Gender-Based Pathology

1. Gender-Based Pathology Ann Sudoh, M.D. SMDC Sports Medicine/Medical Orthopedics

2. Male Conditions • 1. Genital Injury • 2. Scrotal Masses • 3. Testicular Cancer • 4. Gynocomastia

3. Genital Injury Testicular Penile Direct trauma Frostbite Traumatic irritation • Direct trauma • Torsion of spermatic cord • Epididymitis • Cryptorchidism

4. Genital Injury-testicular • Direct trauma – testicular contusion • DX: pain, pallor, nausea, anxiety • TX: ice, elevate • DDX: • Torsion – pain longer than 12-24 hrs • Fracture of testicle or epididymis • Expanding mass does not transilluminate • Epididymis cannot be separated from testicle

5. Genital Injury-testicular • Torsion of spermatic cord • DX: True Emergency • Edema, hyperemia, tender scrotal skin • Increasing abdominal or groin pain and excruciating testicular pain • High-riding testicle/ abnl position of epididymis • TX: within 4-6 hrs • Ice, lidocaine cord block, derotation OR surgery • DDX: epididymitis

6. Genital Injury-testicular • Epididymitis • DX: • Tender indurated epididymis • Fixed to skin with swollen spermatic cord • Fever, elevated WBC, UA with leukocytes • Chlamydia <35 yrs, E. Coli >35 yrs • TX: antibiotics (fluroquinolones) • DDX: torsion of spermatic cord

7. Genital Injury - testicular • Cryptorchidism – undescended or absent • DX: stop short of scrotum or agenesis • TX: surgical repair (orchiopexy) • Anorchia – bilaterally absent • DX: agenesis or vascular compromise

8. Genital Injury - penile • Direct trauma-straddle injury or direct hit to pubis • Uretheral rupture, vascular injury, fracture to tunica albuginea • Frostbite - runners, skiers • Pudendal nerve irritation - cyclists • May cause priapism or ischemic neuropathy

9. Scrotal masses • Spermatocele • Cystic mass within or around epididymis • Extravasation of sperm from trauma or infxn • Hydrocele • Cyst surrounding testicle/epididymis • ↑fluid in tunica vaginalis

10. Scrotal Masses • Varicocele – “bag of worms” • Varicosities of internal spermatic veins • Hematocele • Blood accumulation in tunica vaginalis • Does not transillumintate

11. Testicular Cancer • Most common malignancy in 16-35 y/o men • DX: firm, non-tender mass in testicle • Does not transilluminate, U/S solid mass • Screen: Monthly TSE from age 14-15 yrs

12. Gynecomastia • Benign glandular breast tissue in males • DX: idiopathic or medication • Check testosterone, estradiol, LH, TSH, hCG • Common in infancy, adolescent, elderly males • No risk for breast cancer • TX: within 1 yr, may be reversible • DDX: pseudogynecomastia – adipose tissue

13. Female Conditions • 1. Breast injuries/disorders • 2. Pregnancy • 3. Menstrual Cycle Irregularities • 4. Female Athlete Triad

14. Breast injuries/disorders • Blunt trauma- ecchymosis, swelling, hematoma • Mastitis - skin infection, antibiotics • Mastalgia - breast pain, support, diet, OCP’s • Nipple discharge – pathalogic if spontaneous • Breast mass

15. Breast injuries/disorders breast cancer • Most common female cancer • Lifetime probability 1 in 6 • DX: breast exam, mammogram, fine needle aspiration • Screen: • Monthly SBE from age 18 • Annual clinical BE from age 18 • Mammogram q2yrs from age 40-50 then q1yr

16. Pregnancy – physiologic changes • Cardiovascular • Musculoskeletal • Respiratory • Weight gain and nutrition

17. Pregnancy – cardiovascular change • Increased blood volume • 50% by end of pregnancy • Plasma volume then red cell mass • Dilutional anemia until 32 wks • Greater oxygen carrying capacity • Increased cardiac output and stroke vol • ↑pulse, ↓blood pressure, ↓venous tone

18. Pregnancy – respiratory change • Facilitate gas exchange between mother and fetus through placenta • ↑ventilation, ↓CO2, ↑pH • Prevent fetal acidosis • Feel short of breath, but adequate O2 • Avoid prolonged anaerobic exercise • Maternal hypoxia/acidosis = fetal hypoxia/acidosis

19. Pregnancy – musculoskeletal change • Posture, gait, balance • Forward center of gravity • ↑Ligamentous laxity – progesterone • ↑Pelvic and joint laxity – relaxin (placenta) • Risk for falls and sprains

20. Pregnancy – weight gain and nutrition • Avg wt gain 25-30 lbs • 40% from fetus, amniotic fluid, placenta • ↑baseline caloric needs by 300kcal/day • Dehydration can cause N/V, ketosis, hyperthermia

21. Pregnancy - exercise • Physical benefits • Maternal fitness • Control wt gain • ↓ back pain • ↑ sleep and energy • ↓ water retention • ↓ varicose veins • Shorten labor and decrease complications • Rapid postpartum recovery • Psychological • Improved self-image and mental outlook • Improved sense of control • Relief of tension/stress

22. Pregnancy - exercise Absolute obstetric contraindications Relative obstetric contraindications Multiple gestations Hx of miscarriage (>1) Breech in 3rd trimester Hx of precipitous labor • Pregnancy induced HTN • Premature rupture of membranes • Hx of preterm labor • Incompetent cervix • Persistent 2nd or 3rd trimester bleeding • IUGR

