Repro test 3: ppt 8 & 9

Podcast

Play an AI-generated podcast conversation about this lesson

Questions and Answers

What is one of the main physiological changes during pregnancy that affects multiple organ systems?

Reduction in cardiac output

Increased rate of cellular metabolism

Decreased renal blood flow

Increased secretion of progesterone (correct)

What role does the placenta primarily serve during pregnancy?

It specializes in oxygen and nutrient delivery to the fetus (correct)

It prevents the mother from recognizing the fetus

It acts as a barrier to all maternal antibodies

It produces all the hormones needed for fetal development

Which of the following best describes the function of the lacunae in the placenta?

They facilitate the transfer of all maternal antibodies

They are sites where maternal blood flow and fetal blood vessels intersect (correct)

They are involved in the maternal immune response

They act as storage sites for fetal metabolic waste

What physiological change occurs to the spiral arteries during implantation?

They remain intact and expand to supply blood to the placenta Signup and view all the answers

What is a characteristic feature of the placental barrier?

It selectively permits the passage of IgG antibodies Signup and view all the answers

How does the metabolic activity of the placenta change by the third trimester?

It receives a significant percentage of cardiac output Signup and view all the answers

What is the effect of the expanding uterine size during pregnancy?

Decreased respiratory capacity Signup and view all the answers

Why are pregnant women more susceptible to certain diseases?

Physiological changes alter disease presentation Signup and view all the answers

What physiological change commonly occurs in the heart during pregnancy?

Increased ventricular distention Signup and view all the answers

Which of the following factors contributes to increased renal workload during pregnancy?

Increased production of renin Signup and view all the answers

What is a common clinical sign that may mimic heart disease during pregnancy?

S3 gallop and systolic ejection murmur Signup and view all the answers

What anatomical change occurs to the uterus during the first half of pregnancy?

Reaches the umbilicus by 20 weeks Signup and view all the answers

How does the placenta impact cortisol levels during pregnancy?

It maintains high ACTH and cortisol levels Signup and view all the answers

What change is observed in the acid-base equilibrium of pregnant women?

Respiratory alkalosis Signup and view all the answers

Which cardiovascular adaptation is NOT typically seen in pregnancy?

Decreased heart rate variability Signup and view all the answers

What role does HCG play regarding thyroid function during early pregnancy?

Mimics TSH at the thyroid Signup and view all the answers

Which respiratory adaptation occurs during pregnancy?

Increased thoracic diameter Signup and view all the answers

What is a likely consequence of physiological changes in blood volume during pregnancy?

Increased risk of thromboembolism Signup and view all the answers

What characterizes the positional effects related to the vena cava during pregnancy?

Compression during side-lying position Signup and view all the answers

What is one of the causes of increased urinary stasis in pregnant women?

Hydroureter due to progesterone Signup and view all the answers

Which pregnancy-related skin change is associated with POMC release?

Melasma Signup and view all the answers

Which condition results in foreskin that, once retracted, cannot be returned to its normal position?

Paraphimosis Signup and view all the answers

What is the most common cause of phimosis in males?

Poor hygiene leading to chronic infection Signup and view all the answers

In which patient population is Zoon’s balanitis most commonly observed?

Uncircumcised, middle-aged men Signup and view all the answers

What is considered the definitive treatment for phimosis?

Circumcision Signup and view all the answers

Which imaging modality is commonly used to evaluate inguinal and pelvic areas in penile cancer?

CT scan Signup and view all the answers

Which of the following is a symptom associated with balanitis?

Itching under foreskin Signup and view all the answers

What complication can arise from untreated paraphimosis?

Arterial occlusion and necrosis of the glans Signup and view all the answers

Which type of balanitis is specifically associated with reactive arthritis?

Circinate balanitis Signup and view all the answers

What is the typical first-line treatment for a yeast infection in patients with balanitis?

Antifungal creams Signup and view all the answers

What is a common feature of phimosis presentations?

Presence of purulent discharge Signup and view all the answers

What is the most common cause of Erectile Dysfunction (ED)?

Arterial insufficiency Signup and view all the answers

Which of the following factors is NOT considered a risk factor for erectile dysfunction?

Chronic obstructive pulmonary disease Signup and view all the answers

What is the recommended first-line therapy for treating erectile dysfunction?

