatment: phenol cauterization and curettage.

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Systemically presenting STDs

ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS)

Etiology
Causative Organism
AIDS is caused by human immune-deficiency virus (HIV), which belongs to the
retrovirus group, characterized by the presence of reverse transcriptase
enzyme, which converts the viral RNA into DNA within the infected cell. There
are 2 types of HIV:

HIV-1 is responsible for most AIDS cases in western countries.

HIV-2 is responsible for most AIDS cases in West Africa.

Modes of Transmission
The virus is present in the blood, semen and vaginal/cervical secretion of
infected persons. It is transmitted to non-infected persons via:

1- Sexual transmission: Sexual intercourse (homosexual and heterosexual)

involving anal intercourse, vaginal intercourse and/or orogenital sex can transmit
HIV from infected persons.

2- Donation procedures:

Blood transfusion.

Organ transplantation.

Contaminated needles and syringes.

Contaminated razors (barbershops).

3- Transplacental: from an infected mother to her child.

NB: Unproven modes of transmission include mosquito bites, non-sexual contact,
cough, sneeze, food.

Risk groups

Homosexuals.

Female partners of homosexual (bisexual) men.

Prostitutes and promiscuous individuals.

Intravenous drug abusers.

Patients needing repeated blood transfusion e.g. hemophiliacs.

Organ transplant patients.

Occupational: Surgeons, laboratory and other medical personnel.

Pathogenesis

Lymphocytes are the main cells of the immune system.

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They are of two main types, the B-lymphocytes (mainly responsible for
humoral immunity) and the T-lymphocytes (responsible for the cell
mediated immunity).

The T-lymphocytes are either helper T-lymphocytes or suppressor T-
lymphocytes.

The virus selectively attacks the CD4 receptors on the T-helper
lymphocytes leading to their destruction and immune deficiency.

The immunological defect makes the patient susceptible for certain types
of protozoal, fungal, viral, bacterial and parasitic infections (opportunistic
infections) in addition to certain malignant disorders (Kaposi sarcoma).

Clinical presentation
Following an incubation period of variable duration, the disease passes by the
following stages:

1. Acute retroviral stage:

In 10% of infected persons, glandular fever-like symptoms occur concomitant
with sero-conversion.

2. Asymptomatic stage:
The patient is clinically free but serologically positive and infectious.

3. Persistent generalized lymphadenopathy:

All lymph nodes especially the cervical and axillary groups show mobile, non-
tender enlargement.
4. AIDS-related complex
5. Full blown AIDS
AIDS is characterized by opportunistic infections and Kaposi sarcoma and other
malignant disorders. A wide range of clinical conditions hardly makes the
diagnosis direct or classic.

Clinical case definition: at least 2 major criteria and at least two minor criteria
in absence of a known cause of immuno-suppression.
Major criteria Minor criteria

Weight loss more than 10 %.
Cough for more than 1 month

Diarrhea for more than 1
Generalized pruritic dermatitis
month.
Recurrent herpes zoster

Fever for more than 1 month.
Chronic disseminated herpes
simplex

Oropharyngeal candidiasis

Generalized lymphadenopathy
N.B: Either Kaposi sarcoma or cryptococcal meningitis is sufficient by itself to
diagnose AlDS.
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Neurological Manifestations:

HIV encephalopathy and myelopathy.

Encephalitis, meningitis or retinitis.

Space-occupying lesions (tumors, opportunistic infections).

Respiratory Manifestations:

Pneumocystis carinii pneumonia (commonest opportunistic infection)

T.B

Pulmonary Kaposi sarcoma.

Gastrointestinal Manifestations

Opportunistic infections e.g. monilial infection, Stragyloids stercoralis
infestation etc.

Malignancy e.g. Kaposi sarcoma.

Hematological Manifestations: Lymphomas e.g.

Cerebral lymphoma.

B-cell lymphoma.

Burkit’s lymphoma.

Dermatological manifestations

Seborrhoeic dermatitis-like lesions (most common).

Viral diseases:
a) Oral hairy leucoplakia (Epstein Barr virus),
b) Chronic ulceration especially peri-anal (herpes simplex),
c) Multi-dermatomal bullous and ulcerative lesions (herpes zoster),
d) Genital and common warts (human papilloma virus),
e) Molluscum contagiosum, etc

Bacterial diseases: folliculitis, syphilis.

Monilia: oral thrush, angular stomatitis.

Kaposi sarcoma: Violaceous nodules and plaques commonly affecting lower
limbs and oral mucosa.

Basal cell carcinoma, squamous cell carcinomas and melanomas.

Laboratory Diagnosis
Detection of HIV antibodies
HIV antibodies are detectable 4-8 weeks after exposure to the virus.

Screening test: ELISA

Confirmatory test: Western Blot Test
Detection of HIV

HIV antigen tests: mainly used for detection of HIV core antigen p24
(limited application).

HIV culture.

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Treatment

Prophylaxis e.g.

General community measures against illegal sexual practices

Sex education about AIDS and its modes of transmission

Screening of blood donors

Strict measures against drug addiction

Laboratory precautions in handling specimens of AIDS patients

Surgery candidates should have a preoperative screening for AIDS and
surgeons must take their operative safety precautions.

General measures

Hospitalization and isolation

Treatment of infections: e.g.

Pneumocystis carinii pneumonia: Pentamidine and trimethoprim.

T.B: anti-tuberculous medications.

Herpes simplex and zoster: Acyclovir and val-cyclovir

Condyloma accuminata: interferon

Monilia: Nystatin.

Anti HIV Drugs

Nucleoside reverse transcriptase inhibitors (RTIs): These drugs Inhibit
virus replication through inhibiting reverse transcriptase enzyme e.g.
Zidovudine.

Non-nucleoside reverse transcriptase inhibitors (Non-RTIs): e.g.
Nevirapine.

Protease inhibitors: e.g. saquinavir (prevent cleavage of viral protein
precursors).

Acute scrotum

The acute scrotum presents as testicular pain or swelling and should be
considered as a testicular torsion till proved otherwise. Testicular
torsion represents a surgical emergency because the likelihood of
testicular salvage diminishes with the duration of torsion.

The age of the patient is important. Testicular torsion is most common

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in neonates and post pubertal boys, although it can occur in males of any
age.

The onset and duration of pain must be carefully determined. Testicular
torsion usually begins abruptly. The pain is severe, and the patient often
appears uncomfortable. Moderate pain developing gradually over a few
days is more suggestive of epididymitis or appendiceal torsion.

Diagnosis of Selected Conditions Responsible for the Acute Scrotum :

Condition Onset Age Tenderness Urinalysis Cremasteric Treatment
reflex

Testicular Acute Early puberty Diffuse -ve -ve Surgical

torsion exploration
Appendiceal Subacute Prepubertal Localized to -ve +ve Bed rest &
torsion upper pole scrotal
elevation
Epididymitis Insidious Adolescence Epididymal +ve or +ve Antibiotics
-ve

Torsion Testis Epididmo-orchitis

Age Neonatal or Pre-pubertal Any age

History Sudden move UTI
Temperature Normal Elevated
Scrotal elevation ++ Pain - Pain
Scrotal Duplex(most important) Avascular Hypervascular
Surgical Exploration( Better to Detorsion of affected testis and Close
open than to miss) fixation of BOTH

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A history of trauma does not exclude the diagnosis of testicular torsion.

Scrotal trauma incurred during sports activities or rough play often
causes severe pain of short duration.

Physical Examination

The physician can often assess the severity of pain by observing the
patient before beginning the physical examination.

Diagnostic Studies

Urinalysis should be performed to rule out urinary tract infection in any
patient with an acute scrotum.

Urgent SROTAL DUPLEX is required to detect testicular vascularity,
and so a trial detorsion guided by duplex maybe done but if it failed
,then urgent surgical detorsion with fixation of contralateral testis.

 Spermatic Cord Torsion

The "bell clapper" deformity is one underlying cause of testicular torsion in
older children. In this deformity, the testicle lacks a normal attachment to
the tunica vaginalis and therefore hangs freely. As a result, the spermatic
cord can twist.

 Torsion of Testicular Appendages

The appendix testis, a müllerian duct remnant located at the superior pole of
the testicle, is the most common appendage to undergo torsion. The
epididymal appendix, located on the head of the epididymis, is a wolffian
duct remnant and may also become twisted.

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 Epididymitis or Orchitis
Epididymitis in adolescents and young adults is often related to sexual
activity and does not present with a urinary tract infection.

 Scrotal Trauma
Severe testicular injury is uncommon and usually results from either a direct
blow to the scrotum or a straddle injury. Damage occurs when the testis is
forcefully compressed against the pubic bones.
(1) Penile fracture
• Penile fracture is the traumatic rupture of the corpus cavernosum.
• Traumatic rupture of the penis is relatively uncommon and is considered
andrological emergency.
• Sudden blunt trauma or abrupt lateral bending of the penis in an erect
state can break the markedly thinned and stiff tunica albuginea, resulting
in a fractured penis. One or both corpora may be involved, and
concomitant injury to the penile urethra may occur. Urethral trauma is
more common when both corpora cavernosa are injured.
• Penile rupture can usually be diagnosed based solely on history and
physical examination findings.
Small penile fracture involving the right corpus cavernosum

• Diagnosis is made based on history and physical examination findings.

Most affected patients report penile injury coincident with sexual
intercourse
• Patients describe a popping, cracking, or snapping sound with immediate
detumescence. They may report minimal to severe sharp pain, depending
on the severity of injury.
• Upon physical examination, evidence of penile injury is self-evident. In a
typical penile fracture, the normal external penile appearance is
completely obliterated because of significant penile deformity, swelling,
and ecchymosis (the so-called "eggplant" deformity).

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Upon inspection, significant soft tissue swelling of the penile skin, penile
ecchymosis, and hematoma formation are apparent. The penis is abnormally
curved, often in an S shape. The penis is often deviated away from the site of
the tear secondary to mass effect of the hematoma. If the urethra has also
been damaged, blood is present at the meatus.

Historically, conservative management was considered the treatment of choice

for penile fractures. Conservative therapy consisted of cold compresses,
pressure dressings, penile splinting, anti-inflammatory medications,
fibrinolytics, and suprapubic urinary diversion with delayed repair of urethral
injuries.

Currently, the vast majority of authors favor immediate surgical repair, citing
fewer complications, increased patient satisfaction, shorter hospital stays, and
better outcomes.

