penile raphe and posteriorly along the median line of

the perineum with the perineal raphe.

Internally, deep to the scrotal raphe, the

scrotum is divided into two compartments, one for each
testis, by a prolongation of the dartos fascia, the septum of
the scrotum.

1. What are the layers of the scrotum? And

ANATOMY
1. What are the organs involved?
A.

A.

External genitalia
Penis

Scrotum and its contents

Testes
o
Epididymis
o
Internal genitalia
Vas deferens

Seminal vesicle

Prostate gland

Bulbourethral glands

1. Location and anatomical relations of the

scrotum.

The scrotum is a cutaneous fibromuscular sac for

the testes and associated structures. It is situated
posteroinferior to the penis and inferior to the pubic
symphysis.

Houses the testes, epididymis and the lower ends

of the spermatic cord

Out-pouching of the lower part of the anterior

abdominal wall that fuse to form a pendulous cutaneous
pouch

The bilateral embryonic formation of the scrotum

is indicated by the midline scrotal raphe, which is
continuous on the ventral surface of the penis with the

their counterparts in the anterior abdominal

wall?

Scrotum

The scrotum is a cutaneous sac consisting of two

layers: heavily pigmented skin and the closely related
dartos fascia, a fat-free fascial layer including smooth
muscle fibers (dartos muscle) responsible for the wrinkled
appearance of the scrotum. Because the dartos muscle
attaches to the skin, its contraction causes the scrotum to
wrinkle when cold, thickening the integumentary layer while
reducing scrotal surface area and assisting the cremaster
muscles in holding the testes closer to the body, all of
which reduces heat loss.

The scrotum is divided internally by a continuation

of the dartos fascia, the septum of the scrotum, into right
and left compartments. The septum is demarcated
externally by the scrotal raphe, a cutaneous ridge marking
the line of fusion of the embryonic labioscrotal swellings.

The superficial dartos fascia is devoid of fat and is

continuous anteriorly with the membranous layer of
subcutaneous tissue of the abdomen (Scarpa fascia) and
posteriorly with the membranous layer of subcutaneous
tissue of the perineum (Colles fascia)
Testes

The testes (testicles) are the male gonads - paired

ovoid reproductive glands that produce sperms
(spermatozoa) and male hormones, primarily testosterone.

The testes are suspended in the scrotum by the

spermatic cords, with the left testis usually suspended
(hanging) more inferiorly than the right testis.


The surface of each testis is covered by the
visceral layer of the tunica vaginalis, except where the
testis attaches to the epididymis and spermatic cord.

The tunica vaginalis is a closed peritoneal sac

partially surrounding the testis, which represents the
closed-off distal part of the embryonic processus vaginalis.

The visceral layer of the tunica vaginalis is closely

applied to the testis, epididymis, and inferior part of the
ductus deferens.

The slit-like recess of the tunica vaginalis, the

sinus of the epididymis, is between the body of the
epididymis and the posterolateral surface of the testis.

The parietal layer of the tunica vaginalis,

adjacent to the internal spermatic fascia, is more extensive
than the visceral layer and extends superiorly for a short
distance onto the distal part of the spermatic cord.

The testes have a tough fibrous outer surface, the

tunica albuginea, that thickens into a ridge on its internal,
posterior aspect as the mediastinum of the testis.

From this internal ridge, fibrous septa extend

inward between lobules of minute but long and highly
coiled seminiferous tubules in which the sperms are
produced. The seminiferous tubules are joined by straight
tubules to the rete testis, a network of canals in the
mediastinum of the testis.
Epididymis

The epididymis is an elongated structure on the

posterior surface of the testis.
Efferent ductules of the testis transport newly developed
sperms to the epididymis from the rete testis.

The epididymis is formed by minute convolutions

of the duct of the epididymis, so tightly compacted that they
appear solid. The duct becomes progressively smaller as it
passes from the head of the epididymis on the superior
part of the testis to its tail.

At the tail of the epididymis, the ductus deferens

begins as the continuation of the epididymal duct. In the
lengthy course of this duct, the sperms are stored and
continue to mature.

The epididymis consists of the:

Head of the epididymis: the superior expanded part
that is composed of lobules formed by the coiled
ends of 1214 efferent ductules.
Body of the epididymis: major part consisting of
the tightly convoluted duct of the epididymis.
Tail of the epididymis: tapering continuation with
the ductus deferens, the duct that transports the
sperms from the epididymis to the ejaculatory duct
for expulsion via the urethra during ejaculation.

Spermatic Cord

The spermatic cord contains structures running to

and from the testis and suspends the testis in the scrotum.

The spermatic cord begins at the deep inguinal

ring lateral to the inferior epigastric vessels, passes through
the inguinal canal, exits at the superficial inguinal ring, and
ends in the scrotum at the posterior border of the testis.

Fascial coverings derived from the anterolateral

abdominal wall during prenatal development surround the
spermatic cord. The coverings of the spermatic cord
include the following:
Internal spermatic fascia: derived from the
transversalis fascia.
Cremasteric fascia: derived from the investing
fascia of both the superficial and deep surfaces of
the internal oblique muscle.
External spermatic fascia: derived from the
external oblique aponeurosis and its investing fascia.

The cremasteric fascia contains loops of

cremaster muscle, which is formed by the lowermost
fascicles of the internal oblique muscle arising from the
inguinal ligament.

The cremaster muscle reflexively draws the testis

superiorly in the scrotum, particularly in response to cold. In
a warm environment, such as a hot bath, the cremaster
relaxes and the testis descends deeply in the scrotum.

The cremaster typically acts coincidentally with

the dartos muscle, smooth muscle of the fat-free
subcutaneous tissue of the scrotum (dartos fascia), which
inserts into the skin, assisting testicular elevation as it
produces contraction of the skin of the scrotum in response
to the same stimuli.

1. Identify the component parts of the

spermatic cord.

Mnemonics: Pills Dont Contribute To A Good Sex

Life
Pampiniform venous plexus

Ductus/vas deferens

Cremasteric artery

Testicular artery

Artery of the ductus deferens

Genital branch of the genitofemoral nerve

Sympathetic nerves

Lymphatics

*Note: ilioinguinal nerve runs outside/along the

spermatic cord

1. What are the muscles involved in

ejaculation?

Emission - spermatozoa + mucus from sexual

gland ejected into posterior urethra epithelial secretion and
smooth muscle contraction
o Mixing of sperm and mucus into posterior
urethra

Expulsion- smooth muscle of the bladder contract

preventing backward flow of semen

Main
muscle:
bulbospongiosus
and
ischiocavernosus axn: (compress crura against pubic
arch to maintain erection)
o Ejection from urethra to glans meatus

On the pelvic floor according to an article in

Medscape rhythmic contraction of the pelvic muscle is
probably triggered by the presence of semen in the urethra.

