3. Male Infertility
Can be solely male, solely female, or both
Considered infertile after one year of unprotected
intercourse fails to produce a pregnancy
Male problems include
Changes is sperm or semen
Hormonal abnormalities
Pituitary disorders or testicular problems
Physical obstruction of sperm passageways
Congenital or scar tissue from injury
Semen analysis
Assess specific characteristics
Number, motility, normality
4. Benign Prostatic Hypertrophy (BPH)—
Pathophysiology
Common in older men; varies from mild to severe
Change is actually hyperplasia of prostate
Nodules form around urethra
Result of imbalance between estrogen and testosterone
No connection w/ prostate cancer
Rectal exams reveals enlarged gland
Incomplete emptying of bladder leads to infections
Continued obstruction leads to distended bladder, dilated
ureters, renal damage
If significant, surgery required
5.
6.
7.
8. BPH—Signs and Symptoms
Initial signs
Obstruction of urine flow
Hesitancy, dribbling, decreased force of urine stream
Incomplete bladder emptying
Frequency, nocturia, recurrent UTIs
9. BPH—Treatment
Only small amount require intervention
Surgery when obstruction severe
Drugs (Flomax) used to promote blood flow helpful
when surgery not required
10. Prostate Cancer
Common in men older than 50; ranks high as
cause of cancer death
3rd
leading cause of death from cancer
11.
12. Prostate Cancer—Pathophysiology
Most are adenocarcinomas from tissue near surface of gland
BPH arises from center of gland
Many are androgen dependent
Tumors vary in degree of cellular differentiation
The more undifferentiated, the more aggressive and the faster they grow
and spread
Metastasis to bone occurs early
Spine, pelvis, ribs, femur
Cancer has typically spread before diagnosis
Staging based on 4 categories:
A small, nonpalpable, encapsulated
B palpable confined to prostate
C extended beyond prostate
D presence of distant metastases
13. Prostate Cancer—Etiology
Cause not determined
Genetic, environmental, hormonal factors
Common in North American and northern Europe
Incidence higher in black population than white
Genetic factor?
Testosterone receptors found on cancer cells
14. Prostate Cancer—Signs and Symptoms
Hard nodule in periphery of gland
Detected by rectal exam
No early urethral obstruction
b/c of location
As tumor develops, some obstruction occurs
Hesitancy, decreased stream, urinary frequency, bladder
infection
15. Prostate Cancer—Diagnostic Tests
2 helpful serum markers
Prostate-specfic Antigen (PSA)
Useful screening tool for early detection
Prostatic acid phosphatase
elevated when metastatic cancer present
Ultrasound and biopsy confirms
16. Prostate Cancer—Treatment
Surgery and radiation
Risk of impotence or incontinence
When tumor androgen sensitive:
orchiectomy (removal of testes) or
Antitestosterone drug therapy
5 yr survival rate is 85-90%
17. Female Infertility
Associated w/ hormonal imbalances
Result from altered function of hypothalamus, anterior pituitary,
or ovaries
Typically after long use of birth control pill
Structural abnormalities
Small or bicornuate uterus
Obstruction of fallopian tubes
Scar tissue or endometriosis
Access of viable sperm
Change in vaginal pH
Due to infection or douches
Excessively thick cervical mucus
Development of antibodies in female to particular sperm
Smoking by male or female
18. Female Infertility
Broad range of tests avail
General health status checked 1st
Pelvic examinations, ultrasound, CT scans check for
structural abnormalities
Tubal insufflation (gas/pressure measurement) or
hysterosalpingogram (X-ray w/ contrast material) used
to check tubes
Blood tests throughout cycle to check hormone levels
22. Endometriosis
Presence of endometrial tissue outside uterus
(ectopic)
Found on ovaries, ligaments, colon, sometimes lungs
Responds to cyclic hormonal variations
Grows and secretes then degenerates, sheds and bleeds
What is the problem? (Where does it go?)
