Male and Female Reproductive System: Conditions and Cancers
Male Reproductive System: Conditions and Cancers
Hormones
- Follicle-stimulating hormone (FSH)—initiates spermatogenesis
- Luteinizing hormone (LH)—stimulates testosterone production
- Testosterone—maturation of sperm, sex characteristics, protein metabolism, muscle development
Cryptorchidism
Testis fails to descend into the scrotum properly. The reason for maldescent is not fully understood. 3% of full-term births; 30% of premature births.
- Ectopic testis: outside the scrotum
- Can cause degeneration of seminiferous tubules, and spermatogenesis is impaired
- Risk of testicular cancer increases significantly if treatment is not done by age 5 years
Hydrocele
Occurs when excessive fluid collects in the space between layers of the tunica vaginalis of the scrotum.
- May occur as a congenital defect in newborns
- May be acquired as a result of injury, infection, or tumor
- May compromise blood supply or lymph drainage in testes
- Communicating hydrocele – seen in infants – open space between the peritoneal cavity and testicular cavity.
- Adults – response to infection or injury
Varicocele
A dilated vein in the spermatic cord.
- Lack of valves allows backflow in veins; high pressure
- Causes impaired blood flow to testes and decreased spermatogenesis
- Requires surgery
- Highest incidence in males 15-35.
- Can cause decreased fertility
Testicular Torsion
Testes rotate on the spermatic cord, compressing arteries and veins: ischemia/swelling.
- The testis may be infarcted if torsion is not reduced.
- Can occur spontaneously or following trauma
- Treated manually and surgically
- Can occur at any age, but most cases in adolescence: rapid growth
- Thought to be abnormal attachments around the testis.
- True medical emergency – early recognition & treatment essential to save the testicle
Epididymitis
Inflammation of the epididymis: bacterial infection.
- Sexually transmitted infections associated with urethritis
- Primary nonsexually transmitted infections associated with UTI and prostatitis
Diagnosis
- Laboratory findings usually reveal an elevated white blood cell count.
- Urinalysis and urine culture are important.
- The cause can be differentiated by Gram stain examination or culture of a midstream urine specimen or a urethral specimen.
- Doppler ultrasound may be useful, revealing increased blood flow to the affected testis
Orchitis
An infection of the testes.
- Can be precipitated by a primary infection in the genitourinary tract
- The infection can be spread to the testes through the bloodstream or the lymphatics. Ex: mumps
Prostatitis
Infection/ inflammation of the prostate gland.
- Acute bacterial—gland tender & swollen, bacteria in urine/secretions
- Nonbacterial—urine & secretions contain large numbers of leukocytes
- Chronic bacterial—gland slightly enlarged, dysuria, frequency, urgency
- Asymptomatic inflammatory
Etiology
Often an ascending infection.
- Acute bacterial infection is caused primarily by E. coli
- Chronic bacterial infection is related to repeated infection by E. coli.
Occurs in: Young men with UTIs, Older men with prostatic hypertrophy, STDs, catheterization. Bacteremia
Signs and Symptoms
- Both acute and chronic forms manifested by dysuria, urinary frequency, and urgency
- Decreased urinary stream: urethra compression
- Acute form includes fever and chills: infection
- Lower back pain and abdominal discomfort
Treatment
- Acute or chronic bacterial infection: Antibiotics
- Nonbacterial infection: Anti-inflammatory drugs and prophylactic antibacterial agents
Inguinal Hernia
In some males, the opening still exists where testes descended from the abdominal cavity.
