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SFM5 > Repro Pathophys: Puberty and Repro-age > Flashcards

Repro Pathophys: Puberty and Repro-age Flashcards

1
Q

SRY

A

male gonadal development master regulator

Y chromosome

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2
Q

SOX9

A

male gonadal development TF
interacts with SRY
suppressed by genes of X chromosome when SRY is absent

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3
Q

Wolffian ducts

A

male repro embryology
forms male duct system (epididymis, vas deferens, seminal vesicles)
testosterone production by leydig cells contributes to Wolffian duct formation

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4
Q

sertoli cells

A

male repro

produce antimullerian hormone (AMH) to prevent formation of female mullerian duct system

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5
Q

Mullerian ducts

A

female repro embryology
forms Fallopian tubes, uterus, cervix, and upper vagina
default, in absence of AMH or androgens

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6
Q

5-alpha-reductase

A

male development & embryo
converts testosterone to more potent dihydrotestosterone
essential for complete masculinization of male external genitalia

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7
Q

anosmia and delayed puberty

A

absence of smell
points to GnRH issue
GnRH neurons migrate from olfactory placed during development
therefore abnormal migration of GnRH neurons also tends to accompany abnormal olfactory development

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8
Q

puberty of infancy

A

normal “mini-puberty” due to reduction in placental inhibition of GnRH

females: estradiol monthly cycling + gradual (non-cyclic) decline in FSH and LH after initial spike ~1 mo
males: breast development and genital enlargement, testosterone curve peaks around 6 weeks and then gradually declines to very low levels by about 6 mo

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9
Q

FSH and LH targets in male

A

LH - leydig cells - testosterone production

FSH - Sertoli cells - AMH production and nutritional etc. support of sperm development

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10
Q

timing of lab workup for abnormal puberty

A

morning ~8am

LH is released overnight

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11
Q

initiation of puberty male

A

release of inhibition of hypothalamic GnRH pulse generator
(constant low-level GnRH suppresses FSH and LH, while pulsatile GnRH activates)

following increase in pulsatile GnRH production, pituitary and gonadal sensitivity also increases creating acceleration

testicular enlargement is the first observed sign

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12
Q

normal pubertal window male

A

9-14 y/o onset (testes stage G2, ~4cc)
14-18 y/o testes reach full size (G5, 15-25cc)
timing mainly genetic

height: 10.5-16 onset, 13-17.5 end
penis: 11-14.5 onset, 13.5-17 end
pubic hair coincides with testes usually
strength: ~15-16

very rare to see any changes past age 20

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13
Q

tanner stages male

A

G(gonadal)1 - prepubertal

G2

  • testicular enlargement (~4cc)
  • sparse, fine, straight pubic hair
  • no penile enlargement

G3

  • continued testicular enlargement
  • long, dark, curly pubes around mons only
    • penile length, no girth change

G4

  • continued testicular and penile enlargement (length and girth)
  • pubic hair thick but not yet spread to thighs

G5- mature (

  • testes ~15-25cc
  • flaccid penis ~3.5 in (2-6, 2.5-97.5 percentile)
  • stretched penis ~5 in (4.3-6.5)
  • erect penis ~6 in (4.5-7.5)
  • pubic hair thick, inverted triangle distribution with spread to thighs

note that right testis is generally slightly bigger than left

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14
Q

orchidometer

A

measures testicular size (approx)

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15
Q

pubarche

A

appearance of body hair and odor
d/t adrenarche - androgen precursors from *adrenal gland
separate process from puberty but normally occurs around same time

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16
Q

epithelia of endocervix

A

simple columnar
mucus producing
mucus is responsive to estrogen and changes throughout cycle

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17
Q

epithelia of ectocervix

A

stratified squamous

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18
Q

SCJ (transitional zone)

A

squamous-to-columnar junction of cervix
prone to metaplasia
important to sample during PAP

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19
Q

layers of uterus

A 
endometrium
- functional layer sheds during menstruation
- basal layer
myometrium
perimetrium
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20
Q

cells of inner mucosal lining of fallopian tube

A

ciliated and nonciliated secretory epithelial cells

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21
Q

4 segments of fallopian tube

A

interstitial
- junction w/ uterus

isthmus
- straight segment close to uterus

ampula
- most of tube, after isthmus)

infundibulum
- with fimbriae

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22
Q

layers of fallopian tube

A

mucosa (inner)
muscular
serosa (outer)

