ReproductiveReproductive SystemSystem

Ratirath Samol, MD Content

• Female disease - genital tract : infection (PID), vulva, vagina, cervix, body of uterus with endometrium, ovaries - breast disease - gestational disorders Content

• Male disease - gynecomastia - penis -testis - prostate gland Female disease

Pelvic inflammatory disease (PID)

• Ascending infection begins in vulva or vagina and spreads upward to involve most structure in female genital tract • Clinical : pelvic pain, fever, vaginal discharge Pelvic inflammatory disease (PID)

• Organisms : - Neisseria gonorrhoaea - Chlamydia spp. - Staphylococcus spp. - Streptococcus spp. - Coliform bacteria Pelvic inflammatory disease (PID) Vulva

• Bartholin cyst and abscess • Codyloma acuminatum • Vulva carcinoma Bartholin cyst and abscess

• Acute infection of Bartholin gland produces cyst or abscess • Cyst result from obstruction of Bartholin duct, usually by preceding infection • Cyst may become large, up to 3-5 cm. • Clinical : pain, mass at labia • Rx: excision Bartholin cyst and abscess Condyloma acuminatum

• Sexual transmitted, benign lesion • Frequent multiple lesions involve vulva, perianal region and vagina • Caused by HPV type 6, 11 • Frequent regress spontaneously • No precancerous lesion Condyloma acuminatum

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Verrucous nodules Koilocytosis Squamous cell carcinoma (SCCA) of Vulva

• Cancer-related HPV infection type 16, 18 • May be genetic cause • Tumor metastasis to any organs Squamous cell carcinoma (SCCA) of Vulva Vagina

• Squamous cell carcinoma (SCCA) SCCA of vagina

• Uncommon primary SCCA of vagina • 95% SCCA associated with HPV • Greatest risk factor is previous SCCA of cervix or vulva SCCA of vagina

• Clinical course - insidious tumor growth - irregular spotting or frank vaginal discharge (leukorrhea) - may be silent and become present with urinary or rectal fistulas Squamous cell carcinoma Cervix

• Cervicitis • Intraepithelial and invasive squamous neoplasia - Cervical Intraepithelial Neoplasia (CIN) - Squamous cell carcinoma (SCCA) Cervix Cervicitis

• Acute and chronic inflammation of cervix • Caused by bleeding, sexual intercourse, vaginal douching resulting lactobacilli decrease H2O2 production Æ alkaline vaginal pH Æ pathogenic organisms overgrowth Æ cervicitis CIN and Invasive squamous neoplasia

• Risk factors for cervical neoplasm - early age at first intercourse - multiple sexual partners - increased parity - a male partner with multiple previous sexual partners - HPV infection CIN and Invasive squamous neoplasia

• Risk factors for cervical neoplasm - exposure to oral contraceptive - smoking - genital infections (chlamydia) CIN and Invasive squamous neoplasia

• Specific HPV types associated with - Cervical cancers : high-risk HPV type 16,18,31,33 - Condyloma : low-risk HPV type 6,11, Cervical Intraepithelial Neoplasia (CIN)

• Occurs in transformation zone • Precancerous lesion of cervix, classified in a variety of ways - mild dysplasia (lower 1/3) = CIN I - moderate dysplasia (lower 2/3) = CIN II - severe dysplasia (nearly thickness) = CIN III - carcinoma in situ (CIS) (full thickness)=CIN III Cervical Intraepithelial Neoplasia (CIN) Cervical Intraepithelial Neoplasia (CIN) • Clinical course - CIN I: most likely no progress to carcinoma - CIN III and CIS most frequent associated with invasive SCCA - often no symptom Squamous cell carcinoma (SCCA)

• Occurs at any age from second decade of life to senility • Gross : 3 patterns - fungating (exophytic) mass - ulcerating mass - infiltrative mass Squamous cell carcinoma (SCCA)

• Fig micro Squamous cell carcinoma (SCCA)

• Clinical course - advanced carcinoma direct spread to any structure eg.urinary bladder,ureter, rectum, vagina, liver, lungs - no symptom, vaginal bleeding, contact bleeding, pain during sexual intercourse, swollen leg Prevention and control of carcinoma of cervix

• Papanicolaou (PAP) smear screening • Vaccines for preventing HPV infection Body of uterus and Endometrium

• Endometrial carcinoma • Endometriosis/Adenomyosis • Leiomyoma (myoma uteri) Uterus and Endometrium Endometrial carcinoma

• Malignant endometrial epithelial tumor • Arise mainly in postmenopausal women, causing abnormal postmenopausal bleeding • Peak incidence 55-65 yrs • High frequent in obesity, diabetes, hypertension, infertility Endometrial carcinoma

• Most develops on background of prolong estrogen stimulation •Most endometrial adenocarcinoma Endometrial carcinoma Endometrial carcinoma

