Reproductive System Disorders

1. Reproductive System Disorders Pathophysiology

2. Male Reproductive System • Anatomy • Gonads = Testes • Ductile system = epididymis, vas deferens, ejaculatory duct, urethra • Supportive glands = seminal vesicles, prostate, bulbourethral (Cowper’s) • External genitals = scrotum, penis

3. 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

4. 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

5. 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

6. Hormones and male reproductive function

7. Female Reproductive System • Anatomy • gonads = ovaries • ductal system = fallopian tubes, uterus, vagina • accessory glands = Bartholin's, breasts • external genitalia = clitoris, labia majora & minora, perineum

8. 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

9. 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

10. 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

11. hormonal control • hypothalamus--------GnRH (gonadotropin releasing hormone) • anterior pituitary---- FSH (follicle stimulating hormone) LH (luteinizing hormone) • Ovary --------------- Estrogen Progesterone

12. Male reproductive tract disordersoverall outline • Disorders of testes & scrotum • Disorders of prostate • Disorders of the penis

13. Disorders of the Testes & Scrotum • 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

14. 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

15. 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

16. Torsion of the testis Etiol: Spontaneous Post trauma Timing Usually puberty Path: necrosis & infarction

17. 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%

18. Prostate Diseases • Benign Prostatic Hypertrophy (BPH) • enlargement of the prostate common in older men • Involves central area of gland • complications include: • pyelonephritis • hydronephrosis • uremia

19. 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

20. Pathology of the Penis • Foreskin (prepuce) • phimosis • paraphimosis • redundant foreskin • Glans • Balantitis STD from Yeast (Candida)

21. 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

22. Female reproductive tract disordersoverall outline • Structural abnormalities • Menstrual disorders • Endometriosis • Menopause • Infections • Tumors • Benign • Malignant • Breast • Pregnancy • STD’s

23. Structural abnormalities • Pelvic relaxation disorders • Normal variations of uterine position • Uterine mobility is key to normalcy • Uterine prolapse • First, second, & third degrees • Cystocele • Rectocele

24. Normal variations of uterine position • Uterine mobility is key to normalcy • midline • Anteverted & anteflexed • Retroverted & retroflexed

25. 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

26. 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

27. Menstrual Disorders • 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

28. 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

29. 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

30. 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

31. Infections of the Female Reproductive Tract • 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 !!

32. Note PID spread: • Vaginitis • Cervicitis • Endometritis • Oophoritis • 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

34. 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”

35. Tumors of the Female Reproductive Tract

36. 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

37. 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

38. 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 Functional (follicular) cyst Solid teratoma

40. 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

41. 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

42. Pathology in Pregnancy • 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

43. 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

44. STD’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

45. 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

46. 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

47. 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

48. 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

49. Differences in clinical appearance among genital ulcers