Pathophysiology presentation

Genitourinary and Reproductive Function (Group Three)S. Rieger, V. Roe, K. Schwab, J. Sherburne, K. Simpson and A. Siek

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Define and Describe the Etiology, Pathophysiology and Clinical Manifestations of Benign Prostatic Hyperplasia (BPH).

Describe the Clinical Manifestations of Male Genital Disorders (Phimosis, Paraphimosis, Peyronnie Disease and Priapism).

Objectives for Group Three Male Genitourinary and Reproductive Disorders

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Define and Describe the Etiology, Pathophysiology and Clinical Manifestations of Dymenorrhea.

Define and Describe the Etiology, Pathophysiology and Clinical Manifestations of Premenstrual Syndrome.

Define and Describe the Etiology, Pathophysiology and Clinical Manifestations of Amenorrhea.

Define and Describe the Etiology, Pathophysiology and Clinical Manifestations of Endometriosis.

Define and Describe the Etiology, Pathophysiology and Clinical Manifestations of Dysfunctional Uterine Bleeding (DUB).

Define the various types of Pelvic Structure Disorders (uterine prolapse, cystocele, rectocele and fistula). Compare and contrast the clinical manifestations of pelvic structure disorders.

Objectives for Group Three Female Genitourinary and Reproductive Disorders

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Disorders of the Male Genitourinary System Male Reproductive Anatomy (excerpt from text page 1010)

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The male genitourinary system functions in both reproduction and urine elimination.

The testes produce the male germ cell (sperm) and secrete the male sex hormone, testosterone.

The ductile system transports and stores sperm, and assists in their maturation. It is composed of three structures:

– Epididymides

– Vas Deferens

– Ejaculatory Ducts

Disorders of the Male Genitourinary System Physiologic Basis of Male Reproductive Function

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The accessory glands, including the _________________, seminal

vesicles and bulbourethral glands, prepare the sperm for

ejaculation.

Sperm production requires temperatures lower (2-3 degrees C) body

temperature, which is provided by a unique blood flow in the testes.

The urethra, which is enclosed in the penis, is the terminal portion of

the male genitourinary system. As it carries both urine and semen, it

serves both urinary and reproductive functions.

Unlike the female reproductive system, most of the male

reproductive system is located outside of the body. The external

structures include the penis, scrotum and testicles.

Disorders of the Male Genitourinary System Physiologic Basis of Male Reproductive Function

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The male reproductive system is dependent on hormones.

The three main hormones of the male reproductive tract are:

– __________________

• Primary and Secondary Sex Characteristics

• Anabolic effects, Promotes Spermatogenesis and Maturation of Sperm and Stimulates Erythropoiesis (Chart 39-1)

– Follicle Stimulating Hormone (FSH)

• Necessary for Sperm Production. Assoc. w/ Sertoli Cells

– Luteinizing Hormone (LH)

• Stimulates Testerone Production. Assoc. w/ Interstitial Cells of Leydig.

Disorders of the Male Genitourinary System Hormone Function

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Disorders of the Male Genitourinary System Regulation of Male Hormones (excerpt from text page 1013)

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The prostate gland is about the size of a ___________ . It surrounds the man’s urethra.

The prostate produces the fluid that carries the male germ (sperm).

Disorders of the Male Genitourinary System The Prostate Gland

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What is it? An age-related enlargement of the prostate gland with formation of large, discrete lesions.

Where does it occur? In the periurethral (internal, surrounding the urethra) region of the prostate. The lesions compress the ____________ and produce symptoms of dysuria and difficulty urinating.

What happens? Increased _______________ levels prompt androgen receptors in the prostate gland to increase due to imbalance of hormones.

– This causes a hyperplasia that begins around the urethra.

– Growth causes areas of poor blood flow and adj. tissue damage.

– Enlargment can extend into the bladder and decrease urine flow by compressing or distorting the urethra.

Other known causes of BPH: Neoplasm, Arteriosclerosis, Inflammation or Metabolic or Nutritional disturbances.

Disorders of the Male Genitourinary System Benign Prostatic Hyperplasia

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S/S: Depend on the degree of prostate enlargement and the lobes affected.

– Decreased urine stream size and force.

– Impaired bladder contractability.

– Interrupted urine stream or feeling of strain or incomplete voiding of urine.

