Reproductive System DisordersReproductive System Disorders

Pathophysiology

• Anatomy– Gonads = Testes

– Ductile system = epididymis, vas deferens, ejaculatory duct, urethra

– Supportive glands = seminal vesicles, prostate, bulbourethral (Cowper’s)

– External genitals = scrotum, penis

Male Reproductive SystemMale Reproductive System

• Testes– tunica vaginalis = parietal peritoneum that remains surrounding testis after its descent – tunica albuginea = tough connective tissue membrane that surrounds testis and enters the gland to form septa– seminiferous tubules = where sperm are developed; approx. 100 yards in in testis; contain Sertoli cells; between tubules are inter- -stitial spaces that contain Leydig cells

• Testes (cont)

– Physiology

• Spermatogenesis

– mature sperm formed by process of Meiosis

» Key = getting mature gamete with ½ number of chromosomes

» mature sperm = head (nucleus & acrosome), neck (mitochondria), and tail

» takes 60 days +/- to make a sperm

– primary spermatocyte, secondary spermatocyte, spermatids, sperm

• Testosterone Production

– 2 key functions

» masculinization

» anabolism

• Male Ductal System– Epididymis

– storage tank for sperm– sperm get final maturation

– Vas Deferens– becomes Ejaculatory Duct after it joins

seminiferous tubule duct– Urethra

• Accessory Glands– Seminal Vesicles

– contributes 60% of semen» rich in fructose ; provides energy for

the sperm– Prostate

– contributes 30% of semen ; provides nutrients for the sperm; antibiotic secretion

– Bulbourethral Glands (Cowper’s)– contribute 5-10% of semen ; provides

lubrication & sterilization

• External Genitalia– Penis

– 3 columns of erectile tissue» corpora cavernosa (2) & corpora

spongiosum (1)– glans covered by foreskin (prepuce)

– Scrotum– skin-covered (has hair follicles) pouch

suspended from groin

• Hormones and male reproductive function

• Anatomy– gonads = ovaries

– ductal system = fallopian tubes, uterus, vagina

– accessory glands = Bartholin's, breasts

– external genitalia = clitoris, labia majora & minora, perineum

Female Reproductive Female Reproductive SystemSystem

• Ovaries– contain gametes (oocytes) surrounded by

some cells (follicular cells)

– these called Primary Follicles

» each ovary has appox. 1 million at birth

– life cycle of oocyte after puberty: primary oocyte, secondary oocyte, ovum

– functions

• gamete production

• hormone production

– Estrogen = causes feminization ; from granulosa cells

– Progesterone = prepares for pregnancy ; from corpus luteum

• Female Ductal System– Fallopian Tubes

• distal end = fimbria

• Outer 1/3 = fertilization

– Uterus

• composed of fundus, body, & cervix

• has myometrium & endometrium]

– Vagina

• Accessory Glands– Bartholin’s (greater vestibular)

• exocrine gland

• provides lubrication

– Breasts

• composed of glands & ducts surrounded by fat tissue

• External Genitalia– clitoris, labia majora & minora (no hair follicles), vestibule, perineum

• The Menstrual Cycle– begins after menarche ; ends

with menopause

– 4 basic parts:– Menses– Proliferative

Phase = first half of cycle

» deals with maturation of follicle & development of more granulosa cells thus producing more estrogen

– Ovulation = usually at midcycle

– Secretory Phase = second half of cycle

» deals with conversion of ruptured follicle to corpus luteum

» corpus luteum produces progesterone

• hormonal control• hypothalamus--------GnRH (gonadotropin releasing hormone)

• anterior pituitary---- FSH (follicle stimulating hormone)

LH (luteinizing hormone)

• Ovary --------------- Estrogen

Progesterone

Male reproductive tract disordersoverall outline

• Disorders of testes & scrotum

• Disorders of prostate

• Disorders of the penis

• Cryptorchidism– undescended testis

– By age one, 80% are in scrotum

– incidence: 3% of term babies; 20% of premies

– increases the incidence of carcinoma (Seminoma)

– treat early-------the longer you wait, the greater the chance of decreased sperm & testosterone production

Disorders of the Testes & ScrotumDisorders of the Testes & Scrotum

• Remember:– Tunica Albuginea = thick connective tissue that covers testes & divides substance of testes into lobules– Tunica Vaginalis = peritoneum that remains around testes after descent