- More prone to inguinal hernias (colon into the scrotum)
Benign Prostatic Hypertrophy
- Occurs in up to 50% of men over 65 years old
- Hyperplasia of prostatic tissue
- Compression of the urethra and urinary obstruction
- Related to estrogen–testosterone imbalance
- Does not predispose to prostatic carcinoma
- Age-related, nonmalignant prostate gland enlargement
- Characterized by the formation of large, discrete lesions in the periurethral region of the prostate rather than the peripheral zones, which are commonly affected by prostate cancer
- Enlarged gland palpated on digital rectal examination
- Leads to frequent infections
- Continued obstruction causes distended bladder, dilated ureters, hydronephrosis, and renal failure if untreated
Signs and Symptoms
- Obstructed urinary flow
- Hesitancy in starting flow
- Dribbling
- Decreased flow strength
- More frequency and urgency: incomplete bladder emptying
- Nocturia
Treatment
- Drugs such as dutasteride to slow enlargement
- Smooth muscle relaxers
- Surgery
Cancers of the Male Reproductive System
Cancer of the Testes
- Most testicular tumors are malignant.
- 1 in 300 affected
- Most common solid tumor cancer in young men
- Number of cases increasing
- Testicular self-examination is essential for early detection.
- May originate from one type of cell or mixed cells from various sources
- Teratoma—tumor consisting of a mixture of different germ cells
- Some malignant tumors secrete hCG or AFP, markers for diagnoses
Typical Spreading Pattern
- Appear in common iliac and paraaortic lymph nodes
- Then to the mediastinal and supraclavicular lymph nodes
- Then through the blood to the lungs, liver, bone, and brain
TNM Classification
- Stage I: tumor confined to testes, epididymis, or spermatic cord
- Stage II: tumor spreads to retroperitoneal lymph nodes below the diaphragm.
- Stage III: metastases outside the retroperitoneal nodes or above the diaphragm
Risk Factors
- Heredity (change in chromosome 12)
- Predisposing factor—cryptorchidism
- Exposure to herbicides and other environmental agents may be predisposing factors.
Signs and Symptoms
- Tumors are hard, painless, usually unilateral.
- Testes may be enlarged or feel heavy.
- Dull aching scrotum and pelvis
- Hydrocele or epididymitis may develop.
- Gynecomastia: breast tissue overgrowth- occurs if the tumor is hormone-secreting
Diagnosis
- Biopsy is not usually done.
- Tumor markers (hCG and AFP)
- Ultrasound computed tomography
- Lymphangiography
Treatment
- Surgery: Orchiectomy
- Radiation therapy
- Chemotherapy
Cancer of the Prostate
- Most common cancer in men > 50 years
- Third leading cause of cancer death in men
- One in six men affected
- Most are adenocarcinomas arising near the surface of the gland
- The more undifferentiated the tumor, the more aggressive
- Many tumors are androgen-dependent
Risk Factors
- Age 2/3 diagnosed after age 65
- Over 70 less aggressive
- Family history –having a father or brother with the disease doubles risk
- Testosterone production
- History of recurrent prostatitis
- Fatal prostate cancer – recent smoking history, higher BMI
Symptoms
- Both invasive and metastatic
- Some forms are highly aggressive, but others are not.
- 5% to 10% caused by inherited mutations
Signs and Symptoms
- Hard nodule felt on the periphery of the gland
- Hesitancy in urination
- Decreased urine stream
- Frequent urination
- Recurrent UTI
Tumor Grading System
- T1: Primary-stage tumors are asymptomatic and discovered on histologic examination of prostatic tissue specimens.
- T2: Tumors are palpable on digital examination but are confined to the prostate gland.
- T3: Tumors have extended beyond the prostate.