– Can progress to (as obstruction increases…):

• Frequent urination with nocturia

• Dribbling or Urine retention

• Incontinence

• Hematuria

Clinical Manifestations. The main complication is ________________________ that can lead to urinary tract infection, urinary stones or diverticulum formation (fluid-filled pouch that retains urine after bladder is emptied).

Other bad stuff: Incontinence, acute or chronic renal failure and distention of the renal pelvis with urine (hydronephrosis).


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Labs:

– Elevated BUN and Creatine levels (impaired renal fxn)

– Excretory urography to indicate U.T. obstruction, hydronephrosis, calculi or tumors, and filling an emptying defects in the bladder

– Urinalysis and urine culture show hematuria, pyuria (pus) and U.T.I.

– Cystourethroscopy (endoscope) to exam bladder and urethra

– Check prostate-specific antigens to rule out neoplasm

Risk factors: Well, there’s the bad news… Almost ALL men over age _____ have prostate enlargement. Diagnosis and treatment is based on symptoms.

– Pt. will complete a survey

– Approx. 50% of men over age 60 exhibit symptoms sufficient to make a

diagnosis.


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Disorders of the Male Genitourinary System AUA Symptom Index for Benign Prostatic Hyperplasia

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Treatment:

– If the pt. has MILD symptoms, “watchful waiting”. Condition may remain stable and not require treatment.

– Short term fluid restriction to prevent bladder distention

– Antimicrobials to treat secondary infections

– Regular sexual intercourse to relieve prostatic congestion

– Terazosin (improve urine flow) and Finasteride (reduce prostate size)

– Herbal Therapy (Palmetto Berry)

– Stent for pts. with cardiac or pulmonary pre-existing conditions

– Surgical Removal

• Transurethral Prostatecotomy (TURP) method


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WE WILL DISCUSS:

Peyronie Disease

Priapism

Phimosis

Paraphimosis

IF YOU WANT TO READ MORE (because Nerds are cool too!):

Erectile Dysfunction (pgs. 1015-16) Affects 150 million men worldwide

Acute or Chronic Inflammations (pgs. 1016-17) Commonly from C. Albicans infection or STIs

Neoplasms of the Penis (pg. 1018) Rare, <1% of Male G.U. tumors

Disorders of the Male Genitourinary System Common Male Genital Disorders

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PEYRONIE DISEASE:

What is it? An abnormal bend in the penis that occurs during erection r/t an idopathic localized and progressive fibrosis plaque.

Where does it occur? Usu. in the dorsal midline of the shaft causing upward shift. It can calcify and form bone-like tissue.


Clinical Manifestations: Two-thirds of pts. reports _____________, especially during intercourse. Characterized by hard mass at the site of fibrosis plaque that causes a hard mass and bent erection detectable by physical exam and ultrasound for further assessment. Can also cause a shortening or narrowing of the penis.

Treatment: Oral agents w/ antioxidant properties (Vit. E). Surgery can cause impotence.

Other Notes: Men over 40. Not common. Not related to Hypospadias (seen in infants).

Excerpt from Pg. 1017

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QUICK BY SHOW OF HANDS

Have you ever heard on a commercial?

“CONTACT YOUR DOCTOR IF YOUR ERECTION LASTS MORE THAN FOUR HOURS.”


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PRIAPISM:

What is it? An erection that lasts more than FOUR hours. May impair the blood flow through the Corpus cavernosum (spongy region) of the penis.

Medical Emergency! Prolonged erection can result in ischemia and fibrosis in the erectile tissue. Pt. at risk for severe ______________________.

Clinical Manifestations: Unwanted erection. May be painful or tender. No stimuli.

Too much Viagra? Not necessarily. Priapism can result from many different causes. Primary = Idopathic. Secondary = Drug effect or disease predisposition. Commonly assoc. w/ Blood disorders: SICKLE CELL ANEMIA and LEUKEMIA.

Ischemic vs. Non-Ischemic: Doctors will only treat Priapism invasively when the blood flow is ischemic. Non-ischemic Priapism is usually self-limiting and resolves.

Treatment: Ice pack or cold saline enemas, aspiration with use of local anesthetic, and alpha-adrenergic drugs injection into the penis to limit blood flow.


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PHIMOSIS and PARAPHIMOSIS:

What are they? Dysfunctions of the foreskin. Phimosis is tightening of the foreskin that prevents retraction. Paraphimosis, the opposite, occurs when the foreskin cannot retract to its original position after being pulled back. Say what?

