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Pathology of Reproductive Systems Dr. Donald Allen University of Mary copyright 2000 Functions of Reproductive Systems Production of germ cells Sexual Reproduction Pregnancy Support of Neonate Female Reproductive Anatomy Male Reproductive Anatomy Production of Germ Cells Ovaries - production of oocytes Fallopian tubes - transport of oocytes, site of fertilization Testes - production of sperm Epididymus - maturation of sperm Ductus deferens - transport of sperm Sexual Function Vagina Uterus - menstrual cycle Penis Prostate gland - production of seminal fluid Pregnancy Uterus Support of Neonate Breast Pathology of the Reproductive Systems Infertility Infections and Inflammation Tumors Special Aspects with Regard to Pathology Organs are open to the environment Tissues produce tumors Tumors responsive to hormones Pathology of the Male Reproductive System Congenital abnormalities Infection and Inflammation Tumors Congenital Abnormalities Cryptoorchidism Testicular torsion Cryptoorchidism Most common congenital defect In most boys, the testes are completely descended by birth Malpositioning of the testes outside the scrotum Unilateral or bilateral – if unilateral more common on right Treatment is by surgery Complications Complications of Cryptoorchidism Sterility if untreated Increased risk of testicular cancer Testicular Torsion Abnormal twisting of the spermatic cord Infrequent cause of testicular enlargement SURGICAL EMERGENCY Often associated with congenital abnormalities Can occur after heavy physical activity Most often in men 8-18 y.o., rarely after age 30 Testicular Torsion Manifestations Rapid onset of scrotal pain and swelling Pain may extend into inguinal region Possible nausea, vomiting and tachycardia Testis - firm and tender, often positioned high in scrotum Scrotal erythema and edema Testicular Torsion - Treatment If untreated, may result in atrophy, abscess and infertility Emergency surgery If < 3 hours before surgery, 80% salvage of testis If > 12 hours, 20% salvage Infection and Inflammation Orchiditis - testes Epididymitis Prostatitis Orchiditis Bacterial or Viral Cause Complication of Mumps 18-35% of men with mumps, primarily adults Mumps virus excreted in the urine Often secondary to UTI Orchiditis – Manifestations Severe testicular pain Pain may occur in lower abdominal region Swelling Chills Fever Testes appears swollen and tender, swollen and red scrotum Usually no signs of urinary dysfunction Epididymitis Risk factors Manifestations Complications Epididymitis Caused by bacterial pathogens Necrosis and fibrosis may occlude the genital ducts and produce infertility Epididymitis – Manifestations Fever Chills When bacteriuria is present, Urinary frequency and urgency and dysuria may occur Pain – unilateral scrotal pain is common May also have pain in lower abdominal, groin or hip adductor regions Prostatitis Acute or chronic, bacterial or nonbacterial (Table 16-1) PTs most likely to encounter chronic prostatitis Risk factors Pathogenesis Manifestations Acute Bacterial Prostatitis Urinary frequency and urgency Dysuria Urethral discharge High fever – chills Malaise Myalgia Arthralgia Pain – rectal and or sacral Chronic Bacterial Prostatitis May be asymptomatic Urinary frequency and urgency Dysuria Nocturia Low grade fever Pain: Low back, rectal Nonbacterial Prostatitis Most common kind Urinary frequency and urgency Dysuria Impotence, decreased libido Pain: low back, rectal, scrotal May be related to excessive alcohol or caffeine intake Tumors Testicular Tumors Benign Prostatic Hyperplasia Prostate Cancer Testicular Cancer - Incidence Relatively rare 3% of male urogenital cancers Most common cancer of men 15-35 y.o. Testicular Cancer – Risk Factors Cryptoorchidism – 35X higher incidence Mother taking exogenous estrogen during pregnancy –2-6% higher History of infertility, scrotal trauma, or infection Testicular Cancer Manifestations Enlargement of the testis – most common initial sign Enlargement may be accompanied by ache in abdomen or scrotum, or heavy feeling in the scrotum May metastasize with little or no change in scrotum Testicular Cancer Manifestations Signs of metastasis Back pain – may be primary