Module 8-Genitourinary and Reproductive Health

Hypospadias/Epispadias

• Congenital disorders of the urethra

• Hypospadias (1/350 males)—Urethra terminates on the ventral surface (underside of the penis)

• May be associated with cryptorchidism (undescended testes)

• Diagnosis—Chromosomal studies may be needed to further identify a cause if ambiguous genitalia or masculinization of females is suspected

• Treatment—Surgery in 6–12 months

• Epispadias—Less common—urethra on dorsal surface

• Treatment is dependent on the extent of the defect

Balanitis

Chronic or acute inflammation of the glans penis

Posthitis

Inflammation of the prepuce

Balanoposthitis

Glans penis and prepuce infection and inflammation

Inflammation/Infections

• Uncommon in circumcised males

• Risk factors—Immunosuppressed, diabetes, poor hygiene

• Manifestations—Erythema, itching, soreness, blisters, ulcers, exudate

• Scarring may lead to phimosis (tightening of the foreskin)

• Treatment based on the cause

• May be a precancerous condition

Erectile Dysfunction (ED)

Erectile dysfunction is the inability to achieve and maintain an erection for satisfactory intercourse. This is most commonly due to blood flow alterations to and from the penis.

ED causes

• Psychogenic—Anxiety, depression, psychologic disorders

• Organic—Neurogenic (Parkinson's disease, multiple sclerosis, stroke, nerve injury), hormonal, vascular, medication, or penile related

• Medications—Antidepressants, chemotherapy, antihypertensives

ED risk factors

• Risks of arteriosclerosis (hypertension, hyperlipidemia, smoking), diabetes mellitus, pelvic irradiation

• Aging—Most common between 40 and 70

ED Diagnosis and Treatment

• Diagnosis: History and physical, lab test to exclude disorders. ED is a marker for cardiovascular disease, diabetes, and metabolic syndrome and should be evaluated for these disorders

• Treatment: Dependent on cause and should consider the partner, Counseling, Vacuum devices, Surgery, Pharmacotherapeutics( Androgen replacement, Phosphodiesterase type 5 inhibitors)

Priapism

• Prolonged (> four hours) involuntary erection due to impaired blood flow

• Urologic emergency—Can result in ischemia and fibrosis. Risk of impotence

• Causes: Secondary to disease (hematologic or neurologic) or drug effect, Children 5–10 years old—Sickle cell or neoplasm is the most common cause

Cancer of the Penis

• 10% of malignancies in males in developing countries

• Curable if detected early

• Squamous cell carcinoma may start as an in-situ lesion to invasive carcinoma

• Risk: Poor hygiene, HPV, age, immunodeficiency, Ultraviolet radiation exposure, smoking

• Manifestations—Begins as a small lump or ulcer, painful swelling, and purulent drainage

• Diagnosis—Physical exam and biopsy

• Treatment—Surgery

Cryptorchidism

• Undescended testes (one or both testes remain in the abdomen or the upper scrotum)

• Typically descend into the scrotal sac at seven to nine months in gestation

• Related to birth weight and gestational age (more common in premature males)

• Causes—Unknown

Cryptorchidism Manifestations and Treatment

• Spontaneous descent may occur during first six months (if not, a referral to a specialist is needed)

• If not treated—Infertility, malignancy, testicular torsion

• Manifestations—Absence of one or both testes (unilateral more common)

• Pathologic changes in testes occur in 6–12 months if not corrected

• Treatment—Surgery by one year old with lifelong follow up

Hydrocele

• Fluid accumulation in the scrotum

• In infants/children due to patent processus vaginalis that normally closes spontaneously during testicular descent

• Acute—After local injury, infection

• Chronic—Unknown (adult males)

• Manifestations—Vary if infants or adults

  • Infants—Scrotum is swollen and bluish in color, not tender

  • In adults—Asymptomatic or heaviness in the scrotum, lower back pain

• Diagnosis—Ultrasound; differential from testicular tumors

• Treatments—Observe for the first one to two years, then surgical repair; for adults, surgery if there is pain or discomfort

