C19 Reproductive

Chapter 19
Reproductive System Disorders

Review of Male Reproductive
System
z Testes—spermatogenesis
z Epididymis—maturation of sperm
z Vas deferens—transport of sperm to urethra
z Seminal vesicles—secretion to nourish sperm
z Prostate gland—secretions to balance pH
z Cowper glands (bulbourethral)—secretes
alkaline mucus
z Penis—ejaculation of semen
•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc. •2

Anatomy of the Male
Reproductive System

Review of Male Reproductive
System (Cont.)
z Male hormones
¾ Follicle-stimulating hormone (FSH)—initiates
spermatogenesis
¾ Luteinizing hormone (LH)—stimulates
testosterone production
¾ Testosterone—maturation of sperm, sex
characteristics, protein metabolism, muscle
development

Congenital Abnormalities
of the Penis
z Epispadias—urethral opening on ventral or
upper surface of the penis
z Hypospadias—urethral opening on dorsal
surface (underside) of the penis
¾ Either condition may result in incontinence or
infection.
z Treatment—surgical reconstruction

Disorders of the Testes and
Scrotum
z Cryptorchidism—testis fails to descend into
scrotum properly
z Ectopic testis—testis positioned outside of
scrotum
¾ Can cause degeneration of seminiferous tubules
and spermatogenesis is impaired
¾ Risk of testicular cancer increased significantly if
treatment not done by age 5 years

Cryptorchidism

Disorders of the
Testes and Scrotum (Cont.)
z Hydrocele—occurs when excessive fluid
collects in space between layers of the tunica
vaginalis of the scrotum
¾ May occur as congenital defect in newborn
¾ May be acquired as result of injury, infection,
tumor
¾ May compromise blood supply or lymph drainage
in testes

Disorders of the
z Spermatocele—cyst containing fluid and
sperm that develops between the testis and
the epididymis
¾ May be related to developmental abnormality
¾ Surgical removal

Disorders of the
z Varicocele—a dilated vein in the spermatic
cord
¾ Lack of valves allows backflow in veins; leads to
increased pressure and dilation
¾ Causes impaired blood flow to testes and
decreased spermatogenesis
¾ Requires surgery

Disorders of the
z Torsion of the testes—testes rotate on
spermatic cord, compressing arteries and
veins
¾ Ischemia develops, scrotum swells
¾ Testis may be infarcted if torsion is not reduced
¾ Can occur spontaneously or following trauma
¾ Treated manually and surgically

Abnormalities of the Scrotum

(Cont.)

(Cont.)

Inflammations and Infections
z Prostatitis—infection or inflammation of the
prostate gland
z Four recognized categories
1. Acute bacterial
2. Chronic bacterial
3. Nonbacterial
4. Asymptomatic inflammatory

Prostatitis
z Acute bacterial—gland is tender and swollen,
urine and secretions contain bacteria
z Nonbacterial—urine and secretions contain
large numbers of leukocytes
z Chronic bacterial—gland only slightly
enlarged, dysuria, frequency, urgency

Prostatitis (Cont.)
z Acute bacterial infection is caused primarily
by Escherichia coli and sometimes by
Pseudomonas, Proteus, or Streptococcus
faecalis.
z Chronic bacterial infection is related to
repeated infection by E. coli.
z These are opportunistic bacteria from the
normal flora of the gut.

