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Reproductive

System
Disorders

Overview

Male Infertility
Benign Prostatic Hypertrophy
Prostate Cancer
Female Infertility
Endometriosis
Pelvic Inflammatory Disease
Ovarian Cysts
Cancer
Breast
Cervical
Uterine

Male Infertility
Can be solely male, solely female, or both
Considered infertile after one year of unprotected
intercourse fails to produce a pregnancy
Male problems include
Changes is sperm or semen
Hormonal abnormalities
Pituitary disorders or testicular problems

Physical obstruction of sperm passageways


Congenital or scar tissue from injury

Semen analysis
Assess specific characteristics
Number, motility, normality

Benign Prostatic Hypertrophy


(BPH)Pathophysiology
Common in older men; varies from mild to severe
Change is actually hyperplasia of prostate
Nodules form around urethra
Result of imbalance between estrogen and testosterone

No connection w/ prostate cancer


Rectal exams reveals enlarged gland
Incomplete emptying of bladder leads to infections
Continued obstruction leads to distended bladder, dilated
ureters, renal damage
If significant, surgery required

BPHSigns and Symptoms


Initial signs
Obstruction of urine flow
Hesitancy, dribbling, decreased force of urine
stream
Incomplete bladder emptying
Frequency, nocturia, recurrent UTIs

BPHTreatment
Only small amount require intervention
Surgery when obstruction severe

Drugs (Flomax) used to promote blood


flow helpful when surgery not required

Prostate Cancer
Common in men older than 50; ranks high as
cause of cancer death
3rd leading cause of death from cancer

Prostate CancerPathophysiology

Most are adenocarcinomas from tissue near surface of gland


BPH arises from center of gland
Many are androgen dependent

Tumors vary in degree of cellular differentiation


The more undifferentiated, the more aggressive and the faster they
grow and spread

Metastasis to bone occurs early


Spine, pelvis, ribs, femur

Cancer has typically spread before diagnosis


Staging based on 4 categories:

A small, nonpalpable, encapsulated


B palpable confined to prostate
C extended beyond prostate
D presence of distant metastases

Stages

Prostate CancerEtiology
Cause not determined
Genetic, environmental, hormonal factors

Common in North American and northern


Europe
Incidence higher in black population than
white
Genetic factor?

Testosterone receptors found on cancer


cells

Prostate CancerSigns and


Symptoms
Hard nodule in periphery of gland
Detected by rectal exam

No early urethral obstruction


b/c of location
As tumor develops, some obstruction occurs
Hesitancy, decreased stream, urinary frequency,
bladder infection

Prostate CancerDiagnostic Tests


2 helpful serum markers
Prostate-specfic Antigen (PSA)
Useful screening tool for early detection

Prostatic acid phosphatase


elevated when metastatic cancer present

Ultrasound and biopsy confirms

Prostate CancerTreatment
Surgery and radiation
Risk of impotence or incontinence
When tumor androgen sensitive:
orchiectomy (removal of testes) or
Antitestosterone drug therapy

5 yr survival rate is 85-90%

Female Infertility
Associated w/ hormonal imbalances
Result from altered function of hypothalamus, anterior pituitary, or
ovaries
Typically after long use of birth control pill

Structural abnormalities
Small or bicornuate uterus

Obstruction of fallopian tubes


Scar tissue or endometriosis

Access of viable sperm


Change in vaginal pH
Due to infection or douches

Excessively thick cervical mucus


Development of antibodies in female to particular sperm

Smoking by male or female

Female Infertility
Broad range of tests avail
General health status checked 1st
Pelvic examinations, ultrasound, CT scans
check for structural abnormalities
Tubal insufflation (gas/pressure
measurement) or hysterosalpingogram (X-ray
w/ contrast material) used to check tubes
Blood tests throughout cycle to check
hormone levels

Normal Laparoscopy

Endometriosis
Presence of endometrial tissue outside uterus
(ectopic)
Found on ovaries, ligaments, colon, sometimes lungs

Responds to cyclic hormonal variations


Grows and secretes then degenerates, sheds and
bleeds
What is the problem? (Where does it go?)

