Reproductive System Disorders

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Reproductive System Disorders
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Overview

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

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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

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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

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BPHSigns and Symptoms

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

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BPHTreatment

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

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Prostate Cancer

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

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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

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Stages
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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

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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

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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

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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

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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

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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

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Normal Laparoscopy
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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

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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

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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

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Endometriosis
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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

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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

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PID
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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

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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

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PIDTreatment

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

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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

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Ovarian Cysts
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Malignant Tumors Carcinoma of the
BreastPathophysiology

• 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

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Carcinoma of the BreastPathophysiology

• 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

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Breast Cancer
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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

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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

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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

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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

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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

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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

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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

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Normal Cervix Cancerous Cervix
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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

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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

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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

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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

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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

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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

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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

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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

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Uterine CancerTreatment

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