1. What are the blood supply, venous

drainage,
innervation,
and
lymphatics
involved? (especially of penis, and scrotum and
its contents)

Arteries- Branches of internal Iliac artery

Veins- pampiniform plexus of veins draining the
testis is form by internal spermatic, cremasteric and
deferential veins.
o
It drains to the right and left testicular veins.
Left opens to left renal v. while right open to IVC

Nerve- pelvic plexus/inferior hypogastric

plexus and cutaneuous branch of sacral plexus
o
Mainly Autonomic Nervous system - Sympathetic
Nervous System: T10-L2 crucial in maintaining ejaculatory
function
o
Note: Hypogastric n. is located on the side of the
rectum, posterolateral to seminal vesicle.

Artery

Vein

Innervation

Lymphatic
Drainage

Ductus Deferens

Ductus deferens a.

Testicular v

sympathetic nerve fibers

Seminal Vesicle

from inferior vesical

and middle rectal a.

inferior vesical and

middle rectal v.

Sympathetic n.f.

Ejaculatory duct

Branches of
superior and inferior
vesical a

veins joins prostatic

and vesical
plexuses

Penis

Come from 4
branches
- internal pudendal
a.
- Dorsal a. of the
penis
- Deep artery of the
penis
- Arteries to the
bulb of penis
Prostatic a.

Deep dorsal v.
Superficial dorsal v.

Anterior Scrotal a.
- Posterior Scrotal
a.
*Take note:
Anterior scrotal is
a branch of
external pudendal
a. while posterior
scrotal is a branch
of internal pudendal
a.
Testicular a.

Scrotal v. from
external pudendal v.

Urethra

Scrotum

Testis

1. Histology and morphology

A.

TESTIS

Sympathetic nerve fibers

Prostatic venous
plexus

Internal iliac nodes:

inferior part
Lymphatic vessels
drain to external Iliac
lymph nodes
-

Internal iliac
lymph nodes
Deep
inguinal
lymph nodes

Sympathetic nerve fibers

Pampiniform venous
plexus
Left: left renal v.
Right: IVC

Dorsal nerve of the

penis
Ilioinguinal
Cavernous

External iliac nodes:

superior part

Anterior: Anterior
scrotal n. and genital
branch of
genitofemoral n.
Posterior scrotal n.
and perineal branch
of the posterior
femoral cutaneous n.

- Vagal parasympathetic
- Sympathetic fibers
from T7 of spinal cord

Superficial inguinal
lymph nodes

- Right and left

lumbar
- pre-aortic lymph
nodes

The testis is immediately covered by the tunica

albuginea while the epididymis lies on its posterior
aspect. Groups of up to four seminiferous tubules
are segregated into testicular lobules by fine
interlobular septa (S)
Seminiferous Tubule

Seminiferous tubules are lined by the germinal

epithelium, which is stratified cuboidal
It is lined by:
Germ
cells at various stages of
o
spermatogenesis
Non-germ cells Sertoli cells, which support
o
and nourish the developing spermatozoa
Cytoplasm extends to the lumen of the

tubule giving it an irregular outline

The oval nucleus is at right angles to the

basement membrane. The nucleolus is

prominent with dispersed chromatin
bodies
Bound to one another by junctional

complexes containing extensive tight

junctions
Contributes to the formation of the

blood-testis barrier (different from

somatic cells, to the immune
system,
thus
preventing
an
autoimmune response as it divides
the tubule into basal and adluminal
compartments
Interstitial
spaces contain Leydig cells,
o
whose main function is to secrete
testosterone

Rete Testis

A.

EPIDIDYMIS

The seminiferous tubules converge upon the

mediastinum testis, which consists of the rete
testis,
surrounded
by
highly
vascular
collagenous supporting tissue containing myoid
cells.
Simple cuboidal epithelium with microvilli
and a single cilium
Connected to the seminiferous tubule via straight
ductules
Myoid cell contraction helps to mix the
spermatozoa and move them towards the
epididymis.
The lining epithelium reabsorbs protein and
potassium from the seminal fluid.
Ciliary activity is presumed to aid the progress of
spermatozoa, which do not become motile until
after maturation is completed in the epididymis.

Efferent Ductules

Pseudostratified columnar epithelium with

stereocilia
long, extremely convoluted duct extending down

the posterior aspect of the testis to the lower pole

where it becomes the ductus (vas) deferens.
consists of a head at the upper pole of the testis,

a body lying along the posterior margin and a tail at

the lower pole of the testis.
major function accumulation, storage and

maturation of spermatozoa; in the epididymis, the

spermatozoa develop motility
From the proximal to the distal end of the

epididymis, the muscular wall increases from a single

circular layer, to three layers organised in the same
manner as in the ductus deferens
Proximally, the smooth muscle exhibits slow,

rhythmic contractility which gently moves spermatozoa

towards the ductus deferens.
Distally, the smooth muscle is richly innervated by

the sympathetic nervous system, which produces

intense contractions of the lower part of the epididymis
during ejaculation.

alternating columnar tall ciliated and short

non-ciliated epithelium, giving the lumen a
scalloped appearance
Ciliary action propels the still non-motile
spermatozoa towards the epididymis.
The non-ciliated cells reabsorb some of the fluid
produced by the testis.
Basal cells, which do not reach the lumen, are
also present and probably act as stem cells.
A thin band of circularly arranged smooth muscle
SM surrounds each duct and aids propulsion of
the spermatozoa towards the epididymis

The epithelial lining of the epididymis exhibits a

gradual transition from a tall pseudostratified columnar
form in the head, to a shorter pseudostratified form at
the tail.
The principal cells of the epididymal epithelium

bear tufts of very long microvilli, inappropriately called

stereocilia, which are thought to be involved in
absorption of an excess of fluid accompanying the
spermatozoa from the testis.

A.

Like the distal part of the epididymis, the vas deferens

is innervated by the sympathetic nervous system,
producing strong peristaltic contractions to expel its
contents into the urethra during ejaculation.
The epithelial lining and its supporting lamina propria
are thrown into longitudinal folds, permitting expansion
of the duct during ejaculation.
The dilated distal portion of each vas deferens, known
as the ampulla, receives a short duct draining the
seminal vesicle, thus forming the short ejaculatory
duct; which converge from each side to join the
urethra as it passes through the prostate gland.

VAS DEFERENS

A.

Pseudostratified columnar epithelium with sparse

stereocilia
conducts spermatozoa from the epididymis to the
urethra
thick-walled muscular tube consisting of inner I and
outer O longitudinal layers and a thick intermediate
circular layer CI.

SEMINAL VESICLES

Pseudostratified tall columnar

Each seminal vesicle is a complex glandular
diverticulum of the associated ductus deferens.
secrete 5070% of the total volume of seminal
fluid, most of the rest being secreted by the
prostate gland.
The lumen of each seminal vesicle is highly
irregular and recessed, giving a honeycomb
appearance at low magnification.

A.