(2) Priapism

Priapism is the presence of a persistent, usually painful, erection of the penis

unrelated to sexual stimulation or desire. It is a true andrological emergency
that may lead to permanent erectile dysfunction and penile necrosis if left
untreated. Priapism is frequently idiopathic in etiology but is associated with a
number of important medical conditions and pharmacologic agents.
Two types of priapism are generally described:

a) Low-flow or Ischaemic (veno-occlusive) priapism : is usually due to full

and unremitting corporeal veno-occlusion where venous stasis and
deoxygenated blood pools within the cavernous tissue. Prolonged veno-
occlusive priapism results in fibrosis of the penis and a loss of the ability
to achieve an erection. Significant changes at the cellular level are noted
within 24 hours in veno-occlusive priapism, whereas arterial priapism is
not associated with fibrotic change.
b) Arterial high-flow or Non ischaemic (arterial) priapism: usually is
secondary to a rupture of a cavernous artery and unregulated flow into
the lacunar spaces. This rare type of priapism is usually not painful and
results from penetrating penile trauma or a blunt perineal injury.
Low-flow or ischemic priapism High flow or Non ischemic
priapism
• most common. • less common.
• Penis fully erect (sludging of blood • Penile, perineal or pelvic trauma.
within). • Uncontrolled arterial inflow directly

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• Painful sec to tissue ischaemia and into the penile sinsoidal spaces.
smooth muscle hypoxia • usually penis not fully erect and
(compartment syndrome) . painless.
• Blood gases from corpora – acidosis. • often prolonged history.
• normal local blood gases.

Causes:-
o Medications :
– Only rare case reports of Sildenafil have been associated with priapism.
– Some patients may use injectable medications to induce an erection. In
these patients, excessive use may produce priapism.
– Many psychotropic medications such as chlorpromazine, trazodone,
quetiapine, and thioridazine have been associated with priapism. The
newer agents are not immune to this complication.
– Rebound hypercoagulable states with anticoagulants such as heparin and
warfarin have been associated.
– Cocaine, marijuana, and ethanol abuse .
o Sickle cell disease and thalassemia
o Leukemia and multiple myeloma.
o Trauma (pelvic, genital, or perineal).
o Neoplastic (may be primary or metastatic)
o Rarely, cases of idiopathic priapism have also been reported.

Treatment/Management :-
Ischemic Priapism
1. Therapeutic aspiration (with or without irrigation) under strict aseptic
precautions as blood is good culture for infection.
2. Aspiration of 20ml/10minutes for 5 times ( maxiumn 100 ml).
3. Intracavernous injection of sympathomimetics (e.g. ephedrine).Monitoring
of pulse and blood pressure to avoid side effects of sympathomimetics.
4. Systemic treatment of underlying disease (e.g., sickle-cell disease) plus
intracavernous treatment for patients with underlying disorders or
hematologic pathology .
5. Gonadotropin-releasing hormone (GnRH) agonists or antiandrogens.
6. Intercavernosal self-injection of phenylephrine
7. Surgical shunts, including distal shunts (e.g., Winter, Ebbehoj, and Al-
Ghorab procedures); the cavernospongious shunt (i.e., Quackels
procedure); and cavernosaphenous shunt (i.e. Grayhack procedure)
Nonischemic Priapism
1. Observation as initial management technique.
2. Arterial embolization using autologous clot and absorbable gels.
3.Surgery performed with intraoperative color duplex ultrasonography.

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INGUINO-SCROTAL SWELLINGS

Testis related Epididymis related Tunica Skin related Others

Spermatic vaginalis
cord Related related
• Orchitis • Epididymitis • Varicocele • Hydrocele • Sebaceous Hernia
• Torsion • Spermatocele • Hydrocele • Hematicele cyst
• Tumor tumor • Chylocele • Angeoedema
• tumor • Tumor
SPERMATOCELE

Spermatocele is a cyst that arises from the epididymal head

It presents by a painless scrotal swelling above the testis with a
characteristic figure of “8”

It is usually small but may be large and looks like a third testis.

It may contain spermatozoa.

ACUTE EPIDIDYMO-ORCHITIS

Etiology
Causative organisms:
1. Uropathogens e.g. E.coli, proteus, pseudomonas, etc
2. STDs pathogens e.g. gonococci, chlamydial, mycoplasma, etc
3. Pyogenic organisms e.g. strept, staph, etc

Route of infection:

Ascending infection from lower urogenital infection (urethritis,
prostatitis, cystitis) via the lumen of the vas. This may occur after
straining or after instrumentation

Hematogenous spread from septic foci

Pathology

Inflammatory reaction usually starts at the cauda epididymis (if the
spread is along the vas) or less commonly in the caput (if spread is
hematogenous).

In either case, inflammation soon spreads to affect the whole
epididymis, which will be the seat of catarrhal or suppurative
inflammation.

Secondary small hydrocele is present. Untreated cases may develop
pyocele leading to testicular atrophy.

Epididymal obstruction may occur due to post-inflammatory fibrosis.

Clinical picture
Symptoms

Urinary symptoms (related to the cause)

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Constitutional symptoms: fever, …

Acute scrotal pain

Signs

Scrotal skin is red and edematous

Epididymis and testis are enlarged and tender

Secondary hydrocele may be present.

Treatment
1. Scrotal support to elevate the scrotum and reduce pain
2. Antibiotics for 2 weeks according to urine culture and sensitivity
3. Analgesics and urinary antiseptics
4. Incision and drainage if pyocele develops

HYDROCELE
A hydrocele consists of a collection of clear serous fluid in the tunica or
processus vaginalis.

Congenital Acquired
• Vaginal hydrocele • Primary hydrocele
• Infantile hydrocele • Secondary hydrocele
• Congenital hydrocele (Acute/Chronic)
• Encysted hydrocele of the
cord

Pathogenesis

Defective absorption of tunical fluid (most common)

Excessive production of fluid within the sac (secondary hydrocele)

Interference with lymphatic drainage

Direct connection with peritoneal cavity (congenital)

Diagnosis

Rounded cystic non-tender scrotal mass

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Trans-illumination is positive.

The congenital type is better called communicating hydrocele as it is
caused by patent processus vaginalis, where the cystic mass is soft in
the morning and tense at night.

Scrotal ultrasonography (to reveal the condition of the testis and
epididymis)

Complications
a) Infertility is rarely caused by hydrocele but may occur due to:

Impaired testicular thermoregulation

Compression of testicular vessels

Large hydrocele may mechanically interfere with coitus
b) Hematocele (usually post-traumatic)
c) Hernia of the hydrocele sac

Treatment: Treatment not usually required unless:

 Hydrocele is secondary
 Very tense hydrocele
 Mechanical or cosmetic reasons
Primary hydrocele

Congenital hydrocele requires high ligation of the patent processus

vaginalis at the internal inguinal ring and excision of the distal sac.

In adults, the hydrocele sac is simply opened then merely stitched to
collapse the wall “Lord's operation” or subtotal excision is done with
tunical eversion.
Secondary hydrocele

Medical treatment for epididymo-orchitis

Orchidectomy for malignant tumors.

ANDROLOGY-RELATED DISORDERS

PROSTATITIS

Prostatitis is inflammation of the prostatic gland,

which is commonly associated with a concomitant
affection of the seminal vesicles when the
condition is referred to as prostato-vesiculitis.
ACUTE PROSTATITIS
Causative organisms:

Uro-pathogens e.g. E. coli, Pseudomonas and
Proteus

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STDs pathogens e.g. Gonococci and chlamydia

Others e.g. strept and staphylococci

Mode of infection:

Direct from prostatic urethra

Blood spread from a septic focus

Lymphatic spread from the rectum or bladder

Symptoms:

Constitutional symptoms: e.g. fever and malaise

Pelvic pain (perineal, suprapubic, rectal or low back pain)

Severe urinary symptoms (frequency, dysuria up to retention)
Signs: PR examination shows a swollen markedly tender prostate

Complications:

Retention of urine

Prostatic abscess

Spread of infection

Chronicity

Treatment:

General: Bed rest, analgesics and anti-inflammatory

Antibiotics: systemic penicillin (or cephalosporin) in combination with
aminoglycosides

Abscess: Transurethral or transperineal drainage

Urine retention: suprapubic cystostomy

CHRONIC PROSTATITIS
Causative organisms: E. Coli, Klebsiella, pseudomonas, enterococci, proteus,
Chlamydia trachomatis, ureaplasma, staph and streptococci.

Clinical picture: Asymptomatic cases are frequent.

Urinary symptoms: frequency and dysuria

Pain: perineal, suprapubic, urethral, testicular or low back pain

Urethral discharge (prostatorrhea and morning drop)

Sexual symptoms: premature ejaculation, painful ejaculation and
hemospermia if there is associated seminal vesiculitis

Infertility (functional, immunological or partial obstruction)

PR examination reveals enlarged, firm, tender prostate.
Investigations:
1) Microscopic examination of the expressed prostatic secretion (EPS):
Estimation of the PNL-count in the following samples:

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First urine passed

Midstream specimen

EPS obtained by prostatic massage

Urine after prostatic massage
In Prostatitis, PNL count is higher in the EPS and/or the third sample.

2) Culture of the EPS: This is done to demonstrate the causative organism and
hence to diagnose the type of chronic prostatitis.

Chronic prostatitis can be classified by examining the expressed prostatic

secretion and by bacteriological localization studies into three categories:
1. Chronic bacterial Prostatitis.
2. Chronic non-bacterial Prostatitis.
3. Prostatosis or prostatodynia.

