Pathophysiology presentation

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

Objectives for Group Three
Male Genitourinary and Reproductive Disorders
 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).

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Objectives for Group Three
Female Genitourinary and Reproductive Disorders
Manifestations of Dymenorrhea.
Manifestations of Premenstrual Syndrome.
Manifestations of Amenorrhea.
Manifestations of Endometriosis.
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.

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

Page  4

Physiologic Basis of Male Reproductive Function

 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

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Physiologic Basis of Male Reproductive Function

 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.

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Hormone Function

 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.

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Regulation of Male Hormones (excerpt from text page 1013)

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The Prostate Gland
 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).

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Benign Prostatic Hyperplasia
 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.

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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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AUA Symptom Index for Benign Prostatic Hyperplasia

Page  13

 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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Common Male Genital Disorders
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

Page  15

Common Male Genital Disorders Excerpt from Pg. 1017

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).

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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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Physiologic Basis of Female Reproductive Function
 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.

Page  21

The Menstrual Cycle
 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

Page  22

The Menstrual Cycle
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.
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Hormones of the Menstrual Cycle (excerpt from text pg. 1037)

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Hormones Actions in the Female (excerpt from text pg. 1037)

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Menstrual Cycle Disorders
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.

Page  26

 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

Page  27

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

Page  28

 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.

Page  29

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.
Page  30

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)
Page  31

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

Page  32

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).

Page  33

Common locations of Endometriosis (excerpt from text pg. 1047)

Page  34

Sample of Endometriosis on the Uterosacral Ligaments

Page  35

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

Page  36

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

Page  37

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
Page  38

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)
Page  39

Disorders of the Uterine Support
FISTULA
 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
Page  40

Genitourinary and Reproductive Functions (Group 3)
References
BOOK 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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