Foreskin. Recall from anatomy, the foreskin is a retractable double-layer of skin and membrane that covers the glans (tip) of the penis.

Trends. Recent trends suggest that fewer parents are getting their son’s foreskin removed at birth (approx. 60% of baby boys in the the U.S. ARE circumcised).

Clinical Manifestations: Foreskin is NOT fully retractable in the majority of children until age ________ . Phimosis can cause infection r/t poor hygiene, foreskin injury or scarring, ballooning or Paraphimosis (medical emergency!).

Paraphimosis = when the tight foreskin is pulled back and becomes ‘trapped’ behind the glans. Can constrict blood flow, leading to ischemia and gangrene.

Treatment: Circumcision recommended in severe cases.


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Disorders of the Female Genitourinary System Female Reproductive Anatomy (excerpt from text page 1034)

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The female reproductive system consists of external and internal genitalia. Read more on pgs. 1034-36.

The uterus is a thick-walled, muscular organ.

The uterine wall is composed of three layers:

– Outer Perimetrium

– Myometrium or Muscle Layer

– Inner ________________

The ovaries produce hormones and the female germ cell (ova). Unlike in males, all gametogenesis takes place BEFORE birth.

Disorders of the Female Genitourinary System Physiologic Basis of Female Reproductive Function

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Menstruation is process by which the female body sheds the thickened lining of the uterus via the cervix and vagina.

The typical menstruation lasts between three and five days.

Vital part of normal female reproductive physiology

Disorders of the Female Genitourinary System The Menstrual Cycle

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The complete menstrual cycle lasts an average of _______ days.

– Day One: starts w/ the first day of the woman’s period. Hormone levels have dropped signaling the blood and tissue lining the uterus to break down and shed from the body.

– Day Seven: Bleeding has stopped. Leading up to this time, hormones stimulate fluid-filled pockets called follicles to develop on the ovaries. Each follicle contains an egg.

– Between Day Seven and 14, one follicle will continue to develop and reach maturity. The lining of the uterus will thick and wait for a fertilized egg to implant there. The lining is rich in blood and nutrients.

– Around Day 14, gonadotropic hormones, FSH and LH, cause the mature follicle to burst and release an egg from the ovary (ovulation). The egg travels down the fallopian tube to the uterus.

– If fertilized, the egg attaches to the uterine wall. If not fertilized, all hormone levels will drop around Day 25. This signals the next menstrual cycle. The egg will break apart and be shed with the next period.

Disorders of the Female Genitourinary System The Menstrual Cycle

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Disorders of the Female Genitourinary System Hormones of the Menstrual Cycle (excerpt from text pg. 1037)

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Disorders of the Female Genitourinary System Hormones Actions in the Female (excerpt from text pg. 1037)

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DYSFUNCTIONAL UTERINE BLEEDING (DUB)

What is it? Abnormal uterine bleeding that occurs because of changes in Estrogen and Progesterone levels. Can be a primary condition or occur secondary to disorder.

When does it occur? Most commonly, DUB occurs when the progesterone levels are LOW because of _________________________. Estrogen over compensates by producing thicker tissue. This disrupts the pattern of bleeding and can cause excessive and irregular periods. Whereas, Estrogen deprivation can cause retrogression in present endometrial tissue and bleeding.

Other causes include: Endometrial polyps, submucosal myoma, bleeding disorders, endometrial dysplasia and cancer.

Disorders of the Female Genitourinary System Menstrual Cycle Disorders

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S/S: Bleeding or spotting between periods, irregular periods, heavy or sustained bleeding and fatigue r/t blood loss.

Clinical Manifestations: Pt. may lose the hormonal stimulation that produces the regular cyclic endometrial discharge.

– Chronic elevated estrogen levels continue to stimulate endometrial tissue proliferation. Endometrium may outgrow its blood supply causing it to break down and slough off.

– Chronic low estrogen levels will result in light and infrequent bleeding.

– Strongly associated with anovulatory bleeding or absence of ovulation. Commonly affects adolescents and perimenopausal women.

Complications: Iron deficiency anemia, Endometrial Cancer and Infertility

Treatment: Endometrial ablation and Hormone supplemental therapy


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AMENORRHEA

What is it? The lack of a menstrual period.

When does it occur?

– Primary Amenorrhea: Occurs in girls who haven’t started menstruating by age 15.

