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