Oral phosphodiesterase type 5 inhibitors Signup and view all the answers

What is a characteristic of ischemic priapism?

Painful prolonged erection Signup and view all the answers

Which imaging modality is most useful for diagnosing Peyronie’s disease?

Ultrasound Signup and view all the answers

Which condition can be incorrectly attributed to a normal physiological response rather than a pathological one?

Nocturnal erections Signup and view all the answers

Which medication class is known to have side effects contributing to erectile dysfunction?

Antidepressants Signup and view all the answers

What constitutes the most common treatment method for Peyronie’s disease?

Watchful waiting Signup and view all the answers

What is the primary goal of management for ischemic priapism?

To relieve the painful erection Signup and view all the answers

Which of the following is NOT a symptom associated with Peyronie's disease?

Inability to achieve orgasm Signup and view all the answers

Which of the following is an early sign of potential vascular issues in men with erectile dysfunction?

Lack of spontaneous erections Signup and view all the answers

What is the primary factor determining the severity of penile cancer prognosis?

Presence of metastasis Signup and view all the answers

Which of the following treatments is categorized as a last resort for Peyronie’s disease?

Surgery Signup and view all the answers

Study Notes

Pregnancy Physiology

Pregnancy changes physiology, including pathophysiology.
Most changes are hormonally driven and affect multiple organ systems.
Hormones involved: progesterone, estrogen, renin, aldosterone, cortisol, insulin.
Some changes are driven by anatomical changes, primarily due to the uterus.
Most changes aim to optimize fetal development and prepare for delivery, focusing on oxygen and nutrient delivery.

Placenta

The placenta is a specialized organ crucial for oxygen and nutrient delivery to the fetus.
Weighs 500 grams (1 pound) at birth
It prevents the fetus from being recognized as foreign by the mother's immune system.
Maternal blood flow interacts with fetal umbilical capillaries in pockets called lacunae.
The placenta acts as a low-resistance "sink" for maternal blood flow.

Placental Barrier

Allows the passage of certain materials via passive diffusion.
Mostly large proteins and cells cannot pass.
IgG, responsible for maternal immunity, crosses the placenta.

Placental Metabolic Activity

In the third trimester, the placenta receives 20-25% of cardiac output, about 750 ml/min.
The placenta's high metabolic activity requires significant oxygen, equal to the fetus's needs.
The placenta is refractory to vasoactive medications.

Corticotropin Releasing Hormone

The placenta maintains high ACTH and cortisol levels.
ACTH release causes POMC (pigmentation hormone) release, leading to skin darkening during pregnancy.
POMC contributes to linea nigra and melasma.

Cardiovascular and Hematologic Changes

Vascular tone decreases, leading to vasorelaxation.
Systemic vascular resistance (SVR) decreases by 20% due to the low resistance of the placenta.
Vena cava compression can occur due to positional effects.
Blood volume increases by 50-100%.
Red blood cell (RBC) mass increases by 25-40%.
Physiological dilution results in relative anemia.

Cardiac Changes

Cardiac output (CO) increases significantly due to increased stroke volume (SV) and heart rate (HR).
Cardiac axis is displaced cephalad and left.
Point of maximal impulse (PMI) is lateral and elevated.
Altered thoracic dimensions lead to left axis deviation.
Murmurs are common in over 96% of pregnant women due to increased blood volume flowing through valves.
Virtually all valves can be affected, especially the aortic and pulmonary valves.
Resting heart rate is increased (80s instead of 70s, reaching 100s with minimal exertion).
Ventricular distention increases by 25%.
Cardiomyopathy can occur during pregnancy; don't assume it's solely a physiological change.
Non-specific ST and T wave changes and increased dysrhythmias are common.
Physiological hypokalemia, due to increased mineralocorticoid activity, may contribute to dysrhythmias.
Left ventricular hypertrophy (LVH) and mild pericardial effusion are common.

Blood Pressure Changes

Blood pressure decreases in the second trimester.
It returns to baseline by the end of pregnancy.
Hypertensive disorders of pregnancy are frequent, usually starting towards the end of pregnancy.
Cardiac adaptations: CO up, SVR down, HR up.