Blood irritating to tissues = inflammation and pain
Recurs w/ e/ cycle w/ eventual fibrous tissue
Causes adhesions and obstruction
Diagnosis confirmed w/ laparoscopy
23. Endometriosis
Infertility results from
Adhesions pulling uterus out of normal position
Blockage of fallopian tubes
“chocolate cyst” develops on ovary
Fibrous sac containing old brown blood
Primary manifestations
Dysmenorrhea
More severe e/ month
Painful intercourse if vagina and supporting ligaments
affected by adhesions
24. Endometriosis
Cause not established
Migration of endometrial tissue up thru tubes to
peritoneal cavity during menstruation, development
from embryonic tissue at other sites, spread thru blood
or lymph, transplantation during surgery (C-section) all
possibilities
Treatment
Hormonal suppression of endometrial tissue
Surgical removal of endometrial tissue
Pregnancy and lactation delay further damage
and alleviate symptoms
26. Pelvic Inflammatory Disease (PID)
Common infection of reproductive tract
Particularly fallopian tubes and ovaries
Includes:
Cervicitis (cervix)
Endometritis (uterus)
Salpingitis (fallopian tubes)
Oophoritis (ovaries)
Infection either cute or chronic
Short-term concerns: peritonitis, pelvic abscess
Long-term concerns: infertility, high risk of
ectopic pregnancy
27. PID—Pathophysiology
Usually originates as vaginitis or cervicitis
Often involves several causative bacteria
Uterus fallopian tube
Edema, fills w/ purulent exudate
Obstructs tube and restricts drainage into uterus
Exudate drips out of fimbriae onto ovaries and surrounding
tissue
Peritoneal membrane attempts to localize but peritonitis may
develop
Abscesses may form; life-threatening
Cause septic shock
Adhesions affect tubes and ovaries
Lead to infertility and ectopic pregnancies
30. PID—Etiology
Arise from sexually transmitted diseases
Gonorrhea
Chlamydiosis
Prior episodes of vaginitis or cervicitis precedes
development
Infection acute during or after menses
Endometrium more vulnerable
Can also result from IUD or other contaminated
instrument
Can perforate wall and lead to inflammation and
infection
31. PID—Signs and Symptoms
Lower abdominal pain (1st
indication)
Sudden and severe or gradually increasing in intensity
Tenderness during pelvic exams
Purulent discharge at cervix
Dysuria
Fever and leukocytosis can occur
Depends on causative organism
33. Benign Tumors: Ovarian Cysts
Variety of types
Follicular and corpus luteal cysts common
Develop unilaterally in both ruptured and unruptured follicles
Usually multiple fluid-filled sacs under serosa
that covers ovary
May become large enough to cause discomfort,
urinary retention, or menstrual irreg
Bleeding if ruptures
Cause even more serious inflammation
Risk of torsion of the ovary
Ultrasound and laparoscopy to ID cyst
36. Malignant Tumors: Carcinoma of the Breast
—Pathophysiology
Develop in upper outer quadrant of breast in ½ of
the cases
Central portion of the breast is also common
Most tumors are unilateral
Different types; majority arise from ductal
epithelium
Infiltrates surrounding tissue and adheres to skin
Causes dimpling
Tumor becomes fixed when adheres to muscle or fascia of chest
wall
37. Carcinoma of the Breast—Pathophysiology
Malignant cells spread at early state
1st
to close lymph nodes
Axillary nodes
In most cases, several nodes infected at time of diagnosis
metastasizes quickly to lungs, brain, bone, liver
Tumor cells graded on basis of degree of differentiation or
anaplasia
Tumor then staged based on size of primary tumor, # lymph
nodes, presence of metastases
Presence of estrogen and progesterone receptors
Major factor in determining how to treat the pt’s cancer
39. Breast Cancer—Etiology
Major cause of death in women
Incidence continues to increase after age of 20
Strong genetic predisposition
identification of specific genes related to cancer
Hormones also a factor
Specifically exposure to high estrogen levels
Long period of regular menstrual cycles (early menarche to late
menopause)
No kids (nulliparily)
Delay of 1st
pregnancy
Role of exogenous estrogen (birth control pills,
supplements) still controversial
40. Breast Cancer—Signs and Symptoms
Initial sign is single, hard, painless nodule
Mass is freely movable in early stage
Becomes fixed
Advanced signs
Fixed nodule
Dimpling of skin
Discharge from nipple
Change in breast contour
Biopsy confirms diagnosis of malignancy
41. Breast Cancer—Treatment
Surgery, radiation, chemo
Surgery
Lumpectomy
Preferred; removal of tumor
Mastectomy
Sometimes necessary
Some lymph nodes removed as well
# removed depends on the spread of the tumor cells
Impairs draining of lymph; swelling and stiffness of arm common
Chemo and radiation
Useful for eradicating undetected micrometastases
42. Breast Cancer—Treatment
If responsive to hormones, removal of hormone
stimulation
Premenopausal women: ovaries removed
Postmenopausal women: hormone-blocking agent
Prognosis
Relatively good if nodes not involved
As # nodes increases, prognosis becomes more negative
May recur years later
Longer the period w/o recurrence, better the chances
BSE if over 20 yrs.
