Stiles, Richard E.

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The Linacre QuarterlyVolume 21 | Number 2 Article 55-1-1954Urological AspectsRichard E. StilesFollow this and additional works at: https://epublications.marquette.edu/lnqPart of the Ethics and Political Philosophy Commons, and the Medicine and Health SciencesCommonsRecommended CitationStiles, Richard E. (1954) "Urological Aspects," The Linacre Quarterly: Vol. 21 : No. 2 , Article 5.Available at: https://epublications.marquette.edu/lnq/vol21/iss2/546 THE LJNACRE QUARTERLY in adrenal cortical activity, and thus may be a temporary factor sterility. The pituitary activities are so inter-related with each other ar with other glands, that alm.ost anything causing a derangement of i function will be reflected elsewhere. The Sheehan syndrome has to l considered in cases of secondary sterility. Pituitary neoplasms ar non-sexual gland over-stimulation may adversely affect estrogen ar. 1 androgen production. Search must be made into other disorders that may directly t indirectly depress sexual gland activity. Excessive radiation in x-r workers and those exposed to radio-active substances is an accepte etiological factor in sterility. Disturbances of hormonal metabolism seen in liver disease and the chronic congestion of organs with th inadequate arterial circulation of congestive heart failure are frequent! associated with amenorrhea and inadequate sperm counts. Many othe pathological conditions with deranged body physiology are at time associated with sterility-whether as a coincident or causative agent i difficult to determine. The diagnostic studies for medical evaluation of sterility cases ar, multiple. However, no set of screening tests can be established. Routin< laboratory procedures, as blood counts, sedimentation rate, urinalysi, are a part of any complete examination. Basal metabolic studies, proteir bound iodine determination, blood sugar, glucose tolerance curves, live1 function tests will be required in some cases. Bio-assays of hormones, it more feasible, would add greatly to our knowledge of the subject, but from the practical point of view will seldom be mandatory tests. Enzyme determination may perhaps in future years be very important, but at the present time adds relatively little to the workup. The internist must be aware of all factors and the inter-relationship of factors if he is to contribute to the individual's problem of sterility. A very complete and exhaustive workup may reveal no significant abnor­malities, but the discovery of obscure conditions may make the time consumed a very fruitful experience. The discovery of many of the abnormal conditions will not produce fertility but will obviate further diagnostic procedures and perhaps add to our ever-growing knowledge of sterility. THE LINACRE QUARTERLY 47 Urological Aspects RICHARD E. STILES, M.D. The function of the Catholic urologist in the management of appar­ently infertile marriages is two-fold. He is concerned primarily with t�e diagnosis of infertility or sterility in the male partner, and secondanl_Y with the treatment of such abnormalities. In both these concerns, his medical enthusiasm is tempered by Catholic principles of morality. It is the purpose of this paper to describe how these objectives are achieved within the framework of a hospital out-patient clinic. Patients are usually referred by the obstetrical clinic or family physician, after at least superficial studies of the wife have been made and no obvious cause of infertility found. At this point it is frequently desirable to investigate the male partner, in an effort to determine his role, if any, in the etiology of the problem. When he is first seen, the husband's attitude may vary from genuine interest and enthusiasm, to polite skepticism, or ill-concealed antago­nism. A little time spent in establishing rapport at this point pays dividends later, not only to the- urologist and referring physician, but also to the patient's wife. whose repeated urging has frequently been necessary to get the patient to the clinic. For this reason, an effort is made to personalize each original interview at the clinic to avoid any · impression of assembly-line tactics. At the same time, for consistency inrecord maintenance, a printed blank form is used, which has adequatespace for entering the necessary historical, physical, and laboratory data.In addition to establishing the usual details of medical history, thepatient is questioned concerning previous marriages or pregnancies,episodes of genital infection, especially gonorrhea, mumps orchitis, orepididymitis. Inquiry is also made concerning previous operations forhernia, cryptorchidism, hydrocele, or varicocele, or allied conditions.Detailed information concerning the use of tobacco, alcohol. and otherdrugs is sought, as well as facts concerning the patient's occupation,with particular reference to his exposure to industrial poisons, x-ray, orother noxious agents. Finally, detailed information pertaining to thepatient's marital life is worth eliciting. It is surprising how much vari­ance there may be in the history obtained from the two partners on suchfundamentals as potency and libido, frequency of intercourse, contra­ception, premature ejaculation, and so forth.General physical examination is then carried out, with particular 48 THE LINACRE QUARTERLY attention to the normal development of secondary sex characteristic� and especially the external genitalia. The majority of these patients ar, not hypogonadal