Hematocele

• Blood accumulation due to trauma, post-surgery, tumor

• Scrotal sac appears dark red or purple

Spermatocele

• Sperm cyst that is painless

• May be removed if this becomes painful

Varicocele-Dilation of testicular veins

• Left side most common

• Decreased sperm concentration and motility

• Rarely found before puberty

• Clinical manifestations—Asymptomatic to heaviness in the scrotum

• More apparent when standing

• Diagnostics—Ultrasound

• Treatment—Surgical ligation or sclerosis

Testicular Torsion

• Twisting of the spermatic cord and loss of blood to the testicular—A surgical emergency

Testicular Torsion- Intravaginal

• Twisting of the spermatic cord within the tunica vaginalis causing obstruction of venous drainage, edema, hemorrhage

• Most common in adolescence

• Severe pain—Nausea, vomiting, tachycardia

• Testes is large and tender, high in the scrotum

• Treatment—Surgical intervention

Testicular Torsion-Extravaginal

• Fetus and neonate

• Occurs during neonatal descent of testes

• Firm, smooth, painless scrotal mass with red skin and some edema

Epididymitis

• Acute or chronic inflammation of the epididymis

• Typical causes—Infectious or non-infectious (trauma)

• Children—Congenital urinary abnormalities

• Under the age 14 or over 35—UTIs

• Sexually active males aged 14–35—Sexually transmitted infections

• Risk factors—Sexual activity, heavy physical activity, bicycle riding, prostatic obstructions

Epididymitis clinical manifestations, Diagnosis, Treatment.

• Clinical manifestations—Unilateral pain and swelling (may radiate to the lower abdomen), edema and erythema, UTI with fever, dysuria, discharge

• Diagnostics—WBC, urinalysis, ultrasound

• Treatment—Bedrest, scrotal elevation and support, NSAIDs, antibiotics

Orchitis

• Infection of the testes

• Primary infection of urinary tract

• Systemic infections—Mumps, scarlet fever, pneumonia

• 20%–30% adolescents and young men

Orchitis Clinical Manifestations

• Sudden onset, fever, tenderness, and enlargement of testes, scrotal skin erythema, no urinary symptoms

• Symptoms subside in seven to ten days, but residual effects may remain (atrophy, spermatogenesis impaired in 30% of mumps orchitis infections)

Orchitis Diagnosis and Treatment

• Diagnosis—Cultures, urinalysis

• Treatment—Bedrest, hot or cold packs, scrotal elevation, antibiotics if an infection

Scrotal Cancer

• First occupationally linked cancer (chimney sweeps)

• Squamous cell cancer—Poor hygiene and chronic inflammation, exposure to photochemotherapy or HPV

• Mean age of presentation = 60

• Clinical manifestations—Small tumor or wart-like growth that ulcerates

• Spreads to lymph nodes

• Surgery—Excision

  • Prognosis is related to the extent of lymph node involvement

  • Benign scrotal cancers are common and do not require treatment

Testicular Cancer

• 1%–2% of cancers in men

• 15–35 years old

• Highly curable—95% five-year survival rate

• Risks—Cryptorchidism, genetics, testicular development disorders

• Clinical manifestations—Enlargement of testicle with discomfort, heaviness in scrotum or lower abdomen, pain in late stages. Metastatic presentation—Back pain, neck mass, lower extremity swelling, cough

• Routine screening not helpful

• Diagnostics—H/P, US, CT/MRI

• Treatment—Orchiectomy, radiation, chemotherapy (dependent on staging)

Acute Bacterial Prostatitis

• Most commonly due to UTI (E. Coli)

• Risk factors—Diabetes mellitus, immunodeficiency, recent instrumentation, BPH

• Clinical manifestations—Fever/chills, malaise, myalgia, cloudy urine frequent/urgent urination, dysuria, pain in the perineal area

• Diagnostics—Rectal examination (tender, swollen, warm), urine culture; prostatic massage produces thick discharge

