AG

Reproductive System Disorders

Chapter 19: Reproductive System Disorders

Review of Male Reproductive System (1 of 2)

  • Testes: Site of spermatogenesis (production of sperm cells).

  • Epididymis: Responsible for the maturation of sperm.

  • Vas deferens: Transports sperm to the urethra.

  • Seminal vesicles: Secretes fluid to nourish sperm.

  • Prostate gland: Produces secretions to balance pH of semen.

  • Cowper glands (bulbourethral glands): Secretes alkaline mucus to protect sperm.

  • Penis: Facilitates ejaculation of semen.

Review of Male Reproductive System (2 of 2)

  • Male hormones:

    • Follicle-stimulating hormone (FSH): Initiates spermatogenesis.

    • Luteinizing hormone (LH): Stimulates production of testosterone.

    • Testosterone: Responsible for maturation of sperm, secondary sex characteristics, protein metabolism, and muscle development.

Anatomy of the Male Reproductive System

  • Structures include:

    • Parietal peritoneal membrane, Glans penis, Ductus deferens, Urethra, Epididymis, Testis, Seminiferous tubules, Scrotum, Prepuce (foreskin), Ureter, Surface of urinary bladder, Seminal vesicle, Urinary bladder, Ampulla, Ejaculatory duct, Prostatic urethra, Prostate gland, Rectum, Membranous urethra, Bulbourethral gland, Spongy urethra.

Congenital Abnormalities of the Penis

  • Epispadias: Urethral opening located on ventral or upper surface of the penis.

  • Peyronie's disease: A bend in the penis caused by scar tissue.

  • Hypospadias: Urethral opening on the dorsal surface (underside) of the penis.

  • Consequences include incontinence, infection, and erectile dysfunction.

  • Treatment: Surgical reconstruction.

Disorders of the Testes and Scrotum

  • Conditions include:

    • Cryptorchidism

    • Hydrocele

    • Spermatocele

    • Varicocele

Cryptorchidism

  • Definition: Testis fails to properly descend into the scrotum.

  • The exact cause of maldescent is not fully understood.

  • Ectopic testis: Testis is positioned outside of the scrotum leading to the degeneration of seminiferous tubules, impairing spermatogenesis.

  • If left untreated by age 5, significantly increases the risk of testicular cancer.

Visualization of Testis Descent

  • Normal development involves the testicle forming in the abdomen and descending through the retroperitoneal space during fetal development. Improper descent may lead to locations such as pelvic cavity, inguinal canal, or upper scrotum.

Hydrocele

  • Definition: Excess fluid collects in the space between layers of the tunica vaginalis of the scrotum.

  • Can be congenital or acquired due to injury, infection, or tumor.

  • May compromise blood supply or lymph drainage in the testes.

Spermatocele

  • Cyst containing fluid and sperm that forms between the testis and the epididymis.

  • May be related to developmental abnormalities.

  • Surgical removal is needed in many cases.

Varicocele

  • Definition: Dilated vein in the spermatic cord due to lack of valves, leading to backflow.

  • Results in increased pressure, impaired blood flow to testes, and decreases spermatogenesis.

  • Surgical intervention is required.

Torsion of the Testes

  • Occurs when the testes rotate on the spermatic cord, compressing arteries and veins which leads to ischemia and scrotal swelling.

  • If torsion is not reduced, it can cause testicular infarction.

  • Can occur spontaneously or after trauma.

  • Treated both manually and surgically.

Inflammations and Infections

  • Prostatitis: Infection or inflammation of the prostate gland categorized into four types:

    • Acute bacterial

    • Chronic bacterial

    • Nonbacterial

    • Asymptomatic inflammatory

Categories of Prostatitis

  • National Institute of Health categories:

    • Category 1: Acute bacterial

    • Category 2: Chronic bacterial

    • Category 3: Nonbacterial

    • Category 4: Asymptomatic inflammatory

Prostatitis Symptoms

  • Acute bacterial: Gland is tender and swollen; urine and secretions contain bacteria.

  • Nonbacterial: Urine and secretions have a high leukocyte count.

