Lecture 15: Male and Female Reproductive Systems

Question 1

Male Genital/Reproductive System

Answer 1

• system consists of the testes, epididymis, vas deferens, seminal vesicles, prostate gland, and the penis
• structures are susceptible to inflammatory disorders, neoplasms, and structural defects
• do not typically treat these diseases, but need an understanding of their clinical presentation

Question 2

Aging and Male Reproductive System

Answer 2

• testes become smaller: with thickening of seminiferous tubules impeding sperm production
• prostate gland enlarges: affecting urine outflow
• sclerotic changes in blood vessels: resulting in sexual dysfunction
• ↓ in male sex hormone levels (testosterone)
• decline in bioavailable testosterone correlated with: age-related memory changes, ↓ing sexual interest, physical changes (↓’d strength, body mass, and bone density)

Question 3

Prostatitis

Answer 3

• refers to multiple disorders that can cause pelvic pain and discomfort
• typically preceded by lower urinary tract infections
• half of all men have at least one episode during their lifetime
• poorly controlled diabetes mellitus ↑’s the risk of UTI and prostatitis
• dx: DRE; prostatitis is differentiated from BPH and prostate cancer by the presence of pain (rarely present in BPH or cancer) and by age
• tx: antibiotics

Question 4

SIFTT for Prostatitis

Answer 4

• may be cause of back pain

- bicycle seats can aggravate prostatitis so recumbent bicycle is recommeded which puts less pressure on groin

Question 5

Benign Prostatic Hyperplasia (BPH)

Answer 5

• age-related nonmalignant enlargement of the prostate gland
• of men > 50 y/o, 75% experience symptoms of prostate enlargement
• drinking moderate amounts (1-2 drinks per day) is associated with a ↓’d risk of BPH and cigarette smoking ↑’s the risk for BPH-like symptoms
• patho: pathologic changes are marked by hyperplasia not hypertrophy; compresses urethra and causes urinary obstruction; DHT thought to be the primary mediator of hyperplasia-as men age, the prostate slowly grows larger, restricting urine flow and causing narrowing of the urethra, obstructing urinary outflow
• estrogens sensitize tissue to growth producing effect of DHT
• prostate enlarges, obstructs urethra, inhibiting normal urine flow
• CM: ↓’d caliber and force of the urine stream, urinary hesitancy, difficulty initiating or continuing urine stream, sense of urgency, incontinence, nocturia; residual urine in the bladder results in urine retention and urinary frequency
• tx: alpha-1 blocker (blocks α-1 receptors, which cause smooth muscle constriction)
• renal failure and death may occur if treatment is not initiated
• might have urine backup leading to enlarged pelvices

Question 6

SIFTT for BPH

Answer 6

• therapists conducting PMH with men over the age of 50 can easily include a series of 4 questions to help identify the presence of urologic involvement:
  1. Do you urinate often, especially during the night?
  2. Do you have trouble starting or continuing your urine?
  3. Do you have weak flow of urine or interrupted urine stream?
  4. Does it feel like your bladder is not emptying completely?
• yes answer to any of these questions warrants further medical evaluation
• painful urination, blood in urine, or unexplained lower back, pelvis, hip or upper thigh pain in the presence of any of these symptoms requires medical referral
• if the person notes sexual dysfunction and has a history of the above symptoms, ask him periodically about changes in sexual function: if it appears to worsen, communicate with the physician
• drug side effects: general muscle weakness, ED, loss of libido, gynecomastia, drowsiness, dizziness, tachycardia, postural orthostatic hypotension
• take steps to institute a falls prevention program when appropriate

