Reproductive System Disorders

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

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

BPH Treatment 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 3 rd leading cause of death from cancer

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

Stages

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

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

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

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%

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 1 st 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

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

PID

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

PID Signs and Symptoms Lower abdominal pain (1 st 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

PID Treatment 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 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

Carcinoma of the Breast Pathophysiology Malignant cells spread at early state 1 st 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

Breast Cancer

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 1 st pregnancy Role of exogenous estrogen (birth control pills, supplements) still controversial

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

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

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

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 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

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

Normal Cervix; Cancerous Cervix

Cervical Cancer Etiology 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 Cancer Signs 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 Cancer Treatment 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 Cancer Pathophysiology 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 Cancer Pathophysiology 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 Cancer Etiology Higher risk if increased estrogen levels Assoc w/ exogenous estrogen (postmenopausal women) Recommended dosage lowered Oral contraceptives Infertility Obesity, diabetes, hypertension increase risk

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