Reproductive System MRD515 PDF

REPRODUCTIVE SYSTEM MRD515 LEARNING OBJECTIVES Upon completing this chapter, students will be able to: 1. Discuss the fundamental anatomical structures related to the male and female reproductive systems. 2. Provide a concise explanation of the roles played by general radiography, mammo...

REPRODUCTIVE SYSTEM MRD515 LEARNING OBJECTIVES Upon completing this chapter, students will be able to: 1. Discuss the fundamental anatomical structures related to the male and female reproductive systems. 2. Provide a concise explanation of the roles played by general radiography, mammography, diagnostic medical sonography, computed tomography, and magnetic resonance imaging in the diagnosis and treatment of disorders in the reproductive system. 3. Compare and contrast various breast imaging modalities, including diagnostic and screening mammography, localization techniques, and sonography. 4. Differentiate between the major congenital anomalies affecting the female reproductive system. 5. Describe the different neoplastic diseases that affect both the female and male reproductive systems, covering aspects such as their causes, incidence rates, signs and symptoms, treatment options, and prognosis. 6. Identify and distinguish between common disorders that can occur during pregnancy, while also explaining the role of diagnostic medical sonography in the management of pregnant individuals. ANATOMY AND PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM The female reproductive system consists of: Ovaries (primary sex organs). Fallopian tubes. Uterus. Vagina. Breasts. The primary function is to provide a female reproductive cell (ovum/egg), hormones, and a site for the development of the zygote (fertilized egg). External Genitalia (Vulva): Components include the mons pubis, labia majora and minora, clitoris, urethral and vaginal openings, and the perineum. The vagina connects the external genitalia with the uterus and serves as the exit for menstrual fluids and conception products. Uterus: Pear-shaped organ located in the pelvic cavity. Divided into the fundus (upper portion), body (midportion), and cervix (lower portion). The cervix connects the uterine cavity to the upper vagina. It has three layers: endometrial (inner), myometrial (middle), and parietal peritoneum (outer). The uterus is supported by eight ligaments. Pessary: A device inserted into the vagina to provide support for the uterus in cases of lack of proper uterine support. It can help relieve urinary symptoms and is used for pelvic organ prolapse. Fallopian Tubes: Extend from the upper edges of the uterus, serving as a passageway for mature ova (eggs). Normal site of fertilization, where sperm typically meets the egg. In a normal pregnancy, the fertilized egg travels through the fallopian tube to implant in the uterus. Ovaries: Primary reproductive glands responsible for ovulation. Produce estrogen and progesterone. Contain Graafian follicles that enclose ova. After puberty, one follicle matures each month, leading to ovulation.  Breasts: Considered secondary sex organs. Composed of lobes separated by connective tissue. During pregnancy, hormonal changes prepare breasts for lactation. Lactogenic hormones stimulate milk secretion after delivery. The architecture of the breast changes with age, with fatty tissue replacing fibroglandular tissue. Mastalgia: Refers to breast pain and is related to architectural changes in breast tissue. Not necessarily indicative of breast cancer but can be a concern for some individuals. Breast Structure: Attached to pectoral muscles via Cooper ligaments. Lobes are divided into lobules, which are clustered around small ducts. Ducts join to form larger ducts that terminate at the nipple. Breasts function as accessory reproductive glands to secrete milk for newborns. IMAGING CONSIDERATIONS Hysterosalpingography (HSG) HSG is a common radiographic study for non-pregnant women, especially for infertility screening. It helps assess the patency of fallopian tubes and provides information about the shape of the uterus. Contrast medium is injected into the uterine cavity to visualize the reproductive organs. Spillage of contrast medium from the fallopian tubes indicates tube patency. Sonohysterography (SHG) SHG is an alternative to HSG, where saline is used instead of iodinated contrast. It can reveal abnormalities within the uterus and may indicate