• Treatment—Antibiotics based on culture

Chronic Bacterial Prostatitis

• More difficult to treat—Frequently due to E. Coli pathogen

• Age group—36–50 most common

• Clinical manifestations—Frequent/urgent urination, hesitancy or retention, dysuria, discomfort in the perineal area, hematuria

• Diagnostics—Urine culture

• Treatment—Long-term

Benign Prostatic Hyperplasia (BPH)

• Enlargement of the prostate that is not cancerous

• Age related—50% > 60

• Nonmalignant

• Growth of the prostate after age 25 that continues throughout life

• The enlarged gland impinges on the urethra which obstructs urine flow

• Risk factors—Over 40, family history, obesity, cardiovascular disease, type 2 diabetes

Benign Prostatic Hyperplasia (BPH) Manifestations

• Weak stream, postvoid dribbling, frequency, nocturia

• Residual urine may cause UTIs, bladder wall changes, hydronephrosis, possible renal failure

Benign Prostatic Hyperplasia (BPH) Treatment and Diagnosis

• Diagnostics—H/P, rectal examination, UA, prostate-specific antigen, digital rectal examination

• Treatment based on the degree of symptoms: Watchful waiting with lifestyle changes (limiting liquid intake, reducing caffeine and alcohol, pelvic muscle exercises, preventing constipation)

• Medications: 5 alpha-reductase inhibitors—Decreasing androgen levels can decrease prostate growth, Alpha-adrenergic blockers—Affects smooth muscle to increase urine flow, Surgery

Cancer of the Prostate

• Most frequently diagnosed cancer in the US (non-skin)

• Adenocarcinoma most common

• Risk factors—African-American (highest rate), first or second-degree relatives, dietary (high-fat diets), androgen levels

• Diagnostics—Biopsy and physical exam

• Cancer is staged and graded (Gleason grading system)

• Prostate-specific antigen (PSA) used for staging and management

• Treatment—Watchful waiting, surgery, radiation, hormone therapy, orchiectomy

• Screening—PSA, digital rectal examination, ultrasound (PSA elevations also appear in BPH and prostatitis

Clinical manifestations of prostate cancer

• Clinical presentation—Early stages are asymptomatic, symptoms associated with advanced disease or metastasis (similar to BPH), prostate exam reveals nodules

prostate cancer treatment, diagnosis, and screening

• Diagnostics—Biopsy and physical exam

• Cancer is staged and graded (Gleason grading system)

• Prostate-specific antigen (PSA) used for staging and management

• Treatment—Watchful waiting, surgery, radiation, hormone therapy, orchiectomy

• Screening—PSA, digital rectal examination, ultrasound (PSA elevations also appear in BPH and prostatitis

Vaginitis

• Inflammation characterized by vaginal discharge, burning and swelling, pain with urination or sexual intercourse

• Causes—Infection, chemicals, foreign bodies

• Pre-menarche—Hygiene, parasites, foreign bodies

• Childbearing—Candida, Trichomonas are most common causes

• Menopause—Decreased estrogen causing atrophic changes

• Diagnosis—H/P, exam, and microscopic exam of vaginal mucus

• Treatment based on findings

Cancer of the Vagina

• Rare (1%), older women (60 and older)

• May also be due to cervical cancer with extension, HPV

• More risk with HPV and local irritation

• Begins as precancerous lesions—Vaginal intraepithelial neoplasia

Cancer of the Vagina clinical manifestations, treatment, and diagnosis

• Clinical manifestations—Abnormal bleeding, discharge, mass (mostly asymptomatic)

• Diagnosis—Biopsy

• Treatment—Not standardized (surgery, radiation)

Cervicitis

• Acute or chronic inflammation

• Direct infection or secondary to vaginal/uterine infection

Cervicitis Acute

• Clinical manifestations—Cervix reddened, edematous, mucopurulent drainage

• Treatment—Antibiotics

Cervicitis Chronic

Low-grade inflammation due to small lacerations (trauma, childbirth)