23. Pregnancy - exercise Absolute medical contraindications Relative medical contraindications Malnutrition Cardiac arrythmia Anemia Active thyroid disease Extremely sedentary lifestyle • Hemodynamically sig. heart disease • Hemodynamically sig. anemia • Uncontrolled HTN • Uncontrolled diabetes • Uncontrolled kidney disease

24. Pregnancy - guidelines • Regular vs. intermittent activity • Avoid hyperthermia during 1st trimester • Avoid abdominal trauma • Avoid exercise to exhaustion (65-85% max HR) • Avoid supine position after 3rd trimester • Proper nutrition (300 kcal/day)

25. Menstrual Cycle Irregularites • Has menses started? • Delayed menarche if >16yrs • Irregular? • Short cycles <25 D • Long cycles >35 D • No cycles <3 cycles/year

26. Menstrual Cycle IrregularitiesNormal cycle

27. Menstrual Cycle Irregularities short cycle • Short luteal phase • Decreased progesterone • Anovulatory bleeding • Breakthrough bleeding

28. Menstrual Cycle Irregularities long cycle • Oligo- / amenorrhea • Exercise induced – hypothalamus (GnRH) • PCOS – pituitary gland (FSH,LH) • Ovarian failure – ovary (estrogen, progesterone) • Pregnancy

29. Menstrual Cycle Irregularitiesoligo-/amenorrhea • Risks: • Young age (immature HPO axis) • Activity (run, cycle, dance, swim) • Intensity • Mileage • Hx of irregular menses • Prepubertal training • Delayed menarche • Inadequate nutrition (protein, calories)

30. Female Athlete Triad • Disordered Eating • Amenorrhea • Osteoporosis

31. Who is at risk? • Sports with subjective scoring • dance • figure skating • gymnastics • Endurance sports favoring low body wt • distance running • x-country skiing • cycling

32. Sports involving body contour-revealing clothing for competition • volleyball • swimming/diving • running • Sports with weight categories • horseracing • rowing • martial arts

33. Sports in which pre-pubertal body habitus favors success • gymnastics • diving • figure skating

34. Anorexia Nervosa Wt <85% normal for age Intense fear of gaining weight Body dysmorphic disorder Amenorrhea Bulimia Nervosa Binge eating Inappropriate compensatory behaviors Episodes 2/week x 3 months Body dysmorphic d/o Disordered Eating vs. Eating Disorder

35. Disordered eating • Eating Disorder NOS • Criteria for anorexia nervosa with normal menses • Criteria for anorexia nervosa with normal weight • Criteria for bulimia nervosa with fewer binge/purge episodes • Compensatory episodes after even small intake • Repeatedly chewing and spitting out, but not swallowing large amounts of food • Binge eating disorder

36. Intake monitoring intake restricting foods acceptable foods voluntary starvation Output diet pills laxatives diuretics binge and purge excessive exercise Disordered eating

37. General risk factors chronic dieting low self-esteem family dysfunction physical/sexual abuse biologic factors perfectionism lack of nutrition knowledge Athlete risk factors emphasis on body wt for performance pressure from coaches, parents, judges, peers over trained or sudden increase in training vulnerable times win at all costs athletic personality Disordered eating

38. Disordered eating

39. Disordered eating

40. Disordered eating • Harmful effects • depletion of muscle glycogen stores • dehydration and electrolyte abnormalities • loss of muscle mass • hypoglycemia • anemia • amenorrhea • osteoporosis

41. Amenorrhea • Primary: no menstrual bleeding by age 16 • Secondary: Absence of menstrual bleeding for 6 months or 3 consecutive missed cycles • Prevalence: non-athletes 2-5% athletes 4-66% Otis CL. Clin Sports Med 11:351-62, 1992

42. Amenorrhea • Low body weight and low body fat • Exercise stress theory • Energy availability theory

43. Amenorrhea • Exercise Stress Theory • Exercise = Stress • activation of adrenal axis • inhibition of hypothalamic GnRH pulses

44. Amenorrhea • Energy Drain Theory • energy availability = dietary energy intake - exercise energy expenditure • intake << output • negative energy balance disrupts GnRH release and LH pulsatility

45. Amenorrhea Healthy female • energy balance at 45 kcal/kg(125# female = 2,551 kcal) • reproductive function and bone turnover impaired if less than 30 kcal /kg(125# female = 1,701) • decrease in energy availability by 33% Ilhe R, Loucks AB. J Bone Miner Res 19:1231-40,2004 Loucks AB, Thuma JL. J Clin Endocrinol Metab 88:297-301,2003

46. Amenorrhea • Eumenorrheic athletes restrict energy availability by 30% • Amenorrheic athletes restrict energy availability by 44-67% Thong FS, McLean C, Grahm, TE. J Appl Physiol 88:2037-44,2000

47. Osteoporosis • Premature bone loss • Inadequate bone formation • Risk of osteoporosis: • length/severity of menstrual irregularity • nutritional status • type of previous skeletal loading • genetics • medications

48. Osteoporosis • 60% peak bone mass achieved during adolescence (bone mass increases 45-60% in second decade) • peak bone mass by third decade • pre-menopause bone loss 0.3-0.5% per yr • menopause bone loss 3% per yr x first 10 yrs

49. Osteoporosis • Bone loss generalized throughout skeleton • Increased risk for stress fracture • Increased risk for premature osteoporosis • ?Reversibility?

50. Treatment • Multidisciplinary approach • physician: monitors medical status of the athlete • nutritionist: provides dietary guidance • mental health professional: identifies and addresses psychological issues • coach or trainer: provide performance evaluation