The epithelial lining consists of secretory cells

with lipid droplets in the cytoplasm, giving it a
foamy appearance.
produce a yellowish viscid alkaline fluid
containing a wide range of substances, including
fructose,
fibrinogen,
vitamin
C
and
prostaglandins.
The epithelial cells often contain brown lipofuscin
granules and have variable nuclear shape and
size.
ICOL muscle layers
during ejaculation, muscle contraction forces
secretions from the seminal vesicles into the
urethra via the ampullae.
PROSTATE GLAND

tall columnar secretory cell with prominent

round basal nuclei and pale-staining
cytoplasm
The urethra U lies centrally, surrounded by a
fibrous stroma St. The ejaculatory ducts ED also
lie in this central stroma as they course towards
their junction with the prostatic urethra.
The zones of the prostate are not clearly
demarcated from each other anatomically.
Partial fibrous septa Sp separate the gland into
lobules.
The transition zone TZ surrounds the first part of
the prostatic urethra.
The central zone CZ lies posterior to the
transition zone and encircles the ejaculatory
ducts ED.
The peripheral zone PZ makes up the main bulk
of the gland.
The ducts of the peripheral zone glands empty
into the posterolateral recesses of the urethra on
either side of the verumontanum (urethral
crest) C.
Most cases of carcinoma of the prostate arise in
the peripheral zone, while the transition zone
harbors almost all cases of benign nodular
hyperplasia.
The prostate gland is composed of glands and
stroma. The supporting stroma SS is a mixture of
collagenous fibrous tissue and smooth muscle
fibers.
The tubuloacinar glands G show a convoluted
pattern with the epithelium thrown up into folds,
sometimes into almost a papillary pattern.
The secretory product of the prostate, which
makes up about 3050% the seminal fluid

A.

volume, is a thin liquid rich in citric acid and

proteolytic enzymes, including fibrinolysins,
which liquefies the coagulated semen after it has
been deposited in the vagina.
Inspissated secretions may accumulate in some
glands to form spherical concretions (corpora
amylacea) which increase in number with age
and may become calcified
Contains primarily glycoprotein and keratin
o
sulfate
There is also a scanty population of small, flat,
basal cells at the base of the gland in contact
with the basement membrane. These cells act as
stem cells and may become quite prominent in
prostatic hyperplasia.

PENIS

The two dorsal columns are called the corpora

cavernosa and the single ventral column is the
corpus spongiosum through which runs the
penile urethra.
At its distal end, the corpus spongiosum expands
to form the glans penis.
The erectile corpora are enclosed within and
separated by a fibrocollagenous capsule.
The erectile centre of the penis is enclosed in a
sheath of skin to which it is connected by a loose
subcutis containing prominent blood vessels.
The corpus spongiosum is composed of erectile
tissue, large irregular interconnected vascular
channels with fibrocollagenous stroma between;
the stroma contains some smooth muscle fibres.
Running through the centre of the corpus
spongiosum is the penile urethra. Small
paraurethral mucus glands open into the
urethra.
The vascular sinuses of the cavernous bodies of
the penis are supplied by numerous
anastomosing thick-walled arteries and arterioles
called helicine arteries, since they follow a spiral
course in the flaccid state. Blood drains from the
sinuses via veins which lie immediately beneath
the dense fibroelastic tissue investing the
cavernous bodies. During erection, dilatation of
the helicine arteries, mediated by the
parasympathetic nervous system, results in
engorgement of the vascular sinuses, which
enlarge, compressing and restricting venous
outflow. The process is enhanced by relaxation of
smooth muscle cells in the trabeculae of the
cavernous bodies.

PHYSIOLOGY

A.

Mechanism of Erection

c. Full erection
d. Rigid

There is an increase in both length and

width because the blood supply is trapped. The
engorgement of the veins lead to erection or
rigidity of penis** (2018B trans)

B.

Stages of Male Sexual Act

Emission vs. Ejaculation

OUTLINE

Definition
Process of Ejaculation
C. Process of Spermatogenesis
Sertoli Cells
D. Hormones Involved
E. Hypothalamic-Pituitary-Gonadal Axis

A. MECHANISM OF ERECTION
A. STAGES OF MALE SEXUAL ACT
1. ERECTION

Parasympathetic stimulation

Stimulated by: spinal reflex or

psychogenic stimuli (e.g. thought, smell, touch,
and will lead to erection -- Dra. Bareng)

Phases of Erection:
a. Flaccid
b. Tumescence

Penile erection is the first effect of male

sexual stimulation, and the degree of erection is
proportional to the degree of stimulation,
whether psychic or physical. Erection is caused
by parasympathetic impulses that pass from the
sacral portion of the spinal cord through the
pelvic
nerves
to
the
penis.
These
parasympathetic nerve fibers, in contrast to most
other parasympathetic fibers, are believed to
release nitric oxide and/or vasoactive intestinal
peptide in addition to acetylcholine. The nitric
oxide especially relaxes the arteries of the penis,
as well as relaxes the trabecular meshwork of
smooth muscle fibers in the erectile tissue of the
corpora cavernosa and corpus spongiosum in
the shaft of the penis. This erectile tissue
consists of large cavernous sinusoids, which are
normally relatively empty of blood but become
dilated tremendously when arterial blood flows
rapidly into them under pressure while the
venous outflow is partially occluded. Also, the
erectile bodies, especially the two corpora
cavernosa, are surrounded by strong fibrous
coats; therefore, high pressure within the
sinusoids causes ballooning of the erectile tissue

to such an extent that the penis becomes hard

and elongated. This is the phenomenon of
erection. (Guyton and Hall, 2011)

For sexual intercourse to occur, the

man has to achieve and maintain an erection of
the penis. The penis has evolved as an
intermittent organ designed to separate the walls
of the vagina, pass through the potential space
of the vaginal lumen, and deposit semen at the
distal end of the vaginal lumen near the cervix.
This process of internal insemination can be
performed only if the penis is stiffened from the
process of erection (Koeppen and Stanton,
2010).
2. LUBRICATION

Parasympathetic stimulation

Mucus secretion from bulbourethral

glands: Bulbourethral glands (Cowpers glands)
empty into the penile urethra in response to
sexual excitement before emission and
ejaculation. This secretion is high in mucus,
which lubricates, cleanses, and buffers the
urethra (Koeppen and Stanton, 2010).