• Clinical manifestations—Cervical os distorted, mucopurulent drainage, cysts

• Can lead to pelvic cellulitis, infection of fallopian tubes and uterus

• Diagnosis—Vaginal examination, Pap smear

• Treatment—Surgery cauterization

Cancer of the Cervix

• Easily detected cancer and if detected early, most curable of female reproductive cancers

• Risk—Early age at first intercourse, multiple partners, smoking, history of STIs (HPV and genital warts)

• Prevention—HPV vaccine to prevent genital warts

• Pathogenesis—Precancerous lesions progress to cancer in situ then to invasive cancer

Cancer of the cervix clinical manifestations, treatment, and Diagnosis.

• Clinical manifestations—Abnormal vaginal bleeding, spotting, discharge

  • More advanced—Pelvic or back pain, hematuria, fistulas

• Diagnosis—Pap smear, biopsy

• Treatment—Removal of the lesion, surgery, radiation

Endometritis

• Inflammation of the endometrium

• Acute—Not common

• Can follow abortion, delivery, instrumentation (when the cervix is opened)

• Chronic inflammation of the endometrium—Due to intrauterine devices, pelvic inflammatory disease, retained conceptus

• Clinical manifestations—Abnormal vaginal bleeding, uterine tenderness, fever, foul-smelling discharge

• Diagnostics—Presence of plasma cells

• Treatment—Antibiotics

Endometriosis

• Functional endometrial tissue found in sites outside the uterus

• Pathologic changes depend on the location of the tissues

• Cause is unknown

• Clinical manifestations—Becomes active when reproductive hormones stimulate the tissue. Pelvic pain occurs pre-menstrually and ends after menstruation. Infertility can result

• Diagnostics—Laparoscopy, US, MRI; may be difficult to diagnose

• Treatment: Pain relief—NSAIDs, Endometrial suppression—Oral contraceptives, Surgery with larger endometriomas, cautery, ablation, hysterectomy

Type I endometrial cancer

Prolonged estrogen stimulation and endometrial hyperplasia in perimenopausal women (85%)

• Risk—Diabetes mellitus, hypertension, obesity, polycystic ovary syndrome

• This type has a better survival rate

• Most common cancer of the female pelvis

• Average age is older than 60

Type II endometrial cancer

Post-menopausal with endometrial atrophy, older women

• Poorer prognosis

• Clinical manifestations—Abnormal painless bleeding; later cramping, pelvic discomfort

• Diagnostics—Endometrial biopsy

• Treatment—Dependent on clinical stage

  • Surgery, radiation

  • Early diagnosis has a 96% five-year survival rate

Uterine Leiomyomas (Fibroids)

• Benign neoplasms of the smooth muscle

• Common—Occur in one out of four to five women over 35

• Clinical manifestations—Asymptomatic to menorrhagia, anemia, urinary frequency, constipation, pain

• Fibroids reduce during menopause

• Diagnosed during routine pelvic exam

• Treatment—If needed, myomectomy or hysterectomy

Pelvic Inflammatory Disease (PID) and Risk Factors

• Affects the upper reproductive tract—Inflammatory—Infection ascends through uterus to fallopian tubes and ovary

• Due to sexually transmitted diseases or other infections

• Risk—Age 16–24, multiple sexual partners, previous PID

PID Symptoms

• Pain in lower abdomen, back and cervix

• Purulent discharge, adnexal (in the area of the uterus) tenderness

• Fever > 101

PID Treatment, complications, and Diagnosis

• Diagnostics

  • Increased WBC count

  • Increased C-reactive protein, increased sedimentation rate

  • Pain with cervical motion

• Treatment—IV antibiotics

• Can result in infertility, ectopic pregnancy, adhesions, abscess

True Or False: Ovarian cysts are the rarest cause of enlarged ovaries (fluid-filled)

False, they are the most common cause. Discomfort on the affected side if enlarged or bleeding