fallopian tube patency. SHG is viewed using transvaginal sonography, providing real-time images without radiation. HSG and SHG were equally effective in evaluating tubal disease. Mammography: Mammography is used for diagnosing breast-related symptoms and screening purposes. It detects breast masses, pain, nipple discharge, and skin and lymph node abnormalities. Modern mammography equipment minimizes radiation exposure. Screening is recommended for women over 50 years, as breast tissue is less sensitive to radiation, and breast cancer risk increases with age. Mammography can be used for breast disease evaluation in individuals with breast augmentation. The implant should be displaced to visualize native breast tissue for disease assessment. Techniques like the Eckland maneuver are used for imaging. Needle Guidewire Localization: It's a procedure to identify nonpalpable breast abnormalities detected by mammography. It helps guide surgeons for biopsy, with minimal morbidity. Other biopsy techniques, such as fine-needle and large-core biopsy, are mentioned.  Sonography Sonography is used to differentiate cystic from solid breast masses. It has limitations in diagnosing solid malignant breast diseases. Sonography is highly recommended for evaluating suspected gynecologic adnexal masses. Magnetic Resonance Imaging (MRI): MRI is used in conjunction with sonography for evaluating the female pelvis. It provides detailed information about pelvic, uterine, and ovarian masses. It's also used to assess breast tissue, especially for differentiating malignant from benign lesions. Computed Tomography (CT): CT is used for diagnosing reproductive system diseases, especially in staging cancer. It's used for assessing neoplastic growth, abscess formation, and anomalies. CT-PET fusion studies are valuable for diagnosing and staging neoplastic diseases. CT is indicated for non-pregnant women in the reproductive age group with complex or solid masses that are growing in the short term.  CONGENITAL ANOMALIES: Types of Congenital Anomalies: 1. Bicornuate Uterus: The most common anomaly where paired uterine horns extend into the fallopian tubes. This results in a uterus with a heart-shaped appearance. 2. Unicornuate Uterus: Occurs when the uterine cavity is elongated and has a single fallopian tube emerging from it. Often, the kidney on the side of the missing fallopian tube is also absent. 3. Uterus Didelphys: A rare congenital anomaly characterized by complete duplication of the uterus, cervix, and vagina. The most serious complication of these anomalies is problems with reproduction. Surgical corrections can be performed to address these issues.  Abnormal Uterine Positions: In the normal female reproductive system, the fundus of the uterus lies anterior to the cervix and away from the rectum, a position known as anteverted. Occasionally, the normal uterus may lie in an abnormal position. Retroverted Uterus: The uterus is more vertical than normal and points backward toward the bowel. Retroflexed Uterus: The uterus is completely bent back and lies against the rectosigmoid region of the bowel. Anteflexed Uterus: The uterus is tilted vertically forward and lies on top of the urinary bladder. While these abnormal uterine positions are not normal, they are generally of little clinical significance. INFLAMMATORY DISEASES  Pelvic Inflammatory Disease (PID): PID is a bacterial infection that primarily affects the fallopian tubes. The causes of PID can include Gonococcus, mixed infections, Staphylococcus, or Streptococcus. The disease may result from factors such as unsterile abortion or the introduction of pathogens from other sources. PID is typically a bilateral inflammation, and without treatment, it can spread to the peritoneum, leading to bacteremia. Tubo-ovarian abscess formation is a possible complication of PID and can result in sterility.  Clinical presentation includes pelvic pain, tenderness, guarding, rebound tenderness, fever, chills, elevated white blood cell count, nausea, vomiting, and purulent cervical discharge. Aggressive antibiotic therapy is the most common treatment for PID. Healing from PID may lead to scarring and fallopian tube obstruction, increasing the risk of ectopic pregnancy. Rupture of the fallopian tubes due to infection can result in septic shock, a life-threatening condition. Sonography is commonly used to diagnose and assess the extent of PID. Severe cases with abscess formation may require surgery.  