Pathology of Reproductive Systems

Dr. Donald AllenUniversity of Mary

copyright 2000

Functions of Reproductive Systems

Production of germ cells Sexual Reproduction Pregnancy Support of Neonate

Female Reproductive Anatomy

Male Reproductive Anatomy

Production of Germ Cells Ovaries - production of oocytes Fallopian tubes - transport of

oocytes, site of fertilization Testes - production of sperm Epididymus - maturation of sperm Ductus deferens - transport of

sperm

Sexual Function Vagina Uterus - menstrual cycle Penis Prostate gland - production of

seminal fluid

Pregnancy Uterus

Support of Neonate Breast

Pathology of the Reproductive Systems Infertility Infections and Inflammation Tumors

Special Aspects with Regard to Pathology Organs are open to the

environment Tissues produce tumors Tumors responsive to hormones

Pathology of the Male Reproductive System Congenital abnormalities Infection and Inflammation Tumors

Congenital Abnormalities Cryptoorchidism Testicular torsion

Cryptoorchidism Most common congenital defect In most boys, the testes are completely

descended by birth Malpositioning of the testes outside the

scrotum Unilateral or bilateral – if unilateral more

common on right Treatment is by surgery Complications

Complications of Cryptoorchidism Sterility if untreated Increased risk of testicular cancer

Testicular Torsion Abnormal twisting of the spermatic cord Infrequent cause of testicular

enlargement SURGICAL EMERGENCY Often associated with congenital

abnormalities Can occur after heavy physical activity Most often in men 8-18 y.o., rarely after

age 30

Testicular Torsion - Manifestations Rapid onset of scrotal pain and

swelling Pain may extend into inguinal region Possible nausea, vomiting and

tachycardia Testis - firm and tender, often

positioned high in scrotum Scrotal erythema and edema

Testicular Torsion - Treatment If untreated, may result in atrophy,

abscess and infertility Emergency surgery If < 3 hours before surgery, 80%

salvage of testis If > 12 hours, 20% salvage

Infection and Inflammation Orchiditis - testes Epididymitis Prostatitis

Orchiditis Bacterial or Viral Cause Complication of Mumps

18-35% of men with mumps, primarily adults

Mumps virus excreted in the urine Often secondary to UTI

Orchiditis – Manifestations Severe testicular pain Pain may occur in lower abdominal region Swelling Chills Fever Testes appears swollen and tender,

swollen and red scrotum Usually no signs of urinary dysfunction

Epididymitis Risk factors Manifestations Complications

Epididymitis Caused by bacterial pathogens Necrosis and fibrosis may occlude

the genital ducts and produce infertility

Epididymitis – Manifestations Fever Chills When bacteriuria is present, Urinary

frequency and urgency and dysuria may occur

Pain – unilateral scrotal pain is common May also have pain in lower abdominal,

groin or hip adductor regions

Prostatitis Acute or chronic, bacterial or non-

bacterial (Table 16-1) PTs most likely to encounter

chronic prostatitis Risk factors Pathogenesis Manifestations

Acute Bacterial Prostatitis Urinary frequency and urgency Dysuria Urethral discharge High fever – chills Malaise Myalgia Arthralgia Pain – rectal and or sacral

Chronic Bacterial Prostatitis May be asymptomatic Urinary frequency and urgency Dysuria Nocturia Low grade fever Pain: Low back, rectal

Nonbacterial Prostatitis Most common kind Urinary frequency and urgency Dysuria Impotence, decreased libido Pain: low back, rectal, scrotal May be related to excessive

alcohol or caffeine intake

Tumors Testicular Tumors Benign Prostatic Hyperplasia Prostate Cancer

Testicular Cancer - Incidence Relatively rare 3% of male urogenital cancers Most common cancer of men 15-35

y.o.