Symptoms EPS microscopy EPS culture

Chronic bacterial Positive Positive Positive

prostatitis
Chronic abacterial Positive Positive Negative
prostatitis

Prostatodynia Positive Negative Negative

Treatment:
 Chronic bacterial prostatitis:
• Antibiotics: The “blood prostatic barrier” allows only few antibiotics
to pass to prostatic tissue e.g. erythromycin, co-trimoxazole,
tetracycline (doxycycline or minocycline) and quinolones (e.g.
ciprofloxacin). Treatment should be continued for 4-12 weeks.
• Prostatic massage (few sittings may help drainage of closed acini and
improve the gland vascular perfusion).
 Chronic abacterial prostatitis:
• Non-steroidal anti-inflammatory drugs
• Doxycycline
 Prostatodynia:
• Reassurance
• Anticholinergic drugs
• Tranquilizers
• Non-steroidal anti-inflammatory drugs

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Choose the correct single answer d. Sperm motility ≥ 50% active forward
1- The following hormone(s) are involved in motile sperms after 2 hours
regulation of spermatogenesis: e. Abnormal forms ≥ 40%
a. Testosterone 10- The following are sure causes of
b. LH azoospermia except:
c. FSH a. Varicocele
d. Prolactin b. Sertoli cell only syndrome
e. All the above c. Classic klinefelter syndrome
2- Testosterone is mainly secreted by: d. Bilateral congenital absence of the
a. Leydig cells vas
b. Peritubular cells e. Bilateral cryptoorchidism
c. Sertoli cells 11- Basically the diagnosis of azoospermia
d. Germ cells depends on :
e. B and C a. Testicualr biopsy
3- The main target of FSH is: b. Buccal smear
a. Leydig cells c. Prostatic smear
b. Peritubular cells d. Vasography
c. Sertoli cells e. None of the above
d. Germ cells 12- The following helps differentiate
e. B and C functional from obstructive azoospermia
4- The stem cell from which other germ cells except:
originate is: a. Estimation of serum FSH
a. Spermatids b. Estimation of serum LH and
b. Spermatogonia testosterone
c. 1ry spermatocytes c. Clinical scrotal exam.
d. 2ry spermatocytes d. Scrotal US
e. Spermatozoa e. Testicualr biopsy
5- Testicular causes of infertility includes all 13- Estimation of serum FSH is indicated for:
the following except: a. All infertile males
a. Klinefelter syndrome b. Oligozoospermic males
b. Sertoli cell only syndrome c. Azoospermic males
c. Cryptoorchidism d. Asthenozoospermic males
d. Anti-hypertensive drugs e. Teratoozoospermic males
e. Radiation 14- The following are therapeutic options for
6- The following infections can cause azoospermic males except:
genital duct obstruction except: a. Epididymovasostomy
a. Gonorrhea b. Vasovasostomy
b. TB c. IUI
c. Mumps d. TESE-ICSI
d. Chronic prostatitis e. Gonadotropin therapy
e. Chronic epididymitis 15- Causes of oligozoospermia may include
7- Bilateral undescended testes is the following except:
associated with: a. Varicocele
a. Normal semenogram b. Partial ejaculatory duct obstruction
b. Oligoasthenoteratozoospermia c. Unilateral undescended testis
c. Asthenozoospermia only d. Excess heat exposure
d. Necrozoospermia only e. Antisperm antibody
e. None of the above 16- The mechanism by which varicocele
8- Aspermia stands for: causes infertility:
a. Absence of sperm head a. Disturbed testicular thermoregulation
b. Absence of sperm tail b. Regurgitation of adrenal metabolites
c. Total absence of sperms c. Epididymal dysfunction
d. Total absence of semen d. All the above
e. None of the above e. None of the above
9- Normal semen parameters include all of 17- The commonest semen abnormality seen
the following except: in infertile patients with varicocele is:
a. Volume = 2-5 ml a. Necrozoospermia
b. Liquefaction time ≤ 30 min b. Oligoasthenoteratozoospermia
c. Sperm concentration = 20-250 c. Azoospermia
million/ml d. Leucocytospermia

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e. Polyzoospermia 26- The excitation phase of the female sexual

18- In patients with varicocele semen response cycle include all the following
abnormalities are present in : except:
a. All patients a. Vaginal transudation
b. The majority of patients b. Clitoral congestion
c. Some patients c. Nipple erection
d. Very few patients d. Increase in heart rate
e. No patients e. Rhythmic contraction of pelvic floor
19- Asthenozoospermia: and perineal muscles
a. Abnormally low sexual desire 27- The refractory period of tha male sex
b. Abnormally weak erection response cycle is affected by:
c. Abnormally weak orgasm a. Age
d. Abnormally low sperm motility b. General health
e. Abnormally low sperm functions c. Psychogenic state
20- Asthenozoospermia may be caused by all d. All the above
the following except: e. None of the above
a. Partial and unilateral genital 28- Regarding the etiology of ED the
obstruction following statement is the most
b. Immotile cilia syndrome appropriate:
c. Chronic prostatitis a. Psychogenic factors are only
d. Immune infertility responsible
e. Varicocele b. Organic factors are only responsible
21- The foolowing are possible causes of c. Psychogenic etiology predominates
hemospermia except: the organic
a. Bilharzial seminal vesiculitis d. Organic etiology predominates the
b. Filarial funiculitis psychogenic
c. Prostatic calculi e. Psychogenic and organic factors are
d. Hemophilia almost equally responsible
e. TB prostatitis 29- The single most important organic factor
22- The following conditions can be helped to cause ED is:
by ICSI except: a. Atheosclerosis
a. Resistant oligozoospermia b. Hyperprolactinemia
b. Resistant asthenozoospermia c. DM
c. Resistant teratozoospermia d. Disc prolapse
d. Azoospermia e. Drug induced
e. Anorchia 30- Psychogenic ED may be characterized by
23- ED is defect in which stage of sexual all the following except:
response cycle: a. Suuden onset
a. Excitation stage only b. Intermittent course
b. Excitation and plateau c. Presence of morning erection
c. Resolution stage only d. Usually associated with premature
d. Resolution stage and refractory ejaculation
period e. Affects young age group more than
e. Excitation and resolution stages old group
24- Penile erection is caused by vascular 31- The following are causes of organic ED
changes in: except:
a. Corpus cavernosum and its crura a. DM
b. Corpus spongiosum and bulb b. Liver cell failure
c. Glans penis c. Antihypertensive drugs
d. A and b d. Spinal cord injury
e. B and c e. Traumatic first coital experience
25- Concerning erection all the following are 32- The agent to use during ICI test with least
true except: side effect is:
a. It is a hemodynamic phenomenon a. PGE1
b. Evoked by smooth muscle relaxation b. Papaverine
c. Vasodilatation of cavernosal arteries c. Ephiedrine
is mediated by somatic innervation d. Atropine
d. Passive venoocclusion occurs during e. Phentolamine
erection 33- Arteriogenic ED may be characterized by
e. NO is the main neurotransmitter all the following except:

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a. Gradual onset b. Diarrhea >1 month

b. Progressive course c. Recurrent herpes zoster
c. Loss of morning erections d. Chronic disseminated herpes
d. Normal nocturnal penile tumescence simplex
e. Poor response to PGE1 injection e. Oropharyngeal candidiasis
34- DM can cause impotence by the following 42- Oral manifestations of advanced HIV
mechanisms except: infection includes all the following
a. Diabetic neuropathy except:
b. Atherosclerosis a. Oral thrush
c. Microangiopathy b. Oral hairy leukoplakia
d. Psychogenic factors c. Perforated palate
e. Insulin therapy d. Kaposi sarcoma
35- The most reliable diagnostic test to e. Oral HSV infection
differentiate organic from psychogenic 43- Opportunistic infections in AIDS includes
ED is: the following except:
a. Estimation of FSH, LH, PRL and a. Candidiasis
testosterone b. Trichomoniasis
b. Rigiscan c. Condyloma accuminata
c. Duplex US of cavernosal arteries d. Herpes simplex infection
d. ICI e. Syphilis
e. Biothesiometry 44- In ttt of opportunistic infections in AIDS
36- The following investigations may help in the following is true except:
the diagnosis of ED except: a. Pneumocystis carinii pneumonia is
a. NPT monitoring treated by pentamidine and
b. Duplex test trimethoprime
c. Hormonal test b. TB is mainly traeted by quinolones
d. ICI test c. Herpes simplex and zoster is treated
e. Scrotal US by acyclovir
37- The squeeze technique is sex therapy d. Condyloma acuminata is treated by
method used in the ttt of : interferon
a. ED e. Candida is treated by nystatin
b. Premature ejaculation 45- In ttt of opportunistic infections in AIDS
c. Retarded ejaculation the following is true except:
d. Retrograde ejaculation a. Pneumocystis carinii pneumonia is
e. Inhibited sexual desire treated by pentamidine and
38- Groups at special risk for acquisition of trimethoprime
HIV include the following except: b. Herpes simplex and zoster is treated
a. Sexually promiscious individuals by acyclovir
b. IV drug abusers c. TB is mainly traeted by quinolones
c. Organ transplant patients d. Condyloma acuminata is treated by
d. Alcoholics interferon
e. Surgeons, lab personnel and e. Candida is treated by nystatin
dentists 46- The following lesions are infectious
39- HIV identifies and attacks: except:
a. All lymphocytes a. Chancre
b. B lymphocytes only b. Condyloma lata
c. T helper lymphocytes only c. Mucous patches
d. T- suppressor lymphocytes only d. Ulcerated gamma
e. All body cells e. Snail track ulcer
40- Methods of HIV transmission includes all 47- The most important test for diagnosis of
the following except: chancre is:
a. Accidental needle stick injury durin a. Dark ground examination
surgery on HIV positive patient b. RPR test
b. Mosquito bite c. Biopsy and histological examination
c. Unprotected coitus d. VDRL test
d. Kissing e. None of the above
e. Organ transplantation 48- DD of ulcer on genital area includes all
41- Minor criteria for diagnosis of AIDS the following except:
include all the following except: a. Scabies
a. Cough> 1month b. Drug eruption

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c. Condyloma acuminata e. Constitutional symptoms.

d. Lymphogranuloma venerum 57- Skin rash in secondary syphilis can be of
e. Herpes simplex any of the following except;-
49- Syphilis is an STD caused by: a. Vesiculobullous.
a. Gram –ve cocci b. Macular.
b. Gram +ve cocci c. Papular.
c. Virus d. Papulo-squamous.
d. Fungus 58- Diagnosis of chancre on the cervix uteri
e. Spirochete is best done by;-
50- The IP of syphilis is: a. Dark ground microscopy.
a. Few hours b. Specific serological test of syphilis.
b. 2-20 days c. Non specific serological test of
c. 9-90 days syphilis.
d. 1-6 months d. Culture.
e. 1-3 years e. Tissue culture.
51- Modes of transmission of syphilis 59- Screening of blood donors for syphilis is
includes all the following except: carried out by;-
a. Sexual contact a. RPR.
b. Asexual contact b. TPHA.
c. Trans-placental c. FTA-ABS.
d. Food borne d. Dark ground microscopy.
e. Blood transfusion e. Any of the above.
52- The following syphilitic lesions are 60- The best “screening” test for syphilis is;-
infective except: a. TPHA.
a. Gummatous ulcer on the lip b. FTA.
b. Snail track ulcer c. TPI.
c. Corona veneris d. VDRL.
d. Perianal condyloma lata e. Dark ground microscoy.
e. Condom chancre 61- The following features are true for early
53- Early infectious phase of syphilis is:- congenital syphilis except;-
a. The first 2 months of infection. a. Infectious phase.
b. The first 2 years of infection. b. Treponema reach the foetus via the
c. The primary stage only. placenta.
d. The secondary stage only. c. Primary stage appears on the genital
e. Both primary & secondary stages. region.
54- Which of the following best describe d. Secondary stage manifests mainly
syphilitic chancre;- by skin rash.
a. Multiple grouped vesicles. e. Early latent stage is asymptomatic.
b. Large cauliflower mass. 62- Hutchinson’s triad is a pathognomonic
c. A single painless ulcer. combination of the following except;-
d. Multiple erythematous plaques. a. Notched upper central incisor teeth.
e. Multiple indurated papules. b. Moon molars.
55- The primary stage of acquired syphilis c. Interstitial keratitis.
th
presents by an ulcer characterized by;- d. 8 nerve deafness.
a. Usually multiple, painful with 63- For treatment of chancre the antibiotic
indurated base. that can be used as single dose is;-
b. Usually single, painless with soft a. Procain penicillin.
base. b. Benzathine penicillin.
c. Usually single, painless with c. Erythromycin.
indurated base. d. Sulphonamide.
d. Usually multiple, painless with e. Tetracyclin.
indurated base. 64- A pregnant syphilitic woman allergic to
e. Usually single, painful with indurated penicillin may be treated by;-
base. a. Tetracyclin.
56- Secondary syphilis is clinically b. Erythromycin.
characterized by the following except;- c. Sulphonamide.
a. Skin rash. d. Cephalosporin.
b. Mucous patches. e. Ampicillin.
c. Generalized lymphadenopathy.
d. Oral candida.