Question 7

Prostate Cancer

Answer 7

-adenocarcinoma accounts for 98% of primary prostatic tumors
-usually starts in the outer portion of the prostate and spreads inwardly
-most common visceral malignancy in American men
-2nd most common cause of male death from cancer
-rarely produces S & S until well advanced
-RF: age > 50, african american, geography (US and scandinavian countries), family hx (inherited gene mutation), environmental exposure to cadmium, high-fat diet, alcohol consumption
-patho: precise cause is unknown, a strong endocrine system link is theorized; males castrated before puberty do not develop prostate cancer or BPH; 15% higher serum testosterone level in blacks
-tumors more likely to develop initially in the periphery of the prostate, unlike BPH, where the pathologic changes typically originate close to the urethra
-CM: slow urinary stream, urinary hesitancy, incomplete bladder emptying and, dysuria (painful urination); Gleason score-used to grade prostate cancer; higher the score, the more abnormal and poorly differentiated
the cells are as seen under the microscope
-A: low grade, back to back uniformly sized malignant glands
-B: variable size more widely dispersed, moderately differentiated adenocarcinoma
-C: poorly differentiated adenocarcinoma composed of sheets of malignant cells
-prevention and screening: early detection, DRE, PSA (prostate specific antigen) screening; strong link between physical activity and exercise and ↓’d prostate cancer risk
-Whitmore-Jewett staging system: spread of prostate cancer has been divided into 4 stages
-tumor not spread beyond gland capsules in stages A and B
-stage C tumor spread to adjacent tissues
-D spread to lymphatic system and beyond
-tx: observation, radical prostatectomy, radiation, hormonal therapy
-prognosis: 93% men diagnosed with prostate cancer survive at least 10 years, 77% survive at least 15

Question 8

SIFTT for Prostate Cancer

Answer 8

• screening for medical disease: if no mechanical back pain or the person notes urologic dysfunction, refer to a physician; age over 50, past history of cancer, and unknown cause of musculoskeletal pain or symptoms are three red flags that warrant further medical investigation
• complications of medical tx: complications associated with radical prostatectomy procedures include, infection, incontinence, and impotence; average time to achieve continence is 3 weeks with virtually all individuals being continent within 6 months; postop impotence occurs in 70% of men who undergo retropubic prostatectomy

Question 9

Orchitis

Answer 9

• inflammation of testis often associated with epididymitis
• primary infections of genitourinary tract or in other body regions
• sexually active males with multiple partners are at higher risk of developing genitourinary infections
• often secondary to UTIs
• marked by testicular pain and swelling (tender and swollen testicle)

Question 10

Epididymitis

Answer 10

• inflammation of epididymis
• typically caused by bacterial pathogens
• CM: pain, urinary dysfunction, fever, urethral discharge

Question 11

Testicular Torsion

Answer 11

-abnormal twisting of spermatic cord as testis rotates within tunica vaginalis
-surgical emergency
-patho: Spermatic cord contains vas deferens and nerve and blood supply for the scrotal contents
-if torsion is severe enough to occlude the arterial supply, infarction can quickly occur
-CM: abrupt onset of scrotal pain and then swelling
-SIFTT: if the scrotal or groin pain is associated with musculoskeletal dysfunction, it can be expected that the therapist could alter the symptoms by mechanically
stressing a component of the musculoskeletal system

Question 12

Testicular Cancer

Answer 12

• accounts for < 1% of all male cancer deaths
• risk factors include: cryptorchidism (undescended testes), inguinal hernia in childhood, and ethnicity (mainly in white men)
• patho: originate from germinal cells; typically, when it extends beyond the testes, it spreads through the lymphatic system
• metastases affect lungs, liver, viscera, and bone
• CM: swollen testes, gynecomastia, painless lump, SOB, lethargy and fatigue, hemoptysis
• prevention: promoting testicular self-examination at least every 6 months as a technique for early detection is recommended

Question 13

Erectile Dysfunction (ED)

Answer 13

-also termed impotence: refers to the inability to achieve, keep or sustain an erection sufficient for satisfactory sexual performance
-prevalence: correlation with ↑ing age
-RF: certain meds; chronic diseases, particularly neurological conditions and diabetes mellitus; smoking, age-related testosterone deficiency, CAD, alcohol use
-etiologic factors: may be neurogenic, arteriogenic, venogenic, or psychogenic; 50-80% seeking treatment for sexual dysfunction have an organic lesion; 85% of men > 50 y.o., the cause is organic; 70% of men < 35 cause is psychogenic
-SIFTT: if a sudden change in sexual function is noted, communicate with Dr; prescriptive exercise is often recommended for the individual with
intact nerve innervation and vascular supply