– 2 layers: visceral (on testis) & parietal (around testis)• Hydrocele

– most common disease of testes– it’s fluid in cavity bound by the 2 layers of tunica vaginalis

– this may communicate with peritoneal cavity via congenital patency of process vaginalis

– this may cause size to vary from time to time

• Infertility Problems– deals with decreased production and/or quality of sperm

– 2 distinct reasons

– poor production in sperm development

» One correctable cause = varicocele

– blockage of ductile system

– low count = oligospermia

– zero count = azospermia

• Varicocele– varicosities around the testis (usually left testis)

– left spermatic vein into renal vein (10 cm higher

than insertion of right spermatic

vein into inferior vena cava)

– usually begins at puberty

– may be relieved by lying down

• Torsion of the testis– Etiol:

• Spontaneous

• Post trauma

– Timing • Usually puberty

– Path: necrosis & infarction

• Testicular Cancer– range from VERY aggressive to least aggressive

• Germ cell tumors

» Seminoma = least aggressive (most common)

» Nonseminomas

* embryonal carcinoma

* teratomas

* choriocarcinoma = most aggressive

• Non- germ cell tumors

» May be hormonally active (secrete androgen or estrogen)

» Exp: leydig cell, Sertoli cell

– tumors of young men ( age 15 - 35)

– diagnosis : tumors are solid masses - no transillumination

– Usually unilateral

– predisposing factors:

– undescended testes

– inguinal hernia during childhood

– prior history of mumps orchitis

» Note: in mumps orchitis, 50% of cases result in testicular atrophy

– Cure rate = 95%

• Benign Prostatic Hypertrophy (BPH)– enlargement of the prostate common in older men

– Involves central area of gland

– complications include:

• pyelonephritis

• hydronephrosis

• uremia

Prostate DiseasesProstate Diseases

• Cancer– primarily occurs in men over age 50– third leading cause of cancer death– Involves periphery of gland

– Usually begins as nodule on posterior surface of gland– Many are androgen dependent– If metastases, first usually to bone– diagnosis

» DRE» 2 serum markers

» PSA (prostatic specific antigen)» Prostatic acid phosphatase

» Ultrasound

• Foreskin (prepuce)– phimosis– paraphimosis– redundant foreskin

• Glans– Balantitis

Pathology of the PenisPathology of the Penis

STD from Yeast (Candida)

• Carcinoma– Rare– Risk factors: HPV (now have vaccination)– First sign = usually leukoplakia– circumcision in child prevents it

• adult circumcision does not prevent it

• Impotency– approx. 50% of men age 40 - 70 have, at times, some degree or complete

impotency ( failure to get an erection)

– sexual stimulation causes release of nitric acid from nerves in penis

– an enzyme breaks down the product of nitric acid that causes the erection

– this enzyme’s effect is loss of the erection

– this is where Viagra works ; it prevents loss of the erection

Female reproductive tract disordersoverall outline

• Structural abnormalities

• Menstrual disorders

– Endometriosis

– Menopause

• Infections

• Tumors– Benign

– Malignant

• Breast

• Pregnancy

• STD’s

Structural abnormalities

• Pelvic relaxation disorders– Normal variations of uterine position

• Uterine mobility is key to normalcy – Uterine prolapse

– First, second, & third degrees– Cystocele– Rectocele

Normal variations of uterine position

– Uterine mobility is key to normalcy

– midline

– Anteverted & anteflexed

– Retroverted & retroflexed

Uterine Prolapse• def = downward

displacement of uterus

• etiol = fascial tissue defect

• First degree

• Get vaginal shortening

• Second degree

• Cervix at introitus

• Third degree

• Vagina completely everted

• Uterus hanging outside vagina

• Cystocele• downward displacement of bladder

into vagina• Can get retention & frequent

cystitis• urethra may or may not accompany

it» called cysto-urethrocele» frequently get symptom of

urinary stress incontinence

• Rectocele• displacement of rectum into vagina

• Usually asymptomatic

• If very large may get constipation & inability to completely evacuate rectum

• May get ulceration of vaginal wall• See picture

• Dysmenorrhea– Primary dysmenorrhea = when no obvious pathology found

– ? Hormonal cause » prostaglandins» hormonal changes secondary to teenage ovulatory cycles

– Secondary dysmenorrhea = when obvious pathology found as the cause

• Amenorrhea– Primary Amenorrhea = never having a menstrual flow– Secondary Amenorrhea = having menstrual cycles & then they stop– causes = many !!!

