Overview
• Male Infertility
• Benign Prostatic Hypertrophy
• Prostate Cancer
• Female Infertility
• Endometriosis
• Pelvic Inflammatory Disease
• Ovarian Cysts
• Cancer
– Breast
– Cervical
– Uterine

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

• 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

BPH —Signs and Symptoms
• Initial signs
– Obstruction of urine flow
• Hesitancy, dribbling, decreased force of urine stream
• Incomplete bladder emptying
– Frequency, nocturia, recurrent UTIs

BPH —Treatment
• Only small amount require intervention
– Surgery when obstruction severe
• Drugs (Flomax) used to promote blood flow helpful when surgery not required

Prostate Cancer
• Common in men older than 50; ranks high as cause of cancer death
• 3 rd leading cause of death from cancer

• 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

Stages

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

• 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

• 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

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%

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

Female Infertility
• Broad range of tests avail
– General health status checked 1 st
– 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

Normal Laparoscopy

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

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

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 (Csection) all possibilities
• Treatment
– Hormonal suppression of endometrial tissue
– Surgical removal of endometrial tissue
• Pregnancy and lactation delay further damage and alleviate symptoms

Endometriosis

• 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

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

PID

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

PID —Signs and Symptoms
• Lower abdominal pain (1 st 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

PID —Treatment
• Aggressive antibiotics
– Cefoxitin, doxycycline
• Recurrent infections common
– Sex partners should be treated as well
• Follow-up appt to ensure eradication

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

Ovarian Cysts

• 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

• Malignant cells spread at early state
– 1 st 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

Breast Cancer

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 1 st pregnancy
– Role of exogenous estrogen (birth control pills, supplements) still controversial

• 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

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

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

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

• 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

• 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

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

• Asymptomatic in early stage
– Can be detected by Pap test
• Invasive stage indicated by slight bleeding or spotting
• Anemia and wt loss can accompany

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

• 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

• 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

• 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

Uterine Cancer —Etiology
• Higher risk if increased estrogen levels
– Assoc w/ exogenous estrogen
(postmenopausal women)
• Recommended dosage lowered
– Oral contraceptives
• Infertility
• Obesity, diabetes, hypertension increase risk

• 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

Uterine Cancer —Treatment
• Surgery and radiation
• Prognosis relatively good
– 5 yr survival rate 90% if cancer well localized at time of diagnosis