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Alterations of Sexual Maturation
- Sexual maturation, or puberty, should begin in girls between the ages of 8 and 13 years and in boys between the ages of 9 and 14 years.
- Delayed puberty is the onset of sexual maturation after these ages; precocious puberty is the onset before these ages. Treatment depends on the cause.
Disorders of the Femal Reproductive System
- The female reproductive system can be altered by hormonal imbalances, infectious microorganisms, inflammation, structural abnormalities, and benign or malignant proliferative conditions.
- Primary dysmenorrheal is painful menstruation not associated with pelvic disease. It results from excessive synthesis of prostaglandin F. Secondary dysmenorrheal results from endometriosis, pelvic adhesions, inflammatory disease, uterine fibroids, or adenomyosis.
- Primary amenorrhea is the continued absence of menarche and menstrual function by 14 years of age without the development of secondary sex characteristics or by 16 years of age if these changes have occurred.
- Secondary amenorrhea is the absence of menstruation for a time equivalent to more than 3 cycles or 6 months in women who have previously menstruated. Secondary amenorrhea is associated with anovulation.
- Dysfunctional uterine bleeding (DUB) is heavy or irregular bleeding caused by a disturbance of the menstrual cycle.
- Polycystic ovary (PCO) is a condition in which excessive androgen production is triggered by inappropriate secretion of gonadotropins. This hormonal imbalance prevents ovulation and causes enlargement and cyst formation in the ovaries, excessive endometrial proliferation, and often hirsutism. Hyperinsulinemia plays a key role in androgen excess.
- Premenstrual syndrome (PMS) is the cycle recurrence of physical, psychologic, or behavioral changes distressing enough to disrupt normal activities or interpersonal relationships. Emotional symptoms, particularly depression, anger, irritability, and fatigue, are reported as the most distressing symptoms; physical symptoms tend to be less problematic. Treatment is symptomatic and includes self-help techniques, lifestyle changes, counseling, and medication.
- Infection and inflammation of the female genitalia can result from microorganisms from the environment or overproliferation of microorganisms that normally populate the genital tract.
- Pelvic inflammatory disease (PID) is an acute ascending infection of the upper genital tract caused by a sexually transmitted pathogen. Untreated PID can lead to infertility.
- Vaginitis, or vaginal infection, is usually caused by sexually transmitted pathogens or Candida albicans, which causes candidiasis.
- Cervicitis, which is infection of the cervix, can be acute (mucopurulent cervicitis) or chronic. Its most common cause is a sexually transmitted pathogen.
- Vulvitis is an inflammation of the skin of the vulva. It can be caused by chemical irritants, allergens, skin disorders, irritation from tight-fitting clothing, or spread of vaginal infections, such as candidiasis.
- Bartholinitis, also called Bartholin cyst, is an infection of the ducts that lead from the Bartholin glands to the surface of the vulva. Infection blocks the glands, preventing the outflow of glandular secretions.
- The pelvic relaxation disorders – uterine displacement, uterine prolapse, cystocele, rectocele, and urethrocele – are caused by the relaxation of muscles and fascial supports, usually with age or after childbirth or other trauma, and are more likely to occur in women with a familial or genetic predisposition.
- Benign ovarian cysts develop from mature ovarian follicles that do not release their ova (follicular cysts) or from a corpus luteum that persists abnormally instead of degenerating (corpus luteum cyst). Cysts usually regress spontaneously.
- Endometrial polyps consist of overgrowths of endometrial tissue and often cause abnormal bleeding in the premenopausal woman.
- Leiomyomas, also called uterine fibroids, are benign tumors arising from the muscle layer of the uterus, the myometrium.
- Adenomyosis is the presence of endometrial glands and stroma within the uterine myometrium.
- Endometriosis is the presence of functional endometrial tissue (i.e., tissue that responds to hormonal stimulation) at sites outside the uterus. Endometriosis causes an inflammatory reaction at the site of implantation and is a cause of infertility.
- Most cancers of the female genitalia involve the uterus (particularly the endometrium), the cervix, and the ovaries. Cancer of the vagina is rare.
- Cervical cancer arises from the cervical epithelium and is triggered by human papollomavirus (HPV). The progressively serious neoplastic alterations are cervical intraepithelial neoplasia (cervical dysplasia), cervical carcinoma in situ, and invasive cervical carcinoma. Smoking is a cofactor.
- Most vaginal cancers are not invasive. Like cervical cancers, they arise from the epithelium and are identified as intraepithelial neoplasia (dysplasia), carcinoma in situ, or invasive carcinoma.