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23
Q

epithelia of vagina

A

stratified squamous

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24
Q

significance of glycogen in vagina

A

supports lactobacillus in microbiota

pre-puberty and post-menopause there is less glycogen and therefore less colonization

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25
Q

granulosa cell

A

aka follicular cell
proliferate and hypertrophy to surround developing oocyte
secrete progesterone after ovulation
respond to FSH

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26
Q

theca cell

A

secrete androgens in ovary, which are later converted to estrogens in the granulosa cell
crosstalk with granulose cell
squamous, surround granulosa cells
respond to LH

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27
Q

primordial follicle

A

single layer of granulosa cells

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28
Q

primary follicle

A

several layers of granulosa cells
compact around oocyte
no liquid filled regions

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29
Q

secondary follicle

A

more layers of granulosa cells than primary
liquid filled regions begin to appear
first meiotic division completed
arrest at this stage

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30
Q

graffian follicle

A

aka tertiary
mature, liquid filled
rupture to release egg
second meiotic division starts

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31
Q

atretic follicle

A

degenerated follicle
apoptosis prior to follicle maturity
common pre-puberty and repro age (the oocytes that do not continue to develop each cycle)
in excess can be sign of pathology

atresia occurs when follicles are not stimulate by FSH

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32
Q

thelarche

A

breast development in female

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33
Q

tanner stages female

A

1- prepubertal

2

  • breast budding
  • areolar enlargement
  • some coarse, pigmented hair along labia majora

3

  • breast and areola enlargement
  • spread of pubes over mons pubis

4

  • continued breast enlargement
  • secondary mound of areola
  • near adult pubes

5

  • mature breast contour
  • adult pube distribution
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34
Q

normal pubertal window female

A

first sign usually breast development
average age 10.5, range 8-12 onset
stops 14.5 (11.5-18)

menarche 12.5 (10-16.5)
0.5 yr after peak growth spurt
2-2.5 yr after thelarche

height and pubic hair (usually) lags slightly behind breast development

pubarche first sign in ~15%

thelarche age black (~9.5) < Mexican < white (~10.5)

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35
Q

early menarche pattern

A

irregular cycles for 3-5 years (90% have >10 periods/yr after 3 years)
initially irregular, anovulatory q21-45 days

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36
Q

onset of puberty mechanism

A

similar in male and female
release of brake on pulsatile hypothalamic GnRH

primary signal is unknown other than genetic influence

  • kisspeptin and neurokinin B activation are involved
  • leptin, sufficient adipose needed (and obesity is associated with early puberty)
  • CNS pubertal clock
  • trending earlier
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37
Q

FSH and LH targets female

A

FSH

  • granulosa cell
  • makes estrogens (which support endometrium proliferation)
  • granulosa cell proliferation
  • otherwise atresia

LH

  • theca cell
  • makes androgens
  • stimulates estrogen/progesterone production in granulosa cell
  • LH spike (due to estrogen levels crossing a threshold from negative to positive feedback) induces ovulation
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38
Q

estradiol in menstrual cycle

A 
produced by pre-ovulatory follicle
peaks ~24 h prior to ovulation
when estradiol levels reach critical concentration, there is a switch from negative to positive feedback on LH
causes LH surge that causes ovulation
ovulation ~24-36 h after LH surge
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39
Q

ovulation induction

A

estradiol produced by pre-ovulatory follicle reaches critical concentration, switches from negative to positive feedback on LH

~24 h later, LH surge occurs

~24-36 h after that, ovulation occurs (caused by LH)

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40
Q

LH surge

A
  • resumption of meiosis 1 of primary oocyte
  • synthesis of prostaglandins –> follicle rupture
  • luteinization of granulosa cells –> progesterone production
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41
Q

luteal phase

A
  • after LH surge/ovulation
  • granulosa and theca cells luteinize to form corpus luteum
  • corpus luteum produces estrogen and progesterone
  • – negative feedback on LH/FSH –> no new follicular growth
  • – secretory changes of functional endometrium in support of pregnancy (arteries, glycoproteins, edema)
  • corpus luteum loses function after 9-11 days if not rescued by hCG
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42
Q

normal menstrual cycle duration and ovulation

A

q21-35 days (60% 25-28 days)
if regular, almost always ovulatory (except PCOS)
anovolation common in setting of irregular menses

timing of luteal phase (~14 days) is more consistent than follicular phase (where most of variability in cycle length comes from)
- period will almost always occur ~14 days after ovulation

