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4.8 Pyloric Stenosis

Approximately 1 in 200 newborns is affected by a disorder of the digestive tract known as pyloric stenosis. This condition is characterized by a narrowing of the muscular ring—the pyloric sphincter—that separates the stomach from the first portion of the small intestine. Surgical correction of the disorder may be required

3.3 Transurethral Microwave Thermotherapy (TUMT)

Nonsurgical methods of treating BPH are available. In transurethral microwave thermotherapy (TUMT), heat capable of destroying excess prostatic tissue is delivered to a designated area using a device called a Prostatron. Transurethral needle ablation (TUNA) uses low-level radiofrequency energy to eliminate hyperplastic growth. In addition, a variety of medications have been approved for the relief of BPH symptoms.

1.5 Fertilization Process

last menstrual period (LMP). At ovulation, one of the ovaries releases an ovum, which begins its journey through the uterine tube. Sperm cells and ova each contain one half of the genetic material that will make up a new human being. Fertilization is the union of sperm and ovum to form a zygote. A zygote is a single cell with a complete set of chromosomes that will develop into an embryo. Fertilization normally occurs in the uterine tube, also known as the fallopian tube. If more than one egg is traveling through the uterine tube when sperm cells are present, then multiple fertilizations may occur. Hormones are chemical messengers that play an important role in the female reproductive system.

1.4 STI Cultures and Semen Analysis

A diagnosis of an STI such as gonorrhea is confirmed by a laboratory culture of the urethral secretions. Bacterial infections such as gonorrhea and chlamydia are treated with antibiotics. The rapid plasma reagin (RPR) test is used to screen asymptomatic patients for syphilis, to diagnose symptomatic infections, and to monitor the disease in response to treatment. Unlike the fluorescent treponemal antibody absorption (FTA-ABS) test, which measures specific antibodies to the syphilis bacterium, the RPR test measures nonspecific antibodies that are produced when Treponema pallidum interacts with human tissue. A semen analysis—microscopic examination (-lysis = breakdown; ana- = apart) of the semen to determine the number, motility, and shape of the sperm cells or spermatozoa—is an essential part of fertility studies. A count of fewer than 20 million sperm/mL of semen designates a state of infertility or sterility.

3.4 Threaded Case Study: Treatment of Prostate Cancer

After a biopsy of Frank's prostatic tissue, Dr. Kane concludes that Frank's cancer is localized; that is, it has not spread to other tissues in the body (a process called metastasis). Methods of treating prostate cancer include radiation; prostatectomy, or the removal of the prostate gland; and hormonal chemotherapy because prostatic cells depend on androgens to grow. In some cases, surgical excision of the testicles (castration) can reduce the production and secretion of the hormones that stimulate the growth of malignant cells. Cryogenic surgery, or cryosurgery, destroys cancerous cells using extreme cold (cry/o). Cryosurgery can kill cells that are hard to reach even in a radical prostatectomy.

1.1 Threaded Case Study: Digital Rectal Examination (DRE)

Dr. Kane has ruled out any obstructions or disorders of the penis, urethra, or bladder. Now she turns her attention to a possible prostate disorder as the cause of Frank's symptoms. Dr. Kane has performed a routine digital rectal examination (DRE)—finger palpation of the prostate gland through the rectum. Through the rectal wall, she can palpate Frank's prostate for nodules or enlargement. In the process, she has discovered that Frank's prostate is enlarged. In addition to the DRE, a prostate-specific antigen (PSA) assay can also help identify prostate cancer by checking for elevated levels of PSA in the blood. PSA is a protein produced by the prostate. Elevated levels are found in patients with prostatitis, BPH, and prostate cancer.

1.2 Threaded Case Study: Frank

Dr. Kane's physical examination revealed a unilaterally enlarged prostate gland. Laboratory results also show that Frank's PSA level, which normally should measure no higher than 4 mg/L, is at 6 mg/L. The digital rectal examination (DRE) and the prostate-specific antigen (PSA) blood test are important for detecting changes in the prostate gland, but these tests cannot determine whether changes are due to prostate cancer or to a noncancerous condition such as benign prostatic hyperplasia (BPH).