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65- Gonorrhea in adult woman may be a. Tysonitis.

complicated by any of the following b. Littritis.
except;- c. Cowpritis.
a. Cystitis. d. Skenitis.
b. Skenitis. e. Periurethral abscess.
c. Vaginitis. 74- Which of the following is the drug of first
d. Bartholinitis. choice for NG urithritis;-
e. Salpingitis. a. Ceftriaxone.
66- All of the following statements regarding b. Ciprofloxacin.
Neisseria gonorrhea are true except;- c. Amoxicillin-clavulenate.
a. The drug of choice is ceftriaxone. d. Doxycyclin.
b. Gram negative diplococci. e. Sulphamethoxazole-trimethoprim.
c. Incubation period between 2-5 days. 75- Which of the following chlamydia
d. Selsctive media for growth is serotypes is not a cause of non-
Thayer-Martin agar. gonococcal urethritis;-
e. VDRL test is diagnostic. a. Serotype C.
67- The incubation period of gonorrhea is;- b. Serotype D.
a. Few hours. c. Serotype E.
b. More than ten days. d. Serotype F.
c. Between 2-5 days. e. Serotype G.
d. Less tha 2 days. Case; A 23-years-old healthy man has been
e. Between 9-90 days. unable to father a child. He and his wife had a
68- The following are causes of urethritis workup for infertility. His wife’s reproductive
except;- function proved to be normal. On physical
a. Trichomonus vaginalis. examination of the male, both testes were
b. Mycoplasma. palpable. However, the spermatic cord on the left
c. Granuloma inguinale. gave a feeling like a “bag of worms”. Laboratory
d. Chlamydia. studies show oloigospermia.
e. Intra meatal chancre. 76- Whitch of the following conditions is this
69- Whitch of the following decribes the man most likely to have?
characterestic lesions of genital herpes;- a. Hydrocele.
a. Multiple grouped vesicles. b. Testicular torsion.
b. A single painless ulcer. c. Spermatocele.
c. Large granulomatas mass. d. Varicocele.
d. Multiple erythametous plaques. e. Seminoma.
e. Multiple indurated papules. Case:- A 32 years old diabetic man married for 6
70- Viral STDs include the following except;- years presented with secondary infertility for the
a. Molluscum contagiousm. last 18 months. Genital examination revealed
b. AIDS. normal sized testes through the left testicle is
c. Viral hepatitis B. slightly smaller and softer than right one.
d. Herpes progenitalis. Valsalva’s maneuever showed positive thrill on
e. Herpes zoster. both spermatic cord. Semen analysis showed;-
71- Which of the following organisms is most Sperm concentration 14 million/ml
likely to result in non-ulcerated genital Sperm motility 35% motile
lesions;- Sperm morphology 75% abnormal
a. HPV. 77- You think this patient is having:-
b. Calymmatobacterium granulomatis. a. Oligo-asthenospermia.
c. Treponema palidum. b. Oligo-astheno-teratospermia.
d. Hemophilus ducreyi. c. Astheno-teratozoospermia.
e. HSV. d. Oligo-tteratozoospermia.
72- Agents causing genital ulcer include the 78- The most probable cause for such case
following except;- is;-
a. HSV-2 a. Cryptotorchidism.
b. HPV. b. Klinefelter syndrome.
c. Hemophilus ducreyi. c. Mumps orchitis.
d. Chlamydia. d. Varicocele.
e. Klebsiella donovanis. e. Diabetes.
73- Local complications of anterior urethritis Case A 29 years old man presented to an
in gonorrhea in males include the infertility clinic complaining of azoospermia. Local
following excet;-

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examination revealed no gross abnormality. FSH Urine analysis and blood picture were within
level was normal. normal limits.
79- The most appropriate next step for the 84- The most likely diagnosis is;-
management of this case is;- a. Epididymitis.
a. Ask for post coital test. b. Paraphimosis.
b. Refer the patientfor assisted c. Penile fracture.
conception. d. Priapism.
c. Perform testis biopsy. e. Peyronie’s disease.
d. Try hormonal treatment before Case;- A 17-Year-old male presented by
starting investigations. recurrent scrotal pain radiating inguinally.
e. Ask for fructose in semen. 85- The following are probable causes
Case A male patient presented to andrology except;-
clinic complaining of primary infertility. a. Varicocele.
Examination showed normal testicleswith b. Epididymitis.
bilateral absent vas deferentia. c. Cystitis.
80- His semen analysis is most likely to be;- d. Recurrent testicular torsion.
a. Teratozoospermia with low semen e. Ureteric stone.
volume. Case;- A 20-years-old single male presentedleft
b. Azoospermia with low semen scrotal swelling 4 months after left
volume. varicocelectomy operation. He also stated that
c. Oligozoospermia with normal semen the size of the swelling is increasing gradually.
volume. On examination, left testis could not be felt from
d. Asthenozoospermia with high semen the swelling. Transillumination test was positive.
volume. 86- The most appropriate diagnosis of this
e. Polyzoospermia with poor motility. case is;-
81- Management of this case will be;- a. Recurrent varicocele.
a. Hormonal therapy. b. Primary hydrocele.
b. Reconstructive surgery. c. Secondary hydrocele.
c. IUI. d. Testicular torsion.
d. Varicocelectomy. e. Testicular tumor.
e. ICSI. Case; A 27-year-old heavy vehicle driver comes
Case;- A newly married male asked you about a to the office because he is “not feeling well and
reliable method for contraception that he can use has been losing weight” during the past few
by himself as his wife refused to use months. He also reports that he is feeling
contraceptive biles. increasingly tired. He drives long hours on his
82- You would suugest:- job, smokes heavily, and admits to “moderate”
a. Coitus interrupts. amounts of alcohol intake. He has never seen a
b. Safe period + condom. doctor before and denies any past medical or
c. Vasectomy. surgical history. His temperature is 37.0 C, blood
d. Antiandrogen IM. pressure is 110/80 mm Hg, pulse is 70/min, and
e. Testosterone IM. respiration rate is 16/min. abdominal examination
Case;- A 65-years old diabetic patient presented shows a vague abdominal mass in the midline
with erectile dusfunction for 3 years. Intra that is not pulsatile and non-tender. Rectal
cavernosal injection test failed to induce erection. examination is unremarkable. Scrotal
83- The most probable mechanism of ED in examination shows an enlarged right testicle
this case is;- without sensation.
a. Vascular. 87- The factor in this patient’s history and
b. Neurological. examination that is most helpful for
c. Endocrinal. diagnosing the etiology of the abdominal
d. Psycogenic. mass is;-
e. None of the above. a. Alcohol intake.
Case;- A 43years old man came to the b. His job.
emergency because of a 6-hour persistant c. Non-pulsatile nature of abdominal
erection that became painful 2hours ago. He mass.
denied any trauma associated with intercourse. d. Scrotal examination findings.
He had no significant medical history and was e. Smoking.
not taking any medication. On examination, Case;- A 25-year old single man presented with
corpora cavernosum were rigid and tender, while a painless lesion on his penis for 10 days with
the glans and corpus spongiosum were soft. history of some sexual relation 3 weeks ago.
Rdctal examination revealed normal prostate. Examination showed a small, non-tender ulcer

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having an irregular outline with an indurated 92- Which of the following is the most cost
base on the coronal sulcus of the penis. The effective method for laboratory diagnosis
inguinal nodes were bilaterally enlarged but non- of this man’s lesion:-
tender. Rapid plasma regain (RPR) test and a. Darkfield microscopy.
TPHA test were negative. b. Cytological smear.
88- Your next step is to;- c. Tissue biopsy.
a. Consider the case non-syphilitic and d. Enzyme immunoassay.
give local antibodies. e. Microbiologic culture.
b. Consider the case syphilitic and start Put "True" or "False" :
penicillin therapy. 93- Primary infertility means childless marriage
c. Ask for ground microscopic for more than 1 year.
examination. 94- Secondary infertility means childless
d. Consider malignancy and take a marriage for more than 2 year.
biopsy. 95- Semen analysis must be followed by
e. Herpes progenitalis is strongly testicular biopsy in evaluating male fertility
suggested. potential.
Case;- A 30-year-old sexually active man has 96- Differentiation of obstructive from
experienced a burning pain with urination for the azospermia is based on clinical examination,
past 5 days. On physical examination there’s a serum FSH level and testicular biopsy.
scant pale yellowish urethral discharge. He’s 97- In Klienfelter syndrome , FSH is usually low
afebrile. or low normal .
89- He is most likely to be infected with which 98- Obstructive azospermia complicate some
of the following organisms;- male after mumps.
a. HSV. 99- Obstructive azospermia complicate
b. Treponema pallidum. herniotomy in adults more than in children.
c. Chlamydia trachomatis. 100- Obstructive azospermia may lead to
d. Mumps virus. elevation of FSH serum level.
e. Haemophilus ducreyi. 101- Some azospermic can father children via
Case; A single 24-years-old male complaining TESTE-ICSI.
occasional urethral discharge that may follow 102- Some azospermic can father children via
urination, defecation and sometimes on IUI.
straigning. The patient denies any sexual 103- Congenital absence of vas deference of
relation. Urethral swab for gram stain and culture the vas deference is associated with low
for N gonorrhea were negative. serum volume .
90- The most probable cause is;- 104- Functional azospermia may be corrected
a. Prosemen due to sexual excitation. by epidiymo-vasotomy.
b. Physiological prostatorrhea due to 105- Priapism is an aimless erection that
sexual congestion. persists for more than 6 hours.
c. Chlamydua urethritis. 106- Erectile dysfunction may lead to
d. Herpes progenitalis. retrograde ejaculation.
e. Premature ejaculation. 107- Gonococcal complications may cause
Case;- A 25-years-old presented with multiple obstructive rather than functional infertility .
large sized cauliflower-like watry masses on the 108- Infertile men are commonly impotent.
vulva. Similar lesions were detected on her 109- Large bilateral varicocele may lead ti ED
husband’s penis. .
91- The most likely diagnose is;- 110- Erectile dysfunction is termed " 1ry " if no
a. Condyloma lata. cause is found and " 2ry " if a specific cause
b. Condyloma accuminata. is identified .
c. Herpes progenitalis. 111- ED can lead to depression and vice
d. Genital scabies, versa.
e. Chancroid. 112- The most common psychic factor in ED
Case;- A 21-year-old man notes the presence of is performance anxiety .
a lesion on his penis for the past week, on 113- The most common organic factor in ED
physical examination there’s a solitary 0.7 cm is chronic prostatitis .
diameter circumscribed area of ulceration on the 114- Gender identity conflict is an
dorsal aspect of his penis just proximal to the interpersonal cause of ED.
glans. This ulcer has a firm erythematous base 115- In diagnosing ED, local examination is
containing minimal grey exudates. more important than history taking .
116- All ED must be screened for blood sugar
level and serum testosterone .

