Pathology of Reproductive System

Pathology of Male Reproductive System

• The male reproductive system consists of prostate, testis, and other accessory organs.

Prostate Gland Disease

• Common causes of urinary problems in men over 60 years old: prostatitis, BPH, and prostatic carcinoma.
• a) Prostatitis:
  • Associated with specific infective cause (e.g., coli, Staphylococcus, Neisseria gonorrhoea).
  • Types: acute suppurative, chronic non-specific, and granulomatous prostatitis.
  • Symptoms: enlarged prostate, pain during urination.

Benign Prostatic Hyperplasia (BPH)

• Non-neoplastic enlargement of the prostate.
• Characteristics:
  • ↑ prostate weight/enlarged prostate.
  • 50% in 40-60 years old, 95% in > 70 years old.
  • Severe cases require surgery.
• Clinical Features:
  • Early stage: few symptoms, bladder muscles strong enough to push urine through a narrowing urethra.
  • Later stage: symptoms include weak urine flow, intermittent urination, leakage after urination, unable to empty the bladder, and nocturia.
• Gross:
  • Solid nodules and cysts with yellowish necrotic areas and haemorrhagic margin.
  • Nodules: solid, composed of stroma and hyperplastic acini.
• Histology:
  • Larger glands with tall epithelium lining and papillary projections.
• Diagnosis:
  • Digital rectal examination: size and firmness of the prostate.
  • Urinalysis and urine culture.
  • Prostate-specific antigen (PSA) test.
• Treatments:
  • Transurethral Resection of the Prostate (TURP).

Carcinoma of Prostate

• Etiology:
  • Genetic factors: genetic mutations (BRCA1, BRCA2, DNA repair genes).
  • Hormonal factors: androgens (testosterone, dihydrotestosterone) stimulate the growth of prostate cells.
  • Age: increases with age, majority of cases in men over 65 years old.
  • Inflammation: chronic inflammation of the prostate gland.
  • Environmental factors: diet, lifestyle, exposure to carcinogens, and occupational hazards.
  • Epigenetic changes: affect gene expression.
  • Tumor microenvironment: interactions between cancer cells and surrounding cells.
• Pathology:
  • Hard, irregular, and ill-defined gray area.
  • Histology: adenocarcinomas in the glandular epithelium.
• Clinical Features:
  • Urinary symptoms > BPH.
  • Hard craggy prostate on rectal examination.
  • Bone metastases: pain, pathological fracture, anemia.
  • Lymph node metastasis.
• Diagnosis:
  • Diagnostic imaging: ultrasound, skeletal X-rays, isotope bone scan.
  • Cytoscopy: transurethral resection.
  • Chemical pathology: serum acid and alkaline phosphatase and PSA.
  • Haematology: leucoerythroblastic anemia.
  • Biopsy: transurethral resection, needle biopsy, fine-needle aspiration cytology.
• Clinical Management:
  • Gonadorelin (GnRH).
  • Orchidectomy.
  • Cyproterone (anti-androgenic effects).
  • Radiotherapy.

Testicular Lesions

• Non-neoplastic Disorder:
  • Present with hydrocele (accumulation of fluid around the testis).
  • Incidence increasing worldwide.

a) Developmental and Cystic Lesions

• Undescended Testis (Cryptorchidism):
  • High risk of developing testicular cancer.
• Hydrocele:
  • Accumulation of serous fluid within the tunica vaginalis of the testis.
• Haematocele:
  • Accumulation of blood within the tunica vaginalis of the testis.
• Testicular Tortion:
  • Twisting of the spermatic cord, leading to testicular ischemia.

b) Orchitis

• Inflammatory Condition:
  • Viral or bacterial infection.
  • Children and 50-year-old men with BPH.
• Symptoms:
  • Rapid onset of pain and swelling, including testicular swelling, redness, pain, and tenderness, fever, and chills.
  • Epididymo-orchitis: localized area of pain and swelling on the back of the testicle.
• Diagnosis:
  • Established after a history and physical exam.
  • Ultrasound: exclude other conditions (e.g., testicular torsion, abscess, or epididymitis).
  • Rectal examination: check for prostate gland infection.
  • Sample of discharge: identify the infectious agent.
  • FBC and urinalysis: evaluate patient's condition.

c) Testicular Tumor

• Uncommon:
  • Occur in young men.
• Aetiology:
  • Undescended testis.
  • In-situ neoplastic changes within seminiferous tubules.
• Clinical Features:
  • Swelling of the testis.
  • Secondary hydrocele.
  • Gynaecomastia.
  • Retroperitoneal mass.
  • Metastasis.
• Classification:
  • Seminoma: most common type, age 30-50 years old.
  • Teratoma: germ cell origin, age 20-30 years old.
• Diagnosis:
  • Ultrasound.
  • CT scan.
  • Serum tumor markers (e.g., AFP, β-hCG).
  • Biopsy: orchiectomy.