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43
Q

normal menopause window

A

average 51.5
considered premature if <40
dx if no menses for 1 year

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44
Q

ovulation predictors

A
  • basal body temp (rough)
  • kits: LH surge, ± estrogen
  • luteal phase progesterone
  • cervical mucous changes
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45
Q

when to investigate primary amenorrhea

A
  • age 15-16 if normal growth and secondary characteristics
  • age 13 in absence of secondary characteristics or height <3%ile
  • age 12-13 if + breast dev and + cyclic pelvic pain
  • within 2 years of breast development
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46
Q

when to investigate secondary amenorrhea

A
  • 3 months if previously regular periods
  • 6 months if previously irregular periods
  • likelihood of pregnancy
  • hx of intermenstrual intervals >35 days
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47
Q

Asherman’s syndrome

A

partial or complete blockage of uterine outflow tract d/t adhesions
can cause primary or secondary amenorrhea
usually d/t hx of D&C
genital TB also common cause in endemic areas

48
Q

5-alpha-reductase deficiency

A

primary amenorrhea of person with female genitalia
develops male secondary characteristics at puberty
XY chromosome, but inability to convert testosterone to more potent form prevents formation of male external genitalia

49
Q

androgen insensitivity syndrome

A

primary amenorrhea of person with female genitalia
no male secondary characteristics at puberty
XY chromosome, but does not respond to testosterone
testosterone in male range

50
Q

uterine outflow tract obstruction in primary amenorrhea

A
  • imperforate hymen, transverse vaginal septum, mullein agenesis, Asherman’s syndrome, tumor/mass/polyp/fibroid
  • often presents with cyclic pelvic pain
  • surgical - risk of endometriosis with retrograde menstrual flow
51
Q

initial labs amenorrhea

A

pregnancy test

FSH

  • ovarian or central
  • increased in primary ovarian insufficiency (POI)
  • normal to low in hypothalamic amenorrhea, neuroanatomic abnormality
  • low in idiopathic hypogonadotropic hypogonadism

hyperandrogegism
- PCOS

prolactin
- increased in neuroanatomic abnormality, idiopathic hypogonadotropic hypogonadism, certain drugs

AMH (antimullerian hormone)

  • androgen insensitivity
  • low in POI

all of the above may be normal in functional hypothalamic amenorrhea (FSH may also be low), eating disorder, excess exercise, chronic disease

52
Q

functional hypothalamic amenorrhea

A

dx of exclusion
r/o:
- chronic disease (T1DM, celiac, hypERthyroid, Cushing)
- opioids, glucocorticoids, psychotropes that increase prolactin
- eating disorders

  • typically energy intake:expenditure mismatch
  • stress may also cause
  • certain genes are linked
  • some features of PCOS may also be present

low gonatotropins, normal prolactin

get an MRI if these red flags are present:

  • atypical hx
  • headache
  • signs of other hypothalamic disfunction
  • hyperprolactinemia
53
Q

hypergonadotropic hypogonadism (female)

A

primary ovarian insufficiency
aka premature menopause
~10% of secondary amenorrhea

high FSH
low AMH
low estrogen

d/t:

  • unknown (most)
  • turner’s
  • autoimmune polyglandular failure
  • other rare disorders
  • radiotherapy/chemo

f/u test:

  • karyotype
  • serum anti-cortical Ab
  • serum 21-hydroxylase Ab
  • T3/T4
  • TPO
  • FMR1 permutation screening
  • bone mineral density assessment
54
Q

estrogen and amenorrhea

A

almost always low

55
Q

PCOS

A
  • amenorrhea or oligomenorrhea
  • hirsutism
  • acne
  • dark patches of skin
  • insulin resistance
  • ~50% obese
  • sx onset shortly after menarche, slowly progressive
  • high androgens
  • low estrogen
  • cysts on US (not in all cases)

tx:

  • OCPs
  • spironolactone
  • clomiphene citrate
  • letrozole
  • metformin
56
Q

cyclic pelvic pain ddx

A
  • dysmenorrhea
  • endometriosis
  • Mittelschmerz (painful ovulation)
57
Q

acute noncyclic pelvic pain ddx

A 
PID
ruptured or hemorrhagic ovarian cyst
ectopic
spontaneous abortion
ovarian torsion
endometrioma
endometriosis
acute growth or degeneration of uterine myoma/leioma (fibroid)

non-pelvic:

  • appendicitis
  • cholecystitis
  • diverticulitis
  • SBO
  • IBD
  • GI infection
58
Q

chronic noncyclic pelvic pain ddx

A 
pelvic congestion syndrome (pelvic vein incompetence)
adhesions of uterus
retroversion of uterus
vulvodynia (vulva pain)
chronic PID
tuberculosis salpingitis
hx of traumatic intercourse
59
Q

PID

A 
pelvic inflammatory disease
bilateral lower abd pain
exacerbated by intercourse or jarring movements
recent onset
fever ~50%
abnormal uterine bleeding ~30%
± discharge, urethritis, chills

risk of infertility and ectopic

d/t:

  • STI
  • trachomatis
60
Q

ectopic pregnancy

A 
generally unilateral pelvic pain
clinical signs 6-8 wk post LMP
bleeding ~50%
± orthostatic, fever
life threatening fallopian rupture ~20%

d/t:

  • hx tubal disease
  • hx ectopics
  • hx infertility
  • hx DES exposure of mother in utero
  • hx PID

unruptured can be treated w/ methotrexate ~90%

61
Q

primary amenorrhea with athelarche

A
  • absence of estrogen

low FSH:

  • hypogonadotropic - pituitary or ht problems
  • MRI recommended to r/o neuroanatomical causes
  • may also be (normal-ish) congenital delay of puberty (genetic; dx of exclusion)

high FSH:

  • gonadal dysgenesis
  • 46XY (e.g. 5-alpha-reductase deficiency; note androgen insensitivity usually has thelarche)
  • 45XO (Turner’s)
  • estrogen production defect
62
Q

mullerian agenesis

A 
congenital absence of uterus
primary amenorrhea 
–cyclic pain 
\+thelarche
as with all abnormalities of vagina/uterus, often accompanies renal abnormalities e.g. unitary kidney or double collecting system
63
Q

premature pubarche/adrenarche (male)

A
  • <9 y/o
  • isolated body hair/odor/acne (not full precocious puberty)
  • no genital changes
  • no growth spurt or advancement of bone age

d/t:

  • prematurity
  • small for gestational age
  • excess weight gain
  • elevated DHEA
64
Q

precocious thelarche

A
  • <8 y/o breast budding
  • isolated, no growth spurt, no advancement of bone age
  • ≠ precocious puberty

d/t:

  • over function of pituitary-ovarian axis
  • FSH high-normal but increases more than usual on stim testing
  • LH normal
  • elevated estradiol
  • ovarian microcysts
  • also associated with obesity
65
Q

precocious puberty workup male

A
  • note 5-10x F>M

clinical:

  • growth spurt
  • accelerated bone age
  • testicular enlargement
  • possible pubarche/adrenarche

male:

  • testicular ultrasound - asymmetric testicular enlargement
  • 8am labs:
    • peds LH
    • peds FSH
    • testosterone
    • 17OHP/DHEAS (for signs of pubarche/adrenarche)
    • TSH, free T4
    • HCG/AFT (for germ cell tumors, hepatoblastoma)
66
Q

precocious puberty causes (male)

A

central:

  • gonadotropin dependent, i.e. increased LH/FSH
  • note symmetric testicular enlargement
  • idiopathic
  • congenital anomaly
  • CNS insult (infection, trauma, radiation)
  • tumors
  • sturge-weber
  • tuberous sclerosis
  • neurofibromatosis-1

peripheral:
- gonatotropin independent, decreased LH/FSH
- exogenous testosterone
adrenal tumor
- CAH (note penis enlargement > testicular enlargement)
- familial testotoxicosis (note penis enlargement > testicular enlargement)
- hCG testicular tumor (note penis enlargement > testicular enlargement)
- testosterone/leydig cell testicular tumor (note asymmetric testes)
- primary hypothyroidism
- McCune-Albright

67
Q

delayed puberty (male)

A

> 14 y/o

d/t:

  • constitutional delay of growth ~65%
  • functional hypogonadotropic (central) hypogonadism ~20%
  • permanent hypogonadotropic (central) hypogonadism ~10%
  • gonadal failure 5-10%
68
Q

constitutional delay of growth and puberty (male)

A

CDGP

  • slow growth in childhood
  • growth deviates at puberty
  • eventual catch-up
  • delayed bone age
  • family hx of delay
  • short stature for family (current height < mid parental target = avg(mom+5,dad))
  • negative ROS (chronic illness)
  • evidence of appropriate nutrition
69
Q

isolated hypogonadotropic hypogonadism (male)

A

IHH

  • presents similarly to CDGP
  • anosmia ~50%
  • normal bone age
  • micropenis
  • cryptorchidism (failure to descend)
  • testicular volume 1 ml
70
Q

delayed puberty (male) workup

A
  • bone age XR
  • 8 am labs:
    • systemic: CBC, CMP, ESR…
    • karyotype if gynecomastia, pectus, small testes
    • peds LH
    • peds FSH
    • estradiol/testosterone
    • TSH, free T4
    • prolactin
71
Q

kleinfelter syndrome

A

XXY

signs:

  • male phenotype
  • delayed puberty
  • pectus
  • gynecomastia
  • firm, small testicles
  • above average height
  • low testosterone
  • elevated LH/FSH (hypergonadotropic hypothyroidism)
72
Q

ddx abnormal uterine bleeding

A

PALM-COEIN

local:
polyps
adenomyosis
leiomyomas (fibroids)
metaplasia (endometrial hyperplasia or carcinoma)
systemic:
coagulopathies ~20%
ovulatory dysfunction
endometriosis
iatrogenic
not yet classified

some specifics:

  • vWF disease (AUB at onset of menses is often first sign)
  • hypO AND hypERthyroid
  • chlamydia
73
Q

dx AUB

A 
labs:
CBC (anemia, thrombocytosis)
TSH/T4
PAP
gonharrhea/chlamydia

exam:
- pelvic w/ speculum and bimanual

imaging:

  • transvaginal US
  • in adolescents, trans abdominal US may be preferred
  • if inconclusive, sonohysterography or hysteroscopy
  • if further workup needed, MRI

biopsy if needed

74
Q

tx AUB

A 
NSAIDs
progestins
OCPs
levonorgestrel IUD
tranexamic acid

surgery if structural (e.g., myxomas, polyps)

post-childbearing or no kids desired:

  • endometrial ablation
  • hysterectomy
75
Q

fibroids/leiomyomas

A
  • most common solid and symptomatic neoplasm in women
  • most common indication for hysterectomy
  • incidence increases w/ age thru menopause
  • racial disparity black>white

sx:

  • ~25% symptomatic
  • AUB (heavy or prolonged)
  • ± anemia
  • fertility issues
  • pain
  • bulk symptoms (pressure, constipation, urinary frequency)

dx:

  • transvaginal US
  • pelvic exam
  • PAP
  • r/o cancer

tx:

  • watch and wait
  • oral GnRH antagonist for up to 2 years (elagolix) - reduces uterine size and reduces bleeding
  • OCPs (does not help bulk symptoms)
  • LNG-IUD
  • trainexamic acid (antifibrinolytic)
  • myomectomy (fertility-preserving)
  • uterine artery embolization
  • hysterectomy
76
Q

endometriosis etiology

A
  • ~10% incidence, most common disorder in repro-aged women
  • endometrial tissue outside uterus

mx:

  • estrogen-dependent
  • implantation s/p retrograde menstrual flow thru fallopian tube
  • metaplasia to embryonic mesothelium
  • induction of undifferentiated peritoneal cells –> endometrium
  • metastatic (outside pelvis): lymphatic or vascular dissemination of endometrial cells
  • reduced NK cell or mq clearance of peritoneal cells

sites:
- ovary (most common)
- cul-de-sac
- broad ligament
- bladder peritoneum
- bowel peritoneum
- post surgical:
- - umbilicus (laparotomy)
- - tubal stumps (tubectomy)
- - amputated stumps of cervix

pathology:

  • dark red, blue-ish, or black cyst
  • scarring –> puckered appearance
  • “powder burnt” areas = inactive lesions
  • small risk of conversion to metaplasia
77
Q

endometriosis dx

A

clinical:

  • dysmenorrhea (pain during periods)
  • dyspareunia (pain during sex)
  • dyschezia (constipation)
  • infertility
  • chronic pelvic pain

exam:

  • fixed pelvic mass
  • puckered regions in posterior fornix
  • cervical shift to one side
  • fixed uterus

imaging:

  • US
  • laparoscopy w/ biopsy

histology:

  • biopsy essential
  • endometrial glands
  • endometrial stroma

classification:

  • minimal to severe
  • describes fertility outcome, not symptoms
  • baed on size and location of lesion

ddx:

  • PID
  • fibroid/leiomyoma
  • adenomyosis
  • cervical cancer
  • rectal cancer
  • ovarian cancer
78
Q

endometriosis tx

A
  • fulguration (thermal destruction)
  • cystectomy

symptomatic:

  • combined OCPs
  • progestin
  • GnRH agonist
  • GnRH antagonist

hysterectomy + oophorectomy not definitive (~15% reemergence)
reemergence common with all tx

79
Q

gonorrhea name, structure, dx, tx

A

neisseria gonorrheae
gram negative diplococci

dx: NAAT (PCR)
tx: ceftriaxone 500mg IM x1

80
Q

chlamydia name, structure, dx, tx

A

chlamydia trachomatis
gram negative
intracellular
no peptidoglycan wall

dx: NAAT (PCR)
tx: doxycycline 100mg po BID x7 days

81
Q

specific infections caused by chlamydia

A 
asymptomatic >80%
cervicitis
urethritis
PID
ectopic pregnancy/infertility

baby:
ophthalmia neonatorum
infant pneumonia

82
Q

PID

A

infection/inflammation of upper female repro tract

  • endometritis
  • salpingitis
  • tubo-overian abscess
  • peritonitis

usually gonorrhea or chlamydia
potential long-term problems
- e.g. perihepatitis (rare)
- ectopics

sx:

  • acute
  • lower abd/pelvic pain
  • cervical motion tenderness
  • various
83
Q

trichomoniasis

A

thrichomonas vaginalis
single-celled protozoan parasite (only protozoal infection of genital tract)
anaerobic, flagellated

clinical:

  • mainly sx in women (hence vaginalis)
    • cervicitis, discharge, pain, itching, burning
  • rarely urethritis in males

dx:
- NAAT
- Ag
- wet mount

tx: metronidazole or tinidazole

84
Q

syphilis name, structure, dx, tx

A

treponema pallidum pallidum
spirochete
gram negative

dx:

  • RPR (rapid plasma reagin)
  • treponemal Ag or Ab (TPPA/FTA Ab)
  • dark field microscopy, if ulcerated

tx:

  • primary/secondary: benzathine penicillin x1
  • late latent: benzathine penicillin x3
  • neurosyphilis, otic, ocular: penicillin G
85
Q

stages of syphilis

A

primary
- chancre (ulcer)

secondary

  • body rash
  • alopecia (“moth-eaten” hair)
  • mucous patch

early latent

  • <1 yr
  • asymptomatic

late latent

  • > 1 yr
  • asymptomatic

tertiary

  • gumma
  • aortitis
  • tabes dorsalis
  • paresis
  • neurosyphilis
  • otic
  • ocular
86
Q

genital herpes

A

HSV type 1 and 2 (usually 2)
dsDNA virus

clinical:

  • vesicles
  • then ulceration
  • then healing

dx:
- HSV PCR of lesion swab

transmission:

  • mucosal or epithelia surface
  • genital/oral secretions

tx:
- acyclovir or valacyclovir (decoy nucleotide, chain termination)

87
Q

mucosal HPV risk stratification by strain

A

low oncogenic potential:

  • most common
  • 6, 11, 42, 43, 44
  • types 6 and 11 cause respiratory sx

high oncogenic potential::

  • HPV 16 and 18 >70% cervical
  • HPV 16 is most common in penile carcinoma
  • most of 30’s and 50’s, 66, 68
88
Q

infectious diseases in pregnancy

A

TORCH

  • toxoplasmosis
  • “other”: HIV, syphilis
  • rubella (blueberry muffin rash)
  • CMV (microcephaly)
  • HSV/VZV

parvovirus (fetal hydrops)

listeriosis (neuro; stillbirth)