Blood irritating to tissues = inflammation and pain


Recurs w/ e/ cycle w/ eventual fibrous tissue
Causes adhesions and obstruction

Diagnosis confirmed w/ laparoscopy

Endometriosis
Infertility results from
Adhesions pulling uterus out of normal position
Blockage of fallopian tubes

chocolate cyst develops on ovary


Fibrous sac containing old brown blood

Primary manifestations
Dysmenorrhea
More severe e/ month

Painful intercourse if vagina and supporting ligaments


affected by adhesions

Endometriosis
Cause not established
Migration of endometrial tissue up thru tubes to
peritoneal cavity during menstruation, development
from embryonic tissue at other sites, spread thru
blood or lymph, transplantation during surgery (Csection) all possibilities

Treatment
Hormonal suppression of endometrial tissue
Surgical removal of endometrial tissue

Pregnancy and lactation delay further damage


and alleviate symptoms

Endometriosis

Pelvic Inflammatory Disease (PID)


Common infection of reproductive tract
Particularly fallopian tubes and ovaries

Includes:

Cervicitis (cervix)
Endometritis (uterus)
Salpingitis (fallopian tubes)
Oophoritis (ovaries)

Infection either cute or chronic


Short-term concerns: peritonitis, pelvic abscess
Long-term concerns: infertility, high risk of
ectopic pregnancy

PIDPathophysiology
Usually originates as vaginitis or cervicitis
Often involves several causative bacteria

Uterus fallopian tube


Edema, fills w/ purulent exudate
Obstructs tube and restricts drainage into uterus
Exudate drips out of fimbriae onto ovaries and surrounding
tissue
Peritoneal membrane attempts to localize but peritonitis may
develop
Abscesses may form; life-threatening
Cause septic shock

Adhesions affect tubes and ovaries


Lead to infertility and ectopic pregnancies

PID

PIDEtiology
Arise from sexually transmitted diseases
Gonorrhea
Chlamydiosis

Prior episodes of vaginitis or cervicitis precedes


development
Infection acute during or after menses
Endometrium more vulnerable

Can also result from IUD or other contaminated


instrument
Can perforate wall and lead to inflammation and
infection

PIDSigns and Symptoms


Lower abdominal pain (1st indication)
Sudden and severe or gradually increasing in
intensity

Tenderness during pelvic exams


Purulent discharge at cervix
Dysuria
Fever and leukocytosis can occur
Depends on causative organism

PIDTreatment
Aggressive antibiotics
Cefoxitin, doxycycline

Recurrent infections common


Sex partners should be treated as well

Follow-up appt to ensure eradication

Benign Tumors: Ovarian Cysts


Variety of types
Follicular and corpus luteal cysts common
Develop unilaterally in both ruptured and unruptured follicles

Usually multiple fluid-filled sacs under serosa


that covers ovary
May become large enough to cause discomfort,
urinary retention, or menstrual irreg
Bleeding if ruptures
Cause even more serious inflammation

Risk of torsion of the ovary

Ultrasound and laparoscopy to ID cyst

Ovarian Cysts

Malignant Tumors: Carcinoma of


the BreastPathophysiology
Develop in upper outer quadrant of breast in
of the cases
Central portion of the breast is also common
Most tumors are unilateral
Different types; majority arise from ductal
epithelium
Infiltrates surrounding tissue and adheres to skin
Causes dimpling
Tumor becomes fixed when adheres to muscle or fascia of
chest wall

Carcinoma of the Breast


Pathophysiology
Malignant cells spread at early state
1st to close lymph nodes
Axillary nodes

In most cases, several nodes infected at time of diagnosis


metastasizes quickly to lungs, brain, bone, liver

Tumor cells graded on basis of degree of differentiation


or anaplasia
Tumor then staged based on size of primary tumor, # lymph
nodes, presence of metastases

Presence of estrogen and progesterone receptors


Major factor in determining how to treat the pts cancer

Breast Cancer

Breast CancerEtiology
Major cause of death in women
Incidence continues to increase after age of 20
Strong genetic predisposition
identification of specific genes related to cancer

Hormones also a factor


Specifically exposure to high estrogen levels
Long period of regular menstrual cycles (early menarche to
late menopause)
No kids (nulliparily)
Delay of 1st pregnancy

Role of exogenous estrogen (birth control pills,


supplements) still controversial

Breast CancerSigns and


Symptoms
Initial sign is single, hard, painless nodule
Mass is freely movable in early stage
Becomes fixed

Advanced signs
Fixed nodule
Dimpling of skin
Discharge from nipple
Change in breast contour

Biopsy confirms diagnosis of malignancy

Breast CancerTreatment
Surgery, radiation, chemo
Surgery
Lumpectomy
Preferred; removal of tumor

Mastectomy
Sometimes necessary

Some lymph nodes removed as well


# removed depends on the spread of the tumor cells
Impairs draining of lymph; swelling and stiffness of arm
common

Chemo and radiation


Useful for eradicating undetected micrometastases

Breast CancerTreatment
If responsive to hormones, removal of hormone
stimulation
Premenopausal women: ovaries removed
Postmenopausal women: hormone-blocking agent

Prognosis
Relatively good if nodes not involved
As # nodes increases, prognosis becomes more negative
May recur years later
Longer the period w/o recurrence, better the chances

BSE if over 20 yrs.


