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Frequent ejaculations result in reduced sperm numbers and increased numbers of immotile sperm in the ejaculate generic 50mg penegra mens health institute. The cauda connects to the vas deferens discount 50 mg penegra with amex mens health 7, which forms a dilated tube order discount penegra on-line androgen hormone vitamins, the ampulla, prior to entering the prostate. Vasectomy-the cutting and ligation of the vas deferens-is an effective method of male contraception. Because the sperm are stored in the ampulla, men remain fertile for 4 to 5 weeks after vasectomy. Erection is associated with sexual arousal emanating from sexually related psychic and/or physical stimuli. During sexual arousal, impulses from the genitalia, together with nerve signals originating in the limbic system, elicit motor impulses in the spinal cord. The parasympathetic nerves in the sacral region of the spinal cord carry these neuronal impulses via the cavernous nerve branches of the prostatic plexus that enter the penis. Those signals cause smooth muscle vasodilation of the arterioles and corpora cavernosa. The relaxation of the smooth muscles in those structures dilates blood vessels, which then begin to engorge with blood. The swelling of the blood-filled arterioles and corpora cavernosa compresses the thin-walled veins, restricting blood flow. The result is a reduction in the outflow of blood from the penis, and blood is trapped in the surrounding erectile tissue, leading to engorgement, rigidity, and elongation of the penis in an erect position. The word “impotence” may also be used to describe other problems that interfere with sexual intercourse and reproduction, such as lack of sexual desire and problems with ejaculation or orgasm. Using the term erectile dysfunction makes it clear that those other problems are not involved. Semen, consisting of sperm and associated fluids, is expelled by a neuromuscular reflex that is divided into two sequential phases: (1) emission and (2) ejaculation. Seminal emission moves the sperm and associated fluids from the cauda epididymis and vas deferens into the urethra. The latter process involves efferent stimuli originating in the lumbar areas (L1 and L2) of the spinal cord and is mediated by adrenergic sympathetic (hypogastric) nerves that induce contraction of smooth muscles of the epididymis and vas deferens. Sympathetic discharge also closes the internal urethral sphincter, which prevents retrograde ejaculation into the urinary bladder. Ejaculation is the expulsion of the semen from the penile urethra; it is initiated after emission. The filling of the urethra with sperm initiates sensory signals via the pudendal nerves that travel to the sacrospinal region of the cord. A spinal reflex mechanism that induces rhythmic contractions of the striated bulbospongiosus muscles surrounding the urethra results in propelling the semen out of the tip of the penis. The accessory glands that contribute to the secretions are the seminal vesicles, prostate gland, and bulbourethral glands. The semen contains only 10% sperm by volume, with the remainder consisting of the combined secretions of the accessory glands. The normal volume of semen is 3 mL, with 20 to 50 million sperm per milliliter; normal is considered more than 20 million sperm per milliliter. Their secretion contains fructose (the principal substrate for glycolysis of ejaculated sperm), ascorbic acid, and prostaglandins. In fact, prostaglandin concentrations are high and were first discovered in semen but were mistakenly considered to be the product of the prostate. Seminal vesicle secretions are also responsible for coagulation of the semen seconds after ejaculation. In humans, it occurs in the male testes and epididymis in a stepwise fashion in ~64 days. It is a continual process involving mitosis of the male germ cells, which undergo extensive morphologic changes in cell shape and, ultimately, meiosis to produce the haploid spermatozoa. Although sperm production continues throughout life, beginning at puberty, it declines with age. Spermatogenesis is the process of transformation of male germ cells into spermatozoa. The phases include cellular proliferation by mitosis, two reduction divisions by meiosis to produce haploid spermatids, and cell differentiation by a process called spermiogenesis, in which the spermatids differentiate into spermatozoa (Fig. Spermatogenesis is initiated shortly before puberty, under the influence of the rising levels of gonadotropins and testosterone, and continues throughout life, with a slight decline during old age. The time required to produce mature spermatozoa from the earliest stage of spermatogonia is 65 to 70 days. Several developmental stages of