• Clinical course - irregular vaginal bleeding with excessive leukorrhea - diagnosis by curettage and histology - prognosis depend on clinical staging Endometriosis

• Endometrium locate outer site eg. cervix, myometrium, ovary • Endometrium invade in myometrium = adenomyosis • Endometrium locate in ovary forming cyst = endometriotic cyst or chocolate cyst • Clinical : dysmenorrhea Chocolate cyst Leiomyoma (myoma uteri)

• Most common benign tumor of smooth muscle cells (myometrium) • Present in 75% of female reproductive age • Malignant change in leiomyoma is extremely rare Leiomyoma (myoma uteri)

• Gross finding - well circumscribed, gray white mass with whorled, trabeculation cut section - variable in size Leiomyoma (myoma uteri)

circumscribed gray-white mass Interlacing fascicles of spindle with whorled trabeculation cells Leiomyoma (myoma uteri) • Clinical course : may asymptomatic or symptoms • Most important symptoms - abnormal uterine bleeding (submucosal) - compress bladder (urinary frequency) - sudden pain if disruption of blood supply - impaired fertility - myoma in pregnancy increase frequency of spontaneous abortion, fetal malpresentation, postpartum hemorrhage Ovaries

• Functional cysts - Follicular cysts - Corpus luteum (luteal) cysts • Ovarian tumor - mucinous tumor - serous tumor - germ cell tumor (teratoma) - krukenberg tumor Follicular cysts • Cysts >2 cm, originate in unruptured graafian follicles or in follicles • Usually no symptom • May be pain from rupture, rapid growth, bleeding into cyst, or twisting of cyst Corpus luteum cysts • Occurs when an egg is released from follicle • Variable in size of cyst • Usually no symptom • May be pain from rupture, rapid growth, bleeding into cyst, or twisting of cyst Ovarian tumors

• 80% are benign and occurs in young women (20-45 yrs) • Malignant tumor common in old women (40-65 yrs) • High frequent in unmarried and in married with low parity Ovarian tumors

• Clinical features - abdominal mass, pain and distension - ascites with peritoneal seeding - urinary and GI tract symptom due to compression or invasion by tumor

Surface-epithelial stromal tumor

• Most primary neoplasm in ovary • Gross finding - cysts : most benign - risk of malignancy increase as : solid growth thick cystic wall necrotic friable tissues Serous tumors

• Classified 3 types - Benign (serous cystadenoma) - Borderline serous tumor - Malignant (serous cystadenocarcinoma) : most common malignant ovarian tumors • Common in 20-50 yrs Serous cystadenoma

• Gross finding : single or multiple, smooth cysts filled with clear fluid Borderline serous tumor

• Gross finding : cysts with increase number of papillary projection Serous cystadenocarcinoma

• Gross finding : large amounts of solid or papillary tumor mass Mucinous tumors

• Common in middle age women • Classified 3 types - Benign (mucinous cystadenoma) - Borderline mucinous tumor - Malignant (mucinous cystadenocarcinoma) : 10% of malignant ovarian tumors Mucinous tumors

• Less frequency of bilateral • If bilateral mucinous ovarian tumors, must exclusion of non-ovarian origin tumor eg. appendix, GI tract Mucinous cystadenoma

• Gross finding : single or multiple, smooth cysts filled with sticky, gelatinous fluid Borderline mucinous tumor • Gross finding : single or multiple, smooth cysts filled with sticky, gelatinous fluid, hemorrhage, necrosis, some solid area Mucinous cystadenocarcinoma

• Gross finding : single or multiple cysts filled with scant sticky, gelatinous fluid, but predominate hemorrhage, necrosis and solid mass Germ cell tumor

• Occurs in children and young adult women • Most are mature teratoma Teratoma

• Germ cell tumor derived from pluripotential cells and made up of elements of different types of tissue from one or more of the three germ cell layers (endoderm, mesoderm, ectoderm) • Endoderm : GI tract • Mesoderm : bone, muscle, fat, cartilage • Ectoderm : skin and appendage, brain Teratoma

• Divided to 3 categories - mature teratoma (benign) - immature teratoma (malignant) - monodermal or specialized teratoma Mature teratoma

• Most are cystic and known as “Dermoid cyst” or “Mature cystic teratoma” • Bilateral 10-15% of cases • 1% of dermoid cyst have malignant change of any components Dermoid cyst

• Gross : unilocular cyst contains hair, tooth, and cheesy sebaceous materials Dermoid cyst Dermoid cyst • Microscopic : - cyst wall is squamous epithelium with sebaceous glands, hair shafts - other germ layers : cartilage, bone, brain, fat, thyroid tissue, GI epithelium etc. Krukenberg tumor