- Risk factors for endometrial cancer include exposure to unopposed estrogen, obesity, high-fat diet, infertility or no pregnancies, late menopause, diabetes, and hypertension. Hormonal contraception protects against endometrial and ovarian cancers. Incidence of endometrial cancer is greatest among women in their 50s and early 60s.
- Risk factors for ovarian cancer include family history, residence in an industrialized country, prior breast or endometrial cancer, infertility, early menopause, obesity, a high-fat diet, and exposure to asbestos or talc. Ovarian cancer causes more deaths than any other genital cancer in women.
- Infertility, or the inability to conceive after 1 year of unprotected intercourse, affects approximately 15% of all couples. Fertility can be impaired by factors in the male, female, or both partners.
- Chronic illness, medications, infection, sexual trauma, and a variety of psychosocial concerns have been implicated as causes of female sexual dysfunction.
Disorders of the Male Reproductive System
- Disorders of the urethra include urethritis (infection of the urethra) and urethral strictures (narrowing or obstruction of the urethral lumen caused by scarring).
- Most cases of urethritis result from sexually transmitted pathogens. Urologic instrumentation, foreign body insertion, trauma, or an anatomic abnormality can cause urethral inflammation with or without infection.
- Urethritis causes urinary symptoms, including a burning sensation during urination (dysuria), frequency, urgency, urethral tingling or itching, and clear or purulent discharge.
- The scarring that causes urethral stricture can be caused by trauma or severe untreated urethritis.
- Manifestations of urethral stricture include those of bladder outlet obstruction: urinary frequency and hesitancy, diminished force and caliber of the urinary stream, dribbling after voiding, and nocturia.
- Phimosis and paraphimosis are penile disorders involving the foreskin (prepuce). In phimosis, the foreskin cannot be retracted over the glans. In paraphimosis, the foreskin is retracted and cannot be reduced (returned to its normal anatomic position over the glans). Phimosis is caused by poor hygiene and chronic infection and can lead to paraphimosis. Paraphimosis can constrict the penile blood vessels, preventing circulation to the glans.
- Peyronie disease consists of fibrosis affecting the corpora cavernosa, which causes penile curvature during erection. Fibrosis prevents engorgement on the affected side, causing a lateral curvature that can prevent intercourse.
- Priapism is a prolonged, painful erection that is not stimulated by sexual arousal. The corpora cavernosa (but not the corpus spongiosum) fill with blood that does not drain out, probably because of venous obstruction. Priapism is associated with spinal cord trauma, sickle cell disease, leukemia, and pelvic tumors. It can also be idiopathic.
- Balanitis is an inflammation of the glans penis. It is associated with Phimosis, inadequate cleansing under the foreskin, skin disorders and pathogens (e.g., Candida albicans).
- Cancer of the penis is rare. Penile carcinoma in situ tends to involve the glans; invasive carcinoma of the penis involves the shaft as well.
- A varicocele is an abnormal dilation of the veins within the spermatic cord caused by either congenital absence of valves in the internal spermatic vein or acquired valvular incompetence.
- A hydrocele is a collection of fluid between the testicular and scrotal layers of the tunica vaginalis. Hydroceles can be idiopathic or caused by trauma of infection of the testes.
- A spermatocele is a cyst located between the testis and epididymis that is filled with fluid and sperm.
- Cryptorchidism is a congenital condition in which one or both testes fail to descend into the scrotum. Uncorrected cryptorchidism is associated with infertility and significantly increased risk of testicular cancer.
- Testicular torsion is the rotation of a testis, which twists blood vessels in the spermatic cord. This interrupts the blood supply to the testis, resulting in edema and, if not corrected within 6 hours, necrosis and atrophy of testicular tissues.
- Orchitis is an acute infection of the testes. Complications of orchitis include hydrocele and abscess formation.
- Testicular cancer is the most common malignancy in males 15 to 35 years of age. Although its cause is unknown, high androgen levels, genetic predisposition, and history of cryptorchidism, trauma, or infection may contribute to tumorigenesis.
- Spermatogenesis (sperm production by the testes) can be impaired by disruptions of the hypothalamic-pituitary-testicular axis that reduce testosterone secretion and by testicular trauma, infection, or atrophy from any cause. Sperm production is also impaired by neoplastic disease, Cryptorchidism, or any factor that causes testicular temperature to rise (e.g., circulatory impairment, wearing tight clothing).
- Epididymitis, an inflammation of the epididymis, is usually caused by a sexually transmitted pathogen that ascends through the vasa deferentia from an already infected urethra or bladder.