Mammography routine screening tool
Detect lesions before they become palpable or if they are deep
in the breast tissue

Carcinoma of the Cervix


# deaths has decreased due to Pap smear
Screening and early diagnosis while cancer in
situ

However, # cases of carcinoma in situ has


increased in the US
Avg age of in situ onset is 35
Invasive carcinoma manifests at 45
Age range dropping to younger women

Cervical CancerPathophysiology
Early changes in cervical epithelial tissue consist of
dysplasia
Mild then becomes severe (takes 10 yrs)
Occurs at junction of columnar cells and squamous cells of
external os of cervix

Cervical intraepithelial neoplasia (CIN) graded from I to


III
Based on amount of dysplasia and cell differentiation
Grade III
Carcinoma in situ
Many disorganized, undifferentiated, abnormal cells present (severe
dysplasia)

Takes 10 yrs from mild to carcinoma in situ so plenty of chances


to detect

Cervical CancerPathophysiology
Carcinoma in situ is noninvasive stage
Leads to invasive stage
Invasive has varying characteristics
Protruding nodular mass or ulceration
Eventually all characteristics present in the lesion

Carcinoma spreads in all directions


Adjacent tissues (uterus and vagina); bladder, rectum, ligaments

Metastases to lymph nodes occur rarely or in late stage


Staging:
0: carcinoma in situ
I: cancer restricted to cervix
II to IV: further spread to surrounding tissues

Normal Cervix; Cancerous Cervix

Cervical CancerEtiology
Strongly linked to STDs
Herpes simplex virus type 2 (HSV-2)
Human papillomavirus (HPV)

Virus exerts direct effects on host cell or may cause


antibody rxn
Increased antibodies have been assoc w/ increasing dysplasia

High risk factors

Multiple sex partners


Promiscuous partners
Sexual intercourse in early teen years
Pt history of STDs

Environmental factors such as smoking can predispose


women

Cervical CancerSigns and


Symptoms
Asymptomatic in early stage
Can be detected by Pap test

Invasive stage indicated by slight bleeding


or spotting
Anemia and wt loss can accompany

Cervical CancerTreatment
Biopsy to confirm diagnosis
Surgery and radiation to treat
5 yr survival rate 100% if carcinoma still in
situ
Prognosis for invasive depends on the extent
of the spread of cancer cells

Carcinoma of the Uterus


(Endometrial Carcinoma)
Common cancer in women older than 40
Majority 55-65 yrs old

Simple screening not available for this


cancer
Early indication is bleeding
Significant sign in postmenopausal women

Uterine CancerPathophysiology
Majority are adenocarcinomas
arise from glandular epithelium

Malignant changes develop from endometrial


hyperplasia
Excessive estrogen stimulation major factor for
hyperplasia

Cancer is slow-growing
May infiltrate uterine wall (thickened area) or may
spread out to endometrial cavity
Eventually tumor mass fills interior of uterus
Expands thru wall into surrounding structures

Uterine CancerPathophysiology
Graded from 1-3
1: indicate well-differentiated cells
3: poorly differentiated cells

Staging

Based on degree of localization


I: tumors confined to body of uterus
II: cancer limited to uterus and cervix
III: cancer spread outside of uterus; still in true pelvis
IV: tumor spread to lymph nodes and distant organs

Uterine CancerEtiology
Higher risk if increased estrogen levels
Assoc w/ exogenous estrogen
(postmenopausal women)
Recommended dosage lowered

Oral contraceptives

Infertility
Obesity, diabetes, hypertension increase
risk

Uterine CancerSigns and


Symptoms
Painless vaginal bleeding or spotting is
key sign
b/c cancer erodes surface tissues

Pap smear not dependable for detection


Direct aspiration of cells provides best
analysis
Late signs of malignancy include palpable
mass, discomfort or pressure in lower
abdomen, bleeding following intercourse

Uterine CancerTreatment
Surgery and radiation
Prognosis relatively good
5 yr survival rate 90% if cancer well localized
at time of diagnosis

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