spermatogenic cells occur during this time frame, and the stages are collectively known as the spermatogenic cycle. There is synchronized development of spermatozoa within the seminiferous tubules, and each stage is morphologically distinct. A spermatogonium becomes a mature spermatozoon after going through several rounds of mitotic divisions, a couple of meiotic divisions, and a few weeks of differentiation. Hormones can alter the number of spermatozoa, but they generally do not affect the cycle duration. Spermatogenesis occurs along the length of each seminiferous tubule in successive cycles. New cycles are initiated at regular time intervals (every 2 to 3 weeks) before the previous ones are completed. As a result, cells at different stages of development are spaced along each tubule in a “spermatogenic wave. Approximately 200 million spermatozoa are produced daily in the adult human testes, which is about the same number of sperm present in a normal ejaculate. Because sperm cells are rapidly dividing and undergoing meiosis, they are sensitive to external agents that alter cell division. Chemical carcinogens, chemotherapeutic agents, certain drugs, environmental toxins, irradiation, and extreme temperatures are factors that can reduce the number of replicating germ cells or cause chromosomal abnormalities in individual cells. While the immune system normally detects and destroys defective somatic cells, the blood–testis barrier isolates advanced germ cells from immune surveillance. If physical injury or infection ruptures the blood–testis barrier and sperm cells within the barrier are exposed to circulating immune cells, antibodies can develop to the sperm cells. In the past, it was thought that the development of antisperm antibodies could lead to male infertility. It appears that men with high levels of antisperm antibodies may exhibit some infertility problems. However, men who have developed low or moderate levels of antisperm antibodies after vasectomy and who have had their vas deferens reconnected have normal fertility if the vasectomy was for a relatively short time, according to studies. Nevertheless, in some cases, a high level of antisperm antibodies in men and women leads to infertility. Spermatogonia divide mitotically to produce primary spermatocytes, which, in turn, undergo meiosis to become spermatids. Spermatogonia undergo several rounds of mitotic division prior to entering the meiotic phase (see Fig. The spermatogonia remain in contact with the Sertoli cells, migrate away from the basal compartment near the walls of the seminiferous tubules, and cross into the adluminal compartment of the tubule (see Fig.
One simple postoperative intervention that has a positive effect on all these factors and reduces recovery time is early ambulation penegra 50 mg free shipping man health lifestyles. Additionally purchase 100mg penegra with visa androgen hormone imbalance, early (postoperative day 1 or 2) progressive strength training is safe and improves knee extension strength and maximal walking speed order penegra with a mastercard prostate formula. These immediate adaptations counter atrophic processes that would otherwise ensue and result in muscle wasting and weakness. Studies in unrelated, clinically distinct patient populations have demonstrated that moderate exercise is beneficial in counteracting the inflammatory conditions and atrophy that are associated with immobility and in improving muscle strength and physical function. Prolonged bed rest associated with critical illness typically leads to decreased muscle protein synthesis, increased urinary nitrogen excretion (indicating muscle catabolism), and decreased muscle mass, especially in the lower extremities. Early mobilization and decreased sedation were found to be synergistically beneficial in mechanically ventilated patients. Measuring maximal oxygen uptake is the most common method of quantifying dynamic exercise. Excess in oxygen consumption during the first minutes of recovery is called the oxygen debt. During exercise, blood pressure, heart rate, stroke volume, and cardiac contractility are all increased. Hearts of people adapted to prolonged, rhythmic exercise involving low arterial pressure exhibit large left ventricular volumes with normal wall thickness; in those adapted to activities involving isometric contraction and elevated arterial pressure, wall thickness is increased at normal volume. Exercise has a role in preventing and recovering from several cardiovascular diseases. In lung disease, respiratory limitations appear as shortness of breath or decreased oxygen content of arterial blood and become more apparent during exercise than at rest. Muscle fatigue is defined as an exercise-induced reduction in the maximal