3.8 Threaded Case Study: Frank

Frank's surgery goes well. Afterward, Dr. Kane stops by to tell Frank's wife, Louisa, that absolutely no cancer has spread to other tissues and that Frank required no blood transfusions during the procedure. A full recovery is well underway by the time Frank goes home from the hospital 2 days later. Had Frank's PSA levels continued to rise—or had there been evidence of metastasis—Dr. Kane was going to suggest adjuvant hormone therapy to minimize recurrence. However, neither metastasis nor elevated PSA levels were found; therefore Frank is sent home with some painkillers. At home, Frank complains of some urinary incontinence; however, within a couple of weeks, the incontinence has resolved. Frank has had a complete recovery from his surgery and is back at work. He no longer has to worry about frequent visits to the bathroom while cleaning windows on the 32nd floor!

2.7 Herpes Genitalis

Herpes genitalis is a chronic infection caused by the type II herpes simplex virus (HSV II) and is usually transmitted by sexual contact. When acquired during pregnancy, the HSV II may also be communicated to the fetus or neonate through the placenta and through direct contact with infected tissue at birth. Often, the lesions associated with herpes genitalis spontaneously heal. Medications can suppress the frequency of recurrence, but there is no known cure for herpes infection. Human papilloma virus (HPV), an infection of the skin and mucous membranes, usually shows up as a genital wart, or condyloma, in the anogenital region; it can cause related cancers in both men and women. A vaccine has been developed that offers protection against four types of HPV.

2.3 Orchiopexy and Orchiectomy

If the testes fail to descend spontaneously by the time a child is 2 years old, an orchiopexy is performed. This surgical procedure is used to mobilize and attach a testis (orchi/o), securing it in place (-pexy = surgical fixation) to prevent its retraction. Orchiopexy should not be confused with orchiectomy, which is the removal (-ectomy) of a testis.

2.2 Surgical Ligation, Hydrocelectomy, and Circumcision

Let's look for a moment at surgical options for noncancerous disorders. During surgery for testicular torsion, the spermatic cord is untwisted—restoring the blood supply, and the testicle is sutured to the scrotum. Varicocele can be treated by surgical ligation, or tying off of the spermatic cord. The treatment for persistent hydrocele is surgery. During the procedure, known as hydrocelectomy, a needle and syringe are used to aspirate or remove (-ectomy) the fluid-filled (hydr/o) swelling or mass (-cele). Finally, phimosis is treated by circumcision, the surgical removal of the prepuce, or foreskin, which is the loose-fitting, retractable casing of the glans penis.

2.4 Vasectomy and Vasovasostomy (Animation)

Some procedures alter fertility rather than treat a disorder. In vasectomy, an incision is made into the scrotum, and the vas deferens (vas/o) is surgically cut and tied off for the purpose of sterilization, that is, to prevent the body from producing or releasing reproductive cells. Evaluating the semen for the number, motility, and shape of the sperm (called a semen analysis) is a way to analyze the effectiveness of this procedure. A vasectomy can be reversed in vasovasostomy, a surgical operation to reopen (-stomy) the vessel by rejoining the two ends of the severed vas deferens (vas/o + vas/o).

2.1 Treating Testicular Tumors

Testicular cancers are rare in the United States and, if detected early, can be treated and cured with surgery (orchiectomy—Figure), radiotherapy, and chemotherapy. You may recall that 90% of testicular tumors are germinal cancers—such as seminomas, for example . These cancers are typically treated with radiotherapy and surgical excision. Chemotherapy (chem/o = drug; -therapy = treatment) is recommended for nonseminomatous tumors.

3.5 Factors in Selecting a Treatment for Prostate Cancer

The choice of care depends on the stage of the cancer, which is based on tumor volume and spread. At every stage, more than one treatment option is available; surgery or radiation may be commonly used, but neither option may be considered for older men with slow-growing cancers. Periodic PSA tests and physical examinations to monitor the growth may be the preferred treatment plan in these cases.