  • Chronic bacterial: Gland may be only slightly enlarged; includes symptoms like dysuria, frequency, urgency.

Etiology of Prostatitis

  • Usually results from an ascending infection and can occur in:

    • Young men with UTIs

    • Older men with prostatic hypertrophy

    • Associations with STDs

    • Conditions like instrumentation or bacteremia.

Signs and Symptoms of Prostatitis

  • Symptoms of both acute and chronic forms include:

    • Dysuria, urinary frequency, and urgency

    • Decreased urinary stream

    • Acute form presenting with fever and chills

    • Lower back pain, abdominal discomfort, malaise, anorexia, and muscle aches.

Treatment of Prostatitis

  • Acute or Chronic Bacterial Infection: Requires antibacterial drugs such as ciprofloxacin.

  • Nonbacterial infection: Treat with anti-inflammatory drugs and prophylactic antibacterial agents.

Balanitis

  • Definition: Fungal infection of the glans penis, often sexually transmitted.

  • Typically caused by Candida albicans.

  • Symptoms include vesicles that develop into patches with severe burning and itching.

  • Treatment involves topical antifungal medication.

Epididymitis and Orchitis

  • Epididymitis: Inflammation of the epididymis.

  • Orchitis: Infection of the testicle.

  • Causative organisms vary based on age, history, and sexual activity. Antibiotics are the primary treatment.

Benign Prostatic Hypertrophy (BPH)

  • Affects up to 50% of men over 65 years.

  • Characterized by hyperplasia of prostatic tissue leading to compression of urethra and urinary obstruction.

  • Related to an imbalance of estrogen and testosterone; does not predispose to prostatic carcinoma.

BPH Consequences

  • Untreated BPH can lead to:

    • Frequent infections

    • Bladder distention, dilated ureters, hydronephrosis, and renal failure.

Signs and Symptoms of BPH

  • Obstructed urinary flow, hesitancy in starting flow, dribbling, decreased flow strength, and increased frequency/urgency. Additional symptoms may include nocturia and dysuria if an infection is present.

Treatment of BPH

  • Medications such as dutasteride (Avodart) to slow enlargement, smooth muscle relaxers like tamsulosin (Flomax), and a combination of finasteride (Proscar) and doxazosin (Cardura) to reduce hypertrophy progression. Surgery may also be indicated.

Cancer of the Prostate (1 of 2)

  • Most common cancer in men over 50 years; third leading cause of cancer death among men.

  • Affects 1 in 6 men and most are adenocarcinomas near the gland's surface.

  • The aggressiveness of tumors correlates with the degree of differentiation.

Cancer of the Prostate (2 of 2)

  • The disease can be both invasive and metastatic, with 5%-10% attributable to inherited mutations. Higher androgen levels and history of recurrent prostatitis are also risk factors.

Signs and Symptoms of Prostate Cancer

  • Hard nodule felt on the periphery of the gland; symptoms include hesitancy in urination, decreased urine stream, frequent urination, and recurrent UTIs.

Diagnosis of Prostate Cancer

  • Diagnostic methods include serum markers such as prostate-specific antigen (PSA), prostatic acid phosphatase, ultrasonography, biopsy, and bone scans to detect metastases.

Treatment of Prostate Cancer

  • Standard treatments encompass:

    • Surgery (radical prostatectomy)

    • Radiation (external or implanted pellets)

    • In cases of androgen sensitivity, orchiectomy and antitestosterone drugs may be effective. New chemotherapies are currently in clinical trials.

Cancer of the Testes (1 of 4)

  • Most testicular tumors are malignant; incidence is approximately 1 in 300.

  • It represents the most common solid tumor cancer in young men, with an increasing number of cases.

  • Testicular self-examination is vital for early detection.

Cancer of the Testes (2 of 4)

  • Tumors may originate from one type of cell or a mixture (e.g., teratoma). Some malignant tumors secrete hCG or AFP, serving as useful diagnostic markers.

Cancer of the Testes (3 of 4)

  • Tumoral spread typically follows: common iliac and para-aortic lymph nodes ➔ mediastinal and supraclavicular lymph nodes ➔ blood to lungs, liver, bone, and brain.