presenting complaint (21% of men with germ cell cancer, Cantwell et al., 1987) Abdominal mass Hemoptysis Neck or supraclavicular adenopathy Testicular Cancer – Treatment Orchidectomy Chemotherapy Radiation therapy Peritoneal lymphatic dissection Testicular Cancer – Treatment side effects Changes in posture Changes in movement mechanics of trunk, pelvis and hip Sexual dysfunction Benign Prostatic Hyperplasia Non-malignant tumor Related to changes that occur with aging Changes in estrogen and testosterone levels BPH - Risk Factors Age Geography 75% of men over 50 y.o. have signs of prostatic enlargement More common in North America and Western Europe Race More common in African-Americans BPH - Pathogenesis Proliferation of epithelial cells, smooth muscle cells and fibroblasts in the prostate gland Usually initially in the periurethral part of gland (Fig 16-2) Narrowing of the lumen of the urethra BPH - Clinical Manifestations Secondary to narrowing of urethra Urinary flow obstruction - difficulties in initiation and force Increased risk of UTI Dysuria, hematuria Marked bladder distension Renal failure --> death BPH - Treatment If mild, monitor condition Surgery Side effects: Impotence Drugs Side effects: Impotence, loss of libido, gynecomastia, drowsiness, dizziness, tachycardia, postural hypotension Prostatic Cancer Most common cancer in men Usually develops in the periphery of the gland Treatment Complications of treatments Prostatic Cancer - Risk Factors Age, > 50 y.o. 25% of men 60-69 40% of men 70-79 >50% of men 80 and above Black race Geography (US and Scandinavian countries) Prostatic Cancer - Risk Factors Family history Environmental exposure to cadmium Diet - high fat intake Venereal disease Black race Prostatic Cancer Manifestations Usually asymptomatic in early stages Early symptoms are usually those due to urinary obstruction symptoms – by this time the tumor has often metastasizes Pain Constitutional symptoms Prostatic Cancer – Pain Pain in rectal region Pain in sacral or lumbar spine regions Associated with bony metastasis Pain in thoracic or shoulder girdle regions Associated with lymphatic spread or bony metastasis Prostatic Cancer – Constitutional Symptoms Due to metastatic spread of the cancer Fatigue Anemia Weight loss Dyspnea Prostatic Cancer - Treatments Surgery: Side effects: infection, incontinence, impotence Radiation: Side effects: diarrhea, GI or urinary bleeding Hormonal treatments: Side effects: loss of libido, impotence, hot flashes, gynecomastia, bloating and pedal edema, nausea and vomiting, diarrhea, MI, CVA, deep venous thrombus Pathology of the Female Reproductive Tract Hormonal disorders Infections Benign or malignant tumors Disorders related to pregnancy Endometriosis Abnormal localization of endometrial tissue Can be located in myometrium or in sites outside the uterus Endometrial tissue is functional and responds to hormonal stimulation Endometriosis – Risk Factors Woman of childbearing years (10-15%) More common in women who postpone pregnancy Early menarche Menstrual cycles 27 days or less Menstrual periods lasting 7 days or longer Endometriosis – Signs and Symptoms Depend on location of endometrial tissue Low abdominal or pelvic pain associated with menstrual period Uterine involvement – dyspareunia Bladder involvement – dysuria Rectal – pain on defecation May produce false positive findings Ectopic Pregnancy Fertilized ovum implants outside the uterus – usually the fallopian tubes One of the major causes of maternal death in the US Ectopic Pregnancy – Risk Factors Pelvic inflammatory disease Prior tubal surgery Ruptured appendix Endometriosis Previous ectopic pregnancy Infertility Pathogenesis Implantation in fallopian tube Bleeding occurs during implantation – may be perceived as menstruation Pregnancy outgrows blood supply – resulting in termination of pregnancy If termination does not occur, rupture of tube occurs by 12th week - emergency Clinical Manifestations Amenorrhea or irregular bleeding Lower abdominal quadrant or back pain Can be diffuse and aching or localized Will progress to sharper pain due to leakage of blood into abdominal and pelvic cavities Pain may refer to shoulder if blood reaches high in abdominal cavity