– Secondary Amenorrhea: Occurs in women or girls with established menstrual cycles who haven’t had a period for six months.

Potential Primary Amenorrhea Causes: Gonadal Dysgenesis or Turner Syndrome, Congenital Mullerian Agenesis, Testicular Feminization, Anorexia, Obesity, Congenital Heart Disease, Cushing’s Syndrome, Cystic Fibrosis or Thyroid hormone dysfunctions

Potential Secondary Amenorrhea Causes: Obesity, Anorexia, excessive strenuous exercise, Ovarian, Pituitary or Hypothalamic dysfunctions, Infections (e.g. TB or Syphilis), Pituitary tumors, certain prescription drugs or Thyroid hormone dysfunctions


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S/S: No regular menstruation. Secondary changes may include: breast size changes, weight loss or gain, galactorrhea (breast discharge), headache, hirsutism or vaginal dryness. If caused by a pituitary tumor, other s/s may exist.

Clinical Manifestations: Pt. does not have a regular cyclic endometrial discharge. This can cause build up of endometrial hyperplasia. Risks include:

– Infertility.

– Endometrial and Uterine Cancer.

– Manifestations of the underlying condition causing amenorrhea.

Labs: Physical exam, pregnancy test and pelvic exam must be done to rule out pregnancy before any treatment is administered. Goal is to pinpoint the cause.

Treatment: Correct the underlying cause(s) and induce menstruation with cyclic progesterone or estrogen-progesterone regimens.


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DYSMENORRHEA

What is it? Pain or discomfort with menstruation. Not usually a serious medical problem, however it can reach the extent of causing a monthly disability.

Two Types

– Primary Dysmenorrhea: Caused by the effects of excess prostaglandin production in the endometrium. Prostaglanding is a potent smooth muscle stimulant that causes intense uterine contractions.

– Secondary Dysmenorrhea: menstrual pain caused by structural abnormalities or disease processes such as endometriosis, uterine fibroids, adenomyosis, pelvic adhesions, IUD’s or PID.

S/S: Headache, nausea, vomitting, diarrhea, muscle cramps and spasmodic pains

Clinical Manifestations: Pain in lower abdomen, suprapubic area (above the pubic arch) and lower back. Pain lasts longer than a menstrual period, or may begin before a menstrual period, and can get worse during menstruation.

Treatment: Primary - symptom control with non-steroidal anti-inflammatory drugs (e.g. ibuprofen) or Oral contraceptives. Secondary - identifying the cause.


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PREMENSTRUAL SYNDROME DISORDER

What is it? A cluster of physical, emotional and behavioral changes that occur in a regular, cyclic relationship w/ luteal (post-ovulation) phase of menstrual cycle.

When does it occur? Generally 3 to 14 days prior to menstruation. Most likely a result of sex hormone interaction with neurotransmitters, particularly Serotonin.

S/S: Painful and swollen breasts, bloating, abdominal pain, headache, backache, vomiting, edema, diarrhea, weight gain, nausea, fatigue, exhaustion, cravings (e.g. sweets or salts), constipation, acne, changes in coordination, fatigue, mood swings and/or depression, anxiety, irritability, crying spells and inability to concentrate

Premenstrual Dysphoric Disorder (PMDD): Most severe form of premenstrual distress and generally associated with mood disorders.

Treatment: Keep symptom journal, regular exercise, avoid caffeine, healthy diet with fruits, vegetables and whole grains, Over-the-counter pain relievers and vitamin supplements (e.g. B-6, Folid Acid, Vitamin E)


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ENDOMETRIOSIS

What is it? A disorder characterized by cells from the lining of the uterus growing in other areas of the body.

Where does it occur? Common sites for the development of endometriosis are the ovaries, bowel, rectum, bladder, posterior broad ligaments, pelvis or perineum.

How do they get there?

– Regurgitation/Implantation Theory = Reverse Menstruation

– Vascular/Lymphatic Theory = Metastasize

– Metaplastic Theory = Immature, dormant cell elements


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ENDOMETRIOSIS

S/S: Painful periods, Pain in the pelvis and lower abdomen before or during menstruation, Cramps, Dyspareunia or Pain with bowel movements or urination. R/t severity and location.

Complications: Infertility, endometriomas (cysts) in the pelvis, increased risk for endometrial cancer

Labs: Laparoscopy, imaging techniques, Elevated Serum CA-125 - associated with Ovarian cancer.