Cancer of the Testes (4 of 4)

  • Risks include heredity (change in chromosome 12) and cryptorchidism; exposure to herbicides and environmental agents may also contribute.

Signs and Symptoms of Cancer of the Testes

  • Tumors usually present as hard, painless swellings and can be unilateral. Possible symptoms include heavy feeling in the testes, dull aching in the scrotum/pelvis, hydrocele, or epididymitis. Hormone-secreting tumors lead to gynecomastia.

Diagnostic Tests for Testicular Cancer

  • Typically excludes biopsy, instead using tumor markers (hCG, AFP), as well as ultrasound, computed tomography, and lymphangiography.

Treatment of Testicular Cancer

  • Often includes a combination of:

    • Surgery (orchiectomy)

    • Radiation therapy

    • Chemotherapy. Note: patients may wish to donate sperm prior to treatment to preserve future fertility.

Review of the Female Reproductive System (1 of 5)

  • Vulva: An outer structure composed of:

    • Mons pubis: Adipose tissue and hair covering the pubic symphysis.

    • Labia majora and minora: Outer and inner thin folds of skin extending from the mons pubis.

    • Clitoris: Erectile tissue located anterior to the urethra.

    • Vagina: A muscular, distensible canal extending from the vulva to the cervix.

Review of the Female Reproductive System (2 of 5)

  • Important anatomical structures include:

    • Sacral promontory, uterine tube, ureter, uterosacral ligament, rectouterine pouch (Douglas), cervix, coccyx, anus, suspensory ligament of uterine tube, ovarian ligament, body of the uterus, fundus of the uterus, round ligament, vesicouterine pouch, parietal peritoneum, urinary bladder, pubic symphysis, urethra, clitoris, labium minus, labium majus.

Review of the Female Reproductive System (3 of 5)

  • Uterus: Muscular organ for implanting fertilized ovum. The cervix poses two openings:

    • External os: Opening filled with thick mucus to prevent vaginal flora from ascending.

    • Internal os: Leads into the uterus. Fallopian tubes are the tubes transporting ova from the ovaries to the uterus.

Review of the Female Reproductive System (4 of 5)

  • Ovaries: Produce ova and hormones (estrogen and progesterone).

  • Breasts: Glands responsible for producing colostrum and milk for newborns, consisting of adipose tissue as well.

Review of the Female Reproductive System (5 of 5)

  • Hormones and the Menstrual Cycle

    • The menstrual cycle lasts from 21 to 45 days and includes:

      • Menstruation (days 1-5)

      • Endometrial proliferation and estrogen production (days may vary)

      • Maturation of ovarian follicles and ovulation triggered by LH release.

The Menstrual Cycle

  • The follicle becomes the corpus luteum, producing progesterone.

  • Vascularization of the endometrium prepares for implantation approximately 12 to 14 days before the next menstruation.

  • If implantation does not occur:

    • Corpus luteum atrophies.

    • Uterine muscle contracts causing ischemia.

    • Endometrium degenerates.

Structural Abnormalities (1 of 6)

  • Normal Uterus Position: Slightly anteverted and anteflexed.

  • Retroflexion: Uterus tipped posteriorly and may cause pain, dysmenorrhea, or dyspareunia; in extreme cases, infertility may occur.

Structural Abnormalities (2 of 6)

  • Uterine Prolapse: Classified in degrees:

    • First-degree: Cervix drops into vagina.

    • Second-degree: Cervix at vaginal opening, body of uterus in the vagina.

    • Third-degree: Both uterus and cervix protrude through vaginal orifice. Symptoms can be asymptomatic or lead to discomfort, infection, and decreased mobility.

Structural Abnormalities (3 of 6)

  • Rectocele: Protrusion of the rectum into the posterior vagina, causing constipation and pain.

  • Cystocele: Protrusion of bladder into the anterior vagina, which can lead to urinary tract infections (UTIs). Severe cases require surgical support of pelvic ligaments.

Menstrual Disorders (1 of 2)

  • Amenorrhea: Absence of menstruation; can be primary (genetic) or secondary (usually hormonal imbalance).