Mastitis: Inflammation of the breast tissue, often caused by Staphylococcus aureus. Acute mastitis typically occurs when bacteria enter breast tissue through cracks or fissures in the nipple during lactation and breastfeeding. Common signs and symptoms of mastitis include breast pain, redness, swelling, elevated temperature, and the potential for abscess formation. Treatment for mastitis involves antibiotic therapy and heat application to the affected breast. Risk factors for lactational mastitis include diabetes, steroid use, cigarette smoking, and inverted nipples. Mammography can be challenging for mastitis patients due to significant breast tissue engorgement. Mammography may result in higher radiation doses and has limited diagnostic and treatment value for mastitis. NEOPLASTIC DISEASES Ovarian Cystic Masses: Simple ovarian cysts are common in reproductive-age women and are usually asymptomatic but can cause abdominal discomfort. Follicular and corpus luteum ovarian cysts are part of the normal menstrual cycle. Follicular cysts result from fluid reabsorption issues in underdeveloped follicles. Corpus luteum cysts occur when blood is reabsorbed after ovulation, leaving a small cyst. These cysts can change in size during the menstrual cycle and may cause pelvic discomfort or pressure. Diagnostic imaging methods like sonography, MRI, and CT can visualize these cysts. Treatment is often unnecessary as they tend to resolve on their own. Endometriosis: Endometriosis is a condition where endometrial tissue or glands are found outside the uterus in the pelvic region. It can involve various pelvic structures, including the ovaries, and can cause symptoms like pelvic and back pain, dysmenorrhea, constipation, diarrhea, and infertility. Diagnosis may involve sonography, but laparoscopy is often used for confirmation. Mild cases may be treated with hormone therapy, while severe cases may require surgery.  Polycystic Ovaries: Polycystic ovaries are enlarged ovaries containing multiple small cysts. They are associated with Stein-Leventhal syndrome, a condition that can lead to irregular ovulation, amenorrhea, and sterility. Treatment typically involves medications to induce ovulation. Cystic Teratomas (Dermoid Cysts): Cystic teratomas are benign ovarian tumors composed of various tissue types. They are the most common type of germ cell tumor. Complications can include torsion and rupture, which may require surgical removal. Cystadenocarcinoma: Cystadenocarcinoma is a malignant ovarian tumor, primarily affecting perimenopausal and postmenopausal women. It is the most common ovarian cancer and has a poor prognosis if discovered at an advanced stage. Risk factors include genetics, diet, and late childbearing. CA 125 (lab test) and PET-CT are used for diagnosis and surveillance. Treatment involves surgery, chemotherapy, and radiation therapy.  Cervical Carcinoma (Dysplasia): Cervical carcinoma is a common malignancy of the cervical epithelial cells and is often associated with human papillomavirus (HPV) infection. It is the third most common carcinoma of female genital organs and eighth most common malignancy in American women. Symptoms include abnormal bleeding and ureteral obstruction. Early detection through Pap tests is crucial for improving the chances of cure. Treatment options vary based on the stage and may include radiation therapy, surgery, and chemotherapy. Vaccines like Gardasil can prevent some HPV-related cancers. UTERINE MASSES  Benign, solid masses that develop from an overgrowth of Leiomyomas uterine smooth muscle tissue. Common, present in approximately 30% of all women and in (Uterine Fibroids) 40% to 50% of women over age 50. The most common benign tumors of the female reproductive system. Symptoms may include uterine enlargement, distortion, low back pain, pressure on the bowel and bladder, intermenstrual bleeding, and acute pain. The cause of leiomyomas is unknown, but they tend to grow under the influence of estrogen, may enlarge during pregnancy, and stop growing at menopause. Diagnostic imaging methods like sonography, CT, and MRI are useful in confirming their presence. Treatment depends on patient symptoms and may range from no treatment to surgical removal of the uterus. Uterine artery embolization is a radiologic treatment option in some cases.  