Prostatitis (Cont.)
z Occurs in:
¾ Young men with UTIs
¾ Older men with prostatic hypertrophy
¾ In association with STDs
¾ With instrumentation such as catheterization
¾ Through bacteremia

Prostatitis (Cont.)
z Signs and symptoms
¾ Both acute and chronic forms manifested by
dysuria, urinary frequency, and urgency
¾ Decreased urinary stream
¾ Acute form includes fever and chills
¾ Lower back pain
¾ Leukocytosis
¾ Abdominal discomfort
¾ Systemic signs include fever, malaise,
¾ Anorexia
¾ Muscle aches

Prostatitis (Cont.)
z Treatment for acute or chronic bacterial
infection
¾ Antibacterial drugs such as ciprofloxacin
z Treatment for nonbacterial infection
¾ Anti-inflammatory drugs and prophylactic
antibacterial agents

Balanitis
z Fungal infection of the glans penis
¾ Sexually transmitted
z Caused by Candida albicans
z Vesicles develop into patches
¾ Severe burning and itching
z Treatment—topical antifungal medication

Tumors: Benign Prostatic
Hypertrophy
z Occurs in up to 50% of men > 65 years
z Hyperplasia of prostatic tissue
z Compression of urethra and urinary
obstruction
z Related to estrogen–testosterone imbalance
z Does not predispose to prostatic carcinoma

Hypertrophy (Cont.)

Hypertrophy (Cont.)
z Enlarged gland palpated on digital rectal
examination
z Leads to frequent infections
z Continued obstruction causes distended
bladder, dilated ureters, hydronephrosis, and
renal failure if untreated.

Complications of Benign
Prostatic Hypertrophy

Hypertrophy
¾ Obstructed urinary flow
¾ Hesitancy in starting flow
¾ Dribbling
¾ Decreased flow strength
¾ Increased frequency and urgency
¾ Nocturia
¾ Dysuria occurs if infection is present.

Hypertrophy (Cont.)
z Treatment
¾ Drugs such as dutasteride (Avodart) to slow
enlargement
¾ Smooth muscle relaxers such as tamsulosin
(Flomax)
¾ Combination of finasteride (Proscar) and
doxazosin (Cardura) reduces progression of
hypertrophy
¾ Surgery

Tumors: Cancer of the Prostate
z Most common cancer in men > 50 years
z Third leading cause of cancer death in men
z One in six men affected
z Most are adenocarcinomas arising near
surface of gland
z The more undifferentiated the tumor, the
more aggressive
z Many tumors are androgen-dependent.

(Cont.)
z Both invasive and metastatic
z Some forms are highly aggressive but others
are not.
z 5% to 10% caused by inherited mutations
z Other causes—high androgen levels,
increased insulin-like growth factor, history of
recurrent prostatitis

(Cont.)
¾ Hard nodule felt on periphery of gland
¾ Hesitancy in urination
¾ Decreased urine stream
¾ Frequent urination
¾ Recurrent UTI

(Cont.)
z Diagnosis
¾ Serum markers
• Prostate-specific antigen (PSA)
• Prostatic acid phosphatase
¾ Ultrasonography
¾ Biopsy
¾ Bone scans to detect metastases

(Cont.)
z Treatment
¾ Surgery (radical prostatectomy)
¾ Radiation: external or implanted pellets
¾ If androgen-sensitive, then orchiectomy is
effective, as well as antitestosterone drugs.
¾ New chemotherapies are in clinical trials.

Cancer of the Testes
z Most testicular tumors are malignant.
z 1 in 300 affected
z Most common solid tumor cancer in young
men
z Number of cases increasing
z Testicular self-examination is essential for
early detection.

Cancer of the Testes (Cont.)

z May originate from one type of cell or mixed
cells from various sources
z Teratoma—tumor consisting of mixture of
different germ cells
z Some malignant tumors secrete hCG or AFP,
which serve as useful markers for diagnosis.

z Typical spreading pattern
¾ Appear in common iliac and para-aortic lymph
nodes
¾ Then to the mediastinal and supraclavicular lymph
nodes
¾ Then through the blood to the lungs, liver, bone,
and brain

z Causes
¾ Heredity (change in chromosome 12)
¾ Predisposing factor—cryptorchidism
¾ Exposure to herbicides and other environmental
agents may be predisposing factors.