However, most of the lubrication of

coitus is provided by the female sexual organs
rather than by the male. Without satisfactory
lubrication, the male sexual act is seldom
successful because unlubricated intercourse
causes grating, painful sensations that inhibit
rather than excite sexual sensations. (Guyton
and Hall, 2011)
3. EMISSION
4. EJACULATION (both discussed further)

When the sexual stimulus becomes

extremely intense, the reflex centers of the
spinal cord begin to emit sympathetic impulses
that leave the cord at T-12 to L-2 and pass to the
genital organs through the hypogastric and
pelvic sympathetic nerve plexuses to initiate
emission, the forerunner of ejaculation. (Guyton
and Hall, 2011)

Emission and ejaculation are the

culmination of the male sexual act. Emission
begins with contraction of the vas deferens and
the ampulla to cause expulsion of sperm into the
internal (prostatic, according to Berne) urethra.
Then, contractions of the muscular coat of the
prostate gland followed by contraction of the
seminal vesicles expel prostatic and seminal
fluid also into the urethra, forcing the sperm
forward. All these fluids mix in the internal
urethra with mucus already secreted by the
bulbourethral glands to form the semen. (Guyton
and Hall, 2011)

Once there is a movement already of

the spermatozoa from the epididymis into the
vas deferens and into the ejaculatory duct
together with the secretions coming from the
seminal vesicle and the prostrate, we call that
emission. (Dra. Bareng)

4. EJACULATION

B. EMISSION VS. EJACULATION

Sperm are stored in the tail of the epididymis
and vas deferens for several months without loss of
viability. The primary function of the vas deferens,
besides providing a storage site, is to propel sperm
during sexual intercourse into the male urethra.
Emptying of the contents of the vas deferens into
the prostatic urethra is called emission. Emission
immediately precedes ejaculation, which is the
propulsion of semen out of the male urethra.
3. EMISSION

Immediately precedes ejaculation

Sympathetic stimulation

In response to repeated tactile

stimulation of the penis during coitus, the
muscularis of the vas deferens receives bursts of
sympathetic stimulation that cause peristaltic
contractions (Koeppen and Stanton, 2010)

Sympathetic stimulation
Occurs in response to a reflex arc that
involves a sensory stimulation from the
penis (via the pudendal nerve) followed by
sympathetic motor stimulation to the smooth
muscle of the male tract and somatic motor
stimulation to the musculature associated
with the base of the penis (Koeppen and
Stanton, 2010)

Process of Ejaculation:

The filling of the internal urethra with

semen elicits sensory signals that are
transmitted through the pudendal nerves to the
sacral regions of the cord, giving the feeling of
sudden fullness in the internal genital organs.
Also, these sensory signals further excite
rhythmical contraction of the internal genital
organs and cause contraction of the
ischiocavernosus and bulbocavernosus muscles

that compress the base of the penile erectile

tissue. These effects together cause rhythmical,
wavelike increases in pressure in both the
erectile tissue of the penis and the genital ducts
and urethra, which ejaculate the semen from
the urethra to the exterior. This final process is
called ejaculation (Guyton and Hall, 2011)

generate
daughter
spermatogonia
(spermatocytogenesis).
One
or
more
spermatogonia remain within the stem cell
population, firmly adherent to the basal lamina.
However, the majority of these daughter
spermatogonia enter meiotic division, which
results in haploid spermatozoa on completion of
meiosis.
o
Spermatogonia migrate apically away
from the basal lamina as they enter the first
meiotic prophase. At this time, they are called
the primary spermatocytes
o
Completion of the first meiotic division
gives rise to the secondary spermatocytes,
which quickly (i.e., within 20 minutes) completes
the second meiotic division. The initial products
of meiosis are haploid spermatids. Spermatids
are
small,
round
cells
that
undergo
spermiogenesis
o
The products of spermiogenesis are the
streamlined spermatozoa. As the spermatid
matures into a spermatozoon, the size of the
nucleus decreases and a prominent tail is
formed. The tail contains microtubular structures
that propel sperm, similar to a flagellum.
Spermatozoa are found at the luminal surface of
the seminiferous tubule.
o
Release of sperm, or spermiation is
controlled by Sertoli cells. The process of
spermatogenesis takes about 72 days It is also
important to note that not all spermatogonia
enter the process of spermatogenesis at the
same time along the entire length of the tubule
or in synchrony with every other tubule and that
spermatozoa are continually being generated at
many sites within the testis at any given time (
Koeppen and Stanton, 2010)

Erection can be aborted, but once

emission has taken place, it is mandatory to go
into ejaculation. (how to abort: take a cold
shower) -- Dra. Bareng.

A. SERTOLI CELLS

True epithelia, irregularly shaped cells of the

seminiferous epithelium and extend from the basal
lamina to the lumen. Sertoli cells surround sperm
cells and provide structural support within the
epithelium
Attached to one another by tight junctions
FUNCTIONS

C. PROCESS OF SPERMATOGENESIS

Begins during adolescence (~ 13 y.o)

Spermatogenesis involves the processes of

mitosis and meiosis.
o
Stem cells, called spermatogonia,
reside at the basal level of the seminiferous
epithelium. Spermatogonia divide mitotically to

Maintains blood-testis barrier

o Allows limited substances in and out of
the seminiferious tubule
o The tight junctions form the physical
basis for the blood-testis barrier, which
creates a specialized, immunologically safe
microenvironment for the developing sperm
(Koeppen and Stanton, 2010).

o Androgen Binding Protein (ABP):

Regulate germ cell maturation

(nursing cell)
o By blocking paracellular diffusion, the
tight junctions restrict movement of
substances between the blood and the
developing germ cells through a transSertoili cell transport pathway and, in this
manner, allow the Sertoli cell to control the
availability of nutrients to germ cells.
(Koeppen and Stanton, 2010).

Structural support for maturing

gametes (sustentacular cell)
o Sertoli cells surround sperm cells and
provide structural support within the
epithelium, and they form adhering gap
junctions with all stages of sperm cells
(Koeppen and Stanton, 2010)
o An important structural feature of Sertoli
cells is the formation of tight junctions
between adjacent Sertoli cells. These
Sertoli-Sertoli cell occluding junctions divide
the seminiferous epithelium into a basal
compartment containing the spermatogonia
and early-stage primary spermatocytes
move apically from the basal to the
adluminal compartment the tight junctions
need to be disassembled and reassembled
(Koeppen and Stanton, 2010).

Phagocytose residual spermatid

cytoplasm
o
Sertoli cells engulf residual
bodies, which represent cytoplasm shed by
spermatozoa during spermiogenesis

Secretes homones:
o Antimullerian Hormone (AMH) or
Mullerian Inhibitory Substance (MIS)
in fetus (for the repression of mullerian
ducts at fetal life)

o Inhibin, activin and follistatin

maintains
high
concentration
of
testosterone (according to Dr. Bareng)/
androgens (according to Berne & Levy)
in the seminiferous tubules (allows
entry
of
testosterone
in
the
seminiferous tubules)

Secretes fluid that is high in K+ and HCO3(serves as a bathing medium, enables the
movement of immotile spermatozoa from
seminiferous tubule to the epididymis)

Expresses

receptors

for

FSH

FSH receptor

o FSH is a peptide hormone, plays a role

in regulation of spermatogenesis via HPT
axis

o Located in the plasma membrane

o Activates 2nd messengers (cAMP)

Testosterone receptor

o Testosterone plays a role in the intrinsic

regulation spermatogenesis

o Located in the cytoplasm

o Obligatory to spermatogenesis (along with
FSH)