Signs and Symptoms Mimicking Heart Disease

Clinical signs: peripheral edema and jugular venous distension (JVD).
Symptoms: reduced exercise tolerance and dyspnea.
Auscultation: S3 gallop and systolic ejection murmur.
Chest X-ray: change in heart position and size, increased vascular markings.
Electrocardiogram (EKG): non-specific ST-T wave changes, axis deviation, LVH.
Echocardiogram: mild pericardial effusion.

Anatomical Considerations

Uterine position progresses: pelvic brim by 12 weeks, umbilicus by 20 weeks.
Uterine compression affects: bladder (frequency), ureters (hydroureter), SI joint, pubic symphysis (pain).

Elevated Renin

Progesterone stimulates renin production, also produced by the placenta.
Consequences: increased sodium absorption, increased potassium excretion, water retention (6-8 L).

Renal Changes

Increased renal blood flow due to expanded blood volume.
50-75% increase in renal workload.
Glomerular filtration rate (GFR) increases by 50%.
Diluted plasma proteins like albumin lead to a lower colloid osmotic pressure.

Other Urinary Tract Changes

Ureteral dilation (hydroureter): progesterone leads to decreased ureteral peristalsis, exacerbated by uterine obstruction.
Urinary stasis increases ureteral dilation and the risk of ascending bladder infections (pyelonephritis).
Dilation of the renal pelvis and calyces.
Increased kidney size.

Lung and Respiratory Adaptations

Respiratory rate does not change significantly.
Thoracic diameter increases by 2 cm, circumference by 5-7 cm.
Increased minute ventilation.
Tidal volume increases by 30-40%.

Acid-Base Equilibrium

Pregnancy leads to a compensated respiratory alkalosis.
Increased carbon dioxide (CO2) excretion per minute.
Slight increase in pH (7.44+).
Increased partial pressure of oxygen (PaO2), decreased partial pressure of carbon dioxide (PaCO2) (40-30).
A larger gradient for both O2 and CO2 at the placenta, facilitating gas exchange.

Gastrointestinal Changes

Slowed GI motility (progesterone effect): constipation and early satiety.
Relaxation of lower esophageal sphincter (LES): gastroesophageal reflux disease (GERD).
Nausea and vomiting: often linked to human chorionic gonadotropin (HCG) levels.
Liver and gall bladder: biliary stasis, cholesterol saturation, increased stone risk.
Increased liver production of clotting factors, leading to a greater tendency for clotting.
Increased binding proteins for thyroid hormones, steroids, and vitamin D, altering free hormone levels.

HCG and Thyroid

HCG can mimic thyroid-stimulating hormone (TSH) at the thyroid gland.
Increased T3/T4 levels may contribute to first-trimester nausea.
If TSH levels are mildly abnormal in the first trimester, check T3/T4 and recheck in the second trimester.

Orthopedic Adaptations

Shift in center of gravity.
Altered gait.
Increased joint laxity.
Widening of the symphysis pubis.

Erectile Dysfunction

Most common sexual problem in men
Consistent inability to achieve or maintain an erection sufficient for sexual intercourse
Negatively impacts quality of life
Often caused by arterial insufficiency
May be an early sign of cardiovascular disease
Antihypertensive, antidepressants, and opioid medications are associated with erectile dysfunction (e.g., beta-blockers, diuretics, SSRIs/SNRIs, hydrocodone)

Epidemiology of Erectile Dysfunction

More than half of men aged 40-70 years have erectile dysfunction
Incidence increases with age
Most have an organic rather than a psychological cause

Risk Factors for Erectile Dysfunction

Age
Prostate disorders (e.g., cancer, benign prostatic hyperplasia)
Hypogonadism (insufficient testosterone production)
Vascular disease
Chronic obstructive sleep apnea
Hypertension
Diabetes
Alcohol use
Tobacco use
Recreational drug use
Medication adverse effects (e.g., SSRIs/SNRIs, beta-blockers, opioids)
Peyronie's disease
Psychological disorders (e.g., depression, anxiety)

Labs and Work-up for Erectile Dysfunction

Urinalysis
Fasting serum lipid profile
Serum glucose, HbA1c
Serum total testosterone (free circulating/unbound to protein, and bound to protein)
TSH
Serum prolactin
Patients with abnormal testosterone levels should have measurement of free testosterone and luteinizing hormone (LH) to differentiate hypothalamic-pituitary dysfunction from primary testicular failure