¾ Tumors are hard, painless, usually unilateral
¾ Testes may be enlarged or feel heavy.
¾ Dull aching scrotum and pelvis
¾ Hydrocele or epididymitis may develop.
¾ Gynecomastia occurs if the tumor is hormone-
secreting.

z Diagnostic tests
¾ Biopsy is not usually done.
¾ Tumor markers (hCG and AFP)
¾ Ultrasound
¾ Computed tomography
¾ Lymphangiography

Cancer of the Testis
z Treatment
¾ Combination of:
• Surgery (orchiectomy)
• Radiation therapy
• Chemotherapy
¾ NOTE: the client may wish to donate sperm prior
to treatment to ensure future fertility.

Review of the Female
Reproductive System
z Vulva
¾ Mons pubis—adipose tissue and hair covering the
symphysis pubis
¾ Labia majora and minora—outer and inner thin
folds of skin extending back and down from the
mons pubis
z Clitoris—erectile tissue anterior to urethra
z Vagina—muscular, distensible canal
extending upward from the vulva to the cervix

Reproductive System (Cont.)

z Uterus—muscular organ within which
fertilized ovum may implant and develop
z Cervix—opening into uterus and neck of the
uterus
¾ External os
• Opening from vagina filled with thick mucus
• Prevents vaginal flora from ascending into the uterus
¾ Internal os
z Fallopian tubes (oviducts)—tubes from
ovaries to uterus

z Ovaries—produce ova and estrogen and
progesterone hormones
z Breasts
¾ Glands produce colostrum and milk for newborn
¾ Adipose tissue

z Hormones and the menstrual cycle
¾ Cycle may be from 21 to 45 days
¾ Cycle consists of:
• Menstruation (days 1 to 5)
• Endometrial proliferation and production of estrogen
(days vary)
• Maturation of ovarian follicle
• Release of LH, causing ovulation

The Menstrual Cycle
z Follicle becomes the corpus luteum,
produces progesterone
z Vascularization of endometrium in
preparation for implantation (12 to 14 days
prior to onset of next menstruation)
z If implantation does not occur:
¾ Corpus luteum atrophies
¾ Uterine muscle contracts → ischemia
¾ Endometrium degenerates

The Menstrual Cycle (Cont.)

Structural Abnormalities
z Normal position of uterus
¾ Slightly anteverted and anteflexed
¾ Cervix downward and posterior
z Retroflexion of uterus
¾ Uterus tipped posteriorly
¾ May be excessively curved or bent
¾ Marked retroversion may cause back pain,
dysmenorrhea, dyspareunia
¾ In some cases, infertility may occur.

Structural Abnormalities (Cont.)

z Uterine displacement or prolapse
¾ First-degree prolapse if cervix drops into the
vagina
¾ Second-degree prolapse if cervix lies at opening
to the vagina
• Body of uterus is in the vagina
¾ Third-degree prolapse if uterus and cervix
protrude through the vaginal orifice
• Early stages of prolapse may be asymptomatic.
• Advanced stages cause discomfort, infection, and
decreased mobility.


z Rectocele
¾ Protrusion of the rectum into the posterior vagina
¾ May cause constipation and pain
z Cystocele
¾ Protrusion of bladder into the anterior vagina
¾ May cause UTIs
z If severe, conditions are treated surgically to
increase the support of the pelvic ligaments.


Menstrual Disorders
z Menstrual abnormalities
¾ Amenorrhea (absence of menstruation)
• May be primary or secondary
h Primary form may be genetic.
h Secondary form usually hormonal imbalance
¾ Dysmenorrhea
• Painful menstruation caused by excessive release of
prostaglandins as a result of endometrial ischemia
• Usually begins a few days prior to menses and lasts a
few days after onset
• NSAIDs offer relief.

Menstrual Disorders (Cont.)
z Menstrual abnormalities (Cont.)
¾ Premenstrual syndrome
• Begins approximately 1 week before onset of menses
• Pathophysiology not completely known; may be several
forms
• Breast tenderness, weight gain, abdominal distension or
bloating, irritability, emotional liability, sleep disturbances,
depression, headache, fatigue
• Treatment is individualized and may include exercise,
limiting salt intake, use of oral contraceptives, diuretics,
or antidepressant drugs.