Treatment: Three stages - pain relief, endometrial suppression (p. amenorrhea), and surgery (e.g. ablation).


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Disorders of the Female Genitourinary System Common locations of Endometriosis (excerpt from text pg. 1047)

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Disorders of the Female Genitourinary System Sample of Endometriosis on the Uterosacral Ligaments

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Disorders of the Female Genitourinary System Disorders of the Uterine Support (excerpt from text pg. 1051)

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CYSTOCELE

What is it? A herniation of the bladder into the vagina. Also known as: “fallen bladder”.

When does it occur? When normal muscle support for the bladder weakens and the bladder sags below the uterus. This forces the anterior wall of the vagina to stretch and bulge downward.

S/S: “Bearing-down” sensation, difficulty emptying the bladder, urinary urgency and frequency, cystitis (bladder inflammation) and stress incontinence

Clinical Manifestations: The bladder can protrude into the vagina due to gravity and pressures (e.g. coughing, lifting, urinating)

Treatment: Kegal exercises

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RECTOCELE

What is it? A herniation of the rectum into the vagina. Congenital or acquired.

When does it occur? When the posterior vaginal wall and underlying rectum bulge forward. Perineal muscles are weakened.

S/S: Discomfort r/t protrusion of rectum, difficulty in defecation, lower back pain or sensation.

Clinical Manifestations: The area between the uterosacral ligaments may weaken and form a hernial sac into the small bowel (Enterocele).

Treatment: Kegal exercises

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UTERINE PROLAPSE

What is it? A bulging of the uterus into the vagina.

When does it occur? When the main supportive ligaments are stretched. Three degrees of uterine prolapse.

S/S: Irritation r/t exposed mucous membranes of the cervix and vagina. Discomfort r/t protuding mass.

Clinical Manifestations: Assoc. w/ cystocele or rectocele. Can cause UTIs, vaginal bleeding/discharge, dyspareunia

Treatment: Pessary, weight loss, avoid straining/lifting. Advanced may require surgery (e.g. vaginal hysterectomy)

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Disorders of the Female Genitourinary System Disorders of the Uterine SupportFISTULA

What is it? A hole that develops between the rectum and vagina or the bladder and vagina.

When does it occur? Difficult childbirth, Sexual Assault, Neoplasms (e.g. Cervical cancer)

S/S: Incontinence or involuntary bowels

Clinical Manifestations: Severe infections or ulcerations, Paralysis r/t nervous damage, Tissue necrosis r/t ischemia in the birth canal. Advanced: severe dehydration, renal disease/failure

Treatment: Education, Reconstructive surgery or Foley catheter

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Genitourinary and Reproductive Functions (Group 3) ReferencesBOOK REFERENCES

Lippincott Williams & Wilkins (2009). Pathophysiology Made Incredibly Easy. (4th Ed.). Philadelphia: Author.

Porth, C.M. (2009). Essentials of Pathophysiology: Concepts of Altered Health States (3rd Ed.). Philadelphia: Lippincott Williams & Wilkins.

WEB REFERENCES A.D.A.M. Medical Encyclopedia. (August 8, 2009). Pictures and Images. In Fistula. Retrieved March 4, 2012, from

http://health.allrefer.com/pictures-images/fistula.html.

A.D.A.M. Medical Encyclopedia. (July 25, 2011). Diseases and Conditions. In Painful Menstrual Periods. Retrieved March 1, 2012, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0003637.

A.D.A.M. Medical Encyclopedia. (September 19, 2011). Articles. In Enlarged Prostate. Retrieved February 26, 2012, from http://www.ncbi.nlm.nih.gov/medlineplus/ency/article/000381.htm.

Kapoor, D. (February 21, 2012). Drugs, Diseases & Procedures. In Endometriosis. Retrieved March 1, 2012, from http://emedicine.medscape.com/article/271899-overview#aw2aab6b2b3.

U.S Dept. of Health and Human Services Office on Women’s Health. (n.d.). Publications. In Menstruation and the Menstrual Cycle Fact Sheet. Retrieved February 28, 2012, from http://www.womenshealth.gov/publications/our-publications/fact-sheet/menstruation.cfm.

Web M.D. Medical Reference. (n.d.). Health and Sex Guide. In The Male Reproductive System. Retrieved February 29, 2012, from http://www.webmd.com/sex-relationships/guide/male-reproductive-system.

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Pathophysiology presentation