Reproductive System Disorders

Reproductive System Disorders Ch 28 Pgs 592-621 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 • 3rd 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 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 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 (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 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 – 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 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 1st 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