Imaging and Diagnostic Studies for Erectile Dysfunction

Duplex Doppler ultrasound and penile cavernosography can distinguish arterial from venous erectile dysfunction, helping predict which patients may benefit from vascular surgery.
Direct injection of vasoactive substances into the penis (e.g., prostaglandin E1 or papaverine)

Considerations for Erectile Dysfunction

Thorough review of past medical history and any new chronic conditions that may play a role (e.g., diabetes, hypertension, cardiovascular disease, peripheral vascular disease, endocrine disorders, neurological disorders, kidney disease, cancer, trauma, surgery)
Patient body mass index; obesity
Social history (alcohol, tobacco, recreational drug use, THC use)
History and physical examination are sufficient to make the diagnosis of erectile dysfunction

Treatment and Management of Erectile Dysfunction

First-line therapy consists of oral phosphodiesterase type 5 inhibitors (e.g., sildenafil, vardenafil, tadalafil).
Contraindicated in patients taking nitroglycerine or nitrates due to hypotension and syncope concerns.
Intracavernous injection of prostaglandin E1 (alprostadil) or papaverine (vasodilator)
Alprostadil urethral suppository pellets
Surgery (penile prosthesis implanted into the paired corpora cavernosa)
Therapeutic procedures like vacuum erection devices (draw blood into corpora cavernosa)

When to Refer for Erectile Dysfunction

Patients with unsatisfactory response to oral medications
Patients with Peyronie's disease or other penile deformity (urology)
Patients with a history of pelvic or perineal trauma, surgery, or radiation (urology)
Patients with priapism to the emergency department for immediate intervention to allow restoration of penile perfusion (emergency department)

Priapism

Full or partial erection lasting more than 4 hours
Prolonged painful penile erection in the absence of sexual stimulation
Leads to ischemic injury of the corpora cavernosa, increasing the risk of impotence
Ischemic priapism is a medical emergency requiring immediate medical or surgical intervention to avoid irreversible penile damage
Early recognition (within hours) and prompt treatment of priapism offer the best opportunities to avoid impotence

Etiology of Priapism

Idiopathic in 60% of cases
The remaining 40% of cases are associated with:
- Certain diseases (e.g., leukemia, sickle cell disease, pelvic tumors, pelvic infections)
- Penile trauma
- Spinal cord trauma
- Medications
- Alcohol
- Cocaine
- Currently, intracavernous injection therapy for impotence may be the most common cause

Peyronie's Disease

Common disorder caused by scar formation within the erectile bodies of the penis, resulting in pain, penile deformity, and sexual dysfunction
Examination of the penile shaft will disclose a thickened plaque, typically on the dorsum.
Imaging modalities:
- Ultrasound is useful for detecting Peyronie's disease.
- Direct injection of vasoactive substances into the penis (e.g., prostaglandin E1 or papaverine) can reveal penile curvature.

Peyronie's Disease Clinical Presentation

Scar tissue
Significant bend to the penis
Trouble maintaining erections
Possible penile shortening
Variable amount of pain

Peyronie's Disease Treatment and Management

Watchful waiting
Traction therapy
Injection therapy
Collagenase injections (the only FDA-approved medication for the treatment of Peyronie's disease)
- Injected into the central portion of the plaque by needle.
- Causes enzymatic digestion of the lesion, leading to subsequent correction of penile curvature over time.
No oral therapies are FDA-approved.
Surgery is an alternative for men with severe curvature or lesions causing penile instability (last resort).
Outpatient urology referral is warranted

Penile Cancer

Exhibits a predictable pattern of local, regional, and systemic spread
The earliest route of metastasis is to the regional inguinal and iliac nodes
Metastasis is characterized by a relentlessly progressive course, leading to death for most untreated patients within two years.
Metastatic enlargement of the regional nodes can result in skin necrosis, chronic infection, sepsis, and hemorrhage secondary to femoral vessel erosion
Tumor, node, metastasis (TNM) staging system is used for penile cancer staging

Penile Cancer Risk Factors:

Lack of circumcision
HPV infection
Phimosis
Smoking

Epidemiology of Penile Cancer

Most commonly affects men between 50 and 70 years of age.
Accounts for less than 1% of all malignant neoplasms among men in the United States.
Squamous cell carcinoma (SCC) is the most common histologic subtype, accounting for more than 95% of cases.