89
Q

congenital toxoplasmosis

A
  • cat feces and cow meat
  • 1st trimester: spontaneous abortion
  • 2nd/3rd: chorioretinitis, hydrocephalus
90
Q

congenital syphilis

A
  • miscarriage/stillbirth/prematurity
  • deformed bones
  • anemia
  • hepatosplenomegaly
  • jaundice
  • meningitis
  • skin rash

900% increased incidence in CA since 2012

91
Q

congenital CMV

A
  • most common maternal-fetal infection in US
  • saliva/urine exposure has highest risk
  • 1 in 200 affected, 1 in 5 of those sx

clinical:

  • microcephaly
  • seizures
  • retinitis
  • rash
  • IUGR
  • hepatosplenomegaly
  • jaundice

sequelae:

  • hearing loss
  • dev/motor delay
  • vision loss
  • microcephaly
  • seizures

dx:
- IgG avidity (maternal)
- amniocentesis w/ culture and PCR

92
Q

congenital HSV

A 
skin eyes mucosa ~45%
CNS ~30%
- lethargy
- seizures
- poor feed
- dev delay
- blindness
sepsis, visceral involvement common

prevention:

  • C section
  • avoid fetal scalp monitors
  • ARVs near term if lesions present or recent acquisition

tx (infant)
- IV ACV

93
Q

consequences of untreated STI

A
  • PID
  • infertility
  • spread
  • disease progression w/ some
94
Q

genital ulcers ddx

A
  • syphilis

- HSV

95
Q

urethritis and cervicitis ddx

A
  • GC
  • chlamydia
  • trichomonas
96
Q

dx infertility (time)

A

> 1 year properly timed unprotected intercourse

>6 mo in female >35 y/o

97
Q

male factor infertility (stats)

A

approx 15% couples infertile
male solely responsible 20% infertility
contributes in additional 30-40%
i.e. male factor infertility involved 50-60%

98
Q

ddx male factor infertility

A

ejaculate:

  • azoospermia (no sperm) d/t anatomy or testicular failure
  • oligozoospermia (low sperm count)
  • retrograde ejaculation (semen –> bladder)
  • anejaculation s/p surgery, spinal cord injury (sperm made but not ejaculated)

sperm:

  • infection
  • inflammation
  • DNA damage d/t oxidative stress

testes:

  • varicoceles (enlarged scrotal veins)
  • hypogonadism
  • trauma, surgery, etc.

central:

  • pituitary tumor
  • genetic abnormalities
99
Q

organs of male repro tract

A

production: testes
storage, maturation: epididymis
pathway: epididymis –> vas deferens –> ejaculatory duct via accessory –> urethra

accessory:

  • seminal vesicles produce and store seminal fluid
  • prostate and bulbourethral glands contribute to volume and composition of semen
100
Q

achieving pregnancy male factor infertility

A
  • sometimes continued sexual intercourse
  • intrauterine insemination of concentrated sperm (esp for oligozoospermia)
  • sometimes IVF
  • IVF w/ intracytoplapmic sperm injection
101
Q

hx questions male infertility

A
  • ages M&F
  • how long trying to conceive
  • “how”?
    • ovulation tracking
    • intercourse timing
    • stopping contraception
  • prior pregnancy details
  • prior infertility tx
  • ED
  • libido
  • orgasm
  • pain w/ sex
  • urinary changes
  • hormone use/steroids
  • fever
  • heat exposure (hot tub, sauna, occupational)
  • recent virus
  • olfactory changes
  • vision changes
  • change in testicular size

hx:

  • GU surgery
  • trauma
  • torsion
  • hernia
  • undescended or atrophic testis
  • mumps
  • diabetes
  • htn
  • neurological
  • cancer
  • overall fitness and diet

fhx:
- infertility, GU, endocrine conditions

shx:

  • heavy lifting, desk work
  • drugs
102
Q

meds that affect male fertility

A

erythromycin, tetracycline, gentamicin
chemo - alkylating

exogenous testosterone, anabolic steroids
androgen blockers e.g. spironolactone
5-alpha reductase inhibitors

antidepressants (affects ejaculatory latency, ED, libido)
sulfasalazine (affects sperm count)
cimetidine (affects LH secretion)
alpha blockers e.g. tamsulosin (retrograde ejacualtion)