  • Dysmenorrhea: Painful menstruation due to excess prostaglandins related to endometrial ischemia, typically starting a few days before menses. Treatment involves NSAIDs.

Menstrual Disorders (2 of 2)

  • Premenstrual syndrome (PMS): Symptoms start about a week before menstruation. Can include breast tenderness, weight gain, irritability, and emotional changes. Treatment is individualized and may involve lifestyle adjustments, medications, or contraceptives.

Abnormal Menstrual Bleeding

  • Commonly due to lack of ovulation, but hormonal imbalances in the pituitary-ovarian axis could contribute. Types include:

    • Menorrhagia: Increased flow and duration.

    • Metrorrhagia: Bleeding between cycles.

    • Polymenorrhea: Short cycles ≤ 3 weeks.

    • Oligomenorrhea: Long cycles ≥ 6 weeks.

Endometriosis

  • Condition where endometrial tissue grows outside the uterus, responding to cyclical hormonal changes. This leads to inflammation and pain, possibly causing adhesions and obstructions. Treatment can involve hormonal suppression or surgical removal of ectopic tissue.

Infections: Candidiasis (1 of 2)

  • Form of vaginitis that is not sexually transmitted, caused by Candida albicans—an opportunistic infection often stemming from antibiotic therapy, pregnancy, diabetes, or reduced host immunity.

Infections: Candidiasis (2 of 2)

  • Symptoms include red, swollen, intensely pruritic mucous membranes and thick, white curd-like discharge, possibly extending to vulvar tissues. Treatment involves antifungal medications.

Infections: Pelvic Inflammatory Disease (PID) (1 of 4)

  • Infection involving the uterus, fallopian tubes, and/or ovaries, usually stemming from an ascending infection in the lower reproductive tract; serious complications can arise from STDs, non-sterile abortions, or childbirth.

Infections: PID (2 of 4)

  • Infection can lead to scarring of tubes, increasing risks for infertility and ectopic pregnancy. Potential acute complications include peritonitis, pelvic abscesses, and septic shock.

Infections: PID (3 of 4)

  • Initial signs typically include strong pelvic pain alongside fever, guarding, nausea/vomiting, leukocytosis, and purulent discharge. Treatment typically includes aggressive antibiotic therapy, often necessitating hospitalization.

Leiomyoma (Fibroids)

  • These are benign tumors of the myometrium, common during reproductive years, often classified by location. Usually multiple and non-encapsulated, symptoms may include abnormal bleeding. Treatment can involve hormonal therapy or surgical intervention.

Ovarian Cysts

  • Types of ovarian cysts vary, with physiological types lasting about 8-12 weeks before resolving without complications. If bleeding occurs, inflammation ensues; identification is through ultrasound or laparoscopy, and severe cases may need surgical intervention.

Polycystic Ovarian Syndrome (PCOS)

  • Characterized by a thickened fibrous capsule around ovarian follicles. It can be hereditary and lead to symptoms like amenorrhea, hirsutism, and infertility. Treatment may include anatomical modification or pharmacological therapies.

Fibrocystic Breast Disease

  • Encompasses a range of breast tissue changes and increased density, presenting cyclically with nodules or masses. Increased density complicates self-exams. Associated risks are present with atypical cell findings. Caffeine intake linked to increased cystic masses.

Malignant Tumors Overview

  • Includes:

    • Carcinoma of the Breast

    • Carcinoma of the Cervix

    • Carcinoma of the Uterus

    • Ovarian Cancer

Carcinoma of the Breast

  • Incidence rises after age 20, predominantly observed in women aged 50-69. Tumors are generally unilateral, with earlier onset correlating with more aggressive growth.

  • Different types arise mainly from ductal epithelial cells and metastasize via lymph nodes early on. Treatment effectiveness can hinge on the presence of estrogen/progesterone receptors in tumor cells.

Carcinoma of the Breast - Risk Factors

  • Includes family history, strong genetic links (BRCA1/BRCA2), prolonged high exposure to estrogen, nulliparity or late-first pregnancy, lack of physical activity, smoking, high-fat diet, previous chest radiation, and prior uterine or ovarian cancer.