• Metastatic GI tumor to ovary, most often from stomach • Often bilateral metastasis Krukenberg tumor

• Gross: multiple masses in both ovaries • Micro: mucin-producing signet ring cells Female breast disease

• Acute mastitis • Fibrocystic change • Fibroadenoma • Invasive ductal carcinoma Female breast Normal breast

• Ducts and lobules lined by two cell types • Myoepithelial cells lies on basement membrane and luminal epithelial cells lines lumens • Luminal epithelial cells produce milk Clinical presentations of breast disease

•Pain • Palpable mass • Nipple discharge or skin discharge Acute mastitis

• Occur during lactation • Cracks and fissures in nipples • Usually Staphylococcus aureus • Erythematous painful breast, usually accompanied by fever • If not treated, infection may spread to entire breast Fibrocystic change

• Related hormonal fluctuation • Clinical : breast pain, lump with firm breast • There are three principal patterns of morphologic change: 1. Cyst formation, often apocrine cyst 2. Fibrosis 3. Adenosis Fibrocystic changes Fibrosis

• Cysts frequently rupture, with release of secretory material into adjacent stroma • Resulting chronic inflammation and fibrous scarring contribute to palpable firmness of breast Adenosis

• Increase in number of acini per lobule • Often enlarged acini • May be calcifications Fibroadenoma

• Most common benign tumor of breast • More common before age 30 • Frequently multiple mass and bilateral • Cure by excision • Rare carcinoma arising in it Fibroadenoma

• Gross: well-circumscribed, rubbery, gray white mass, variable in size Fibroadenoma Carcinoma of breast

• Risk factors –Age – Age at menarche – Age at first live birth – First-degree relatives with breast cancer – Estrogen exposure – Breast-feeding – Environment toxins Carcinoma of breast

• Risk factors – Breast density – Radiation exposure – Carcinoma of contralateral breast or endometrium –Diet – Obesity –Exercise – Genetic Invasive ductal carcinoma

• Almost presents as a palpable mass • More 50% of case have axillary lymph node metastases • Larger carcinomas may be fixed to chest wall or cause dimpling of the skin Invasive ductal carcinoma

firm to hard, gray-white mass with irregular border Prognosis and predictive factors

• Major prognostic factors – Invasive carcinoma – Distant metastases – Lymph node metastases – Tumor size – Locally advanced disease – Inflammatory carcinoma Ectopic pregnancy

• การตั้งครรภนอกมดลกู • พบบอยที่ทอนําไข “Tubal pregnancy” • ปจจัยเสี่ยง -PID - การใสหวงคุมกําเนิด (intrauterine device) • มักมีการแทงภายในอายุครรภ 3 เดอนื

Hydatidiform mole

• Classified 2 type - complete hydatidiform mole - partial hydatidiform mole Complete hydatidiform mole

• Diploid karyotype from only sperm • No fetal part Partial hydatidiform mole • Triploid karyotype from egg and sperm • Presence of fetal part Feature Complete Mole Partial Mole Karyotype Diploid Triploid (46XX, 46XY) (69xxx, 69xxy) Villous edema All villi Some villi Trophoblast Diffuse; Focal; slight proliferation circumferential Atypia Often present Absent Serum hCG Elevated Less elevated HCG in tissue ++++ + Behavior 2% Rare choriocarcinoma choriocarcinoma Male disease Gynecomastia

• Enlargement of male breast • Presents as a subareolar enlargement • Imbalance between estrogen, which stimulate breast tissue, and androgens • Condition of elevated estrogen : - cirrhosis of the liver - increase in adrenal estrogen - drugs : alcohol, heroin, steroid - functioning testicular tumor Gynecomastia

Gynecomastia Normal

Paraffinoma of penis

• Injection foreign body (paraffin) to penis result as enlarged penis • Inflammation or abscess of penis Carcinoma of penis

• Most of squamous cell carcinoma • Occurs in 40-70 years • Clinical : mass, ulcer at penis • Risk factor : smoking and HPV infection (type 16, 18) Carcinoma of penis Seminoma

• Germ cell tumor of testis • Occurs in 20-30 years • Predisposing factors: - cryptorchidism (undescended testis) - genetic factor • Clinical : testicular mass • Radiosensitive Seminoma Benign prostate hyperplasia (BPH) • Common in > 50 year • Hyperplasia of prostate gland result as enlarged prostate Æ compress urethra cause to obstruction • Clinical : urinary retention, frequency, flow dribbling, dysuria, urinary infection Benign prostate hyperplasia (BPH) Prostate carcinoma

• Most of adenocarcinoma • Common in old men • Increase level of serum PSA (prostate specific antigen) • Localized cancer : no symptom • Advance cancer : dysuria, hematuria, back pain (bone metastasis) Prostate carcinoma THE END