Penile Cancer Imaging and Work-up

Patients with clinically palpable lymph nodes should undergo imaging to define the full extent of the disease.
CT and MRI imaging depend primarily on lymph node enlargement for detection of metastases.
CT has often been the imaging modality chosen in penile cancer to examine the inguinal and pelvic areas, as well as to rule out distant metastases.
In known inguinal metastases, CT-guided biopsy of enlarged pelvic nodes can help with consideration of neoadjuvant chemotherapy.

Penile Cancer Treatment and Management

Surgical amputation of the primary tumor remains the gold standard for definitive treatment

Phimosis

Condition where the contracted foreskin cannot be retracted over the glans penis
May appear as a tight ring or "rubber band" of foreskin around the head of the penis.
Chronic infection from poor hygiene is the most common cause
Most cases occur in uncircumcised males.
Squamous cell carcinoma (SCC) may develop under the foreskin, increasing the risk of penile cancer.
In diabetic older men, chronic balanoposthitis may lead to phimosis.
Balanoposthitis is an inflammatory condition of the foreskin and glans that affects uncircumcised men (e.g., infections like Candida).

Phimosis Clinical Presentation

Edema
Erythema
Tenderness of the prepuce
Presence of purulent discharge

Phimosis Management

Circumcision is curative.
Topical steroid treatment (e.g., betamethasone 0.05% to 0.10% twice daily) applied from the tip of the foreskin to the glans penis for 1 to 2 months, along with daily manual preputial retraction, is an effective nonsurgical management option for phimosis.
Initial infection should be treated with broad-spectrum antimicrobials.

Paraphimosis

Condition where the foreskin, once retracted over the glans penis, cannot be replaced in its normal position due to chronic inflammation.
Results in phimosis and formation of a tight ring of skin when the foreskin is retracted behind the glans.
This skin ring causes venous congestion leading to edema and enlargement of the glans penis.
As the condition progresses, arterial occlusion and necrosis of the glans may occur.
Usually, can be treated by firmly squeezing the glans for 5 minutes to reduce tissue edema and decrease the size of the glans.
The skin can then be drawn forward over the glans.
Occasionally, the constricting ring requires incision under local anesthesia.
Antibiotics should be administered, and circumcision should be done after inflammation has subsided.

Balanitis

Inflammation and pain of the glans (head) of the penis.
Most often occurs in uncircumcised males and boys younger than 4 years old.
Typically caused by yeast infection, but can be due to bacterial and viral infection etiology.
Estimated that up to 10% of males will have balanitis during their lifetime.

Types of Balanitis

Balanitis (Zoon's balanitis):
- The main type of balanitis
- Usually affects uncircumcised, middle-aged men
- Causes an inflamed, red penis head.
Circinate balanitis:
- Result of reactive arthritis.
- In addition to inflammation and redness, causes small lesions (sores) on the head of the penis.
Pseudoepitheliomatous keratotic and micaceous balanitis:
- A rare form of balanitis, resulting in scaly warts on the glans.

Balanitis Clinical Presentation

Pain and irritation on the glans penis.
Erythema/redness on the glans penis.
Itching under the foreskin.
Swelling/inflammation.
Areas of shiny or white skin on the penis.
White discharge (smegma) under the foreskin.
Foul smell.
Painful urination.
Sores or lesions on the glans (rare and appears with a type of balanitis that affects men older than 60).

Balanitis Diagnosis

Often made clinically through physical examination.
May need to swab the urethral opening for testing.
Urinalysis
CBC with differential
Labs to check for diabetes
STD check

Balanitis Treatment and Management

Antifungal creams (e.g., clotrimazole) for yeast infections.
Antibiotics to treat any infections, including STDs.
Improved hygiene: Wash and dry under the foreskin regularly.
Diabetes management: Lifestyle modifications with good blood sugar control.
Circumcision: Usually considered if symptoms recur.

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

Ppt 8: Physiologic Changes in Pregnancy, Ppt 9: Penile Disorders ppt