Mammography routine screening tool
Detect lesions before they become palpable or if they are deep in
the breast tissue
43. Carcinoma of the Cervix
# deaths has decreased due to Pap smear
Screening and early diagnosis while cancer in situ
However, # cases of carcinoma in situ has increased
in the US
Avg age of in situ onset is 35
Invasive carcinoma manifests at 45
Age range dropping to younger women
44. Cervical Cancer—Pathophysiology
Early changes in cervical epithelial tissue consist of
dysplasia
Mild then becomes severe (takes 10 yrs)
Occurs at junction of columnar cells and squamous cells of
external os of cervix
Cervical intraepithelial neoplasia (CIN) graded from I to
III
Based on amount of dysplasia and cell differentiation
Grade III
Carcinoma in situ
Many disorganized, undifferentiated, abnormal cells present (severe
dysplasia)
Takes 10 yrs from mild to carcinoma in situ so plenty of chances to
detect
45.
46. Cervical Cancer—Pathophysiology
Carcinoma in situ is noninvasive stage
Leads to invasive stage
Invasive has varying characteristics
Protruding nodular mass or ulceration
Eventually all characteristics present in the lesion
Carcinoma spreads in all directions
Adjacent tissues (uterus and vagina); bladder, rectum, ligaments
Metastases to lymph nodes occur rarely or in late stage
Staging:
0: carcinoma in situ
I: cancer restricted to cervix
II to IV: further spread to surrounding tissues
49. Cervical Cancer—Etiology
Strongly linked to STDs
Herpes simplex virus type 2 (HSV-2)
Human papillomavirus (HPV)
Virus exerts direct effects on host cell or may cause
antibody rxn
Increased antibodies have been assoc w/ increasing dysplasia
High risk factors
Multiple sex partners
Promiscuous partners
Sexual intercourse in early teen years
Pt history of STDs
Environmental factors such as smoking can predispose
women
50. Cervical Cancer—Signs and Symptoms
Asymptomatic in early stage
Can be detected by Pap test
Invasive stage indicated by slight bleeding or spotting
Anemia and wt loss can accompany
51. Cervical Cancer—Treatment
Biopsy to confirm diagnosis
Surgery and radiation to treat
5 yr survival rate 100% if carcinoma still in situ
Prognosis for invasive depends on the extent of the
spread of cancer cells
52. Carcinoma of the Uterus (Endometrial
Carcinoma)
Common cancer in women older than 40
Majority 55-65 yrs old
Simple screening not available for this cancer
Early indication is bleeding
Significant sign in postmenopausal women
53. Uterine Cancer—Pathophysiology
Majority are adenocarcinomas
arise from glandular epithelium
Malignant changes develop from endometrial
hyperplasia
Excessive estrogen stimulation major factor for
hyperplasia
Cancer is slow-growing
May infiltrate uterine wall (thickened area) or
may spread out to endometrial cavity
Eventually tumor mass fills interior of uterus
Expands thru wall into surrounding structures
54. Uterine Cancer—Pathophysiology
Graded from 1-3
1: indicate well-differentiated cells
3: poorly differentiated cells
Staging
Based on degree of localization
I: tumors confined to body of uterus
II: cancer limited to uterus and cervix
III: cancer spread outside of uterus; still in true pelvis
IV: tumor spread to lymph nodes and distant organs
57. Uterine Cancer—Signs and Symptoms
Painless vaginal bleeding or spotting is key sign
b/c cancer erodes surface tissues
Pap smear not dependable for detection
Direct aspiration of cells provides best analysis
Late signs of malignancy include palpable mass,
discomfort or pressure in lower abdomen, bleeding
following intercourse