Other Male Reproductive Organs

• Penis and Scrotum:
  • Congenital disorders (e.g., hypospadias, epispadias).
  • Inflammation and infections (e.g., balanophosthitis, phimosis, paramiphosis, syphilis).
  • Tumor and carcinoma of the scrotum.

Endometriosis

• Tissue similar to the lining of the uterus grows outside the uterus, leading to pain, inflammation, and adhesions.
• Causes are unknown, but may be related to retrograde menstruation, hormonal imbalance, or genetic factors.
• Symptoms include pelvic pain, cramping, or heavy bleeding during menstruation, pain during intercourse, infertility, and bowel or urinary symptoms.
• Diagnosis involves laparoscopy, ultrasound, or MRI.
• Treatment options include hormonal medications, surgical removal of endometrial tissue, and assisted reproductive technologies.

Polycystic Ovary Syndrome (PCOS)

• A hormonal disorder characterized by irregular menstrual cycles, cysts on the ovaries, and insulin resistance.
• Causes are unknown, but may be related to genetic, environmental, or hormonal factors.
• Symptoms include irregular or absent periods, weight gain, acne, or excess hair growth, infertility, and insulin resistance or type 2 diabetes.
• Diagnosis involves clinical evaluation, ultrasound, and laboratory tests.
• Treatment options include hormonal medications, fertility medications, and lifestyle modifications.

Cervical Cancer

• A type of cancer that occurs in the cervix, the lower part of the uterus that opens into the vagina.
• Causes include human papillomavirus (HPV) infection, smoking, and weakened immune system.
• Symptoms include abnormal vaginal bleeding, pain during intercourse, pelvic pain, and unusual vaginal discharge.
• Diagnosis involves Pap smear, HPV testing, colposcopy, and biopsy.
• Treatment options include surgery, radiation therapy, and chemotherapy.

Ovarian Tumors

• Abnormal growths on the ovaries, which can be benign or malignant.
• Causes are unknown, but may be related to genetic, hormonal, or environmental factors.
• Symptoms include pelvic pain or discomfort, abdominal swelling or bloating, abnormal vaginal bleeding, and fatigue or weight loss.
• Diagnosis involves ultrasound, CT or MRI, and tumor marker tests.
• Treatment options include surgery, chemotherapy, and radiation therapy.

Uterine Fibroids

• Noncancerous growths that develop in the uterus, often leading to heavy bleeding, pain, and infertility.
• Causes are unknown, but may be related to hormonal, genetic, or environmental factors.
• Symptoms include heavy or prolonged menstrual bleeding, pelvic pain or pressure, infertility or recurrent miscarriage, and frequent urination.
• Diagnosis involves ultrasound, MRI, or hysteroscopy.
• Treatment options include hormonal medications, surgical removal of fibroids, and uterine artery embolization.

Premenstrual Syndrome (PMS)

• A set of physical, emotional, and behavioral symptoms that occur before menstruation.
• Causes include hormonal fluctuations, neurotransmitter imbalance, and genetic factors.
• Symptoms include breast tenderness, bloating or water retention, mood swings or irritability, fatigue or insomnia, and headaches or joint pain.
• Diagnosis involves clinical evaluation and symptom tracking.
• Treatment options include lifestyle modifications, hormonal medications, and selective serotonin reuptake inhibitors (SSRIs) for mood symptoms.