Abnormal Menstrual Bleeding
z Usual cause is lack of ovulation, but a
hormonal imbalance in the pituitary-ovarian
axis may be a factor.
¾ Menorrhagia
• Increased amount and duration of flow
¾ Metrorrhagia
• Bleeding between cycles
¾ Polymenorrhea
• Short cycles of less than 3 weeks
¾ Oligomenorrhea
• Long cycles of more than 6 weeks

Menstrual Disorders (Cont.)
z Endometriosis
¾ Endometrial tissue occurs outside the uterus.
¾ Ectopic endometrium responds to cyclical
hormone changes.
¾ Bleeding leads to inflammation and pain.
¾ Fibrous tissue may cause adhesions and
obstructions of the involved structures.
¾ Cause has not been established but thought to be
congenital in some cases
¾ Treatment
• Hormonal suppression
• Surgical removal of ectopic tissue
Endometriosis: Possible Ectopic
Sites

Infections: Candidiasis
z Form of vaginitis that is not sexually
transmitted
z Caused by the fungus Candida albicans
z Opportunistic infection by normal flora of
vagina
¾ Antibiotic therapy
¾ Pregnancy
¾ Diabetes
¾ Reduced host resistance

Infections: Candidiasis (Cont.)
z Candidiasis causes red and swollen,
intensely pruritic mucous membranes and a
thick, white, curdlike discharge.
z May extend to vulvar tissues
z Antifungal treatment

Infections: Pelvic Inflammatory
Disease
z Infection of uterus, fallopian tubes, and/or
ovaries
z May be acute or chronic
z Infection usually originates as an ascending
infection from lower reproductive tract.
z May occur because of bacteremia
z Most infections arise from sexually
transmitted diseases, nonsterile abortions, or
childbirth.

Disease (Cont.)

Disease (Cont.)
z Scarring of tubes increases risk of infertility
and ectopic pregnancy.
z Potential acute complications
¾ Peritonitis
¾ Pelvic abscesses
¾ Septic shock

Disease (Cont.)
z Pelvic pain is usually first sign
¾ Increased temperature
¾ Guarding
¾ Nausea and vomiting
¾ Leukocytosis
¾ Purulent discharge may be present.
z Treatment usually requires aggressive
antibiotic therapy in hospital.

Benign Tumors
z Leiomyoma (fibroids)
¾ Benign tumor of the myometrium
¾ Common during the reproductive years
¾ Classified by location
¾ Usually multiple, well-defined, unencapsulated
masses
• Abnormal bleeding may occur.
• May interfere with implantation
¾ Often asymptomatic until large growth
¾ Hormonal therapy or surgery

Types of Benign Uterine Fibroids

Benign Tumors (Cont.)
z Ovarian cysts
¾ Variety of types occur
¾ Physiological type lasts about 8 to 12 weeks and
disappear without complications
¾ Usually multiple, small, fluid-filled sacs
¾ If bleeding occurs, more serious inflammation
occurs.
• Requires surgical intervention
¾ Ultrasound or laparoscopy for identification

z Polycystic ovarian disease
¾ Fibrous capsule thickens around follicles of ovary
¾ May be hereditary
¾ Absence of ovulation and infertility
¾ Hormonal imbalance
¾ Amenorrhea
¾ Hirsutism
¾ Treatment may be surgical wedge resection or
pharmacology.