Testicular Cancer – Risk Factors Cryptoorchidism – 35X higher

incidence Mother taking exogenous estrogen

during pregnancy –2-6% higher History of infertility, scrotal

trauma, or infection

Testicular Cancer - Manifestations Enlargement of the testis – most

common initial sign Enlargement may be accompanied

by ache in abdomen or scrotum, or heavy feeling in the scrotum

May metastasize with little or no change in scrotum

Testicular Cancer - Manifestations Signs of metastasis

Back pain – may be primary presenting complaint (21% of men with germ cell cancer, Cantwell et al., 1987)

Abdominal mass Hemoptysis Neck or supraclavicular adenopathy

Testicular Cancer – Treatment Orchidectomy Chemotherapy Radiation therapy Peritoneal lymphatic dissection

Testicular Cancer – Treatment side effects Changes in posture Changes in movement mechanics

of trunk, pelvis and hip Sexual dysfunction

Benign Prostatic Hyperplasia Non-malignant tumor Related to changes that occur with

aging Changes in estrogen and testosterone

levels

BPH - Risk Factors Age

75% of men over 50 y.o. have signs of prostatic enlargement

Geography More common in North America and

Western Europe Race

More common in African-Americans

BPH - Pathogenesis Proliferation of epithelial cells,

smooth muscle cells and fibroblasts in the prostate gland

Usually initially in the periurethral part of gland (Fig 16-2)

Narrowing of the lumen of the urethra

BPH - Clinical Manifestations Secondary to narrowing of urethra Urinary flow obstruction -

difficulties in initiation and force Increased risk of UTI Dysuria, hematuria Marked bladder distension Renal failure --> death

BPH - Treatment If mild, monitor condition Surgery

Side effects: Impotence Drugs

Side effects: Impotence, loss of libido, gynecomastia, drowsiness, dizziness, tachycardia, postural hypotension

Prostatic Cancer Most common cancer in men Usually develops in the periphery

of the gland Treatment Complications of treatments

Prostatic Cancer - Risk Factors Age, > 50 y.o.

25% of men 60-69 40% of men 70-79 >50% of men 80 and above

Black race Geography (US and Scandinavian

countries)

Prostatic Cancer - Risk Factors Family history Environmental exposure to

cadmium Diet - high fat intake Venereal disease Black race

Prostatic Cancer - Manifestations Usually asymptomatic in early

stages Early symptoms are usually those

due to urinary obstruction symptoms – by this time the tumor has often metastasizes

Pain Constitutional symptoms

Prostatic Cancer – Pain Pain in rectal region Pain in sacral or lumbar spine

regions Associated with bony metastasis

Pain in thoracic or shoulder girdle regions Associated with lymphatic spread or

bony metastasis

Prostatic Cancer – Constitutional Symptoms Due to metastatic spread of the

cancer Fatigue Anemia Weight loss Dyspnea

Prostatic Cancer - Treatments Surgery: Side effects: infection,

incontinence, impotence Radiation: Side effects: diarrhea, GI or

urinary bleeding Hormonal treatments: Side effects: loss

of libido, impotence, hot flashes, gynecomastia, bloating and pedal edema, nausea and vomiting, diarrhea, MI, CVA, deep venous thrombus

Pathology of the Female Reproductive Tract Hormonal disorders Infections Benign or malignant tumors Disorders related to pregnancy

Endometriosis Abnormal localization of

endometrial tissue Can be located in myometrium or

in sites outside the uterus Endometrial tissue is functional

and responds to hormonal stimulation

Endometriosis – Risk Factors Woman of childbearing years (10-

15%) More common in women who

postpone pregnancy Early menarche Menstrual cycles 27 days or less Menstrual periods lasting 7 days or

longer

Endometriosis – Signs and Symptoms Depend on location of endometrial

tissue Low abdominal or pelvic pain

associated with menstrual period Uterine involvement – dyspareunia Bladder involvement – dysuria Rectal – pain on defecation May produce false positive findings

Ectopic Pregnancy Fertilized ovum implants outside

the uterus – usually the fallopian tubes

One of the major causes of maternal death in the US

Ectopic Pregnancy – Risk Factors Pelvic inflammatory disease Prior tubal surgery Ruptured appendix Endometriosis Previous ectopic pregnancy Infertility

Pathogenesis Implantation in fallopian tube Bleeding occurs during implantation –

may be perceived as menstruation Pregnancy outgrows blood supply –

resulting in termination of pregnancy If termination does not occur, rupture

of tube occurs by 12th week - emergency

Clinical Manifestations Amenorrhea or irregular bleeding Lower abdominal quadrant or back pain

