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What is one of the main physiological changes during pregnancy that affects multiple organ systems?
What role does the placenta primarily serve during pregnancy?
Which of the following best describes the function of the lacunae in the placenta?
What physiological change occurs to the spiral arteries during implantation?
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What is a characteristic feature of the placental barrier?
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How does the metabolic activity of the placenta change by the third trimester?
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What is the effect of the expanding uterine size during pregnancy?
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Why are pregnant women more susceptible to certain diseases?
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What physiological change commonly occurs in the heart during pregnancy?
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Which of the following factors contributes to increased renal workload during pregnancy?
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What is a common clinical sign that may mimic heart disease during pregnancy?
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What anatomical change occurs to the uterus during the first half of pregnancy?
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How does the placenta impact cortisol levels during pregnancy?
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What change is observed in the acid-base equilibrium of pregnant women?
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Which cardiovascular adaptation is NOT typically seen in pregnancy?
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What role does HCG play regarding thyroid function during early pregnancy?
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Which respiratory adaptation occurs during pregnancy?
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What is a likely consequence of physiological changes in blood volume during pregnancy?
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What characterizes the positional effects related to the vena cava during pregnancy?
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What is one of the causes of increased urinary stasis in pregnant women?
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Which pregnancy-related skin change is associated with POMC release?
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Which condition results in foreskin that, once retracted, cannot be returned to its normal position?
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What is the most common cause of phimosis in males?
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In which patient population is Zoon’s balanitis most commonly observed?
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What is considered the definitive treatment for phimosis?
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Which imaging modality is commonly used to evaluate inguinal and pelvic areas in penile cancer?
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Which of the following is a symptom associated with balanitis?
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What complication can arise from untreated paraphimosis?
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Which type of balanitis is specifically associated with reactive arthritis?
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What is the typical first-line treatment for a yeast infection in patients with balanitis?
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What is a common feature of phimosis presentations?
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What is the most common cause of Erectile Dysfunction (ED)?
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Which of the following factors is NOT considered a risk factor for erectile dysfunction?
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What is the recommended first-line therapy for treating erectile dysfunction?
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What is a characteristic of ischemic priapism?
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Which imaging modality is most useful for diagnosing Peyronie’s disease?
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Which condition can be incorrectly attributed to a normal physiological response rather than a pathological one?
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Which medication class is known to have side effects contributing to erectile dysfunction?
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What constitutes the most common treatment method for Peyronie’s disease?
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What is the primary goal of management for ischemic priapism?
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Which of the following is NOT a symptom associated with Peyronie's disease?
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Which of the following is an early sign of potential vascular issues in men with erectile dysfunction?
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What is the primary factor determining the severity of penile cancer prognosis?
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Which of the following treatments is categorized as a last resort for Peyronie’s disease?
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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.
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Ppt 8: Physiologic Changes in Pregnancy, Ppt 9: Penile Disorders ppt
