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					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 (C-
    section) 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

				
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