1.3 Transrectal Ultrasound (TRUS)

The diagnosis of prostate cancer is confirmed with a prostate needle biopsy. The tissue sample for the biopsy is taken with the guidance of transrectal ultrasound (TRUS). TRUS is an outpatient procedure that uses sound waves to create an image of the prostate gland. A small, lubricated probe, which is inserted into the rectum, gives off sound waves that create echoes as they enter the prostate gland. Prostate tumors will create echoes that are different from normal prostate tissue. The returning echoes are processed by a computer to produce an image of the prostate gland. TRUS can detect tumors that are not felt by DRE and plays an important role in guiding the biopsy needle into the right part of the prostate gland. Frank is diagnosed with prostate cancer. Two scoring systems are used to determine how aggressive Frank's cancer is: the TNM staging system and the Gleason scoring system. Both scores suggest a fairly aggressive but localized tumor in Frank's prostate.

3.6 Prostatectomy (Animation)

The oncologist, Dr. Daniels, recommends a radical prostatectomy—the surgical removal of the entire prostate gland, plus some surrounding tissue. Several methods can be used. In the retropubic approach, a 6-inch incision below the umbilicus allows the removal of the prostate gland, along with pelvic lymph node dissection. In the perineal, the prostate is removed through an incision between the anus and scrotum (the perineum); although this approach minimizes visible scarring, it requires a separate incision if the lymph nodes are to be removed. A suprapubic prostatectomy involves an abdominal incision above (supra-) the symphysis pubis. A laparoscopic approach, which entails several 1-inch incisions with a larger one made for the actual removal of the prostate from the body, is being used in some settings.

3.1 Treatment for BPH

You may recall that Frank was assessed for benign prostatic hyperplasia (BPH). BPH may be surgically treated by transurethral resection of the prostate gland (TURP). During this procedure, a resectoscope—an instrument used to excise prostatic tissue—is inserted through the urethra, an electrical hot-loop destroys prostatic tissue, and these portions of the gland are removed through the resectoscope. This procedure can also be performed using lasers (laser TURP) to destroy tissue and relieve obstruction. Another name for this alternative procedure is photo-selective vaporization of the prostate, or green-light PVP. When the prostate gland is less enlarged, an alternative surgical intervention—transurethral incision of the prostate (TUIP)—may be used. In this procedure, the urethra is widened by means of small incisions in the bladder neck and prostate gland.

2.8 Syphilis

syphilis is a sexually transmitted disease caused by a spirochete, which is a spiral-shaped bacterium. It is characterized by distinct stages that mark its progression. The illness can affect any organ system and, because the infecting organism can pass through the placenta, syphilis can be congenital. The first stage of the disease, primary syphilis, is accompanied by the appearance of a chancre (Figure), a red, bloodless ulcer on the external genitals. Indications of secondary syphilis, usually several months later, include papulosquamous eruptions or erythematous papules, hair loss, swelling of the lymph nodes, and bone and joint pain. In late stages of the disease (tertiary syphilis), damage to the central nervous and cardiovascular systems may occur, and the disease may lead to death if not treated.

1.4 Endometrial Carcinoma

Endometrial carcinoma is a malignant (carcin/o) tumor (-oma) of the endometrium, or the inner lining of the uterus. It is the most commonly occurring gynecologic cancer, usually developing in women after menopause. As with cervical cancer, endometrial carcinoma tends to be preceded by abnormal changes in uterine tissue. Overgrowth of the endometrium caused by sustained estrogen stimulation, a condition known as endometrial hyperplasia, is a precursor to this malignancy.

1.4 Hysterosalpingography

You may recall that before her pregnancy, Jackie's infertility was associated with benign growths called fibroids. When Dr. Sharp suspected Jackie had fibroids, she confirmed her diagnosis with hysterosalpingography (HSG), a diagnostic test that involves the radiographic imaging (-graphy) of the uterus (hyster/o) and fallopian tubes (salping/o) after the injection of contrast dye.