Can be diffuse and aching or localized Will progress to sharper pain due to leakage of

blood into abdominal and pelvic cavities Pain may refer to shoulder if blood reaches high

in abdominal cavity Pelvic mass S & S of normal pregnancy

Fatigue, nausea, breast tenderness, urinary frequency

Amenorrhea Primary – failure to begin

menstrual cycles Secondary – failure after a variable

period of normal function

Amenorrhea – causes Physiological Anatomical Genetic Endocrinological Constitutional Psychogenic In athletes

Toxic Shock Syndrome Caused by bacterial toxin Most common in women under 30

who use tampons Also linked to barrier

contraceptives, burns, IV drug use, insect bites, surgical and non-surgical wounds, postpartum and gynecological infections, vaginitis and lung abscesses

TSS – Manifestations Sudden elevated temperature Vomiting and diarrhea Erythematous macular rash Renal dysfunction Hypotension and shock may

develop

Pelvic Inflammatory Disease General term of infection of upper

reproductive tract Risk factors Symptoms Complications

Ovarian Cancer 2nd most common urogenital

cancer 1st in number of deaths Difficult to diagnose

At diagnosis, 60-70% metastasis

Ovarian Cancer – Risk Factors Age – peak incidence 40-60 Geography – NW Europe, US and

Canada Race – White and Hawaiian Nulliparity Family history History of infertility

Ovarian Cancer – Protective Factors 1 or more full term pregnancies History of breastfeeding Use of oral contraceptives Native American women

Ovarian Cancer – Clinical Manifestation Asymptomatic or vague

Abdominal bloating Flatulence Abnormal vaginal bleeding – not

common Local pelvic pain – a late sign

Ovarian Cancer – Clinical Manifestation Metastasis

Unexplained weight loss Cachexia Weakness Ascites Shoulder girdle or thoracic pain

Breast Diseases Infections Hormonally-induced changes Tumors

Inflammation – Acute Mastitis Usually occurs in lactating women Can form a localized abscess or

spread through entire breast Signs

Swelling Redness Painful area – sensitive to palpation

Hormonally-induced changes Normal changes

Breast enlargement during puberty After menopause, the breasts

undergo atrophy – can be prevented by exogenous estrogens

Hormonally-induced changes Fibrocystic change – fibrosis and cysts

that occur in the breasts About 50% by biopsy or autopsy Only 10-15% of women have symptoms May or may not be painful Usually affects both breasts, but

symptoms may be asymmetrical Pain, fine nodules in breast tissue,

tenderness

Benign tumors - Fibroadenoma Usually well encapsulated Usually 2-5 cm in diameter Usually affect young women – peak

incidence in 20’s

Malignant tumors 2nd most common tumor in women Causes are hormonal and genetic

Risk factors Gender – 100X more often in women Genetic predisposition Hormonal factors

Early menarche - <12 Late menopause > 50 Nulliparous women or late first

pregnancy Presence of other cancers Premalignant fibrocystic change

Risk factors Age

Rare before puberty Increased incidence after 35 Peaks in postmenopausal women

about 60 y.o. Race – White Diabetes Obesity

Potential Risk Factors Oral contraceptives Hormone therapy High-fat diet Alcohol consumption

Breast Cancer Manifestations Tumors usually surrounded by dense

connective tissue Pulls on adjacent tissue – causing

puckering of the skin and retraction of the nipple

Tumors are firm, but do not have sharp margins

Most tumors are in upper lateral breast quadrant (45%)

Typically not painful

Breast Cancer Manifestations Most tumors metastasize into the

axillary lymph nodes Distant metastasizes common in liver,

bones, brain, and adrenals S & S – upper extremity edema, bone pain,

jaundice, weight loss Most breast cancers are detected by

self-examination, examination by a doctor, or mammography

Role of PT Awareness of non-muscular tissues

in shoulder and shoulder girdle Lymph nodes – 50% of women

have metastasis to axillary nodes at time of diagnosis

Menopause Cessation of menstruation Average age 50 Complete when there are no

menstrual periods for 1 year Also occurs after surgical removal

of ovaries

Physiological Changes Hot flashes Changes in reproductive organs

Dryness and atrophy Dyspareunia, stress incontinence,

vaginal itching and burning Osteoporosis Cardiovascular diseases

Hypertension, stroke, heart disease

Psychological Changes Nervousness Depression and feelings of

worthlessness and hopelessness Headache Insomnia Decreased sex drive Memory loss Vertigo