- Benign prostatic hyperplasia (BPH), also called benign prostatic hypertrophy, is the enlargement of the prostate gland. This condition becomes symptomatic as the enlarging prostate compresses the urethra, causing symptoms of bladder outlet obstruction and urine retention.
- Bacterial prostatitis is an infection of the prostate. Acute bacterial prostatitis causes an inflammatory response in which the prostate becomes enlarged, tender, and firm. Infection may spread to the bladder. Chronic bacterial prostitis is recurrent prostatic infection that eventually causes fibrosis.
- Prostate cancer is the second leading cause of cancer deaths in men (after lung cancer). Possible causes include genetic predisposition, environmental and dietary factors, and alterations in hormones (testosterone, dihydrotestosterone, and estradiol) and growth factor (IGF-1). Incidence is greatest among northwestern European and North American men (particularly blacks) older than 65 years.
- Most cancers of the prostate are adenocarcinomas that develop at the periphery of the gland. Routine screening is recommended for early detection of disease.
- Sexual dysfunction in males can be caused by any physical or psychologic factor that impairs erection, emission, or ejaculation.
Disorders of the Breast
- Most disorders of the breast are disorders of the mammary gland – that is, the female breast.
- Galactorrhea, or inappropriate lactation, is the persistent secretion of a milky substance by the breasts of a woman who is not in the postpartum state or nursing an infant. Its most common cause is nonpuerperal hyperprolactinemia, a rise in serum prolactin levels.
- Benign breast conditions are numerous and involve both ducts and lobules. Benign epithelial lesions can be broadly classified according to their future risk of developing breast cancer as (1) nonproliferative breast lesions, (2) proliferative breast disease, and (3) atypical hyperplasia.
- Nonproliferative lesions include fibrocystic changes (FCC). In addition to FCC, many women experience several other types of benign breast tumors.
- Proliferative breast lesions without atypia are characterized by proliferation of ductal epithelium or stoma or both without cellular signs of malignancy.
- Atypical hyperplasia is an increase in the number of cells, and the cells have some variation in structure.
- Ductal carcinoma in situ (DCIS) refers to a heterogenous group of lesions, presumably malignant epithelial cells, within the ductal system. It is unclear whether the increase in incidence of DCIS reflects an increase in cancer or increased detection by mammography.
- Breast cancer is the most common form of cancer in women and second to lung cancer as the most common cause of cancer death.
- The major risk factors for breast cancer are reproductive factors, such as nulliparity; hormonal factors and growth factors such as excessive estradiol and IGF-1; familial factors, such as family history of breast cancer; and environmental factors, such as ionizing radiation. Physical activity and human chorionic gonadotrophin hormone may be protective factors.
- Pathogenesis involves several steps including modification of DNA, alteration of chromosomes, suppression of apoptosis, alterations of breast stroma, and modifications of oncogenes or tumor-suppressor genes or both. Approximately one third of breast cancers are hormone dependent (progesterone-receptor positive or estrogen-receptor positive). Treatment protocols are often based on whether the tumor is receptor positive or negative.
- Most breast cancers arise from the ductal epithelium and then may metastasize to the lymphatic, opposite breast, abdominal cavity, lungs, bones, kidneys, liver, adrenal glands, ovaries, and pituitary glands.
- The first clinical manifestation of breast cancer is usually a small, painless lump in the breast. Other manifestations include palpable lymph nodes in the axilla, dimpling of the skin, nipple and skin retraction, nipple discharge, ulcerations, reddened skin, and bone pain associated with bony metastases.
- Gynecomastia is the overdevelopment (hyperplasia) of breast tissue in a male. It is first seen as a firm, palpable mass at least 2 cm in diameter and is located in the subareolar area.
- Gynecomastia affects 32% to 40% of the male population. Incidence is greatest amount adolescents and men older than 50 years of age.
- Gynecomastia is caused by hormonal or breast tissue alterations that cause estrogen to dominate. These alterations can result from systemic disorders, drugs, neoplasms, or idiopathic causes.
- Breast cancer is relatively uncommon in males, but it has a poor prognosis because men tend to delay seeking treatment until the disease is advanced. Incidence is greatest in men in their 60s.
- Most breast cancers in men are estrogen receptor positive.
Sexually Transmitted Infections
- Sexually transmitted diseases are infections contracted by intimate as well as sexual contact and include systemic infections, such as tuberculosis and hepatitis, that can spread to a sexual partner.
- The etiology of an STI may be bacterial, viral, protozoan, parasitic, or fungal.
- Although the majority of the STIs are considered incurable.