D. HORMONES INVOLVED

Hormones involved in the male

reproductive system are of the Peptide and
Steroid classification
1. Classification of Hormones

Secretes enzymes for conversion of

testosterone to dihydrotestosterone (DHT)
(conversion via 5 reductase) and estradiol
(conversion via aromatase)

Hormones are classified according to

solubility properties

Produces protein:

and

Androgen:

location of receptors

nature of signal used to mediate

hormone action within the cell

modulating
gene
expression

STRUCTURE/CHEMICAL
COMPOSITION

PROPERTIES

Synthesis,
Storage and
Release

STEROID
HORMONES
(e.g.
Testosterone)

Usually
synthesized
from
cholesterol
and are not
stored

PROTEIN
HORMONES
(e.g. LH)

Much of
cholesterol in
steroidproducing
cells
come
from plasma
although
there is also
de
novo
synthesis

Large
stores
of
cholesterol
esters
in
cytoplasm
vacuoles can
be
rapidly
mobilized for
steroid
synthesis
after
a
stimulus

Effect

growth
and
division of the
testicular germinal
cells, which is the
first
stage
in
forming sperm

stimulates
the
Leydig cells to
secrete
testosterone

Structure

Consists of 3
cyclohexyl rings
and 1 cyclopentyl
ring combined in
a single structure
with a hydroxyl
group at C17

Source

Leydig cells

heterodimer
structure
consisted of subunit and subunit; -Subunit
is a glycoprotein
which is common
to other pituitary
hormones folliclestimulating
hormone (FSH)
and
thyroidstimulating
hormone (TSH),
while -subunit is
specific to LH,
and is also a
glycoprotein
Anterior pituitary
gland

Solubility

Lipophilic

Plasma Half life

Long (hours
days)

Synthesized in
the RER
stored
in
secretory
vesicles
inside
the
endocrine cell
of origin
Released by
exocytosis
through
the
regulated
secretory
pathway; thus,
hormones are
not
continually
secreted
bind to a cell
membrane
bound
receptor
Second
messengers
amplify signal
and cause the
effect

Bind to
key
regulatory
regions
in
the DNA and
would cause
either
an
increase
or
decrease of
transcription
of
key
regulatory
proteins
(structural
proteins,
enzymes,
hormones, or
any
other
protein)

Localize
d
intracellularly
and act by

Hydrophilic

to

Short (minutes)

Receptor

Intrac
ellular

the spermatids to sperm (the

spermiogenesis) will not occur.

Plasma
Membrane

process

of

2. Estrogens, formed from testosterone by the

Sertoli cells when they are stimulated by
folliclestimulating hormone, are probably also
essential for spermiogenesis.

3. Growth hormone (as well as most of the other

Mode
Transport

of

Protein Bound
*Male
gonadal
steroids
are
bound
to
the
following during
transport:
o 65% - SHBG /
TeBGSex
Hormone Binding
Globulin or
Testosterone
Binding
Hemoglobin)
o 33% - Albumin
and
CBG
(corticotropin
binding globulin)
o 2% - Free

Unbound

body hormones) is necessary for controlling

background metabolic functions of the testes.
Growth hormone specifically promotes early
division of the spermatogonia themselves; in its
absence, as in pituitary dwarfs, spermatogenesis
is severely deficient or absent, thus causing
infertility.
Androgen Hormones

Steroidogenesis it is the process of synthesizing

steroids such as testosterone and dihydrotestosterone
Major Gonadal Steroids in Adult Males

Regulation

When
testoste
rone levels are low, gonadotropinreleasing hormone (GnRH) is released by
the hypothalamus, which in turn
stimulates the pituitary gland to release
FSH and LH. These latter two hormones
stimulate the testis to synthesize
testosterone. Finally, increasing levels of
testosterone
through
a
negative
feedback loop act on the hypothalamus
and pituitary to inhibit the release of
GnRH and FSH/LH, respectively.

Steroid

Plasma
Concentration
(mg/dl)

Relative
Androgenic
Activity

Testosterone

650

110

Dihydrotestosterone

45

250-300

Androstenedione

120

10-20

Other Hormones Involved in Spermatogenesis

1. Follicle-stimulating hormone, also secreted by

the anterior pituitary gland, stimulates the Sertoli
cells; without this stimulation, the conversion of

*Testosterone is the main androgen, but the most potent

is DHT

1.

Testosterone

Primarily synthesized in Leydig cells

A gonadal steroid

Diffuses into Sertoli cells major effect

Secreted into bloodstream

Testosterone functions:
o Regulates the development of male
gonads
o Important in spermatogenesis
o Determines male sexual characteristics
o Responsible for male behavior (i.e.
libido, aggression)
o Descent of testes in fetal life

Other organs affected: brain, muscle

1.

Dihydrotestosterone

Causes negative feedback at the HPT

axis

Synthesized from testosterone in the

prostate gland, testes, hair follicles, and
adrenal glands by 5-alpha reductase

Inhibits LH release
Reduces

endogenous

testosterone

Responsible for the formation of male

primary sex characteristics and most male
secondary sex characteristics during
puberty, such as muscular growth, facial
and body hair growth, and deepening of
voice.

production
Biosynthesis:
Cholesterol (oxidative cleavage, 6 carbon
loss, CYP11A) Pregnenolone (2 carbon
loss,
CYP17A)

Androstenedione
(oxidation of 3-hydroxyl group, 3--HSD)
Testosterone
(17-
hydroxysteroid
dehydrogenase)

2.

A steroid produced in the adrenal gland

that is a precursor to testosterone and other
male hormones (androgens)

Conversion of testosterone

Testosterone is also converted into

other hormones

Aromatase Estradiol - in fat, liver,

CNS, skin, and hair

5 reductase DHT - in prostate,

scrotum, penis, and bone

Androstenedione

E. HYPOTHALAMIC-PITUITARY-TESTICULAR
AXIS

Outside the testis via the HPT (hypothalamicpituitary- testicular) axis

Hypothalamus secretes GnRH stimulates

adenohypophysis to secrete FSH and LH

17 dehydrogenase 17 ketosteroids,
in liver, kidney, for excretion in the urine and
feces
(1) FSH (hormone for spermatogenesis) stimulates
sertoli cells to:

Metabolism:

Majority of testosterone transport

bound to:

65% - SHBG (TeBG)

33% - Albumin

2% - Free form (active; long

life span)

a. Maintain the stages of sperm maturation and

development

b. Secrete inhibin, activin, follistatin and ABP

o Inhibin: exerts long loop negative
feedback on anterior pituitary gland

o Activin: excitatory to pituitary to release

FSH

o Follistatin: inhibits activin

o ABP: allows entry and concentrates

a more viscous fluid, which has occupied the central

portion of the follicle, to evaginate outward. This viscous
fluid carries with it the ovum surrounded by a mass of
several thousand small granulosa cells, called the corona
radiata.

testosterone in the seminiferous tubules

(2) LH stimulates Leydig cells to secrete testosterone

o Testosterone:
Exerts a long loop negative feedback on
the anterior
hypothalamus

pituitary

as

well

as

Converted

to
other
hormones:
dihydrotestosterone (DHT) (via 5
reductase of Sertoli cells) and estradiol (via
aromatase of Sertoli cells)
* DHT & estradiol exhibit long loop negative
feedback to the anterior pituitary and
hypothalamus

Action not limited in the testis; goes into

the circulation bound
binding globulin(mostly)

to

testosterone

*Note: frequency GnRH pulses FSH release

frequency GnRH pulses LH release
*3 Different Kinds of Loops (according to Dra. Bareng):
1.
Long from peripheral endocrine gland
to either Anterior Pituitary to Hypothalamus

2.