Signs and Symptoms of Breast Cancer

  • Changes visible on mammograms, with initial signs manifesting as a small, hard, painless nodule. As the disease progresses, signs may include distortion of breast tissue and nipple discharge. Diagnosis confirmed via ultrasound or needle biopsy.

Course of Breast Cancer

  • Metastasis can occur when tumors are 1-2 cm in diameter, with axillary lymph nodes impacted leading to secondary locations in bones, lungs, brain, and liver.

Treatment of Breast Cancer

  • Surgical options may include lumpectomy or mastectomy, with lymph node removal based on cancer stage. Tissue biopsies help determine necessary targeted therapies and chemotherapy.

Drug Therapy for Breast Cancer

  • Hormone blocking agents include Tamoxifen, raloxifene (Evista), and toremifene. Estrogen receptor blockers like fulvestrant (Faslodex) serve to destroy estrogen receptors on cancer cells. Other inhibiting drugs include anastrozole (Arimidex) and letrozole (Femara).

Targeted Drug Therapies for Breast Cancer

  • Includes:

    • Trastuzumab (Herceptin) and Pertuzumab (Perjeta)

    • Ado-trastuzumab (Kadcyla): Combines trastuzumab with a cytotoxic agent.

    • Lapatinib (Tykerb) targets growth factor proteins and can be used in combination with chemotherapy.

    • Palbociclib (Ibrance): Used in advanced hormone receptor positive cases.

    • Everolimus (Afinitor): Targets pathways aiding cancer cell growth.

Carcinoma of the Cervix

  • Most instances arise from HPV infection, which is sexually transmitted. Vaccination exists against high-risk HPV strains. Regular Pap smears are crucial for early detection starting at age 20 or upon sexual initiation.

Pathophysiology of Cervical Cancer

  • Progresses from early dysplasia (abnormal cell growth) through in situ tumors to invasive carcinomas affecting adjacent organs. Late-stage metastasis occurs as the disease progresses.

Cervical Cancer Etiology

  • Risk factors include:

    • Age under 40

    • Strong HPV linkage

    • Multiple sexual partners

    • Early sexual activity

    • Smoking

    • History of STDs.

Carcinoma of the Uterus

  • Most prevalent in postmenopausal women, indicated by painless vaginal bleeding or spotting. Risk factors encompass age over 50, unopposed estrogen therapy, obesity, and diabetes. Pap smears do not detect this condition as it typically arises from glandular epithelium.

Ovarian Cancer Overview

  • Ovarian cancer commonly remains silent in its presence, with no reliable screening methods; pelvic examination often reveals large masses. Increasing investigational focus targets serum diagnosis markers and types reveal variance in malignancy.

Treatment of Ovarian Cancer

  • Standard approaches include surgery and chemotherapy. Certain protective factors include the use of progesterone-containing oral contraceptives.

Infertility Factors

  • Can stem from female or male conditions (or a combination), often linked to hormonal imbalances, parental age, structural abnormalities, infections, chemotherapy, environmental toxins, or idiopathic causes.

Sexually Transmitted Diseases

  • Bacterial Infections: Chlamydia, Gonorrhea, Syphilis.

  • Viral Infections: Genital Herpes, Condylomata Acuminata (Genital Warts).

  • Protozoan Infection: Trichomoniasis.

Chlamydial Infections

  • One of the most widespread STDs caused by Chlamydia trachomatis. Males primarily experience urethritis and epididymitis. Symptoms include dysuria and white discharge. In females, infections are often asymptomatic until complications arise (PID, infertility).

Gonorrhea

  • Caused by Neisseria gonorrhoeae, affecting both males and females with potentially severe complications (PID, infertility) and dual treatment for resistance management.

Syphilis Overview

  • Caused by Treponema pallidum, progression involves primary (chancre), secondary (flu-like illness with widespread rash), latent, and tertiary stages. Treatment relies on multiple antimicrobial drugs, beleaguered by increasing antibiotic resistance among strains.