Reproductive System Disorders

1. Reproductive System Disorders

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

3. 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

4. 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

8. BPH—Signs and Symptoms • Initial signs • Obstruction of urine flow • Hesitancy, dribbling, decreased force of urine stream • Incomplete bladder emptying • Frequency, nocturia, recurrent UTIs

9. BPH—Treatment • Only small amount require intervention • Surgery when obstruction severe • Drugs (Flomax) used to promote blood flow helpful when surgery not required

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

12. Prostate Cancer—Pathophysiology • 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

13. Stages

15. Prostate Cancer—Etiology • 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

16. Prostate Cancer—Signs 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

17. Prostate Cancer—Diagnostic 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

18. Prostate Cancer—Treatment • 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%

19. 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

20. 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

22. Normal Laparoscopy

24. 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

25. 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

26. 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 (C-section) all possibilities • Treatment • Hormonal suppression of endometrial tissue • Surgical removal of endometrial tissue • Pregnancy and lactation delay further damage and alleviate symptoms

29. Endometriosis

30. 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

31. PID—Pathophysiology • 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

33. PID

34. PID—Etiology • 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

35. PID—Signs 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

36. PID—Treatment • Aggressive antibiotics • Cefoxitin, doxycycline • Recurrent infections common • Sex partners should be treated as well • Follow-up appt to ensure eradication

37. 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

38. Ovarian Cysts

40. Malignant Tumors: Carcinoma of the Breast—Pathophysiology • Develop in upper outer quadrant of breast in ½ 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

41. 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 pt’s cancer

42. Breast Cancer

43. Breast Cancer—Etiology • 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

44. Breast Cancer—Signs 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

45. Breast Cancer—Treatment • 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

46. Breast Cancer—Treatment • 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

47. 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

48. Cervical Cancer—Pathophysiology • 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

50. Cervical Cancer—Pathophysiology • 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