Premenstrual Syndrome (PMS)

Definition

• A set of physical, emotional, and behavioral symptoms occurring in the premenstrual phase of the menstrual cycle
• Affects 3-8% of women of reproductive age

Causes

• Hormonal fluctuations (estrogen and progesterone) contribute to PMS
• Serotonin levels play a role in PMS
• Genetic predisposition is a contributing factor
• Lifestyle factors such as stress, diet, and sleep affect PMS

Symptoms

Physical Symptoms

• Breast tenderness
• Bloating and weight gain
• Fatigue
• Headaches
• Joint or muscle pain

Emotional and Behavioral Symptoms

• Mood swings
• Irritability
• Anxiety
• Depression
• Emotional reactivity
• Symptoms occur 1-2 weeks before menstruation and resolve with onset of menses

Diagnosis

• Based on clinical evaluation and symptom severity
• No single diagnostic test, but tools like the Premenstrual Syndrome Diary aid in tracking symptoms
• Must rule out other underlying conditions (e.g., thyroid disorders, depression)

Treatment and Management

Lifestyle Modifications

• Regular exercise
• Balanced diet
• Stress management techniques

Pharmacological Interventions

• Hormonal therapies (e.g., birth control pills)
• Selective serotonin reuptake inhibitors (SSRIs)
• Pain relievers (e.g., ibuprofen)

Alternative Therapies

• Acupuncture
• Herbal supplements (e.g., omega-3 fatty acids)

Menstrual Disorders

• Premenstrual Syndrome (PMS)
  • Defined as a syndrome, not a disease, due to varying symptoms
  • Symptoms: physiological and psychological, varying from month to month
  • Treatment: stress reduction techniques, exercise programs, diet therapy, and drug therapy
• Dysmenorrhea
  • Defined as painful cramps before or during menstruation
  • Causes: excessive prostaglandins leading to smooth muscle contraction
  • Types: primary (common) and secondary (disorder of female reproductive organs)
  • Signs and symptoms: abdominal pain, pressure, vomiting, diarrhea, and pain in hips, lower back, and thighs
  • Treatment: drug therapy, relaxation techniques, heat therapy, exercise, and acupuncture
• Abnormal Vaginal Bleeding
  • Types: oligomenorrhea (light or infrequent periods), amenorrhea (absence of periods), menorrhagia (prolonged bleeding), and metrorrhagia (bleeding between periods)
  • Complications: anemia, toxic shock syndrome
  • Treatment: drug therapy, balloon thermotherapy, myomectomy, and endometrial ablation

Menopause

• Defined as cessation of menses, function of ovary ceases
• Stages: premenopause, perimenopause, menopause, and postmenopause
• Causes: natural decline of reproductive hormones, hysterectomy, bilateral oophorectomy, chemotherapy, and radiation therapy
• Treatment: hormone replacement therapy, antidepressants, selective estrogen receptor modulators, bisphosphonates, and non-hormonal therapy

Pelvic Inflammatory Disease (PID)

• Defined as infection of uterus, fallopian tubes, ovaries, and peritoneal cavity
• Causes: gonorrhea and chlamydial infections spreading up the reproductive system
• Manifestations: abdominal pain, fever, vaginal discharge
• Diagnosis: vaginal culture
• Complications: septic shock, infertility, ectopic pregnancy
• Treatment: drug therapy, forced fluids, heat therapy, and patient teaching for prevention of re-infection

Endometriosis

• Defined as presence of normal endometrial tissue outside the uterus
• Clinical manifestations: dysmenorrhea, pelvic pain, dyspareunia, and infertility
• Diagnosis: pelvic exam, ultrasound, laparoscopy
• Treatment: ibuprofen, oral contraceptives, medroxyprogesterone, danazol, and gonadotropin-releasing hormone agonists

Benign Reproductive Tumors

• Leiomyomas (uterine fibroids)
  • Defined as benign smooth muscle tumors in uterus
  • Diagnosis: hysteroscopy
  • Signs and symptoms: abnormal uterine bleeding, pain, pelvic pressure
  • Treatment: myomectomy, hysterectomy, cryosurgery
• Polycystic Ovarian Syndrome (PCOS)
  • Defined as bilateral enlarged ovaries with multiple outer follicular cysts and hyperplastic ovarian stroma
  • Causes: insulin resistance, hyperinsulinemia, and androgen excess
  • Signs and symptoms: irregular menstrual periods, hirsutism, obesity, acne, and infertility
  • Diagnosis: ultrasound and laparoscopy
  • Treatment: medication, surgery, and additional treatment (weight management, exercise, monitoring lipid profile and glucose levels)

Cancers of Female Reproductive System

• Cervical Cancer
  • Defined as early changes in cervical epithelial tissue
  • Etiology: strongly linked to STDs (HSV-2, HPV)
  • High-risk factors: multiple sex partners, early sexual intercourse, and history of STDs
  • Staging: cervical intraepithelial neoplasia (CIN) graded from I to III