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117- All ED must be screened for serum 145- Benzathine penicillin is the treatment of
T3,T4,FSH and LH levels. choice for both syphillis and gonorrhea.
118- Rigiscan is used in diagnosing the 146- H.ducreyi causes multiple painful genital
degree of penile rigidity during intercourse. ulcers.
119- NPT monitoring differentiates 147- Chlamydia is the causative organism of
psychogenic from organic ED. lymphogranuloma venerum.
120- The ICI test is based on the VD effect of 148- Topical podophylline application is the
Sildenafil. treatment of choice for condyloma lata.
121- Sildenafil works best if taken on full 149- HPV infection may predispose to cancer
stomach 1h before intercourse. cervix.
122- The erectogenic effects of sildenafil is 150- G.lymphadenopathy can be a feature of
due to inhibition of phosphodiesterase-5. gonorrhea and 2ry syphilis.
123- Penile prosthesis is used either simirigid 151- Early lesions of AIDS appear as genital
rods or inflatable devices . ulcers.
124- Premature ejaculation is mainly caused 152- The screening test for HIV is western
by psychogenic factors. blot test.
125- External vacuum suction devices are 153- The verulence factor of HIV is reverse
designed for treatment of premature transcriptase enzyme.
ejaculation. 154- Oral hairy leukoplakia is caused by Pox
126- SSRIs and squeeze technique may help virus.
people with premature ejaculation. 155- Patients with advance HIV usually die
127- Chancre occurs exclusively on genital from opportunistic infections.
organs . 156- Kaposi Sarcoma in AIDS ia caused by
128- Infectivity of syphilis is only for the first 2 EBV.
years of infection . 157- Asymptomatic HIV infection is non
129- Early latent syphilis can be infective by infective by sexual contact.
sexual contact. 158- AIDS, Syphilis , gonorrhea herpes and
130- Chancre presents by a single, painless condyloma can all be transmitted from an
and indurated genital ulcer. infected pregnant mother to her infant.
131- In 2ry syphilis there is G. bilateral 159- Gonorrhea and Chlamydia urethritis are
symmetrical vesiculo-bullos rash. common opportunistic infections in AIDS .
132- All patients with untreated chancre are 160- Gonococci are more common than
VDRL positive . chlamydia in causing urethritis.
133- All patients with untreated 2ry stage of 161- Prostatorrhea is a physiological
syphilis are VDRL positive . phenomenon , where urethral discharge
134- All patients with untreated 3ry stage of occurs on straining.
syphilis are VDRL positive . 162- Gonorrhea may primarily present by
135- Generalized lymphadenopathy may urethritis , proctitis , pharyngitis.
occur in AIDS but never in syphilis . 163- Thayer & Martin medium is diagnostic for
136- Vesiculo-bullos rash can occur in 2ry the causative organism in non-gonococcal
stage of acquired syphilis. urethritis.
137- Late latent syphilis may be infective by 164- Perihepatitis may complicate gonococcal
blood transfusion . and chlamydial PID.
138- Gummatous ulcers are always no- 165- In prepupertal girls , gonorrhea presents
infective. by vulvovaginitis.
139- Aortic regurge can be a manifestation of 166- When gonococci disseminate to blood
cardiovascular syphilis . stream they cause dermatitis and arthritis .
140- The most infective lesion in syphilis is 167- Smear examination is less sensitive than
condyloma accuminata . direct immunofluorescence in diagnosing
141- Hutchinson teeth extraction is associated gonorrhea.
with a risk of syphilis transmitted to the 168- Herpes progenitalis is commonly caused
dentist. by HSV-2 more than HSV-1.
142- Under dark ground microscopy , 169- Severe constitutional symptoms
T.Pallidum appear as luminescent spiral accompany each attack of HSV-1.
organism . 170- Zidovudine is the drug of choice for
143- VDRL test may give false +ve results in treatment of herpes progenitalis .
leprosy.
144- TPHA test may give false +ve results in
leprosy.

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171. Sarcoptes mite a.AIDS

172.Chlamydia urethritis serotypes D-K b.Syphilis
173. Chlamydia urethritis serotypes L1,2,3 C.Chancroid
174.Calymmatobacterium donovanis D.Herpes progenitalis
175.Hemophilus ducreyi E.Condyloma accuminata
176.Treponema Pallidum F.Scabies
177.POX virus G.Non-gonococcal urethritis
178.HIV H.Lymphogranuloma venerum
179.HPV I.Granuloma inguinale
180.HSV-2 J.Molluscum contagiosum

181. Differentiation between psychogenic & organic ED a.penile duplex US

182.Differentiation between vasculogenic and non –vasculogenic b.ICI test
ED
183. Confirmation of venous leak as a cause of ED C.Semen analysis
184.Diagnosis of arterial insufficiency as a cause of ED D.Testicular biopsy
185.Screening test for neurogenic ED E.Postcoital test
186.Diagnostic test for male fertility potential F.Examination of postcoital
urine
187.Differentiation between functional from obstructive G.Cavernosometry
azoospermia
188.Diagnosis of Klienfelter syndrome H.Biothesiometry
189.Diagnosis of mechanical infertility I.Rigiscan
190.Diagnosis of retrograde ejaculation J.Karyotyping

191. The commonest cause of a.Mumps

oligoashenoozospermia
192.The commonest congenital cause of b.Bilateral congenital absent vas
mechanical infertility
193. The commonest infection to cause C.Immotile cilia syndrome
functional infertility
194. The commonest cause of organic ED D.Chronic prostatitis
195. The commonest cause of absence of E.Chronic epidiymitis
fructose in semen
196. The commonest cause of failed puberty F.Hypospadias
197. The commonest cause of haemospermia G.Hypogonadism
198. The commonest organic cause of premature H.Varicocele
ejaculation
199. The commonest acquired cause of I.DM
obstructive infertility
200. The commonest cause of isolated J.Bilharziasis
astheozoospermia
Answers:
1.E 26.E 51.D 76.D 101.T 126.T 151.F 176.B
2.A 27.D 52.A 77.B 102.F 127.F 152.F 177.J
3.C 28.E 53.B 78.D 103.T 128.T 153.T 178.A
4.B 29.C 54.C 79.C 104.F 129.F 154.F 179.E
5.D 30.D 55.C 80.B 105.T 130.T 155.T 180.D
6.C 31.E 56.D 81.E 106.F 131.F 156.F 181.I
7.E 32.A 57.A 82.B 107.T 132.F 157.F 182.B
8.D 33.D 58.A 83.A 108.F 133.T 158.T 183.G
9.E 34.E 59.A 84.D 109.F 134.T 159.F 184.A
10.A 35.B 60.D 85.C 110.F 135.F 160.F 185.H
11.A 36.E 61.C 86.C 111.T 136.F 161.T 186.C
12.B 37.B 62.B 87.D 112.T 137.F 162.T 187.D
13.C 38.D 63.B 88.C 113.F 138.T 163.F 188.J

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14.C 39.C 64.B 89.C 114.F 139.T 164.T 189.E

15.E 40.B 65.C 90.B 115.F 140.T 165.T 190.F
16.D 41.B 66.E 91.B 116.T 141.F 166.T 191.H
17.B 42.C 67.C 92.A 117.F 142.T 167.T 192.F
18.C 43.B 68.C 93.T 118.F 143.T 168.T 193.A
19.D 44.B 69.A 94.F 119.T 144.F 169.F 194.I
20.A 45.C 70.E 95.F 120.F 145.F 170.F 195.B
21.B 46.D 71.A 96.T 121.F 146.T 171.F 196.G
22.E 47.A 72.B 97.F 122.T 147.T 172.G 197.J
23.B 48.C 73.D 98.F 123.T 148.F 173.H 198.D
24.A 49.E 74.D 99.F 124.T 149.T 174.I 199.E
25.C 50.C 75.A 100.F 125.F 150.F 175.C 200.C
_______________________________________________

1.Psychogenic erectile dysfunction has

• sudden onset, intermittent course
• morning erection
• normal nocturnal
• full erection in response to PGE1
2.Erectile dysfunction due to artery cause has
• gradual onset, progressive course
• poor response to PGE1
• absent morning erection
3.Drug of choice for ICI is prostaglandin but papaverin and phentolamine may produce
priopism
4. 26 years old patient , diabetic, ICI,no erection duplex is done and it is suggestive of venous
leak
• Best treatment for venous leak is penile prosthesis
• If venous leak is treated by venous ligation it is recurrent after 6 months
5.A 29 years old patient has prolonged painful erection for 5 hours
First line of treatment is aspiration and irrigation by cold saline
6.Erection : desire with stimulus and relieved by coitus
priapism : aimless erection and not relieved by coitus
7.If priapism is left up to 12 hours without treatment ischemia will occur which end by fibrosis
called post priapism fibrosis.
8.Post priopism fibrosis is treated by penile prosthesis.
9.Treatment of priapism
• first line of treatment is aspiration and irrigation by cold saline for corpora
• if failed ephedrine intercorporal because it is a strong v.c
• if failed surgery is done cavernous spondiosod shunt
10.The first sign of puberty is increase in the longitudinal axis of the testicles.
11.Diabetic patient has secondary infertility , left testis is slightly smaller and softer than the
right one this will lead to varicocele.
12.varicocele
• make one testis is smaller and softer than the other
• produce oligospermia count less than 2o million
• produce asthenospermia motility less than 50 y
• produce teratospermia (abnormal forms more than 35 %)
13.Normal volume of semen is 2-5 ml
14. Normal semen is alkaline
15. Picture of absent vas :
• Obstructive azospermia
• Volume of semen is less than 1 ml which represent prostatic secretion that is acidic