1.8 Hydrocele and Sperm Count Disorders

A hydrocele is an accumulation (-cele = swelling, mass) of fluid (hydr/o) in the scrotum. This disorder may be caused by inflammation of the testis or epididymis or may result from poor lymph drainage. Diagnosis of the condition is made by transillumination—shining a light source through the scrotal tissue to identify the fluid-filled mass. The testes are also the site of inflammatory conditions, such as epididymitis, which is inflammation of the epididymis—the elongated cordlike structure located along the posterior border of the testis. Some conditions, such as aspermia and azoospermia, can cause infertility disorders. Although these conditions can be easily confused, aspermia is an abnormal condition (-ia) of the sperm (sperm/o) characterized by a lack (a-) of formation or emission of semen. Azoospermia is a condition of no living sperm (zo/o = living animal) in the semen. A low sperm count is called oligospermia (olig/o = scanty

3.4 Abruptio Placentae

Abruptio placentae is another potentially life-threatening condition that may occur during pregnancy. This condition involves the separation, or tearing away, of a normally implanted placenta from the uterine wall and often results in severe hemorrhage.

1.7 Varicocele and Orchitis

Another disorder most commonly seen in adolescent boys is the varicocele—an enlargement of the veins of the spermatic cord (varic/o = varicose veins). This enlargement affects the left spermatic cord more often than the right, because of the position of the left testicular vein. The condition is often asymptomatic and develops over time. Varicoceles are a common cause of low sperm production and decreased sperm quality in men, which can cause infertility. Not all varicoceles, however, affect sperm production. For the most part, orchitis, which is the inflammation of one or both testes, occurs in adolescence and adulthood. Orchitis is associated with the virus that causes mumps. At least one third of men who contract mumps after puberty develop orchitis. Other causes are usually bacterial, including sexually transmitted diseases such as gonorrhea or chlamydia. Bacterial orchitis that results from epididymitis is called epididymo-orchitis.

4.3 Yolk Sac and Amnion

As the embryo develops, it forms an outer layer of cells and an inner cell mass. The inner cell mass becomes a structure with two cavities—the yolk sac, which produces blood cells, and the amniotic cavity, which is the inner membranous layer and is called the amnion (amni/o). This amniotic cavity becomes a fluid-filled, protective sac of amniotic fluid, in which the embryo floats during development.

3.2 Ovum

At the time of birth, the ovaries of a female child contain approximately 1 million ovarian follicles, each enclosing an oocyte or immature ovum (Fig. A). By the time a girl reaches puberty and experiences menarche—the beginning (-arche) of menses, or menstruation, (men/o)—the number of oocytes will have been reduced to approximately 400,000. Over the course of a woman's reproductive life, only 400 to 500 of these sex cells will develop into mature ova (Fig. B).

3.4 Cystectomy and Oophorectomy

Because cysts often arise in response to hormone stimulation, many spontaneously resolve when hormone levels diminish. When tumors are large or symptomatic, either a cystectomy (surgical removal of the cyst) or an oophorectomy (excision of one or both ovaries) may be performed.

4.1 Threaded Case Study: Jackie and Alan

Because her labor is slow, the drug oxytocin is administered to promote uterine contractions and to ensure that the baby is delivered within 24 hours of Jackie's water breaking.

1.7 AFP, Amniocentesis, and Culdocentesis

Between 14 and 19 weeks, a maternal alpha-fetoprotein (AFP) test is often performed. This test can reveal multiple gestations and can detect conditions such as neural tube defects. In the 16th week of pregnancy, the woman may undergo a procedure called prenatal amniocentesis. This procedure involves the insertion of a needle through the abdomen for aspiration of amniotic fluid (amni/o = amnion; -centesis = surgical puncture to remove fluid). Fetal cells contained in the fluid are cultured for microscopic analysis, and a karyotype is made to analyze chromosomes. The fluid can also be tested for chemical signs of fetal spinal cord and spinal column defects. In a similar diagnostic procedure known as culdocentesis, fluid is removed through a needle inserted through the vagina into the cul-de-sac (culd/o). The presence of blood in the aspirated fluid can help signal a ruptured ectopic pregnancy.

5.2 Carcinoma of the Breast

Carcinoma of the breast is the most common malignancy in women in the United States. The most common form is invasive ductal carcinoma. Although its causes are not completely understood, risk factors associated with the development of breast cancer include heredity, early menarche, late menopause, nulliparity, environmental influences, diet and body weight, and, possibly, postmenopausal hormone replacement therapy. A precursor exists that can aid in preventing this type of cancer; ductal carcinoma in situ (DCIS) is a precancerous lesion that indicates a higher risk for invasive ductal breast carcinoma.