- T4: Tumors have pushed beyond the prostate to involve adjacent structures
Diagnosis
- Prostate-specific antigen (PSA)
- Prostatic acid phosphatase
- Ultrasonography
- Biopsy
- Bone scans to detect metastases
Treatment
- Surgery: radical prostatectomy
- Radiation: external or implanted pellets
- If androgen-sensitive: androgen receptor, then orchiectomy is effective, as well as antitestosterone drugs: less testosterone slows progress
Female Reproductive System: Conditions and Cancers
Uterus—muscular organ within which a fertilized ovum may implant and develop
Cervix—opening into the uterus and neck of the uterus
- External os
- Opening from the vagina filled with thick mucus
- Prevents vaginal flora from ascending into the uterus
- Internal os
Fallopian tubes (oviducts)—from ovaries to the uterus
Ovaries: produce ova and estrogen and progesterone
Progesterone
- “Pro-gestation” maintains pregnancy
- Important throughout the cycle in non-pregnant women
- Smooth muscle relaxation
- Raise body temperature – increase before ovulation
Menstrual Cycle
- Maturation of the ovarian follicle, rupture of the mature follicle: ovulation
- The follicle becomes the corpus luteum and produces progesterone
- Vascularization of the endometrium in preparation for implantation (12- 14 days before the next menstruation)
- If implantation does not occur:
- Corpus luteum atrophies
- Uterine muscle contracts: ischemia
- Endometrium degenerates
Structural Abnormalities of the Uterus
- Normal: Slightly anteverted and anteflexed, Cervix down and posterior
- Rectocele: Protrusion of the rectum into the posterior vagina
- May cause constipation and pain
- Cystocele: Protrusion of the bladder into the anterior vagina
- May cause UTIs
- Uterine displacement or prolapse
- First-degree prolapse if the cervix drops into the vagina
- Second-degree prolapse if the cervix lies at the opening to the vagina- the body of the uterus is in the vagina
- Third-degree prolapse if the uterus and cervix protrude through the vaginal orifice
- Early stages of prolapse may be asymptomatic.
- Advanced stages: discomfort, infection, and less mobility.
Menstrual Disorders
- Amenorrhea: no menstruation
- Primary: genetic, or secondary: hormonal imbalance
- Dysmenorrhea: painful menstruation caused by a high release of prostaglandins due to endometrial ischemia
- Premenstrual syndrome: begins approximately 1 week before the onset of menses
- Breast tenderness, weight gain, abdominal distension or bloating, irritability, emotional liability, sleep disturbances, depression, headache, fatigue
Abnormal Menstrual Bleeding
The usual cause is a lack of ovulation, but a hormonal imbalance in the pituitary-ovarian axis may be a factor.
- Menorrhagia: increased amount and duration of flow
- Metrorrhagia: bleeding between cycles
- Polymenorrhea: short cycles of less than 3 weeks
- Oligomenorrhea: long cycles of more than 6 weeks
- Menometrorrhagia: heavy bleeding during and between menstrual periods
Endometriosis
- Endometrial tissue occurs outside the uterus.
- Ectopic endometrium responds to cyclical hormone changes.
- Bleeding leads to inflammation and pain.
- Fibrous tissue may cause adhesions and obstructions of the involved structures.
- The cause has not been established but is thought to be congenital in some cases.
- Treatment
- Hormonal suppression
- Surgical removal of ectopic tissue
Pelvic Inflammatory Disease
Infection of the uterus, fallopian tubes, and/or ovaries.
- Infection usually originates as an ascending infection from the lower reproductive tract.
- May occur because of bacteremia
- Most infections arise from sexually transmitted diseases, nonsterile abortions, or childbirth
- Scarring of tubes: risks infertility and ectopic pregnancy
- Potential acute complications
- Peritonitis
- Pelvic abscesses
- Septic shock
- Pelvic pain is usually the first sign.
- Increased temperature
- Guarding
- Nausea and vomiting
- Leukocytosis
- Purulent discharge may be present.
- Treatment usually requires aggressive antibiotic therapy in a hospital
Leiomyoma (Fibroids)
- Benign tumor of the myometrium
- Common during the reproductive years
- Classified by location
- Usually multiple, well-defined masses
- Abnormal bleeding may occur
- May interfere with implantation
- Often asymptomatic until a large growth
- Hormonal therapy or surgery
Symptoms
- Risk factors
- Genetic factors: familial
- Dietary: red meat, low vegetables
- Symptoms
- 50% asymptomatic
- Menorrhagia
- Anemia
- Urinary frequency
- Rectal pressure, constipation
Polycystic Ovarian Disease
A spectrum of hormonal imbalance coupled with insulin resistance.