Pelvic mass S & S of normal pregnancy Fatigue, nausea, breast tenderness, urinary frequency Amenorrhea Primary – failure to begin menstrual cycles Secondary – failure after a variable period of normal function Amenorrhea – causes Physiological Anatomical Genetic Endocrinological Constitutional Psychogenic In athletes Toxic Shock Syndrome Caused by bacterial toxin Most common in women under 30 who use tampons Also linked to barrier contraceptives, burns, IV drug use, insect bites, surgical and non-surgical wounds, postpartum and gynecological infections, vaginitis and lung abscesses TSS – Manifestations Sudden elevated temperature Vomiting and diarrhea Erythematous macular rash Renal dysfunction Hypotension and shock may develop Pelvic Inflammatory Disease General term of infection of upper reproductive tract Risk factors Symptoms Complications Ovarian Cancer 2nd most common urogenital cancer 1st in number of deaths Difficult to diagnose At diagnosis, 60-70% metastasis Ovarian Cancer – Risk Factors Age – peak incidence 40-60 Geography – NW Europe, US and Canada Race – White and Hawaiian Nulliparity Family history History of infertility Ovarian Cancer – Protective Factors 1 or more full term pregnancies History of breastfeeding Use of oral contraceptives Native American women Ovarian Cancer – Clinical Manifestation Asymptomatic or vague Abdominal bloating Flatulence Abnormal vaginal bleeding – not common Local pelvic pain – a late sign Ovarian Cancer – Clinical Manifestation Metastasis Unexplained weight loss Cachexia Weakness Ascites Shoulder girdle or thoracic pain Breast Diseases Infections Hormonally-induced changes Tumors Inflammation – Acute Mastitis Usually occurs in lactating women Can form a localized abscess or spread through entire breast Signs Swelling Redness Painful area – sensitive to palpation Hormonally-induced changes Normal changes Breast enlargement during puberty After menopause, the breasts undergo atrophy – can be prevented by exogenous estrogens Hormonally-induced changes Fibrocystic change – fibrosis and cysts that occur in the breasts About 50% by biopsy or autopsy Only 10-15% of women have symptoms May or may not be painful Usually affects both breasts, but symptoms may be asymmetrical Pain, fine nodules in breast tissue, tenderness Benign tumors Fibroadenoma Usually well encapsulated Usually 2-5 cm in diameter Usually affect young women – peak incidence in 20’s Malignant tumors 2nd most common tumor in women Causes are hormonal and genetic Risk factors Gender – 100X more often in women Genetic predisposition Hormonal factors Early menarche - <12 Late menopause > 50 Nulliparous women or late first pregnancy Presence of other cancers Premalignant fibrocystic change Risk factors Age Rare before puberty Increased incidence after 35 Peaks in postmenopausal women about 60 y.o. Race – White Diabetes Obesity Potential Risk Factors Oral contraceptives Hormone therapy High-fat diet Alcohol consumption Breast Cancer Manifestations Tumors usually surrounded by dense connective tissue Pulls on adjacent tissue – causing puckering of the skin and retraction of the nipple Tumors are firm, but do not have sharp margins Most tumors are in upper lateral breast quadrant (45%) Typically not painful Breast Cancer Manifestations Most tumors metastasize into the axillary lymph nodes Distant metastasizes common in liver, bones, brain, and adrenals S & S – upper extremity edema, bone pain, jaundice, weight loss Most breast cancers are detected by selfexamination, examination by a doctor, or mammography Role of PT Awareness of non-muscular tissues in shoulder and shoulder girdle Lymph nodes – 50% of women have metastasis to axillary nodes at time of diagnosis Menopause Cessation of menstruation Average age 50 Complete when there are no menstrual periods for 1 year Also occurs after surgical removal of ovaries Physiological Changes Hot flashes Changes in reproductive organs Dryness and atrophy Dyspareunia, stress incontinence, vaginal itching and burning Osteoporosis Cardiovascular diseases Hypertension, stroke, heart disease Psychological Changes Nervousness Depression and feelings of worthlessness and hopelessness Headache Insomnia Decreased sex drive Memory loss Vertigo