Adenocarcinoma of the Endometrium: Adenocarcinoma of the endometrium is the most common malignancy of the uterus, accounting for over 80% of all endometrial cancers. It mainly affects postmenopausal women and becomes more common with age. Risk factors include hormonal changes, obesity, tamoxifen use, late menopause, a family history of breast or ovarian cancer, or previous pelvic radiation therapy. It typically begins with endometrial hyperplasia and progresses through stages, often completely filling the uterine cavity. Symptoms commonly include irregular or postmenopausal bleeding. Treatment depends on the stage of the disease. Curative treatment for stage 0 involves a hysterectomy. Stages I and II are treated with a combination of surgery and radiation therapy, with good survival rates. Stage III and IV are treated with chemotherapy, but survival rates are lower. BREAST MASSES Fibroadenoma: A fibroadenoma is a common benign breast tumor, often found in women under 30 years of age. It consists of a solid, well-defined mass in the breast, typically located in the upper, outer quadrant. Fibroadenomas are estrogen-dependent and may grow during pregnancy. They are generally painless and can usually be moved within the breast. Diagnostic tools include mammography, physical breast examination, and sonography. Surgical removal of the fibroadenoma is curative. Fibrocystic Breasts: Fibrocystic breasts result from an overgrowth of fibrous tissue or cystic hyperplasia, occurring in 60% to 75% of women. Symptoms include masses that become larger and more tender before menstruation, ropy and thick breast tissue, and breast pain. Sonography can help differentiate between solid and cystic masses. Large cysts are commonly aspirated for cytologic evaluation. Treatment is largely symptomatic, including breast self-examination and proper support. Breast Carcinoma: Breast carcinoma is a common malignancy in women, with an increased risk between ages 30 and 50 years. Factors contributing to breast cancer include heredity, hormonal influence, oncogenic factors, and environmental factors. The availability of biologically active estrogen and progesterone plays a role in breast cancer development. Early detection through mammography can reduce breast cancer mortality. Radiographically, breast cancers appear as dense, irregular, stellate masses.  Fine-needle aspiration, core needle biopsy, or incisional biopsy may be performed for diagnosis. Needle localization of nonpalpable cancerous lesions aids in surgical removal. ER and PR receptor status information helps determine treatment options. Treatment depends on disease extent and may involve modified radical mastectomy, breast-conserving surgery followed by radiation, chemotherapy, and radiation therapy. DISORDERS DURING PREGNANCY Diagnostic medical sonography is used to confirm pregnancy and diagnose multiple and ectopic pregnancies. Transvaginal sonography allows the visualization of the sac and early fetal pole as early as 3 weeks of gestation. Sonography may be performed if the size of the pregnant uterus is abnormal for the calculated delivery date. Sonography is used for screening fetal anomalies, usually performed at 6 to 8 weeks of gestation. Additional laboratory tests like amniocentesis, chorionic villus sampling, and DNA analysis are conducted in cases of suspected congenital fetal anomalies. Amniotic Fluid: Amniotic fluid is produced by various physiological functions within the mother and fetus. The amount of amniotic fluid varies with the stage of pregnancy. Oligohydramnios refers to too little amniotic fluid, while polyhydramnios indicates an excess. Fetal swallowing and urine production are essential for maintaining amniotic fluid volume. Oligohydramnios may result from poor fetal kidney function or urinary system blockage. Polyhydramnios may occur if the fetus cannot swallow due to certain conditions. Amniotic fluid plays a crucial role in fetal development and protecting the fetus.  