Ovarian Cyst

z Fibrocystic breast disease
¾ Includes a broad range of breast changes and
increased density of breast tissue
¾ Cyclic occurrence of nodules or masses in breast
tissue
¾ Increased risk of breast cancer if atypical cells are
present.
¾ Increased density makes breast self-examination
difficult
¾ Increased cystic masses with caffeine intake

Malignant Tumors
z Carcinoma of the breast
¾ Incidence increases after age 20 years
• Most cases in women between ages 50 and 69 years
¾ Most tumors are unilateral
¾ Earlier onset associated with more aggressive
growth
¾ Different types
• Most arise from ductal epithelial cells
¾ Metastasis occurs via lymph nodes early in the
course of the disease.
¾ Presence of estrogen or progesterone receptors
on tumor cells influences treatment
Carcinoma of the Breast
z Predisposing factors
¾ First-degree relative with the disease
¾ Strong genetic predisposition (BRCA1 and
BRCA2)
¾ Longer and higher exposure to estrogen
¾ Nulliparous or late first pregnancy
¾ Lack of exercise
¾ Smoking
¾ High-fat diet
¾ Radiation therapy to the chest
¾ Cancer of the uterus, ovaries, or pancreas

Carcinoma of the Breast (Cont.)
¾ Change on mammogram
¾ Initial sign—single, small, hard, painless nodule
¾ Later—distortion of breast tissue, dimpled skin,
discharge from nipple
¾ Ultrasound or needle biopsy confirms diagnosis.

z Course of breast cancer
¾ Metastasis occurs by the time the tumor is 1 to 2
cm in diameter.
¾ Axillary lymph node involvement
¾ Secondary tumors in:
• Bone
• Lung
• Brain
• Liver

Metastatic Breast Cancer

z Treatment
¾ Surgery may be a lumpectomy or removal of the
breast.
¾ Lymph nodes may be removed, depending on the
stage of the disease.
¾ Tissue biopsy will determine the presence of
specific growth factors to design drug treatment
and chemotherapy.
¾ Radiation therapy may be done before or after
surgery.

z Staging is based on the TMN system and the
presence of receptors for specific growth
accelerators in the tumor.

Carcinoma of the Cervix
z Most cases of cervical cancer are caused by
human papillomavirus (HPV) infection, a
sexually transmitted virus.
z Vaccines now exist against the causative
strains of HPV.
z Routine Pap smears of cervical cells are
important in identifying early, treatable stages
of the disease:
¾ By age 20 years or in the year that sexual
intercourse begins
¾ At intervals, as advised by health care worker
Positive Pap Smear

Carcinoma of the Cervix (Cont.)
z Course of disease
¾ Early dysplasia of cells; abnormal cells showing
less differentiation
¾ In situ tumor is located on the mucosal surface.
¾ Invasion to submucosa
¾ Invasion and spread to adjacent organs
¾ Late metastasis

Development of Carcinoma of the
Cervix


z Risk factors
¾ Age < 40 years
¾ Strongly linked to HPV viral infection (STD)
¾ Multiple partners
¾ Sexual intercourse beginning in early teenage
years
¾ Smoking
¾ History of prior STDs

Carcinoma of the Uterus
z Most common in postmenopausal women
z Early indicator is painless vaginal bleeding or
spotting
z Risk factors
¾ Age > 50 years
¾ High-dose estrogen hormone treatment without
progesterone
¾ Obesity
¾ Diabetes

Carcinoma of the Uterus (Cont.)
z Pap smear does not detect this cancer
z Usually arises from glandular epithelium
z Relatively slow-growing but is invasive
z Staging of cancer based on degree of
localization
z Treatment—surgery and radiation are
commonly used.

Carcinoma of the Uterus (Cont.)

Ovarian Cancer
z Ovarian cancer
¾ No reliable screening available
• Large mass detected by pelvic examination
• Transvaginal ultrasound
¾ Considered a silent tumor
• Few diagnosed in the early stage
• Research is ongoing to identify markers for serum
diagnosis.
¾ Different types—vary in aggressiveness

Ovarian Cancer (Cont.)
z Risk factors
¾ Obesity
¾ BRCA1 gene
¾ Early menarche
¾ Nulliparous or late first pregnancy
¾ Use of fertility drugs
z Oral contraceptives containing progesterone
are somewhat protective.
z Surgery and chemotherapy are usual
treatments.