- Follicles develop
- But they do not ovulate after the LH surge
- The high LH levels continue
- LH stimulates androgen production
- Androgens interfere with ovulation even more
- Ovaries contain many unovulated follicles: cysts
Management
- Regulate menses with oral contraceptives: low androgens
- Metformin – insulin sensitizer, ↓ circulating effect of insulin on ovaries
Carcinoma of the Breast
- Incidence increases after age 20 years
- Most tumors are unilateral.
- Earlier onset is associated with more aggressive growth. Different types: most from ductal epithelial cells
- Predisposing factors
- First-degree relative with the disease
- Strong genetic predisposition (BRCA1 and BRCA2)
- Longer and higher exposure to estrogen
- Nulliparous: no pregnancy or late first pregnancy
- Cancer of the uterus, ovaries, or pancreas
Detection of Breast Cancer
- Approx. 40% of BCs can be detected only by mammography
- Mammography has a sensitivity of 80-90% for detecting cancer: follow with biopsy
- M. better at detecting cancer in older women, breast tissue less dense = glandular
Signs and Symptoms
- Initial sign: single, small, hard, painless nodule
- Later: distortion of breast tissue, dimpled skin, discharge from the nipple
- Ultrasound or needle biopsy confirms the diagnosis.
- Metastasis occurs by the time the tumor is 1 to 2 cm in diameter.
- Axillary lymph node involvement: secondary tumor in bone, lung, liver, brain
Treatment
- Surgery may be a lumpectomy or removal of the breast.
- Lymph nodes may be removed, depending on the stage of the disease.
- Tissue biopsy will determine the presence of specific growth factors to design drug treatment and chemotherapy.
- Radiation therapy may be done before or after surgery.
- The presence of estrogen or progesterone receptors on tumor cells influences treatment.
Carcinoma of the Cervix
- Most cases of cervical cancer are linked to human papillomavirus (HPV) infection: risk factor, a sexually transmitted virus.
- Vaccines now exist against the causative strains of HPV.
- Certain types of sexual behavior increase the risk of HPV contraction
- Routine Pap smears of cervical cells: identify early treatable stages of the disease
Course of Disease
- Early dysplasia of cells; abnormal cells showing less differentiation
- In situ, the tumor is located on the mucosal surface.
- Invasion to submucosa
- Invasion and spread to adjacent organs
- Late metastasis
Carcinoma of the Uterus (Endometrial Carcinoma)
- Type 1 – Occurs in women in their 40s (peri- menopausal)
- Accounts for 80% of cases
- Associated with estrogen excess, obesity, DM, nulliparity, early menarche, late menopause
- Type 2 – Occurs in menopausal women, peak age 55-65
- Associated with uterine atrophy, poorer prognosis
- Abnormal bleeding is an early warning sign in 90% of cases of both types of cancer
- Pap smear does not detect this cancer.
- Usually arises from glandular epithelium
- Relatively slow-growing but is invasive
- Staging of cancer is based on the degree of localization
- Most frequent invasive cancer of the female reproductive tract in developed countries
- Treatment—surgery and radiation
Ovarian Cancer
- Considered a silent tumor: few diagnosed in the early stage
- Causes vague GI symptoms: increased abdominal size, indigestion, bloating, early satiety
- No reliable screening available: large mass detected by pelvic examination, transvaginal ultrasound: best for early detection
- Up to 75% of cases have metastasized by the time they are discovered. 5 -year survival – 20-30%
- Surgery and chemotherapy are usual treatments
Risk Factors
- Ovulatory age – the length of time in which ovulation has not been suppressed by pregnancy, lactation, or oral contraceptive use: high risk from nulliparous or late 1st pregnancy
- Frequency much lower in countries where women bare numerous children breastfeed
- Other factors: use of fertility drugs, BRCA 1 gene, obesity
- High-fat Western diet, and use of talc (talcum powder) in the genital area have been linked to the disease
Stages of Gynecologic Cancer
- Stage 0: rarely used; preinvasive lesions
- Stage I: cancer is confined to the organ it originated in.
- Stage II: cancer involves some structures surrounding the organ of origination.
- Stage III: regional spread of cancer with lymph node involvement
- Stage IV: distant spread of cancer with metastasis