force capacity of the muscle and is independent of lactic acid. Endurance activity at low loads enhances muscle oxidative capacity without hypertrophy, whereas increased activity at high loads produces muscle hypertrophy. Although exercise effects on gastrointestinal function remain poorly understood, chronic physical activity plays a major role in the control of obesity and type 2 diabetes. As people age, the effects of exercise on functional capacity are more profound than its effect on longevity. In an effort to strengthen selected muscles after surgery and immobilization has led to muscle atrophy, isometric exercise is recommended. A maximal voluntary contraction involving the identical muscles in an identical form of contraction provides the most readily quantified and accurate basis for normalization of isometric exercise intensity. Choice A is incorrect because the basis for comparison involves rhythmic, dynamic exercise. The other choices also contradict the principle that exercise can only be compared with other exercise involving the same muscles and the same types of muscle contraction. Two people, one highly trained and one not, each exercising at 75% of the maximal oxygen uptake, become fatigued: A. The physiological responses to dynamic exercise are predictable when healthy individuals differing in endurance exercise capacity are compared at matched levels of relative oxygen transport demand. Exercise at 75% of the maximal oxygen uptake will lead to exhaustion in typically 1 to 2 hours, rendering choice B incorrect. The more highly trained person will show increased work output despite fatiguing at about the same time as the person with lower capacity, rendering choices C and D incorrect. Training lowers lactic acid production at any matched fractional use of the maximal oxygen uptake, making choice E incorrect. A patient completes a graded, dynamic exercise test on a treadmill while showing a modest rise (25%) in mean arterial blood pressure. In contrast, during the highest level of exercise at the end of the test, an indirect method shows that cardiac output has risen 300% from rest. These results indicate that during graded, dynamic exercise to exhaustion, systemic vascular resistance: A. Active muscle vasodilation during dynamic exercise is quantitatively much greater than the net vasoconstriction in the gut, skin, kidneys, and inactive muscle. Total systemic vascular resistance can be measured, albeit indirectly, from measurements of systemic arterial pressure and cardiac output. A patient with inflammatory bowel disease and compromised kidney function asks if exercise will alter blood flow to either the gastrointestinal tract or the kidneys. The answer is that vasoconstriction in both the renal and splanchnic vascular beds during exercise: A. This answer presumes that vasoconstriction occurs in these vascular beds and that its effect is to help balance vasodilation in active skeletal muscles and prevent exercise- induced systemic hypotension. This effect is ubiquitous across all individuals during all forms of dynamic exercise, making choices B, C, and E incorrect. Cerebral blood flow is held constant during all forms of exercise, unlike renal or splanchnic blood flow. A young, healthy, highly trained individual enters a marathon (40 km) run on a warm, humid day (32°C, 70% humidity). The best medical advice for this individual is to be concerned about the possibility for: A. Even highly trained and heat-acclimatized individuals are at risk for heat- related illness if exercise is sufficiently prolonged and if environmental conditions are sufficiently severe. In healthy persons during exercise, coronary vasodilatory capacity is adequate, renal blood flow reductions in health are entirely safe, and gastric mucosal blood flow reductions are easily tolerated. In long-term exercise in a warm environment, hypotension, not hypertension, is the possible cardiovascular risk. He is subjected to a stress test, with noninvasive monitoring of heart rate, blood pressure, arterial blood oxygen saturation, and cardiac electrical activity. What are three lines of evidence for ventilatory limitation to this subject’s exercise? Why would endurance exercise training likely increase this individual’s exercise capacity? Ventilatory limitation is evidenced by severe dyspnea as a primary symptom in exercise, falling arterial blood oxygenation, and exercise termination at relatively low heart rate. Arterial blood oxygen saturation fell during exercise because increased cardiac output (increased pulmonary blood flow) and decreased pulmonary arterial blood oxygen content (a result of increased skeletal muscle oxygen extraction) increase demands for oxygenation in the lungs with inadequate diffusing capacity. Exhaustion