Question 14

Female Genital/Reproductive System

Answer 14

• ovaries, fallopian tubes, uterus, vagina, and external genitalia
• pelvic floor disorders
• other conditions put women at ↑’d risk of developing other diseases

Question 15

Aging and Female Reproductive System: Perimenopause

Answer 15

• “change before the change”
• menstrual cycle, sleep disturbances, ↑’d body temperature, anxiety, depression, mood changes, fatigue, and difficulty concentrating

Question 16

Aging and Female Reproductive System: Menopause

Answer 16

• permanent cessation of ovarian function and the end of a woman’s reproductive potential (average age is early 50’s)
• causes: gradual cessation of ovarian function with reduced estrogen levels
• during reproductive years the primordial ovarian follicles, from which ova are expelled, steadily ↓ in number: by middle age, the ovaries, which each held about 300,000 eggs at puberty, have resorbed or shed nearly all of them
• sx: hot flashes; fatigue; anxiety; sleep disturbances; reduced libido; mood swings; irritability; endometrial, vaginal, and breast atrophy are physiologic changes
• local changes, secondary to ↓’d estrogen levels: strength and tone loss in the pelvic floor musculature
• continued vaginal bleeding: always requires a medical evaluation
• ovaries continue to produce significant amounts of testosterone: natural means of preserving bone and muscle mass and of alleviating menopausal symptoms, particularly the loss of libido

Question 17

Menopause and Hormone Replacement Therapy

Answer 17

• much remains unknown about the long-term effects of HRT, but studies have been ongoing and new information is available daily and subject to change
• PT’s do not evaluate the need for HRT or prescribe these medications, but clients frequently ask questions and seek additional educational information
• decision to use or not to use based on a thorough understanding of the risks and benefits and individual risk factors
• HRT doesn’t help with heart disease and may even worsen the condition
• PT remains a key health care provider in risk assessment, assessment and prevention of falls, osteoporosis education, and exercise prescription

Question 18

Exercise and Reproductive System

Answer 18

• too much exercise yields negative effects (reproductive/skeletal systems): 1° and 2° amenorrhea d/t low body weight and improper nutrition; female athlete is at particular risk
• delayed menarche
• disruption or cessation of menstrual cyclicity
• Gn-RH results in hypoestrogenism 10
• obesity: contributes to menstrual disorders, infertility, miscarriage, poor pregnancy outcome, impaired fetal well being, diabetes mellitus
• fertility is improved through exercise and balanced nutrition
• exercise can stop early postmenopausal bone loss

Question 19

Endometriosis

Answer 19

• functioning endometrial tissue found outside the uterus
• during menstruation, the dislocated tissue is responding just as the uterine lining, but since it cannot shed as the endometrium dies, it remains where it is, eventually forming scar tissue and irritating the affected area
• patho: endometrial cells migrate to other parts of the body and form pockets of tissue referred to as implants, implants swell in response to the cyclic surge of estrogen and progesterone forming cysts on the underlying organs
• CM: dysmenorrhea, abnormal uterine bleeding, pain, and infertility
• dx: dysmenorrhea, dyspareunia, infertility
• tx: no cure; try to preserve fertility; pregnancy does appear to suppress disease

Question 20

SIFTT for Endometriosis

Answer 20

• women note that back pain is cyclic so PTs need to consider all possibilities
• dyspareunia is a common complaint associated with sacroiliac lumbar or hip dysfunction: if painful intercourse is related to endometriosis, the pain will be present regardless of position; if the pain is related to joint dysfunction, typically certain positions will be comfortable and others painful
• endometriosis may account for false-positive findings during the PT’s physical examination
• for example if there are endometrial implants on the psoas major muscle, local palpation and testing of the psoas may be provocative