1.3 Cone Biopsy and LEEP

Cervical conization, or cone biopsy, is the removal of a cone-shaped sample of tissue from high in the cervical canal. Conization may be used for either diagnostic purposes or for therapeutic purposes to remove precancerous cells. A small amount of normal tissue around the cone-shaped wedge is also removed to ensure that a margin free of abnormal cells is left in the cervix and cervical canal. The tissue sample may be removed using loop electrosurgical excision procedure (LEEP), a carbon dioxide (CO2) laser, or a surgical knife (scalpel).

1.5 Cervical Dysplasia and Carcinoma in situ

Cervical dysplasia is a change in the size, shape, and/or appearance of the cells that form cervical tissue. This condition is most often caused by infection with the human papilloma virus (HPV). If left untreated, then cervical dysplasia may develop into cancer. In 2006, the U.S. Food and Drug Administration (FDA) approved Gardasil, the first vaccine developed to prevent cervical cancer, precancerous genital lesions, and genital warts caused by HPV types 6, 11, 16, and 18. The FDA has also licensed two HPV vaccines for use in young men. Dysplasia that is observed on a biopsy of the cervix is called cervical intraepithelial neoplasia (CIN) and is grouped into three categories: CIN I is mild dysplasia; CIN II is moderate-to-marked dysplasia; and CIN III is severe dysplasia to carcinoma in situ. Carcinoma in situ (CIS) is a strong predictor of cervical cancer. With CIS, the cells are more abnormal than those with dysplastic changes, but they have not yet invaded adjacent structures.

1.6 Choriocarcinoma

Choriocarcinoma is a malignant (carcin/o) neoplasm (-oma) of the uterus that arises from the chorionic (chori/o) membrane, or placenta. The tumor may appear during a normal pregnancy, in association with an ectopic pregnancy, or after an abortion, whether spontaneous (miscarriage) or induced. Choriocarcinoma is an uncommon but often curable cancer that occurs during pregnancy. A fetus may or may not develop in these types of pregnancies

3.11 Menstrual Cycle: Days 1 to 12

Cyclic changes involving the uterus simultaneously occur with the events of the monthly ovarian cycle. These changes typically take place over a period of 28 days. Days 1 to 5: During each month in which an ovum is not fertilized, menstruation occurs, and patches of dead cells, torn tissue, and blood from torn arteries are shed from the endometrium and discharged from the uterus through the vagina. Days 6 to 12: Now the cells of the uterine lining reproduce, and the endometrium undergoes a period of repair. At the same time, another ovarian follicle—containing a maturing ovum—is developing, and the follicle-stimulating hormone (FSH) is causing estrogen production to increase toward its peak level.

1.2 Colposcopy and Laparoscopy

Colposcopy is a common follow-up procedure for abnormal Pap smears. This procedure uses a special magnifying device with a light called a colposcope to examine the vulva, cervix, and vagina (colp/o) (Fig. A). If the visual examination reveals anything unusual, then a small tissue sample (biopsy) may be taken from the cervix or from inside the opening of the cervix (endocervical canal) for microscopic examination. Other diagnostic and therapeutic endoscopic procedures include culdoscopy, which uses a culdoscope to examine the Douglas cul-de-sac (culd/o); hysteroscopy, which can also use the hysteroscope to remove fibroids or polyps from the uterus (hyster/o); and laparoscopy (Fig. B), which uses a laparoscope to remove abdominal (lapar/o) lesions or to perform a hysterectomy or biopsy the ovary.

2.3 Bulbourethral Glands

Cowper glands, or bulbourethral glands are two round, pea-sized exocrine glands that lie just below the prostate gland. Similar to the seminal vesicles and the prostate gland, the bulbourethral glands secrete a fluid into the urethra that helps transport sperm and contributes to the survival of the male sex cells.

3.12 Menstrual Cycle: Days 13 to 28 (Slideshow)

Days 13 and 14: As the estrogen content in the blood increases, the pituitary gland is stimulated to secrete luteinizing hormone (LH), causing the mature follicle to eject the ovum. Ovulation often occurs on day 14. Days 15 to 28: With the ovum moving through the fallopian tubes for possible fertilization, the uterine lining again begins to prepare for pregnancy. LH triggers the corpus luteum to secrete an increased level of progesterone, and, in response, the uterine lining becomes thicker and develops a greater blood supply. When fertilization does not occur, secretions from the corpus luteum diminish, progesterone levels drop, endometrial cells die, and the reproductive cycle repeats with the onset of menstrual bleeding.