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16. Treatment of primary infertility due to absent vas is ICI

17. 20 years old single has left scrotal swelling 4 months after varicocelectomy
Complications of varicocelectomy
a. recurrence
b. testicular atrophy due to ligation of testicular artery
18. 2ry infertile patient had a history of urinary tract troubles , renal stones , hypospadius and
normal testicles : infertility is due to inflammatory obstruction
Renal stones recurrence of UT infections most common cause of epididymitis end by
fibrosis in tail of epididymis  obstruction infertility
19. Patient with occasional urethral discharge following urination , defecation and straining
this case is called prostatorrhea.
20. Urethral discharge
a. may be physiological :
1-prosemen : before semen to lubricate and neutralize acidity
2- prostatorrhea : due to repeated sexual desire without release
b. pathological : gonorrhea or non gonorrheal uretheritis
21. Chancre : single , painless and indurated
22. Best description of condyloma acuminate is cauliflower like
23. Diagnosis of syphilis :
• +ve dark ground micropasy…for syphilis
• +ve serological tests ….is non effective 1ry syphilis used foe 2ry syphilis
24. Gumma is non infective
25. 17 years old patient with recurrence of scrotal pain causes :
a. testicular torsion……..it's an emergency
b. sexual congestion ……..most common cause
c. varicocele
d. thrombophlebitis in spermatic vein
e. epididymitis
f. urethral stone
26. AIDS is transmitted by blood borne routes but not by alcohol
27. Most common cause of E.D. is Diabetes Mellitus
28. 65 years diabetic male, E.D. for 3 years , ICI failed , the cause is
• Vascular
• Organic
• Psychogenic
• None of the above
29. Male married for 6 years with 2ry infertility (pregnancy 13 months) , normal testis , but left
smaller , softer, sperms 14 million , motility 35% & morphology 75 % normal
Answer: oligo atheno spermia , oligo atheno terato spermia
30. 43 years old male , 1ry infertility , bilateral absence of vas deferens , decreased semen ,
acidic , liquid , azospermia  Treatment is ICSI
31. Obstructive azospermia caused by the following except:
• Vasectomy
• Epididimitis
• Obstructive duct
• Bilateral absence of Vas
• Perineal hpospadius
32. 24 years old male , with discharge that follows urination , defecation
The cause is prostatorrhea
33. Risk of AIDS is increased by the following except:
• Alcohol addiction
• Homosexuals
• Breast feeding
• Heterosexuals
34. Scrotal pain is caused by the following except:
• Epidydimitis
• Ureteric stone
• Varicocele
• Cystitis

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35. 2ry Stage of syphilis includes the following except:

Generalized Vesicular Rash
36. 25 years female with cauliflower masses similar on husband penis
This is condyloma accuminata
37. Pubic and axillary hair is not a sign of puberty
38. Diabetes Mellitus cause impotence through retrograde ejaculation
39. Aspermia is anejaculation but orgasm is present
MCQ Questions
1. The following occur in the excitation stage 10. A case of 2ry infertility with history of ut
of female except: infection bilateral scrotal swellings &fever
a. vaginal transudation the condition ended by bilateral azo
b. congestion of clitoris spermia Azospermia is due to:
c. Erection of nipple a. diabetes
d. Rhythmic contraction of pelvic floor b. Bilateral epidydmitis
2. complication of gonorrhea in female c. varicocele
includes the following except: d. None of the above
a. arthritis 11. The diagnosis of the case above is by:
b. Prostitis a. prostatic smear for pus cells
c. Scenitis b. fracture in semen
d. None of the above c. Testicular biopsy
3. Lymphoi granuloma venerium is caused d. None of the above
by: 12. Treatment of the case is
a. gram-ve cocci a. Surgical
b. Gram+cocci b. medical
c. gram-ve bacilli c. Sedative
d. Gram+ve bacilli d. None of the above
e. none of the above 13. Semen analysis after half an hour and
4. Non specific tests are characterized by patient has abnormal forms 20 % he is
except: complaining of
a. good screening tests a. Teratospermia
b. Diagnostic of 2ry syphilis b. Oligospermia
c. Antigen used is treponema extract c. Athenospermia
d. diagnostic of late syphilis d. A+B
5. Trichonomas vaginalis is: e. A+C
a. gram-ve cocci 14. Tender lymphnode involvement occurs in
b. Gram+ve bacilli the following except:
c. Flagellated protozoa a. lymphogranuloma venerium
d. virus b. granuloma ingiunal
6. The following cause haemospermia c. infected chancre
except: d. chancroid
a. hypertension 15. Testosterone is secreted by:
b. blood diseases a. sertoli cells
c. Varicocele b. layding cells
7. The treatment of premature ejaculation is c. spermatognia
by: d. all of the above
a. sedative 16. Specific tests for syphilis are
b. Surgical characterized by except:
c. Behavioral a. +ve in early
d. None of the above b. used in diagnosis
8. Bilateral undecided testes can cause: c. become s-ve after complete care
a. azospermia d. diagnostic for 2nd stage of syphilis
b. oligospermia 17. Specific tests for syphilis are except:
c. athenospermia a. +ve in 100% in late
d. none of the above b. +ve in 50% in early syplis
9. The diagnostic method of chancroid: c. the used antigen is treponema palledum
a. serological extract
b. biopsy d. diagnostic and prognostic
c. none of the above

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18. The following cause Heamospermia d. teratospermia

except: 28. The syphilitic lesions are infective except:
a. seminal vesiculitis a. chancre
b. coagulation defects b. chondyloma lata
c. calculus of seminal vesicles c. mucus patches
d. hydrocele d. ulcerative gumma
19. Varicocele causes increase : 29. The viral disease are sexually transmitted
a. in n of abnormal sperms except:
b. in the n of pus cells in semen a. h simplex
c. in the no and/or motility b. HPV
d. all the above c. aids
20. Bilateral epidydmitis or oorchitis due to d. condyloma lata
mumps may be followed by the following 30. In adults gonorrhea affect the following
except: except:
a. functional azospermia a. urethra
b. obstructive azospermia b. cervix
c. a &b c. vagina
d. none d. Bartholin glands
21. The following are causes of obstructive 31. These are recurrent ulcers of genetalia
azospermia except: except:
a. bilat congintal absence of vasdeferuns a. h simplex
b. cryptorchdism b. drug eruption
c. bilateral hemoplashy c. Chancre
22. In the adult male the most commen d. scabies
painless swelling is: e. Pyogenic ulcers
a. 1ry varicocele 32. Testosterone secretions are under the
b. seminoma control of:
c. Epidydmitis a. FSH
23. Incubation period in syphilis is: b. LH
a. 9 weeks c. Estrogen
b. 90 days d. ACTH
c. 90 weeks 33. Granuloma inguinale is caused by:
d. 3 weeks a. gram –ve bacillus
24. In case of male infertility the following b. gram+ bacilli
investigations are done except: c. gram-ve cocci
a. testicular biopsy d. Gram +ve cocci
b. Chromosomal pattern e. None of the above
c. Prostate biopsy 34. 2ry stage of syphilis is presented by the
d. Hormonal assay following except:
25. Impotence in diabetes may be due to the a. generalized lymphadenopathy
following except b. Hepatomegaly
a. vascular affection c. Polymorphic skin rash
b. Peripheral neuropathy d. Condyloma lata
c. Hormonal disturbances e. Mucus patches
d. treatment with insulin 35. Gonococci infection of human male is
26. The cause of functional azospermia are complicated by the following except:
except: a. Arthritis
a. congenital bilateral absence of vas b. bactreamia
deference c. Epidydmitis
b. Klinfelter d. Skenitis
c. Undescended testes e. azospermia
d. Radiation 36. Impotence may be precipitated by the
27. In semen analysis of infertility following except:
Count 22000/mm3 a. DM
Motility after 1 hour 70% b. Estrogen therapy
Abnormal forms 20% c. Androgen therapy
40 pus cells in HPF , the patient has: d. Lerichs syndrome
a. oligospermia 37. The most imp test for diagnosis of
b. athenospermia syphilitic chancre is
c. pyospermia a. hanging drop test

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b. Wassermann reaction c. Azospermia with low semen volume

c. biopsy and histological examination d. oligospermia
d. none of the above e. Azospermia with high semen volume
38. Haemospermia may be caused by the 46. Among the following the least effective
following except: group of drugs for treatment of rapid
a. blood coagulation ejaculation is
b. hypertension a. androgens
c. prostatic calculi b. Sympatholitics
d. hydrocele c. Sedatives
e. Seminal vesculitis d. Antidepressant
39. Lines of treatment of rapid ejaculation 47. In 2ry syphilis one would except:
causing either infertility or sexual a. most but not all pt to have +ve VDRL
problems include the following except: b. All pt to have +ve VDRL
a. artificial insemination c. No pt to have +ve VDRL
b. Surgical correction d. None of the above
c. Medical treatment 48. Which of the following best describe the
d. Behavioral therapy characteristic features of genital herpes?
40. Non specific tests of the syphilis are a. a single painless ulcer
characterized by the following except: b. Multiple shallow painless ulcers
a. good screening tests c. Multiple vesicles grouped on
b. Give 100% +ve results in the 2ry stage of erthyematous base
syphilis d. Multiple indurated papules
c. The antigen used is treponema extract e. none of the above
41. Bilateral undescende testis is 49. Dark field examination should be
characterized by: performed on :
a. normal semen gram a. suspected gumatous ulcer
b. Oligospermia b. any genital ulcer more than one week
c. Necro spermia duration
d. Athenospermia c. only on oropharyngeal lesions
e. None of the above d. only on patients who have positive VDRL
42. Trichomonus vaginalis organism is 50. The male hormone is mainly secreted by :
a. large virus a. leydig cells
b. superficial fungus b. sertoli cells
c. Spirochete c. peritubular cells
d. Protozoan d. spermatogenic cells
e. None of the above e. none of the above
43. A male patient presented to an infertility 51. A 65 years old diabetic patient of complete
clinic complaining of absence of erectile failure for the last 3 years which
ejaculation sexual history show that, he was not responding to medical treatment
experiences orgasm the most suitable Doppler examination and papaverine test
clinical term is: confirmed the presence of severe arterial
a. anorgasmia a. Insufficiency the most appropriate
b. retrograde ejaculation treatment for him is :
c. aspermia b. surgical revascularization
d. azospermia c. penile prosthesis implantation
44. A male patient presented to an infertility d. retry vasodilators
clinic complaining of 1ry infertility on e. retry aphrodiasics
examination both vas differences were not f. give combination of aphrodiasics and
palpable his semen analysis is most likely vasodilators
to be: 52. Agents commonly associated with
a. azospermia with normal semen volume vaginitis affecting adult females include
b. asperminas the following except :
c. Azospermia with low semen volume a. neisseria gonorrhea
d. oligospermia b. trichomonas vaginitis
e. Azospermia with high semen volume c. candida albicans
45. The semen analysis of an infertile patient d. hemophilus vaginitis
who has bilateral undescended testes is e. none of the above
most likely to be: 53. A pregnant 25 years old female with
a. azospermia with normal semen volume history of recent abortion presented to
b. asperminas agynelogical clinic during routine