Question 21

Uterine Fibroids

Answer 21

• benign tumors of the uterus (myomas)
• form on outer surface of the uterus or within the walls or lining of the uterus
• become malignant in < .1% (leiomyoma)
• overgrowth of smooth muscle and CT in the uterus
• genetic predisposition exists
• fibroids have both estrogen and progestin receptors (so, ↑’d estrogen levels may cause fibroid enlargement)
• CM: usually asymptomatic; in 10-20%, pain, pelvic pressure, and heavy bleeding
• can grow to the size of a grapefruit or larger-can place pressure on the bladder or spinal nerves
• NSAIDS or hormonal agents, surgical removal
• assess for abnormalities and asymmetries in muscle strength and function throughout abdomen, trunk, pelvis, and hips

Question 22

Endometrial Carcinoma (Uterine Cancer)

Answer 22

• fourth most common cancer in women
• no apparent genetic component
• environmental, social and lifestyle factors are the most important
• RF: older age, white race, affluent, obese, low parity (births), any condition that increases exposure to unopposed estrogen
• patho: adenocarcinoma that metastasizes late and may spread to lungs and brain
• CM: uterine enlargement, abnormal bleeding, pain and weight loss (advanced)
• tx: usually sx
• SIFTT: physical activity and exercise known to decrease risk of endometrial cancer

Question 23

Cervical Cancer

Answer 23

-largely a preventable disease with preventative sexual practices, regular screening and intervention at the precancerous stage
-classification: preinvasive-from mild to carcinoma in situ; invasive-cells penetrate basement membrane and can spread
-causes: human papilloma virus (HPV), smoking, high parity, young age at first intercourse (17 or younger), multiple sexual partners, other STDs
-patho: dysplastic changes occur in thin layer of epithelium that covers cervix
-CM: most never know that they have had HPV; abnormal or persistent vaginal bleeding, pelvic pain, anorexia, anemia; when it persists, it can cause lesions; if left untreated, can lead to cancer
-prevention and screening: using barrier contraceptives, monogamous sex, sexual abstinence,
routine cervical screening beginning ~ 3 years after first intercourse
-vaccine: gardasil blocks viruses that cause cervical cancer
-dx: pap test, sentinel lymph node biopsy
-prognosis: slow-growing neoplasm with good response to intervention
-SIFTT: important role of educator and prevention specialist when conducting a
personal/family history that includes questions about the consistency of Pap testing and presence of sexually transmitted diseases

Question 24

Ectopic Pregnancy

Answer 24

-implantation of a fertilized ovum outside the uterine cavity
-true gynecologic emergency, since accompanying complications are one of two primary causes of maternal death in the US
-patho: caused by delayed ovum transport secondary to ↓’d fallopian tube motility or distorted tubule anatomy; three to four days are typically required for the ovum to travel through the fallopian tube to the uterus; if pregnancy does not terminate, the thin-walled tubule will no longer support the growing fetus, and rupture can occur: life-threatening because rapid intrabdominal hemorrhage can occur
-CM: amenorrhea, or irregular bleeding and spotting, non-specific lower abdominal quadrant or back pain, and a pelvic mass
-SIFTT: if a woman of childbearing age complains of an onset of lower abdominal or back pain, the therapist should ask questions regarding her menstrual cycle
and if any of the symptoms of pregnancy are present
-if PT suspects ectopic pregnancy, immediate call to the physician is warranted

Question 25

Ovarian Cystic Disease

Answer 25

-usually non-neoplastic sacs on an ovary that contain fluid or semisolid material…most are benign, but could be sites of malignant change
-common cysts are follicular, corpus luteum, and dermoid
-patho: some ovarian cysts are a normal part of the reproductive cycle – at least one follicle matures in an ovary during each cycle: during ovulation, the follicle ruptures to release the egg
-ovarian cysts develop when hormone imbalance causes ↑’d LH to be produced: LH causes the ovary to produce and secrete more androgens, cysts develop when excess circulating androgens are converted to
estrone in the peripheral adipose tissue
-CM: breast tenderness, incomplete bladder emptying, fullness in abdomen, rectal or bladder pressure, dyspareunia, menstrual irregularities, pelvic pain
-SIFTT: PTs may ask if menstrual dysfunction is present; a history of ovarian cystic disease could account for a woman’s low back or sacral pain, but usually there is some indication in the menstrual history to suggest a gynecologic link