Ectopic Pregnancy: Ectopic pregnancy occurs when an embryo develops outside the uterine cavity, often in the fallopian tube. Common signs and symptoms include abdominal pain, tenderness, vaginal bleeding, fainting, and shock. Tubal pregnancy can lead to internal hemorrhage, which can be life-threatening. It is more common in women with a history of pelvic inflammatory disease (PID) or uterine tube obstructions. Diagnosis is confirmed via laparoscopy, and treatment involves surgical removal of the embryo and affected uterine tube. MRI may provide additional information in cases of ectopic pregnancy located in the cervix or interstitial area of the tube. Disorders of the Placenta: The placenta is a temporary organ that facilitates nutrient and oxygen exchange between the mother and fetus. Placenta previa occurs when the placenta partially or fully covers the cervical os, leading to painless vaginal bleeding. Placenta abruption involves the premature separation of the placenta from the uterine wall and can be life-threatening. Placental percreta occurs when the placenta extends into the myometrium. Sonography and Doppler ultrasound are recommended for diagnosing and distinguishing between these placental pathologies. Hydatidiform Mole: A hydatidiform mole is an abnormal conception where usually no fetus is present. The uterus is filled with cystically dilated chorionic villi resembling a bunch of grapes. This condition is characterized by swelling of the villi and absence of fetal heart sounds. It usually aborts spontaneously, but suction curettage may be performed if necessary. Some molar pregnancies may develop invasive disease, and sonography, clinical factors, and pelvic MRI are used for diagnosis. ANATOMY AND PHYSIOLOGY OF THE MALE REPRODUCTIVE SYSTEM The male reproductive system functions to produce and deliver sperm for fertilization of the female egg. To produce hormones, primarily testosterone, which plays a crucial role in the development of secondary sexual characteristics and the regulation of various physiological processes in the male body. Glands of the Male Reproductive System: Testes: There are two testes, which are enclosed by a white, fibrous covering within the scrotum. The primary functions of the testes are the production of sperm (spermatogenesis) and the secretion of hormones, primarily testosterone. Seminal Vesicles: There are two seminal vesicles, which contribute to the production of seminal fluid. This fluid contains nutrients and enzymes that nourish and support sperm. Bulbourethral Glands: There are two bulbourethral glands, also known as Cowper's glands. They secrete a clear, viscous fluid that lubricates the urethra and neutralizes any residual acidity in the urethra due to urine, creating a more suitable environment for sperm. Prostate Gland: The prostate gland is a single gland located just inferior to the bladder. The urethra passes through this gland. It secretes the majority of the seminal fluid, which plays a vital role in sperm motility and viability. The prostate gland is approximately the size of a walnut. Ducts of the Male Reproductive System: Epididymides: There are two epididymides, which are coiled tubes located superior and lateral to the testes. They serve as a passageway for sperm and also contribute to the secretion of seminal fluid. Sperm mature and gain motility in the epididymides. Vasa Deferentia: There are two vasa deferentia, also known as the ductus deferens. They extend from the epididymides and pass through the inguinal canal into the pelvic cavity. The vasa deferentia continue superiorly, passing above the bladder, and then descend along the posterior surface of the bladder. Ejaculatory Ducts: The ejaculatory ducts are formed by the junction of the vasa deferentia with the ducts emerging from the seminal vesicles. These ducts are responsible for transporting seminal fluid into the urethra. Urethra: The urethra is a single tube that carries both urine from the bladder and seminal fluid from the reproductive glands to the exterior of the body. It passes through the prostate gland and runs within the penis.  IMAGING CONSIDERATIONS Testicular Imaging: Scrotal Sonography: Sonography is commonly used to assess testicular masses, scrotal pain, and scrotal enlargement. It helps differentiate between conditions such as epididymitis, orchiditis, and testicular torsion. MRI: Magnetic resonance imaging (MRI) can also be used to evaluate testicular masses and conditions. It can help in detecting and staging testicular cancer, as well as determining if the cancer is present in one or both testicles. Prostate Imaging: Prostatic Sonography: Transrectal sonography is used to evaluate the prostate gland. It can help identify nodules and guide physicians during prostate biopsy procedures. MRI of the Pelvis: MRI of the male pelvis is performed to assess the prostate gland and seminal vesicles. It is particularly useful in detecting and staging prostate cancer, especially in cases with elevated prostate-specific antigen (PSA) levels. Specialized rectal coils may be used for better prostate imaging.  