» Treatment directed at the underlying cause

Menstrual DisordersMenstrual Disorders

• Dysfunctional Uterine Bleeding (DUB)– abnormal menstrual flow when no obvious cause is known

– frequently thought to be secondary to some type of hormonal imbalance, but specific diagnosis not necessary to have DUB

– Types:» oligomenorrhea » polymenorrhea» menorrhagia» metrorrhagia» meno-metrorrhagia

• Premenstrual Syndrome (PMS)– group of symptoms that occur in the woman’s secretory phase of cycle– Currently called : PMDD (premenstrual dysphoric disorder)

• Def of dysphoria = excessive pain, anguish, & agitation

– usually secondary to inappropriate ovulation– Key = too much estrogen & not enough progesterone in the second half of the cycle

• Endometriosis– A condition when you get

endometrial tissue located outside its normal position, which is the inside lining of the uterus

– symptoms depend on where the ectopic tissue is located

– the tissue has function, i.e.

bleeds with menstruation

– Sx : pain

– Complications

• Fibrosis

• Scarring

• Adhesions

• Infertility

• Dyspareunia

• menopause– Get cessation of menses & drop in estrogens which can cause:

– general symptoms

» irritability

» short term memory loss

» Insomnia

» Vasomotor instability = hot flashes & night sweats

– gynecological symptoms

» vaginal dryness & dyspareunia

» urinary stress incontinence

– Cardiovascular problems

» ASHD

» coronary artery disease

» strokes

– Osteoporosis

– Dx:

– High FSH; low estrogens

• Vaginitis– 3 types:

• Yeast Vaginitis– caused by fungus from genus Candida or Monilia

• Trichomonas

– caused by a protozoa

– may be sexually transmitted

• Bacterial Vaginosis

– caused by different bacterial overgrowth

– used to be called non-specific vaginitis or Gardnella

• Generally most cases of vaginitis are NOT sexually transmitted, but at times they ALL may be sexually transmitted !!

Infections of the Female Reproductive TractInfections of the Female Reproductive Tract

• Pelvic Inflammatory Disease (PID)– usually acute, but may be chronic

– may involve some or all of the pelvic organs

– get tissue inflammatory reaction with resultant symptoms

– Key symptom = pelvic pain

– Pain worsens with movement & sex

– frequently secondary to untreated or inadequately treated STD

– Complications

– Infertility (pyosalpinx)

– Adhesions

– Dysuria

– Irregular vaginal bleeding

See next slide

• Note PID spread:– Vaginitis

– Cervicitis

– Endometritis

– Oophoritis

• Toxic Shock Syndrome (TSS)– vaginal infection with systemic symptoms

– caused by staphlococci toxin which comes from nidus of infected tampon

– prevention by proper tampon toilet

– Symptoms begin immediately post menses

Bartholin cyst (Bartholinitis) Etiol = pathogens that cause inflammation Duct become obstructed

Get “large pimple”

TumorsTumors of the Female Reproductive Tract of the Female Reproductive Tract

• Cervix– Benign

• Cervical polyps

– malignant• key ages: 20 - 40• pap smear• Etiol: HPV

– Vaccine available

• Uterus– benign

• fibroids = commonest tumor of female repo. System

– leiomyomas– only in premenopause– See next slide

– malignant• ? Estrogen related• Age: 50 – 70• Dx: pmb

• Estimated that half the women get them during the reproductive years

• Clinically symptoms depend on size & location

• Submucous = bleeding problems, infertility

• Intramural = sx only if large

• Subserous = pressure sx from surrounding structures

• Ovary– Benign

• Functional (commonest)– Follicular cyst– Corpus luteum cyst

• Non-functional (benign germ cell)

(e.g. Teratoma)

– Malignant• Factors that suppress ovulation

decrease the risk• Avg age = 40• 2 basic types

– Epithelial (line ovary or

follicles)– Germ cell – aggressive

» Mainly in children & adolescents

• See next slide re:– Late diagnoses – seeding

Solid teratoma

Functional (follicular) cyst

Breast disorders• Fibrocystic breasts

• Was called fibrocystic “disease”

• “lumpy” breasts

• Fibroadenoma• Benign

• In young girls (age 15-25)