Question 26

Ovarian Cancer

Answer 26

-second most common female urogenital cancer and the most lethal
-difficult to diagnose - 60%-70% have metastatic disease at time of diagnosis
-RF: family history of ovarian cancer, having first child after age 30, history of breast cancer, infertility, late menopause, long-term estrogen replacement
therapy, starting menses at young age (before age 12)
-patho: correlate with the number of times a woman ovulates during her lifetime: anything that interferes with ovulation diminishes the risk
-CM: most ovarian cancers are asymptomatic or present with vague symptoms; dyspepsia, urinary frequency, constipation, pain, ascites, pleural effusions; paraneoplastic cerebellar degeneration (PCD)-affects women with gynecological cancers, ataxic gait, ataxia, nystagmus, and dysarthria
-common metastatic sites: diaphragm, liver, nodes, colon, ovaries, omentum, stomach, pleura

Question 27

SIFTT for Ovarian Cancer

Answer 27

-gait disturbance may be the first sign of a paraneoplastic syndrome associated with gynecologic cancer
-other symptoms associated with metastases may include thoracic or shoulder girdle pain secondary to lymphadenopathy, symptoms associated with lung or
liver disease, and weight loss and fatigue
-any of these complaints warrants communication with the physician

Question 28

Pelvic Inflammatory Disease (PID)

Answer 28

• pelvic floor disroder
• infection and inflammation of the female upper genital tract
• result of multimicrobial bacteria; often associated with STDs
• CM: S&S vary widely and patients are often asymptomatic
• make safer choices to avoid STDs

Question 29

Pelvic Floor Dysfunction SIFTT

Answer 29

-routinely ask women questions about pelvic floor function (e.g., presence of urinary incontinence, pain with sexual intercourse or other sexual dysfunction,
presence of known reproductive organ or pelvic floor dysfunction, past history) and provide education and exercise programs for these muscles

Question 30

Cystocele, Rectocele, and Uterine Prolapse

Answer 30

• cystocele: herniation of the urinary bladder into the vagina
• rectocele: herniation of the rectum into the vagina
• uterine prolapse: bulging of the uterus into the vagina
• stages of uterine prolapse: 1st-cervix remains in vagina; 2nd-cervix appears at perineum or protrudes on straining, 3rd-entire uterus protrudes outside of body, total inversion of vagina
• patho: weak or stretched pelvic floor muscles or ligaments
• CM: various S&S-urinary frequency and urgency, perineal pain, and difficulty with defecation, urinary incontinence
• SIFTT: avoid valsalva maneuver

Question 31

Breast Cancer

Answer 31

• most common malignancy of females in US
• spreads by way of lymphatic system and bloodstream
• patho: classified by histologic appearance: adenocarcinoma, intraductal, infiltrating, inflammatory, lobular carcinoma in situ (involves glandular lobes), medullary or circumscribed (appears as large tumor)
• stages of breast cancer…
• stage 1: tumor less than 2 cm, no axillary or other metastases
• stage 2: tumor greater than 2 cm, may be non-fixed axillary metastasis but doesn’t extend into other areas
• stage 3: tumor is greater than 5 cm in size, fixed axillary but no other metastasis
• stage 4: tumor any size, supraclavicular or intraclavicular nodes affected and distant metastasis
• high risk: family history, genetic mutations, long menses, no history of pregnancy, history of endometrial or ovarian cancer, exposure to low-level ionizing radiation
• lower risk: history of pregnancy before age 20, history of multiple pregnancies, native American or Asian ethnicity
• CM: thickening of breast tissue, skin changes, erythema, edema in the arm (indicating advanced nodal involvement), cervical supraclavicular and axillary node lumps
• SBE: . ACS no longer recommends that all women conduct regular SBE, but women should be informed about the potential benefits associated with SBE; should start in your 20’s, performed monthly, performed 1 week after cessation of menstrual bleeding
• mammogram beginning at age 40
• sentinel lymph node mapping and biopsy for metastatic diagnosis eliminates unnecessary dissection
• SIFTT: axillary lymph node palpation in upper quarter screening; clear relationship between physical activity and exercise and breast cancer prevention