occurred before a maximal heart rate was reached because lung disease creates severe dyspnea even in mild exercise. The pulse pressure rose during exercise because sympathetic stimulation and enhanced venous return increase the stroke volume at constant arterial compliance. Endurance exercise training would have little effect on any aspect of lung function. However, training would cause adaptations within exercising muscle that would increase muscle oxidative capacity and reduce lactic acid production. By reducing the ventilatory demands of exercise, these changes would increase exercise capacity in this individual. Explain how hormone receptors, restricted distribution of hormones, and hormone activation processes determine target tissues for a specific hormone.
Hyperprolactinaemia is a condition caused Pituitary lesions by elevated serum prolactin levels which could be ● prolactinoma physiological quality 100mg penegra mens health 2013, pathological order penegra mastercard androgen hormone joke, or idiopathic in origin purchase penegra line mens health quotes. Other transient causes of hyperpro- ● spinal cord injury lactinaemia are vigorous exercise and physical or Systemic illness psychosocial stress. Hyperprolactinaemia is com- ● hypothyroidism monly caused by certain medications (see Box 2) ● chronic renal failure or by a pituitary tumour such as prolactinoma. The decision to treat galactor- rhoea should be based on the severity of the galactor- galactorrhoea rhoea, the level of serum prolactin, the patient’s desire Dopamine depleting agent for fertility, and other symptoms related to hypotha- ● methyldopa lamic and pituitary tumour or stalk efect. Medication- ● reserpine induced galactorrhoea should be replaced with Dopamine receptor blockers alternative drugs. Dopamine agonists are ● metoclopramide the mainstay treatment for most patients with galac- ● phenothiazines torrhoea and hyperprolactinaemia. Dopamine ago- ● selective serotonin reuptake inhibitors nists have been shown to be efective in normalising ● tricyclic antidepressants the prolactin level, shrinking the pituitary adenoma, ● butyrophenones and restoring reproductive hormones and ovulation. Inhibition of dopamine release Bromocriptine and cabergoline are the commonest ● codeine ● morphine dopamine agonists used for treatment. Cabergoline is ● heroin better tolerated owing to fewer side efects and is more Histamine receptor blockade efective than bromocriptine. Patients with isolated galac- ● verapamil torrhoea and normal prolactin levels do not require ● high-dose oral contraceptive pills treatment if they are not bothered by the galactorrhoea and are not pursuing fertility. Tose patients who have symptomatic idiopathic galactorrhoea usually respond Visual feld testing should be performed in patients if to a short course of a low-dose dopamine agonist. Hyperprolactinaemia is usu- not always display hyperprolactinaemia-related symp- ally defned as fasting serum prolactin levels of above toms such as galactorrhoea or menstrual disturbances. Serum prolactin levels are higher in important to avoid unnecessary repeated radiological the afernoon than in the morning and hence should investigation and treatment. Investigation for macro- preferably be measured in the morning, although prolactinaemia should always be done in cases with diurnal and physiological variations occur. If no identifed cause of hyperprolactinaemia is found by history, exami- References nation, or thyroid and renal function tests, a mag- 1. American High prolactin levels are commonly associated with a Academy of Family Physicians 2012; 85: 11. Macroprolactinaemia: a new Table 1 Proposed revised nomenclature for intersex conditions cause of hyperprolactinaemia. John Ho It is helpful to examine the child in the presence of the parents to demonstrate the precise abnormalities It is estimated that genital anomalies occur in 1 in of genitalia. The birth of a child with ambiguous of both sexes develop from the same fetal structures genitalia is a social emergency. The frst encounter of and either overdevelopment and underdevelopment the parents with the health professional in the delivery is possible, and that the abnormal appearance can be room may have a lasting impact on parents and their rectifed and the child will be raised either as a boy or relationship with their infant. It is also important not to encourage the par- be referred as ‘your baby’ or ‘your child’, and not ‘he’, ents to name the child or register the birth until the ‘she’, or ‘it’. It is impor- tant to emphasise that the infant with genital anomaly normal genital development has the potential to become a functional member of society. It should be Undiferentiated gonadal tissue with potential to