• nontender

• Intraductile papilloma• Get nipple discharge

• Mammary duct ectasia– Get lumpiness beneath areola

– Seen in

– Postmenopausal

– Pregnancy

– Lactation

– Get thick nipple discharge

– Pathophysiology: ducts dilate & fill with cellular debris; get inflammation

• Breast cancer– 1 out of 8 women in USA

– Most are intraductile carcinomas

– 50% in upper outer quadrant

– Ca in situ = mammary dysplasia

– Risk factors:

– Family history

– Menstrual history

– Reproductive history

• Morning Sickness– severe form = Hyperemesis Gravidarum

• Spontaneous Abortion– 3 Types : Complete, Incomplete, Missed

• Ectopic Pregnancy• Toxemia of Pregnancy = syndrome of hypertension, proteinuria,

& edema• called Preeclampsia• If severe & accompanied by convulsions, called Eclampsia

• Placental Problems– Placenta Praevia– Abruptio Placenta

• Hydatidiform Mole = development abnormality of conception• may progress to Choriocarcinoma

Pathology in PregnancyPathology in Pregnancy

• Preterm Birth – 8% of all births in US

– Preterm labor

– Preterm PROM (premature rupture of membranes)

» Responsible for half of all premie deliveries in US

• Trauma during pregnancy– Complicates 1 out of 12 pregnancies in US

– Watch for:» Uterine contractions» Uterine tenderness &/or irritability» Ruptured BOW» Nonreassuring FHR pattern» Vaginal bleeding

• Maternal hemorrhage– Is the leading cause of maternal mortality

– Hemorrhagic shock

– Postpartum hemorrhage

• Endometritis– Occurs in 1-3% of vaginal births

– Occurs in 10-50% of cesarean sections

STD’sSTD’s• AIDS (Acquired Immunodeficiency Syndrome)

• Def: progressive impairment of the immune system caused by the immunodeficiency virus (HIV)

– Attacks helper T lymphocytes

• Initial infection similar to URI• Then latency• Then AIDS

– Begins with generalized adenopathy, weight loss, fatigue, nt. Sweats, and diarrhea

– Get opportunistic infections:» PCP (pneumocystis carinii pneumonia) = caused by small

protozoa (? fungus) that can normally be found in lung tissue of certain animals (dogs) and in humans

» Toxoplasmosis = small protozoan that can infect many mammals including cats and dogs

» Herpes simplex» Herpes zoster (shingles)» TB

• AIDS (continued)– Get opportunistic cancers

» Non-Hodgkins lymphoma

» Kaposi’s sarcoma

• HIV also has predilection to attack G-I cells & CNS cells– Get malabsorption, colitis, and proctitis

– Dementia

• Diagnosis– ELISA (enzyme-linked immunosorbent assay)

– Western blot test

• Treatment– AZT = reverse transcriptase inhibitors

– Protease inhibitors

– Fusion inhibitors

• Chlamydia– Most frequent bacterial STD– Known as the “silent STD”– Transmitted via oral, anal, or genital intercourse

» Oral route can lead to conjunctivitis– If symptomatic, get urethritis – Incubation = 1-3 weeks

• Gonorrhea– Bacterial– Incubation = 1-3 weeks (usually less than 1 week)– Very similar in signs & symptoms to chlamydia– Antibiotic resistance

• Syphilis– Bacterial – Can get primary, secondary, and tertiary forms– New cases at an all time low– Primary = hard, painless chancre in 2-3 weeks ------------ see pictures– Secondary syphilis may appear 1-3 months later– Then latency for years & then possible tertiary syphilis

• Chancroid– Soft chancre (painful) with

bubo(necrotizing ulceration & lymphadenopathy) in 1 week

• See pictures

– Bacterial

– Frequent in developing tropical countries

– Increasing in urban USA

• Genital Herpes– Type I & type II

– Short incubation of 2-7 days

– See pictures

• Hepatitis B & C– Transmitted in body fluids

• Genital warts– Very contagious

– First exposure incidence:– 40% ---to--- 90%

– Viral; HPV– 120 different serotypes– A few cause dysplasia &

neoplasia– Condylomata accuminatum

– Benign growths– See picture

– Prolonged incubation of 1-6 months

– Most frequent STD– Estimated that 60% of

sexually active young women in USA have it

– New vaccine available

Differences in clinical appearance among genital ulcers