2.3 Dermoid Cysts

Dermoid cysts are ovarian tumors that contain different kinds of tissue, including fatty material, hair, teeth, bits of bone, and cartilage. Ovarian cysts can be asymptomatic for long periods. If symptoms are present, then they may include menstrual irregularities and complaints of dull pain or heaviness in the lower abdomen. Because cysts often arise in response to hormone stimulation, many spontaneously resolve when hormone levels diminish.

2.6 Detection and Treatment of Breast Cysts

Diagnosis of fibrocystic breasts will begin with your physician asking you questions about your pain and any medications you take, as well as performing a physical examination. Depending on your age and symptoms, further diagnostic testing may be recommended. A biopsy may be used to distinguish fluid-filled cysts from fibroadenoma or cancer. Ultrasound can show whether a lump is a fluid-filled cyst or a solid tumor. If imaging tests reveal a fluid-filled cyst, then a fine-needle aspiration procedure may be performed to remove the fluid. This procedure can alleviate the pain of the cyst and confirm that the lump is benign. Many different types of treatment, including dietary changes and hormone therapy, are used to try to alleviate breast pain caused by fibrocystic changes.

1.6 Dilation and Curettage

Dilation and curettage (D&C) is the widening of the uterine cervix and scraping off of the endometrial lining of the uterus. This procedure helps diagnose uterine disease and may be therapeutically performed to temporarily halt prolonged or heavy uterine bleeding. Endometrial biopsy (EMB) is a procedure during which a tissue sample is taken from the endometrial lining of the uterus and checked under a microscope for any abnormal cells or signs of cancer.

1.2 Male Reproductive Structures

Does it surprise you that the presenting symptom of our patient is a urinary disorder in a module on the reproductive system? The genitourinary (GU) tract, or genitourinary system, is an organ system made up of the organs related to the production and excretion of urine, as well as organs related to reproduction (genit/o = reproduction; urin/o = urine). The reproductive and urinary systems are grouped together because of their proximity to each other, their common embryologic origin, and the use of common pathways, such as the male urethra in the male genitourinary tract. The male (andr/o) reproductive system includes both internal and external structures. The testis, or testicle (test/o, orch/o, orchi/o, orchid/o), is an essential structure of the male reproductive system because sperm cells are produced within this organ. The testes are small, smooth, oval-shaped, and paired glands. Before birth, these glands descend from their position in the abdominal cavity into the scrotum, a pouch of skin suspended between the thighs. The external, diamond-shaped area observed between the scrotum and anus is called the perineum.

4.3 Down Syndrome

Down syndrome—a chromosomal abnormality known as trisomy 21—is the most well-known chromosomal abnormality. Infants with this syndrome are often identifiable by a distinct set of physical characteristics, including slanted eyes, a flattened nose, an enlarged tongue, and stubby hands and feet. A hallmark feature of Down syndrome is mental retardation, which may vary from moderate to severe. The condition occurs in approximately 1 in 600 births.

1.3 Threaded Case Study: Frank

Dr. Kane tells Frank that although he does, indeed, have a urinary tract infection, she is also concerned about the blood in Frank's urine, a condition known as hematuria. Frank has had a vasectomy and wonders whether that might be a contributing factor, but Dr. Kane says it is unlikely. Instead, she says, "I think something may be obstructing your flow of urine into the bladder." She suspects he may have either a bladder obstruction or a condition called benign prostatic hyperplasia, or enlarged prostate.

1.5 Diagnostic Sonography

Dr. Sharp also performed pelvic ultrasonography—the process of imaging deep body structures by measuring and recording sound waves—to detect leiomyomas. These sound waves are sent and received by means of a device called a transducer that converts them into electrical impulses. Transvaginal ultrasound, which involves placing a transducer in the vaginal canal, offers a sharper image of internal structures than transabdominal ultrasonography.