from the endocrine standpoint. However, such impor tant abnormailties as hypospadias. cryptorchidism, varicocele. herni. and hydrocele. to mention a few, may be demonstrated and their impor tance evaluated. Careful physical evaluation of the testes and thei adnexae, with thoughtful search for evidence of prior epididymitis, o vas deferens abnormalities is essential. Rectal examination. includin� palpation and massage of the prostate and seminal vesicles, is alway· carried out to detect associated pathology, usually of an inflammator; nature. in these vital structures. Routine laboratory studies include a urinalysis and inspection of th\ expressed prostatic secretion. a complete blood count and blood serology and semen analysis. Material for the latter may be obtained by the usE of Doyle's cervical spoon. or by the perforated condom technique. 1 Thr material thus obtained is examined within a few hours and note is mad( of its volume, gross appearance. including color and viscosity, motility including an estimate of its duration and vigor, and count. which i: usually reported in number of sperm per cc. together with a percentag{_ estimate of the number of abnormal forms. If significant abnormalitie� are noted, one or preferably two repeat examinations are made at inter· vals of one or two months to rule out temporary depression of sperma­togenesis by acute toxic influences. With the above information at hand the urologist can then venture a diagnosis. This is frequently best expressed as ai:i opinion of the degree of fertility. For example. adequately fertile, relatively infertile, or sterile, together with the pathology present, and such etiologic factors as have been discovered. If the patient appears adequately fertile no treatment is  indicated and further management of the couple is largely a problem for the wife's physician. If complete azoospermia is confirmed by repeated examinations, testicular biopsy, a simple. relatively painless out-patient procedure, is indicated, and if the pathologic examination discloses absent sperma­togenesis with permanent tubular damage, the case is hopeless. The patient is so informed and adoption is recommended. In this connection, an effort is made to emphasize for the patient the dual function of the male gonad, to impress on him that in spite of the lack of spermato­genesis, his androgenic production is normal, and consequently his virility. These men need some such reassurance at this time. Very occasionally, in the presence of azoospermia, testicular biopsy discloses 1 For the moral status of this latter procedure, see footnote 3 of the concluding articleof this series, p. 55. THE LINACRE QUARTERLY 49 normal spermatogenesis, and search must then be made for some pathology in the vas or epididymis. An occasional such case may be suitable for epididymovasostomy in an effort to re-establish a patent duct system. Varying degrees of oligospermia, which arbitrarily is considered to be a count of less than 60 million per cc. may be encountered. The basal metabolic rate is determined for these patients. and if they have minus readings, thyroid is administered. With a normal metabolism, thyroid, although widely used. is probably of no value. When possible, testicular biopsies are also obtained in persistent oligospermic patients to correlate the degree of spermatogenic depression with the degree of oligospermia. as well as for scientific interest. Unfortunately. therapy directed at improving spermatogenesis per se is not very productive of results. Wherever indicated, surgical correc­tion of genital abnormalities is always recommended. General measures, which include consumption of a diet high in protein, minerals and vita­mins, adequate rest and exercise. the elimination of foci of infection, are certainly of some value. Such common spermatogenic depressants as jockey-type underwear or scrotal suspensories are eliminated. Occa-· sional cases are treated by gonadotropis or testosterone. The latter has been reported to produce a complete azoospermia in oligospermic patients when administered over several weeks or months, followed by a rebound of spermatogenesis, after the drug has been withdrawn, to levels higher than before its administration. This rebound is apparently not consistent. and the recovery of spermatogenesis may req-uire a period of a year or more. We are skeptical of its value and reserve it as a last resort for oligospermic patients when all else has failed. The Catholic urologist, then, has a definite place in the diagnosis and treatment of the male partner of apparently infertile marriages. Such a function can be closely integrated with the obstetrician or gyn­ecologist in the operation of a fertility clinic. Not the least function of such a clinic is the protection of Catholic patients from the immoral techniques and practices to which they will not infrequently be exposed by clinics or physicians who do not consider themselves limited in their investigative or therapeutic enthusiasm by established principles of morality. These unhappy couples have high motivation for the most part, and accept without question, usually, whatever is recommended to them by the medical authority to whom they have entrusted their problem. The Catholic urologist and gynecologist, operating in unison in the management of a fertility clinic, can off er much to such people. 

Urological Aspects

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Urological Aspects

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