Short
Hypothalamus

3.

Ultra Short
Hypothalamus

Anterior

effect

Pituitary

to

of

to

FSH

Ovulation
Ovulation in a woman who has a normal 28-day female
sexual cycle occurs 14 days after the onset of
menstruation. Shortly before ovulation the protruding
outer wall of the follicle swells rapidly, and a small area in
the center of the follicular capsule, called the stigma,
protrudes like a nipple. In another 30 minutes or so, fluid
begins to ooze from the follicle through the stigma, and
about 2 minutes later, the stigma ruptures widely, allowing

Surge of LH Is Necessary for Ovulation. LH is

necessary for final follicular growth and ovulation. Without
this hormone, even when large quantities of FSH are
available, the follicle will not progress to the stage of
ovulation. About 2 days before ovulation, the rate of
secretion of LH by the anterior pituitary gland increases
markedly, rising 6- to 10-fold and peaking about 16 hours
before ovulation. FSH also increases about twofold to
threefold at the same time, and the FSH and LH act
synergistically to cause rapid swelling of the follicle during
the last few days before ovulation. The LH also has a
specific effect on the granulosa and theca cells,
converting them mainly to progesterone-secreting cells.
Therefore, the rate of secretion of estrogen begins to fall
about 1 day before ovulation, while increasing amounts of
progesterone begin to be secreted.
It is in this environment of (1) rapid growth of the
follicle, (2) diminishing estrogen secretion after a
prolonged phase of excessive estrogen secretion, and (3)
initiation of secretion of progesterone that ovulation
occurs. Without the initial preovulatory surge of LH,
ovulation will not take place.
Initiation of Ovulation. The figure below gives a schema
for the initiation of ovulation, showing the role of the large
quantity of LH secreted by the anterior pituitary gland.
This LH causes rapid secretion of follicular steroid
hormones that contain progesterone. Within a few hours,
two events occur, both of which are necessary for
ovulation: (1) The theca externa (the capsule of the
follicle) begins to release proteolytic enzymes from
lysosomes, and these cause dissolution of the follicular
capsular wall and consequent weakening of the wall,
resulting in further swelling of the entire follicle and
degeneration of the stigma. (2) Simultaneously there is
rapid growth of new blood vessels into the follicle wall,
and at the same time, prostaglandins (local hormones
that cause vasodilation) are secreted into the follicular
tissues. These two effects cause plasma transudation into
the follicle, which contributes to follicle swelling. Finally,
the combination of follicle swelling and simultaneous
degeneration of the stigma causes follicle rupture, with
discharge of the ovum.

Sixth, the entire sperm enters the egg and the

flagellum and mitochondria disintegrate. As a result,
most mitochondrial DNA is maternally derived. Sperm
DNA is decondensed and a pronucleus surrounds it to
nd
complete second 2 meiotic division.
Seventh, a pronucleus forms around the decondensed
female chromosomes and a centrosome from the sperm
pulls together the male and female pronuclei. When in
contact, the nuclear membranes break down, the
chromosomes align on a common metaphase plate, a
first cleavage occurs.
FERTILIZATION

1.

Fertilization
Capacitation is the process by which spermatozoa in the
ampulla of the Fallopian tube becomes capable of going
through the female tract and fertilizing the ovum. Sperm is
hyperactive, indicated by the discharging whiplash motion
of the flagellum, and larger sideways swinging
movements of the head.
Fertilization (according to Berne & Levy):
Fertilization recombines genetic material to form a new,
genetically distinct organism and initiation of events that
begin embryonic development.
First, the expanded cumulus is penetrated by the
sperm. The extracellular matrix is digested by a
membrane hyaluronidase, PH-20.
Second, the zona pellucida is penetrated by the sperm.
The sperm binds to zona protein ZP3 and induces
release of acrosomal enzymes. As the zona pellucida is
digested, and the sperm swims through to the egg, sperm
secondarily binds to zona protein ZP2.
Third, fusion of the sperm and egg membrane occurs.
Fourth, this fusion sets of a calcium signaling cascade
via the IP3-DAG pathway (according to Dr. Bartolome),
that triggers completion of the 2nd meiotic division.
Fifth, polyspermy is prevented through the cortical
reaction. Cortical granules are exocytosed, altering ZP2
and ZP3 so they can no longer bind with capacitated,
acrosome-intact sperm, and activating the egg. Should
more than one sperm enter the egg, this results in a
triploid cell that is unable to develop.

Penetration of follicular cells of

cumulus
2.
Binding of sperm head to ZP3 of the
zona pellucida leads acrosome reaction
release of enzymes that dissolve pellucida
3.
Sperm binds to ZP2 and swims through
to the egg
4.
Fusion of the sperm and egg
membrane
5.
A Calcium (Ca2+) signalling cascade
(IP3-DAG pathway) triggers 2nd meiotic
division and cortical reaction triggered
6.
Prevention of polyspermy
a.
Exocytosis of cortical granules ZP2
and ZP3 can no longer bind capacitated,
acrosome-intact sperm
b.
The oocyte completes 2nd meiotic
division which was arrested in prophase I, then
until metaphase II of the 2nd meiotic division just
before fertilization
7.
Entire sperm enters egg during fusion
a.
Flagellum
and
mitochondria
disintegrate
b.
Sperm DNA decondenses
c.
Pronucleus forms around the sperm
DNA as egg completes 2nd meiotic division.
d.
Haploid chromosomes of the oocyte
decondenses and mature ovum becomes female
pronucleus
8.
The pronuclei are pulled together,
nuclear
membranes
break
down,
and
chromosomes align. First cleavage occurs.

Varicocoele & Infertility

when an intestinal artery impedes the blood flow

from the left renal vein, which will cause the
backflow of blood back to the testicles.
(Nutcracker Syndrome) compression of the
left renal vein between the superior mesenteric
artery and aorta.