2.2 Breast Imaging

Dr. Sharp arranges for Jackie to have a mammogram. Diagnostic studies such as mammography—x-ray imaging of the breast—and biopsy help to either establish or rule out a diagnosis of a breast tumor. Breast ultrasound imaging and breast magnetic resonance imaging (MRI) are other imaging techniques that can confirm the presence of a mass and can also distinguish a cystic from a solid mass. MRI is very useful for detecting masses in young women with dense breasts. Ultrasound imaging is useful for evaluating a specific area of cancer visualized on a mammogram. Stereotactic core biopsy uses mammography to guide a biopsy needle into an area of concern.

1.3 Pelvic Tumors and Fibroids

Dr. Sharp considers Jackie's symptoms and wonders whether Jackie might have fibroids, or leiomyomas. Fibroids, or leiomyomas, are the most commonly occurring pelvic tumor (leiomy/o = smooth, visceral muscle; -oma = tumor or mass). These benign growths consist of smooth muscle and fibrous connective tissue. The cause is unknown, although their development is believed to be stimulated by estrogen. Fibroids are often asymptomatic; however, if symptoms are present, then they may include abnormally long or heavy menstrual periods called menorrhagia. Depending on their location, fibroids can also interfere with fertility.

3.4 Fertilization

During fertilization in the woman, if more than one egg is traveling through the fallopian tube when sperm cells have been deposited there, multiple fertilizations may occur. Fraternal twins develop when two different spermatozoa fertilize two different ova (sing., ovum). Although these offspring are born of the same pregnancy, they have separate placentas and are no more similar than siblings from different pregnancies. Identical twins are produced from a single fertilized ovum, usually with one placenta and two amniotic sacs. During the early stages of embryonic development, the ovum splits into equal halves, each of which gives rise to a separate fetus. These offspring are always of the same sex and closely resemble each other in their physical, psychologic, and mental characteristics.

2.1 Threaded Case Study: Breast Examination

During this same postpartum follow-up examination, Dr. Sharp discovers a lump in Jackie's left breast. The initial signs of breast cancer are usually a small, painless lump (most often located in the upper outer quadrant of the breast), thick or dimpled skin, and/or retraction of the nipple. Most of these signs are discovered by the woman herself during a monthly breast self-exam (BSE). Some lumps, like Jackie's, are found during a routine examination in a physician's office.

3.5 Dystocia and Oxytocia

Dystocia means difficult (dys-) labor and delivery (-tocia), whereas oxytocia means rapid (oxy-) labor and delivery.

2.4 Divisions of the Breasts

Each breast contains 15 to 20 glandular divisions, called lobes or lobules, which house milk-secreting cells. These cells are activated for lactation (secretion of milk) only after childbirth, or parturition. Small tubular structures—the lactiferous ducts—extend from the milk-secreting cells, slightly expanding into lactiferous sinuses as they converge in a spoke-like fashion toward the nipple. The nipple—also called the mammary papilla—is surrounded by a pigmented area known as the areola.

1.4 Spermatogenesis

Each testis is divided into 200 or more cone-shaped lobules that contain tiny coiled tubes, known as the seminiferous tubules. Spermatogenesis—the formation (-genesis) and development of sperm cells (spermat/o, sperm/o)—occurs along the lining of the tubules. Because the seminiferous tubules perform the essential work of the testes, they are the parenchyma. Spread among these many tubules, interstitial (Leydig) cells of the testes form the connective and supportive tissue (stroma) of the testes. These interstitial cells manufacture the hormone (-one) testosterone.

2.4 Pelvic Inflammatory Disease and Salpingitis

Earlier, we noted that infection, caused by a variety of pathogens, might affect the uterus and ovaries. In fact, infection and inflammation of any of the pelvic organs may be generally referred to as pelvic inflammatory disease (PID). PID is most frequently caused by repeated bacterial infections or sexually transmitted diseases (STDs), such as chlamydia or gonorrhea. Characteristics of PID include fever, a foul-smelling vaginal discharge, pain in the lower abdomen, and abnormal bleeding. When the fallopian tubes are affected—a condition called salpingitis—purulent material can collect, causing a partial or complete tubal obstruction. PID can also take the form of oophoritis, or inflammation of the ovary.