Ovarian Cysts and Polycystic Ovary Syndrome

• Polycystic ovary syndrome—Common endocrine disorder. It Causes chronic anovulation and Amenorrhea or irregular menses. LH > FSH—cause unknown

• Stimulates androgen production—Acne, hirsutism, infertility and Interferes with ovulation

• Ovaries contain many un-ovulated follicles

• Metabolic syndrome can result in long-term cardiovascular disease and diabetes

• Diagnosis—Clinical presentation, ultrasound (US) of ovaries

• Treatment—Symptom relief, reduce diabetes and cardiovascular disease development

Ovarian Cancer and Risk Factors

• Ovarian cancer is often deadly since it is difficult to diagnose

• Risk factors: Ovulatory age—Most significant risk factor (amount of time when ovarian cycle is not suppressed—more time is higher risk), Family history, BRCA1 and BRCA2 increase susceptibility, High-fat diet and genital talc powders linked

Ovarian Cancer Prevention, Treatment, and Manifestations

• Clinical presentation—Causes vague GI symptoms, abdominal and pelvic pain, bloating, feeling full after eating

• Prevention—Long-term oral contraceptive use may be useful, surgical removal of ovaries and fallopian tubes

• No accurate, cost-effective screening tests available

• Treatment—Surgery, chemotherapy

Dysfunctional Menstrual Cycles

Typically related to dysfunctional bleeding (hormone-related)

Abnormal Uterine Bleeding

Any bleeding outside of normal menstruation

Amenorrhea

Absence of menstruation

• Primary—Failure to menstruate by 15 (or 13 with no secondary sex characteristics)

• Secondary—Cessation of menstruation for six months

• Treatment is aimed at correcting the underlying cause and introducing menstruation

Dysmenorrhea

Pain or discomfort during menstruation producing disability

• Primary—Excess prostaglandin production causing smooth muscle stimulation

• Secondary—Structural or disease process (endometriosis, fibroids, PID)

• Treatment is symptom control

Premenstrual Syndrome

• Physical, emotional, and behavioral changes

• Variable symptoms—Mild to severe

• Clinical manifestations—Headache, backache, breast discomfort, bloating, abdominal pain, irritability, depression

• Diagnosis—H/P and studies to rule out other disorders

• Treatment—Symptom management (diuretics for fluid retention, analgesics, and anti-anxiety agents)

Mastitis

• Breast inflammation most common in lactating women

• Ascending infection from nipple to ducts—Breast becomes hard, inflamed, tender

• Treatment is heat or cold application, mild analgesics, antibiotics, supportive brassiere (may need aspiration)

Fibroadenoma

Firm round mass that is easily movable

• Asymptomatic and non-cancerous that can be excised

Fibrocystic changes

Nodular breast masses that are more painful during menstrual cycle

• The most common form is non-proliferative

Benign Epithelial Disorders—Fibroadenoma and Fibrocystic Disease

• Discomfort during menstrual cycle—No additional risk for breast cancer

• Diagnostics—Breast exam, mammography, US, biopsy to ensure any mass is not cancerous

• Treatment is symptomatic—Analgesics, heat/cold, support

Breast Cancer

• Most common female cancer after skin cancer

• Breast cancer may develop in men

• Cancer develops when cells mutate and are not repaired

Breast Cancer Risk Factors

• Risk factors—Sex, age, personal or family history, history of benign breast disease, hormonal influences

• Modifiable—Obesity, inactivity, alcohol intake over one drink/day

• Mutation of BRCA1 or BRCA2 increases the risk

• Risk reduction for high risk—Prophylactic mastectomy, aromatase inhibitors

Breast Cancer detection, diagnosis, and treatment

• Detection: Mass, puckering, nipple retraction, discharge, Mammography

  Clinical breast examination—Typically a solitary, painless, firm-fixed lesion with poorly defined borders

• Diagnosis—Mammography, physical examination, needle aspiration, and biopsy

• Treatment—Surgery, chemotherapy, radiation, hormonal therapy