103
Q

varicoceles

A

enlargement of pampiniform plexus
15-20% of all men

sx:

  • often asymptomatic
  • heaviness
  • aching or throbbing discomfort
  • impaired sperm count and motility
  • may cause DNA damage to sperm d/t hypoxic stress

exam:

  • visible enlargement/gnarling of spermatic vein
  • more common on left d/t angle of insertion of gonadal vein to renal vein
  • isolated right varicocele: imaging to look for tumor

tx:
- surgery or embolization may improve chances of spontaneous pregnancy

104
Q

CUAVD/CBAVD

A

congenital unilateral or bilateral absence of vas deferens
associated w/ CFTR mutations including carrier (CBAVD ~80%)

tx:
- testicular sperm extraction

105
Q

labs and imaging male infertility

A

always:

  • semen analysis x2 (4 weeks apart, each following 48-72 h of abstinence from ejaculation)
  • testosterone
  • FSH
  • testicular, transrectal (prostate + seminal vesicles) US

optional, useful:

  • LH
  • estradiol
  • prolactin

special cases:

  • post-ejaculatory urinalysis
  • karyotype
  • Y chromosome microdeletion
  • CFTR mutations
  • sperm DNA fragmentation
  • abd/pelvic imaging
  • pituitary MRI
  • vasography or seminal vesiculography
106
Q

hypospermia or aspermia ddx

A

low or no semen volume

  • retrograde ejaculation
  • post-ejaculatory UA
  • tx pseudoephedrine or TCA (imipramine) ~65% effective
  • alt tx sperm harvesting from PEU

obstructive azoospermia

  • no sperm
  • negative PEU

other rare causes

107
Q

azoospermia ddx

A

no sperm count

obstructive - obstruction of seminal tract preventing passage of sperm

  • hypospermia w/ negative PEU
  • transrectal US
  • aspirate seminal fluid to check for sperm
    • if yes, ejaculatory duct obstruction
    • tx w/ transurethral resection of ejaculatory duct
  • if vas deferens obstruction, vasography + nasal reconstruction

non-obstructive - failure to manufacture

  • measure pituitary and testicular hormones
  • karyotype for klinefelter esp if other clinical signs ~11%
  • – atrophic testes
  • – tall
  • – hypergonadotropic hypogonadism
  • Y chromosome micro deletion testing
  • same ddx as abnormal male puberty
108
Q

anejaculation

A

most often s/p spinal cord injury
inability to climax

tx:

  • penile vibratory stimulation to glans
  • electroejaculation - electrical probe in rectum against prostate (often –> retrograde ejaculation; alkalinize urine with oral meds to improve sperm viability)
109
Q

seminiferous tubules

A

long, coiled tubules comprising testes

make sperm

110
Q

interstitial tissue of testes

A

Leydig cells (LH responsive, produce testosterone)

  • large
  • eosinophilic
  • crystals of Reinke

neurovasculature

111
Q

Sertoli cell fx

A

“mother cell”
structural and nutritional support
androgen-binding protein aids w/ DHT and T transport
AMH secretion (prevents formation of mullein ducts)

112
Q

stages of spermatogenesis

A

spermatogonia A –> B (most basal)
spermatocyte I –> II
spermatid - no tail yet (most luminal)
sperm (in epididymis)

113
Q

epithelium of epididymis

A

pseudo stratified columnar w/ microvilli

previously thought to be cilia but actually seem to fx in resorption of excess testicular fluid

114
Q

vas deferens histology

A

3 thick layers of smooth muscle
innervated
pseudo stratified columnar epithelium

115
Q

seminal vesical histology

A

glandular sacs

116
Q

zones of prostate

A

peripheral zone

  • most prone to malignancy, inflammation
  • bulk of prostate
  • outer parenchyma
  • glandular

central zone

  • least prone to inflammation, hyperplasia
  • surrounds ejaculatory duct and utricle (mullerian remnant)

transitional zone

  • hyperplasia –> BPH
  • surrounds prostatic urethra (large central “U” or V shape)
  • fibrous mucosa, submucosal glands

glands are histologically similar throughout but vary in density

117
Q

features of dysplastic cervical cells on PAP

A

larger, hyper chromatic (purple to brown), darker, irregular shape

SFM5 (14 decks)

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