Common Cause of Infertility Among Males

o The backflow of blood to the pampiniform

Product of Ejaculation
Semen spermatozoa + seminal fluid (secreted by
accessory glands)
Normal Pathway of Sperm:
Seminiferous tubules rete testis efferent tubules
epididymis (head, body, tail) Vas deferens
penetrates inguinal canal enters pelvic cavity
loops around the urinary bladder ampulla of vas
deferens (joins with seminal vesicle) ejaculatory duct
penile urethra urethral orifice of glans penis

plexus would result to the pooling of the blood in

that area, which causes the worm-like
appearance on the outside.
o Depending on the severity of the varicocele,
the pooled blood can also raise the temperature
of the testicles making it harder to produce
sperm and may decrease fertility.
o
Elevated
intrascrotal
temperature
results in reductions in testosterone synthesis by
Leydig cells and reduced Sertoli cell secretory
function.
o Note that the scrotum and testicles are placed
outside the body because the bodys
temperature is warm and by placing the testicles
outside the body, it would be cooler and makes it
easier to produce sperm.
ERECTILE DYSFUNCTION VS INFERTILITY
Erectile Dysfunction
Infertility

What is Varicocele?

It is an abnormal dilatation of pampiniform

plexus
o From the anatomy of the male reproductive
organ and its blood supply and venous
drainage. The spermatic cord contains: Vas
deferens, Testicular arteries, Pampiniform
Plexus (Veins) and a smaller vein just around the
vas deferens.
o From the pampiniform plexus, blood flows to
the testicular veins. Normally the veins have a
one-way valve in which they prevent the
backflow of blood all the way back to the
pampiniform plexus.
o If the valve is damaged, it would lead to the
failure of the closure of the one way valve and
would allow blood to flow back the veins to the
testicles.
o In addition, the left testicular vein is longer
than the right testicular vein; there is a greater
downward pressure on the blood.
o Almost all occur on the left side (because left
testicular vein drains into the left renal vein, left
renal vein has higher pressure because of its
smaller caliber)
o Another reason for the backflow of blood is,

Inability to develop or
maintain
an erection of
the penis during sexual
activity

Normal Sperm Count

Inability of a person to
reproduce by
natural
means

Low sperm count, fewer

sperm
with
normal
motility/morphology.

Signs and Symptoms

A lump in one of your testicles

Swelling in your scrotum
Visibly enlarged or twisted veins in your scrotum,
which are often described as looking like a bag of
worms

 A dull, recurring pain in your scrotum. The pain is

generally mild to moderate, occurs with long periods
of sitting, standing or activity and is relieved by lying
down.

It is not associated with urination issues

or erectile dysfunction, but it is associated with
infertility
Treatment Options

Varicocele treatment may not be

necessary. However, if your varicocele causes
pain, testicular atrophy or infertility or if you are
considering assisted reproductive techniques,
you may want to undergo varicocele repair.

o
o
o
o

Varicocelectomy
Performed under general anesthesia in an
outpatient setting
An incision is made above the scrotum and cuts
through the layers of tissue to expose the veins
The affected veins are ligated, or tied off, to
detour the flow of blood into normal veins near
the vas deferens
Recovery time may require up to six weeks
before heavy lifting and other strenuous activities
can be performed. Light activities may be
resumed more quickly.

A dye is injected to create an x-ray map

(venogram) of the vein
o
A tiny metal coil or other embolizing
substances are inserted through the catheter to
block the flow of blood to the vein

The tube is removed and no stitches

are needed
o
Recovery takes less than 24 hours

Varicocele Embolization
In this type of varicocele treatment, a
small tube is inserted into the groin through a
small nick in the skin (about the size of the lead
in a pencil) but sometimes the tube is put in
through a vein in the right side of the neck
o
The skin is numbed in this procedure =
no pain (twilight sedation)
o
A small catheter, or tube, is painlessly
guided up into the abdomen and into the
varicocele vein under the guidance of x-ray
imaging

Risk Factors for Infertility

RISK FACTORS FOR MALE INFERTILITY
(ACCORDING TO UNIVERSITY OF MARYLAND
MEDICAL CENTER)
According to the University of Maryland, more than 90%
of male infertility cases are due to low sperm counts, poor
sperm quality, or both. The remaining 10% can be caused
by anatomical problems, hormonal imbalances, or genetic
defects.
Sperm abnormalities:

Low sperm count

Poor sperm motility

Abnormal sperm shape

Risk factors:

Varicocele

Aging, which reduces sperm counts,

motility, and genetic quality of sperm

STDs which can cause scarring in the

reproductive system or impair sperm function

Lifestyle factors like smoking and

substance abuse

Long-term or intensive exposure to

certain types of chemicals, toxins, or
medications

Genetic risk factors like unbalanced

chromosome complement, transmission of Ychromosal microdeletion, and cystic fibrosis
(Dohle, et al., 2002)
Diagnosis:

Semen analysis
Blood tests to evaluate hormonal levels
Imaging tests to look for structural
problems

Genetic testing to identify sperm DNA

fragmentation, chromosomal defects, or genetic
diseases
(http://umm.edu/health/medical/reports/articles/infertility-in-men)
(Dohle, G.R., Halley, D.J., Van Hemel, J.O., van den Ouweland,
Pieters, M.H., Weber, R.F., Govaerts, L.C., Genetic risk factors in
infertile men with severe oligozoospermia and azoospermia,
2002, Human Reproduction, Vol. 17 (13-16))

Physical Exam Male Repro

Assessment of the Male Reproductive System
An assessment of the male reproductive system begins
with a physical examination. Common signs and
symptoms of male reproductive disorders include:

Testicular Pain
o May result from a variety of infections,
including gonorrhea or other sexually
transmitted diseases, and mumps
o Can also result from testicular torsion,
testicular cancer, cryptorchidism or the
presence of a hernia. The pain may also
originate elsewhere along the reproductive
tract, such as along the ductus deferens or
within the prostate, or in other systems, as in
appendicitis or a urinary obstruction.

Urethral Discharge and Dysuria

Often
associated
with
sexually
transmitted diseases. These symptoms also
accompany disorders, such as epididymitis or
prostatitis, which may be infectious or
noninfectious.

Impotence
o
An inability to achieve or maintain an
erection. It may occur as the result of
psychological factors, such as fear or anxiety,
medications, or alcohol abuse. It may also

develop secondary to cardiovascular or

nervous system problems that affect blood
pressure or blood flow to the penile arteries.

Male infertility
May be caused by a low sperm count,
abnormally shaped sperm, or abnormal semen
composition.
o
Analysis of the semen can often yield
important diagnostic information

Inspection of the male reproductive system usually

involves the examination of the external genitalia and
palpation of the prostate gland. Inspection of the external
genitalia entails the following observational steps:

1.

Inspection of the penis and scrotum for

skin lesions such as vesicles, chancres, warts,
and condylomas (wartlike growths).

2.

In the course of the examination of

uncircumcised males, the foreskin is retracted to
observe the preputial lining.

Phimosis - an inability to retract the

foreskin in an uncircumcised male, usually
indicates inflammation of the prepuce and
adjacent tissues

1.