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investigation RPR test was positive in a. arthritis

such case we should b. skenitis
a. give antisphilitic treatment immediately c. perihepatitis
b. repeat RPR test before considering d. tysonitis
anything e. meningitis
c. ask for TPHA and VDRL 62. Chancrold is characterized by the
d. ignore the finding following except :
e. none of the above a. painless genital ulcers
54. A 42 years old male complained of a b. incubation period 1-5 days
painless scrotal swelling for the last 1 year c. causative organism Hemophilus ducreyi
the following procedures might be helpful d. enlargement of inguinal lymph nodes
for the diagnosis of the case except : 63. Semen analysis of an infertile male
a. transillumination showed a count of about 10.000
b. surgical exploration spermatozoa per mm the motility was 90%
c. ultrasonography after the first half an hour while abnormal
d. darkfield mleroscopy forms were 20% pus cells were over
55. Primary syphilitic ulcers are characterized 100/HPF this patient is regarded
by the following except : complaining from
a. small and grouped a. athenospermia
b. indurated base b. pyospermia
c. sloping edges c. oligospermia
d. accompanied with inguinal nodes d. a and b
e. painless e. b and c
56. Pituitary hormones which are mainly CASE:
involved in the regulation of A single male patient presented to our clinic
spermatogenesis include the following complaining of urethral discharge 2 days after
except : heterosexual intercourse on examination
a. LH profuse mucopurulant discharge was present
b. TSH inguinal lymph nodes were free
c. FSH 64. The most probable diagnosis :
d. PRL a. syphilis
57. Viral disease which may be sexually b. non specific urethritis
transmitted include the following except : c. gonorheac.
a. herpes progenitalis d. chancroid
b. molluseum contagiosum 65. The most helpful test in diagnosis
c. condyloma lata a. Testicular biopsy
d. hepatitis b. frie's intrademarl test
58. The following tests are used in the c. smear and culture
diagnosis of azoospermic cases except : d. wasseran reaction
a. testicular biopsy 66. The following syphilitic lesions are
b. hormonal assay infective except
c. tests for immobilizing antisperm a. chancre
antibiotics b. ulcerated gumma
d. diabetes mellitus c. mucous patches
59. The following are possible causes of d. condyloma lata
aspermia except : 67. Spermatogenesis is under the control of :
a. bilateral mumps orchitis a. testerone
b. retrograde ejaculation b. LH
c. antihypertesive drugs c. FSH
d. diabetes mellitus d. All of the above
60. A patient coming to our clinic complaining 68. Bilateral undescended testis is associated
of ascrotal swelling dating since 3 years with :
the following procedures are helpful in a. necrospermia
diagnosing the case except : b. oligospermia
a. transillumination c. athenospermia
b. ultrasound d. All of the above
c. surgical exploration e. none of the above
d. ground microscopy 69. Nonspecific tests for syphilis is
61. Complications of gonorrhea in females characterized by the following except
includes the following except : a. good screening tests

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b. used to diagnose latent syphilis 78. Heamospermia may be caused by the

c. give negative results after successful following except
treatment a. blood coagulation defect
d. the antigen used is a treponemal extract b. hypertension
70. Relapse of gonoccoreal urthritis is caused c. prostatic calculi
by the following except d. seminal vesiculitis
a. reinfection e. hydrocele
b. inadequate treatment 79. The most diagnostic test for syphilitic
c. the sexual partner is not treated chancre is :
d. associated syphilitic infection a. hanging drop test
71. The drug of choice in treatment of b. wasserman reaction
gonorrhea is : c. biopsy and histological examination
a. procaine penicillin d. none of the above
b. benzathine penicillin 80. Impotence may be precipitated by the
c. tetracyclin following:
d. All of the above a. Diabetes mellitus
72. The excitation stage of the female sex b. Estrogen therapy
response cycle includes the following c. Leriche’s syndrome
except : d. Androgen therapy
a. vaginal transudation e. Transverse section of the cord
b. nipple erection 81. Gonococcal infection of human males can
c. clitoral congestion be complicated by the following:
d. increase in heart rate a. Arthritis
e. rythmic contraction of the perineal b. Azospermia
muscles c. Epididymitis
73. The following are possible causes of d. Bacteraemia
aspermia except : e. Skenitis
a. antihypertensive drugs 82. Secondary state of syphilis may present
b. retrograde ejaculation by the following except:
c. bilateral mumps orchitis a. Generalized lymphadenopathy
d. anorgasmia b. Mucous patches
74. Trichomonas vaginalis organism is : c. Polymorphic skin rash
a. large virus d. Condyloma accuminata
b. spirochete e. Hepatomegaly
c. superficial fungus 83. Lymphogranuloma venereum is caused
d. flagellated by:
e. none of the above a. Gram negative bacilli
75. Bilateral undescended testis is associated b. Gram positive cocci
with : c. Gram negative cocci
a. normal semenogram d. Gram positive bacilli
b. oligospermia e. None of the above
c. athenospermia Case:
d. necrospermia A male patient complaining of secondary
e. none of the above infertility presented to an andrology clinic. He
76. Non specific tests for syphilis are gave a past history of urinary tract infection
characterized by the following except : followed by bilateral scrotal swelling
a. good screening tests associated with pain and fever. Examination
b. important for the follow up of the cases revealed no abnormality except a firm nodule
c. the antigen used is atreponemal extract at the tail of epididymis on both sides and a
d. give 100% positive results in the mild left hydrocele. Semen analysis
secondary stage Azospermia.
77. Lines of treatment of rapid ejaculation 84. The most probable cause of infertility is
causing either infertility or sexual this case is:
problems include the following except a. Obstruction due to congenital cause
a. artificial insemination b. Functional due to genetic factor
b. surgical correction c. Obstruction of the epididymal duct by
c. medical treatment by sedatives post-inflammatory fibrous tissue
d. behavioral therapy utilizing special d. Pressure by the hydrocele fluid
exercises 85. The most important diagnostic measure in
this case is:

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a. Fructose in semen 91. A pregnant 25-years-old female presented

b. Buccal smear for Barr body to the famous gynecologist Dr. HH
c. Testicular biopsy complaining of multiple large sized
d. Prostatic smear for pus cells masses on the vulva. The patient stated
86. Management of this case will be: that her husband had similar lesions on
a. Surgical the penis but smaller in size. Examination
b. Medical of the patient revealed multiple
c. Artificial insemination husband cauliflower-like warty lesions that are large
d. No treatment is available in size located on the fourchette and labia
87. A patient 29 years old came to the minora. Dr. HH diagnosed the case as
andrology clinic complaining of weak venereal warts. The post appropriate
erection for more than 3 months. the best therapy in this case is:
drug to use during intracorporeal injection a. Chemical cautary with podophylline
(ICI) is b. To induce abortion so as to avoid neonatal
a. papaverine infection
b. ephedrine c. cryocautary of genital warts
c. testosterone d. Erythromycin 500mg 4 times/day for 10
d. prostaglandin E1 days
e. phentolamine e. Topical antibiotics
88. A 43 years old male present to an infertility 92. All the following can cause obstructive
clinic complaining of secondary infertility azoospermia EXCEPT:
with past history of urinary tract troubles, a. Bilateral absent vas deferens
few years ago. The patient performed 2 b. Epididymitis
kidney stone operations 3 years ago. c. Perineal hypospadius
Examination showed glandular d. Ejaculatory duct obstruction
hypospadius ,normal testicles,bilateral e. Vasectomy
epididymal nodules. Semen analysis 93. The following are considered high risk for
revealed azospermia with occasional transmitting HIV infection EXCEPT:
pyospermia. The expected cause of the a. sexual intercourse
problem is b. Mosquito bites
a. congenital defects
b. hormonal changes
c. Breast feeding
c. testicular failure secondary to aging d. Blood transfusion
d. acquired obstruction 94. You are performing a discharge
e. the cause cannot be explained examination on a 1-day old healthy
89. An 18 years old single male came to your newborn. He was born by a normal
clinic complaining of left scrotal swelling spontaneous vaginal delivery at 39 weeks
which was diagnosed by another doctor gestation .During the routine physical
as varicocele. The patient was concerned examination you identify the right testicle ,
about his future fertility. On examination but are unable to palpate the left testicle
the patient has normal secondary sexual .palpation of the left inguinal canal does
characters ,bilateral normal size testes not reveal a mass . The rest of the
,normal vasadeferentia and left varicocele examination is normal. the most
grade 3 , you should inform the patient appropriate management at his time is to:
that infertility due to varicocele may be a. Do a CT scan of the pelvis to search for
expected in an undescended testis
a. all patients b. Follow up as an outpatient and if no testis
b. some patients are present at one year of age , then
c. very few patients refer for possible orchiopexy
d. no patients c. Follow up as an outpatient and if no testis
90. Which statement of the following is present at ten years of age , refer for
concerning secondary stage of syphilis is possible orchiopexy
INCORRECT: d. Reassure the parents that this is common
a. There is generalized lymphadenopathy and no treatment or follow up is
b. There is non- itchy maculo-papular rash necessary
c. The mucus membrane lesion is non- e. Refer for orchipexy prior to discharge
infectious 95. A male patient presented to andrology
d. Dark field examination reveals treponama clinic complaining of primary infertility .On
pallidum examination both vasa deferentia were not
e. TPHA test is positive