Infertility
z Cause may be a female condition, male
condition, or a combination of both
¾ Associated with hormonal imbalances
¾ Age of parents
¾ Structural abnormalities
¾ Infections
¾ Chemotherapy
¾ Workplace toxins
¾ Other environmental factors
¾ Idiopathic

Sexually Transmitted Diseases
(STDs): Bacterial
z Chlamydial infections
¾ Considered one of the most common STDs
¾ Caused by Chlamydia trachomatis
¾ Males—urethritis and epididymitis
• Symptoms include dysuria, itching, white discharge from
penis (urethritis symptoms)
• Painful, swollen scrotum, usually unilateral, fever
(epididymitis); inguinal lymph nodes swollen
¾ Females
• Often asymptomatic until PID or infertility develops
• Newborns may be infected during birth.

(STDs): Bacterial (Cont.)
z Gonorrhea
¾ Caused by Neisseria gonorrheae
• Many strains have become resistant to penicillin and
tetracycline.
¾ Males
• Most common site is urethra, which is inflamed
• Some males are asymptomatic.
¾ Females
• Frequently asymptomatic
• PID and infertility are serious complications.

(STDs): Bacterial (Cont.)
z Gonorrhea
¾ May infect the eyes of the newborn, causing
irreversible damage and blindness
¾ May spread systemically to cause septic arthritis

Acute Epididymitis Caused by
Gonococcal Infection

STDs: Syphilis
z Caused by Treponema pallidum, a spirochete
z Primary stage
¾ Presence of chancre at site of infection
• Genital region
• Anus
• Oral cavity
¾ Painless, firm, ulcerated nodule
¾ Occurs about 3 weeks after exposure
¾ Lesion heals spontaneously but client is still
contagious

STDs: Syphilis (Cont.)

z Secondary stage
¾ If untreated, a flulike illness occurs, with a
widespread symmetrical rash—self-limited but
client remains contagious
z Latent stage
¾ May persist for years
¾ Transmission may occur.
z Tertiary syphilis—irreversible changes
¾ Gummas in organs and major blood vessels
¾ Dementia, blindness, motor disabilities

z Organism can be transmitted to fetus in utero
z Baby born with tertiary syphilis changes that
are not reversible
z Treatment is usually antimicrobial drugs.
z Increase in antibiotic resistant strains causing
an increase in prevalence

STDs: Viral Infections
z Genital herpes—herpes simplex
¾ Caused by HSV-2 or HSV-1
• HSV-1 possible with oral sex
¾ Lesions similar to HSV-1
¾ Recurrent outbreaks of blister-like vesicles on the
genitalia
• Preceded by tingling or itching sensation
• Lesions are extremely painful.
¾ After acute stage, virus migrates back to dorsal
root ganglion
¾ Infectivity greater when symptoms are present

STDs: Genital Herpes

STDs: Genital Herpes (Cont.)
z Reactivation is common and may be
associated with:
¾ Stress
¾ Illness
¾ Menstruation
z Antiviral drugs are used for treatment and
prevention of transmission.
z Infection is considered lifelong.

STDs: Viral Infections (Cont.)
z Condylomata acuminata—genital warts
¾ Caused by HPV
¾ Incubation period may be up to 6 months
¾ Disease may be asymptomatic
¾ Warts vary in appearance.
¾ Warts can appear wherever contact with virus has
occurred.
¾ Warts can be removed by different methods.
¾ May predispose to cervical or vulvar cancer

STDs: Viral Infections (Cont.)
z Trichomoniasis
¾ Caused by Trichomonas vaginalis, a protozoan
parasite
¾ Localized infection
¾ Men
• Usually asymptomatic
¾ Women
• May be subclinical
• Flares up when microbial balance in vagina shifts
• Causes intense itching
¾ Systemic treatment necessary for both partners

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Chapter 19

Reproductive System Disorders

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