Transcript Reproductive System Disorders

Reproductive
System
Disorders
Overview
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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
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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:
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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
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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
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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
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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
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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