Palpation of each testis, epididymis,

and ductus deferens to detect the presence of
abnormal masses, swelling, or tumors. Possible
abnormal findings include:
o
Scrotal swelling

Due to distortion of the scrotal cavity by

blood (a hematocele), lymph (a chylocele), or
serous fluid (a hydrocele).
o
Testicular swelling

Due to enlargement of the testis or

formation of a nodular mass.

Orchitis is a general term for

inflammation of the testis.
o
Epididymal swelling

Due to cyst formation (spermatocele),

tumor formation, or infection.

Epididymitis is an acute inflammation of

the epididymis that may indicate an infection of
the reproductive or urinary tracts. This condition
may also develop due to irritation caused by the
backflow, or reflux, of urine into the ductus
deferens.
o
Swelling of the spermatic cord may
indicate:

1)Inflammation of the ductus deferens

(deferentitis)

2)Serous fluid accumulation in a pocket of

the peritoneal cavity (a hydrocele),

3)Bleeding within the spermatic cord,

4)Testicular torsion
5)Formation of varicose veins within the
testicular venous networka condition
known as a varicocele

1.

A digital rectal examination (DRE) is

usually performed as a screening test for
prostatitis or inflammation of the seminal
vesicles. In this procedure, a gloved finger is
inserted into the rectum and pressed against the
anterior rectal wall to palpate the posterior walls
of the prostate gland and seminal vesicles.
Testicular examination

A testicular examination includes a

complete physical exam of the groin and genital
organs (penis, scrotum, and testicles) by the
doctor.

Testicular self-examination (TSE) is painless and

takes only a minute. It is best performed after a bath or
shower, when the scrotal muscles are warm and relaxed.

The doctor will palpate the organs and

examine them for the presence of lumps,
swelling, shrinking (testicular atrophy), or other
visual signs of an abnormality.

A testicular examination can detect the

causes
of
pain, inflammation,
swelling,
congenital abnormalities (such as an absent or
undescended testicle), and lumps or masses
that may indicate testicular cancer.

No special preparation is needed prior to the

procedure, but for comfort, you should empty
your bladder ahead of time. You will be asked to undress
and put on a hospital gown.

The examination may be done initially while you

are lying down, and then repeated while standing.

The doctor will inspect your abdomen, groin, and

genital area (penis, scrotum, testicles). The scrotum and
both testicles will be felt (palpated) for their size, weight,
texture, and consistency and for physical signs of
swelling, lumps, or masses. The absence of one testicle
usually indicates an undescended testicle. Shrinking
(atrophy) of one or both testicles will also be noted.

If a mass is found in a testicle, your doctor will

place a strong light behind the testicle to see whether light
can pass through it (called transillumination).

A testicular tumor is too solid for light to pass

through it. Also, a testicle with a tumor generally appears
heavier than a normal testicle. A palpable mass or
swelling caused by a hydrocele will allow light to pass
through it. A hydrocele feels like water in a thin plastic
bag. The other testicle also will be felt and examined to
make sure it does not contain any lumps, masses, or
other abnormalities.
Testicular self-examination (TSE)

Done to familiarize a man with the normal size,

shape, and weight of his testicles and the area around the
scrotum. This allows him to detect any changes from
normal.

Best performed after a bath or shower,

when the scrotal muscles are warm and relaxed.
If you do the exam at another time, remove your
underwear so that your genitals are exposed.

Stand and place your right leg on an

elevated surface about chair height. Then gently
feel your scrotal sac until you locate the right
testicle. Roll the testicle gently but firmly
between your thumb and fingers of both hands,
carefully exploring the surface for lumps. The
skin over the testicle moves freely, making it
easy to feel the entire surface of the testicle.
Repeat the procedure for the other side, lifting
your left leg and examining your left testicle. Feel
the entire surface of both testicles.
RESULTS FOR PHYSICAL EXAMINATION
TESTICULAR EXAMINATION AND TSE
Stand and place your right leg on
NORMAL
an elevated surface about chair
height. Then gently feel your scrotal
sac until you locate the right
testicle. Roll the testicle gently but
firmly between your thumb and
fingers of both hands, carefully
exploring the surface for lumps.
The skin over the testicle moves
freely, making it easy to feel the
entire surface of the testicle.
Repeat the procedure for the other
side, lifting your left leg and
examining your left testicle. Feel
the entire surface of both testicles.
No
pain
or
discomfort
is
experienced
during
testicular
examination or TSE.
ABNORMAL A small, hard lump (often about the
size of a pea) is felt on the surface
of the testicle, or the testicle is
swollen or enlarged. If you notice a
lump or swelling during TSE,
contact your doctor immediately.
Do not delay or wait for the lump to
go away, because it may be an
early sign of testicular cancer.
Immediate treatment provides the
best chance for a cure.
One or both testicles are not felt. If
you cannot feel one or both
testicles while performing TSE,
contact your doctor. This may mean
an undescended testicle.
A soft collection of thin tubes (often
referred to as a "bag of worms" or
"spaghetti") is felt above or behind
the testicle. This may mean
a varicocele.
Sudden (acute) pain or swelling in
the scrotum that is noticed during
the testicular examination or TSE
may
mean
an
infection
(epididymitis) or blockage of blood
flow to the testicle (testicular
torsion), either of which requires
immediate medical evaluation.
A free-floating lump in the scrotum
that is not attached to a testicle

OF

may be present but is not a cause

for concern.

Diagnostic Tests for Male Infertility

(FROM EUNICE KENNEDY SHRIVER NATIONAL
INSTITUTE OF CHILD HEALTH AND HUMAN
DEVELOPMENT)
Evaluation of a mans fertility includes looking for signs of
hormone deficiency:

Increased body fat

Decreased muscle mass

Decreased facial and body hair

Evaluating the mans health history:

Past injury to the testicles or penis

Recent high fevers

Childhood diseases such as mumps

Physical examination of the testes and penis for
identification of:

Infection, signaled by discharge or

prostate swelling

Hernia

Malformed tubes that transport sperm

Hormone deficiency as indicated by

small testes

Presence of a mass in the testicles

Varicocele
Semen analysis (From National Institutes of Health via
MedlinePlus
https://www.nichd.nih.gov/health/topics/infertility/conditioni
nfo/Pages/diagnosed.aspx)
Semen analysis measures the amount and quality of a
mans semen and sperm. Abnormal results suggest a
male infertility problem. Sperm count that is very low or
very high may mean a man is less fertile. The acidity of
the semen and the presence of white blood cells my
suggest infection. Testing may also reveal abnormal
sperm shapes or movements.
Normal results:
Normal volume: 1.5-5.0 mL/ejaculation
Sperm count: 20-150 million sperm/mL (60-100 million
sperm/mL normal, less than 20 million sperm/mL
considered infertile according to Berne & Levy)
Sperm motility: At least 60% should have normal shape
and show normal forward movement
Leukocyte count: 0-2000/mL
pH: 7.2-7.8
Fructose concentration: 150-160 mg%