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palpable. His semen analysis is most likely but he is unable to sustain it. The
to be: remainder of his medical .sexual and
a. Teratozoospermia psychological history is unremarkable. He
b. Aspermia takes isosorbide mononitrate for chest
c. Azoospermia with low semen volume pain. His blood pressure is 130/90 mm Hg
d. Oligozoospermia .Physical examination is unremarkable.
e. Asthenozoospermia Prolactin and testosterone levels are
96. The father of a 14-year –old male visited within normal limits .He asks for its "Little
Dr.MR the father was worried about his blue pill" that is so often heard about .At
son having no facial hair. After a short this time you should:
examination Dr.MR assured the father that a. Advise him to discontinue the isosorbide
everything will be fine. The most important mononitrate
sign noticed by Dr.MR was: b. Explain that he cannot take sildenafil
a. Scanty hair started to grow over the lip because of his current medication
b. The testicular size was enlarged c. Prescribe sildenafil tablets for him to take
c. The height of the patient was appropriate an hour before sexual activity
for age d. Recommend implantation of an inflatable
d. The axillary hair was present prosthesis
e. The voice was low pitched e. Tell him that his erectile dysfunction is
97. The newly married Mr.TZ asked his friend psychogenic
Dr.MR about a reliable method for 99. Psychogenic erectile dysfunction may be
contraception that he can use by himself characterized by all the following EXCEPT:
for contraception .Mr.TZ added that his a. Sudden onset
wife refused to use contraceptive b. Loss of morning erection
pills.Dr.MR should offer:
a. Vasectomy
c. Normal nocturnal penile tumescence
b. Condom d. Good response to PGE1 injection
c. Safe period e. Stationary course
d. Testosterone IM 100. A male patient complaining of
e. Coitus interrupts azospermia and clinical examination
98. 58 years old man comes to the office shows nothing you must do
because of difficulty with erections for the a. prostate biopsy
past few years. He says that he has a great b. surgical correction
relationship with his wife and is still very c. testicular biopsy
sexually aroused by her .He is d. none of the above
occasionally able to initiate an erection,
Exam 2012
1- HIV attacks the following:
a- All lymphocytes
b- Only B lymphocytes
c- Only T-helper lymphocytes
d- Only T suppressor lymphocytes
e- All body cells
2- A 29 year old male presented with pain. On examination the penis was ecchymotic,
swollen and deformed (Eggplant deformity)
a- Testicular torsion
b- Penile fracture
c- Epididimitis
d- Priapism
e- None of the above

3- What causes the lesion shown?

a- Syphilis
b- Herpes simplex
c- Human papilloma virus
d- HIV
e- Neisseria Gonorrhea

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4- Best way to describe this lesion?

a- multiple, painful with indurated base
b- single, painless with soft base
c- Single, painless with induarted base
d- Multiple, painless with indurated base
e- Single, painful, indurated base

5- The Father of a 14 year old male visited

the doctor worried about his son not having facial hair. After examination the doctor
assured him that everything will be fine.
The most important sign noticed by the doctor was:
a- Scanty hair started to grow over the lips
b- The testicular size was enlarged
c- The height of the patient was appropriate for age
d- The axillary hair was present
e- The voice was low pitched
6- The following are therapeutic options for e- Poor responses to PGE1 injection
azospermic males except: 12- A single 24 year old male complaining of
a- Epididymovasostomy occasional urethral discharge that may
b- Vasovasostomy follow defecation and sometimes on
c- IUI straining. The patient denies any sexual
d- TESE-ICSI relation. Negative cultures for gram –ve
e- Gonadotropin therapy neisseria gonorrhea
7- The orgasmic phase of the female The most probable cause is:
includes the following except: a- Prosemen due to sexual excitation
a- Followed by a refractory phase b- Physiological protatorrhea due to sexual
b- Can be multiple congestion
c- Consists of multiple contractions of the c- Chlamydia urethritis
pelvic floor d- Herpes progenitalis
d- Is shortest part of the sexual cycle e- Premature ejaculation
e- None of the above 13- All the following can be used in treatment
8- The treatment of ischaemic prapism is of premature ejaculation except:
best when done a- Behavioral therapy like squeeze
a- 12-24 hrs technique
b- 24-48 b- Sex therapy
c- 1 hour c- Antideppressants
d- < 6 hrs d- SSRIs
e- 3 days e- Sympathomimetics
9- The Incubation period of gonorrhea is 14- Diabetes can cause ED by all the
a- 9-90 days following mechanisms except:
b- 2-5 days a- Atherosclerosis
c- 2-3 weeks b- Insulin therapy
10- A patient presented to the STDs clinic c- Psychogenic
with urethral discharge 2 days after d- Microangiopathy
sexual intercourse. On examination, e- Peripheral neuropathy
profuse mucupurelent discharge was 15- Varicocele can cause Infertility by:
present while inguinal lymph nodes were a- Disturbed thermoregulation
free , Most likely diagnosis: b- Reflux of renal metabolites
a- Syphilis c- Epididymal dysfunction
b- Chancroid d- All of the above
c- Non gonorrheal urethristis e- None of the above
d- Gonorrheal urethrists 16- All of the following statements regarding
e- prostatorrhea neisseria gonorrhea are true except:
11- Arteriogenic erectile dysfunction is a- Ceftraixone is the drug of choice
characterized by except b- Gram –ve diplococci
a- Gradual onset c- Incubation period between 2-5 days
b- Progressive course d- Thayer martin is the selective media for
c- Loss of morning erection culture
d- Normal nocturnal penile tumescence e- VDRL is diagnostic

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17- The following conditions can be helped c- 1 year

by ICSI except: d- 2 years
a- Resistant oligozoospermia 19- Testicular torsion is characterized by all
b- Resistant asthenozospermia except:
c- Resistant teratozoospermia a- Negative urine analysis
d- Azoospermia b- Acute onset
e- Anorchia c- Normal temperature
18- Undescended Testis is best treated by: d- More common in neonatal and pre
a- 3 years pubertal age
b- Before puberty e- Pain is relieved by lifting the testicles up
ANSWERS
1.D 17.D 33.A 49.B 65.C 81.E 97.B 12.B

2.B 18.D 34.D 50.A 66.B 82.D 98.B 13.E

3.E 19.A 35.D 51.C 67.D 83.A 99.B 14.B
4.C 20.C 36.C 52.A 68.E 84.C 100.C 15.D
5.C 21.B 37.D 53.C 69.D 85.C Exam 16.E
2012
6.C 22.A 38.D 54.D 70.D 86.A 1.C 17.E
7.C 23.B 39.B 55.A 71.A 87.D 2.B 18.C
8.A 24.C 40.C 56.B 72.E 88.E 3.C 19.E
9.C 25.D 41.E 57.C 73.C 89.E 4.C
10.B 26.A 42.D 58.C 74.D 90.C 5.B
11.C 27.C 43.B 59.A 75.E 91.C 6.C
12.A 28.D 44.C 60.D 76.C 92.C 7.A
13.C 29.D 45.A 61.D 77.B 93.B 8.C
14.B 30.C 46.A 62.A 78.E 94.B 9.B
15.B 31.C 47.B 63.E 79.D 95.C 10.D
16.C 32.B 48.A 64.C 80.D 96.B 11.D
Put T OR F
1.testis is responsple for 70% of erection F
2.drug of choice for gonorrhea is penicillin T
3.drug of choice for monilian is flagyl F
4.diabetes cause impotence T
5.gumma of syphilis is highly infective F
6.the commenst manifestation of gonorrhea in adult female is vaginitis F
7.erection in male is mainly sympathetic F
8.varicicele is usually in the left side T
9.herpes progenetalis may predispose to cancer T
10.gynecomastia is a manifestation of xxy syndrome T
11.flagyl is used in trichomonus T
12.testes are responspile for 70%of ejaculation F
13.aids is uncommen in homosexual mens F
14.frits test is used for gonorrhea F
15.theyer – martin medium is used for trichomonus F
16.diabetes causes azospermia F
17.chancer is strictly genetal F
18.granuloma inguinalis is cused by antigen called Donovan bodies F
19.an infertile male is always impotant F
20.concomitant infection of syphilis and gonorea occurs T
21.corpora sponguisum are responspile for erectionwhile corpora cavernosum is responsible for F
ejaculation
22.hyper prolactenimia in males may cause impotence T
23.syphlis cause abortion in the first3 months of pregnancy F
24.bartholin glands lubricate the vagina during the exitment T
25.herpes progenitalis predispose to cancer cervix in adult females T

69 MedadTeam More Than You Dream

ANDROLOGY NMT13

26.seminal vesicles contribute for more than 70% of ejaculatory volume T

27.Trichomonus is treated by flagyl T
28.Aids is uncommon in homosexual F
29.lymphogranuloma venereal is caused by a virus F
30.Concomitant infection by gonorrhea and syphilis can occur at the same time T
31.Oligosparmia mean a sperm count below 20000/mm3 T
32.the vagina is the main site of affection by gonorrhea in adult female F
33.Herpes progenetalis may cause cancer cervix T
34.The female show refractory period after orgasm F
35.Erection is the main function of corpora cavernous T
36.The infertile males are always impotence F
37.DM may cause aspermin T
38.in all cases varicocele associated with infertility F
39.Chancier IS STRICTLY ON GENITAL AREA F
40.crystalline penicillin 12 million unit is the proper treatment for syphilis F
41.chlamydia TRIC agent is the causative organism of condyloma accuminata F
42.prostatorea is a physiological phenomenon T
43.husband artificial insemination is the best line of treatment in cases of functional azoospermia. F
44.all males having varicocele are infertile F
45.hyperprolactinemia in males may cause impotence T
46.squeeze technique of master and Johnson is a helpful aid in treatment of psychogenic F
impotence
47.congenital syphilis may cause abortion in the first 4 months of pregnancy T
48.AIDS acquired immunodeficiency syndrome is common in homosexuals T
49.chancre usually bleeds easily F
50.prostate contributes to more than 70 % of the volume of ejaculate F
51.the vagina is the main site of affection by gonococci in adult female F
52.kleinfelter is a cause of obstructive azoospermia F
53.bilateral absent vas may present by athenospermia F
54.scabies is a common cause of genital ulceration in EGYPT T
55.testis contribute to 70% of the volume of ejaculate. F
56.the drug of choice in gonorrhea is benzathin penicillin. F
57.gumma of syphilis is highly infectious. F
58.streptomycin is the drug of choice in clamydial urethrotism. F
59.granuloma inguinale is caused by a protozoan called Donovan bodies. F
60.AIDS ( acquired immunodeficiency disease ) is most common in homosexuals. T
61.herpes progenitals may predispose to cancer cervix in women. T
62.the vagina is the main site of affection by gonococci in adult women. F
63.monolliasis is treated by Metronidazole (flagyl). F
64.bilateral absent vas may present by athenozoospermia. F
65.Varicocele may cause athenospermia without affecting the sperm count T
66.Hyperprolactinemia may cause impotence T
67.Chancre may occur on extragenital area T
68.Erection is a hemodynamic phenomenon controlled mainly by somatic nerves F
69.Chancre may be painful T
70.The excitation phase of the human sex response cycle is of fixed duration for both sexes F
71.Chronic prostatitis is uncommon complication of gonococal urethritis T
72.Non gonococcal urethritis is treated by tetracyclins T

70 MedadTeam More Than You Dream