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
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
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 Testes and Scrotum (Cont.) 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 Testes and Scrotum (Cont.) 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 Testes and Scrotum (Cont.) 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
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
Tumors: Benign Prostatic 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.
Tumors: Benign Prostatic 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.
Tumors: Cancer of the Prostate (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
Tumors: Cancer of the Prostate (Cont.) z Signs and symptoms ¾ Hard nodule felt on periphery of gland ¾ Hesitancy in urination ¾ Decreased urine stream ¾ Frequent urination ¾ Recurrent UTI
Tumors: Cancer of the Prostate (Cont.) z Diagnosis ¾ Serum markers • Prostate-specific antigen (PSA) • Prostatic acid phosphatase ¾ Ultrasonography ¾ Biopsy ¾ Bone scans to detect metastases
Tumors: Cancer of the Prostate (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.
Cancer of the Testes (Cont.) 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
Cancer of the Testes (Cont.) z Causes ¾ Heredity (change in chromosome 12) ¾ Predisposing factor—cryptorchidism ¾ Exposure to herbicides and other environmental agents may be predisposing factors.
Cancer of the Testes (Cont.) z Signs and symptoms 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.
Cancer of the Testes (Cont.) 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
Review of the Female 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
Review of the Female Reproductive System (Cont.) z Ovaries—produce ova and estrogen and progesterone hormones z Breasts ¾ Glands produce colostrum and milk for newborn ¾ Adipose tissue
Review of the Female Reproductive System (Cont.) 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
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.
Structural Abnormalities (Cont.) 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
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.
Infections: Pelvic Inflammatory 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
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
Benign Tumors (Cont.) 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.
Benign Tumors (Cont.) 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
Carcinoma of the Breast (Cont.) z Signs and symptoms 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.
Carcinoma of the Breast (Cont.) 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
Carcinoma of the Breast (Cont.) 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.
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
Carcinoma of the Cervix (Cont.) 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.
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.
Sexually Transmitted Diseases (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.
Sexually Transmitted Diseases (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
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
STDs: Syphilis (Cont.) 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 (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