Urethrography and Intravenous Urography: These radiographic techniques are limited but may be used to assess the male urinary tract and the urethra. Nuclear Medicine: Nuclear medicine imaging can be valuable in distinguishing between epididymitis and testicular torsion. Specialized MRI (erMRI): For patients with elevated PSA levels, endorectal coil MRI (erMRI) may be considered as a pretreatment staging for prostate cancer. Contrast-Enhanced MRI: Contrast-enhanced MRI may be used in some cases to provide additional information for the evaluation of prostate cancer. CONGENITAL ANOMALIES Cryptorchidism is a condition where one or both testes fail to descend into the scrotum by the end of gestation. This condition is associated with a higher risk of malignancy, particularly testicular cancer. Treatment options include surgically bringing the testicle down and fixing it or removing it. Sonography is commonly used to locate the undescended testicle. MRI may also be valuable for diagnosis due to its superior tissue differentiation capabilities. NEOPLASTIC DISEASES  Prostatic Hyperplasia Prostatic hyperplasia is a common benign enlargement of the prostate gland. It is characterized by the development of discrete nodules within the gland. Diagnosis often involves a digital rectal examination and a blood test to assess serum PSA (Prostate- Specific Antigen) levels. It is believed to be associated with hormonal changes that occur with aging on men over 50 years. Their location often leads to compression of the urethra, causing urinary obstruction. Symptoms include urinary difficulties and incomplete bladder emptying. Residual urine in the bladder can lead to infections, potentially affecting the kidneys. Treatment options include partial excision of the prostate gland (transurethral resection of the prostate : TURP)or nonsurgical approaches. Imaging modalities such as CT and MRI are useful for assessing prostatic hyperplasia. Carcinoma of the Prostate Prostate adenocarcinoma is a common cancer in older men, with an increased incidence with age. Diagnosis is often made through physical examination and elevated acid phosphatase levels in blood. Imaging techniques like MRI and sonography help determine the location and extent of the disease. Common symptoms include urinary tract obstructions, an enlarged prostate, and low back pain. Treatment involves surgical removal of the tumor, hormone therapy, or radioactive seed implantation. Prostate cancer staging and grading are important for treatment decisions. Bone scans and CT are recommended for monitoring recurrence.  Testicular Masses Testicular torsion occurs when a testicle twists on itself, leading to severe pain and swelling. Doppler ultrasound and nuclear medicine scans assess blood supply to the testicle. Inflammation and infection may also lead to scrotal swelling. Benign masses like hydroceles and spermatoceles (fluid-filled, painless scrotal masses within the testis adjacent to the epididymis) may require differentiation from malignant neoplasms using sonography.  Malignant testicular tumors, while rare, are typically treated with surgical resection, chemotherapy, or radiation therapy. The four main types of malignant germ cell tumors are seminomas, embryonal carcinomas, teratomas, and choriocarcinomas. Gynecomastia is the proliferation of breast tissue in males and may present as palpable lumps, sometimes associated with nipple discharge. Breast ultrasonography can be used for diagnostic confirmation in cases of gynecomastia. Breast cancer in men is rare, affecting older men and often forming in the ducts, requiring mammography for imaging. Pathology Imaging Modalities of Choice Breast cancer in men Mammography PID (acute pelvic pain) Sonography, MRI pelvis (with or without contrast) Ovarian cysts (acute pelvic pain) Sonography, MRI pelvis (with or without contrast) Cystadenocarcinoma Sonography Carcinoma of the cervix Staging: MRI pelvis (with or without contrast) and FDG-PET whole body Staging: MRI pelvis (with or without contrast), CT chest (with or without contrast), Leiomyoma of uterus (abnormal bleeding) CT abdomen with contrast, radiography of the chest Adenocarcinoma of endometrium (abnormal bleeding