explained to the parents that, although the best course develop into either a male or female genital structure of action may not initially be clear, the health care pro- is present in the fetus as early as 6 weeks’ gestation. The fessionals will work with the family to reach a decision presence or absence of genetic and hormonal infu- that is best suited in the particular circumstances. An abnormality along the male pathway gical techniques, understanding the psychosocial that interferes with masculinisation or, in the case of issues, and accepting the place of patient advocacy. The new nomenclature hormone suppresses the Müllerian structures (fallo- for this condition is disorders of sex development pian tubes, uterus, and upper vagina). Clinical fndings in a neonate with suspected DsD Apparent male Severe hypospadias with separation of scrotal sacs. Figure 1 A male infant with micropenis and underdeveloped Hypospadias with undescended testis. Causes of genital abnormality in a neonate Conceptually, it is simpler to think of the causes in terms of histology of the gonads, which dictates the prognosis with regard to fertility. Clinical evaluation A detailed obstetric history is vital to determine the possibility of maternal endocrine disturbances or any exposure to drugs or hormonal agents. A positive Figure 2 A female infant with clitoromegaly and fullness of the family history of unexplained neonatal death, abnor- labia. Physical examination includes examination of the phallus, the extent to which the urogenital sinus has investigations closed, and the position of urethral meatus. Hence a biochemical screen for this disorder and an attempt should be made to palpate any gonads is indicated in all infants with signs of virilisation and in these folds or the inguinal region. Affected individuals have multiple congenital anomalies: intrauterine growth restriction, dysmorphic facial features, microcephaly, low-set ears, cleft palate, genital anomaly, syndactyly, mental retardation. Features include short stature, hydrocephalus, anterior bowing of the femur and tibia, talipes, and poor masculinisation. Deciding the sex of rearing A karyotype (chromosome analysis) is also Tis is based on a number of considerations: done as an initial investigation. A fuorescent in situ hybridisation for the Y chromosome can be obtained fertility potential; within 48 hours in most places; however, a detailed capacity for normal sexual function; endocrine status; karyotype (with G banding) ofen takes up to 1 week. Straightforward cases are usually managed biochemical tests will be required to identify any tes- by the paediatric endocrinologists. Complicated cases tosterone biosynthetic defect, 5α reductase activity, should be referred to a highly specialised tertiary centre or androgen sensitivity. Tese investigations are best where multidisciplinary input is required from the clin- undertaken in a tertiary centre which has expertise in ical geneticist, paediatric endocrinologist, paediatric dealing with this condition. Prenatal management of disorders pregnancies) but this depends on the local prevalence of sex development. J Pediatr Urol 2012; of both type 1 and type 2 diabetes in women of child- 8(6): 576–84. Consensus state- of type 1 diabetes in women aged 15–40 years in ment on management of intersex disorders. Long-term in type 2 diabetes in Far Eastern, Middle Eastern, outcome of prenatal dexamethasone treat- Hispanic American, African, South Asian, and ment of 21-hydroxylase defciency. Pregnancy in a diabetic mother carries Useful website (for parents and a greater risk to both mother and the ofspring than professionals) pregnancy in the general obstetric population. Terefore, maternal insulin dosage Bashier Dawlatly and Rina Davison requirements increase as pregnancy progresses – up to 2–3 times the pre-pregnancy doses. Maternal renal Most women will demonstrate glycosuria at some disease and proliferative retinopathy may accelerate time during their pregnancy owing to a fall in the during and afer pregnancy, thereby making regular renal tubular threshold for glucose. Any suspicion of diabetes must be confrmed by blood Effect of pre-existing diabetes on pregnancy outcome glucose measurement. About 2–5 percent of pregnant Recent data confrm that women with poorly women will have one form of diabetes. Perinatal, stillbirth and pregnancy: neonatal mortality rates are all 5–10-fold higher pre-existing type 1 diabetes; than in non-diabetic pregnancies. Congenital pre-existing type 2 diabetes; abnormalities are up to three times higher than the gestational diabetes, which is hyperglycaemia frst rec- background rate, particularly neural tube defects ognised in pregnancy.
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