1.7 Endometriosis, Endometritis, and Endocervicitis

Endometriosis is a condition in which the endometrial tissue that lines the uterus proliferates and is transferred to sites outside the uterine cavity. One possible cause for this condition is the backward flow of endometrial fragments during menstruation. These fragments can then attach to the fallopian tubes, ovaries, and other structures in the pelvic cavity. Pelvic inflammatory disease (PID) is an inflammation and infection of any number of organs in the pelvic region—including the ovaries, fallopian tubes, uterus, and cervix. PID can include inflammation of the endometrium, called endometritis, as well as endocervicitis, which is an inflammation of the inner (endo-) lining of the cervix (cervic/o). We will look closer at PID in the next lesson.

4.2 Erythroblastosis Fetalis

Erythroblastosis fetalis is a hemolytic disease in the newborn (HDN) caused by a blood group (Rh factor) incompatibility between the mother and the fetus. This incompatibility leads to the destruction of red blood cells in the newborn. Depending on the severity of the condition, either intrauterine transfusions of blood or immediate exchange transfusions after birth may be required.

1.5 Epididymis

Eventually, the spermatozoa (sing., spermatozoon) (zo/o = animal life) are released into the lumen of each seminiferous tubule. From there they are transported into the epididymis (epididym/o) through a system of small ducts. The epididymis is one of a pair of comma-shaped, tightly coiled tubes above each testis in which sperm cells continue to mature until they are either conveyed by ejaculation through the urethra or disintegrate and are reabsorbed by the body.

5.1 Threaded Case Study: Fibrocystic Breast Disease

Fibrocystic breast disease involves the presence of numerous small sacs of fluid (cysts) surrounded by dense strands of fibrous tissue and is the most frequently occurring breast disorder. The causes that give rise to the formation of these benign cysts are not fully known. Fibrocystic changes of the breast are often most evident before and during menstruation and subside afterward, indicating that they are influenced by hormonal changes. Incidence of the condition is greatest among nulliparous women—women who have never (nulli-) given birth (-parous)—and those who are between 40 and 50 years of age.

3.2 Threaded Case Study: Preeclampsia

For the most part, Jackie's pregnancy proceeds without incident. However, in her sixth month, she begins to notice swelling in her legs and feet and reports this to Dr. Sharp at her next visit. The nurse records Jackie's blood pressure as elevated, and a urine specimen shows a high protein content (proteinuria). Dr. Sharp suspects that Jackie may have preeclampsia, an abnormal condition of pregnancy characterized by high blood pressure, large quantities of protein in the urine (proteinuria), and swelling of the legs and feet (edema). Preeclampsia may be mild or severe. Jackie's case is mild and treated with bedrest and an antihypertensive medication. Eclampsia is the final and most severe phase of untreated preeclampsia and often causes seizures and even death of the mother and baby.

1.1 Threaded Case Study: Testicular Carcinoma

Frank confides to Dr. Kane, "Whenever I have any kind of male or urinary problems, I always get this little nagging thought that it could be testicular cancer or something. I know that probably doesn't make much sense, but I can't help thinking about it because my brother, Sam, had it when he was younger, and I'm older now, so I figure that my chances can only increase, right?" Actually, Frank is only partly right. Although it is true that many disorders of the testes are age related, testicular carcinoma—cancer (CA) of the testes (testicul/o)—accounts for less than 1% of all forms of cancer in men, and it occurs most frequently in the 15- to 35-year-old age group. Therefore Frank's chances actually decrease with age.

2.5 Structure of the Penis

Frank continues to have irritation and difficulties with urination. Urinary problems may be related to problems with the penis (pen/o), more specifically, with the urethra, the innermost structure of the penis. The penis is an external reproductive organ. It contains the urethra, which serves as a passageway for semen during ejaculation and for urinary elimination. Its structure consists of three cylindrical masses of erectile tissue; one mass surrounds the urethra, and the outermost mass is covered with skin. An overlap of erectile tissue at the tip of the organ forms the slightly bulging structure called the glans penis (balan/o), in the center of which is located the urethral opening. A fold of skin covering the tip of the penis is called the prepuce, or foreskin.

3.1 Threaded Case Study: Male Sex Cells and Hormones

Frank has had a vasectomy. The purpose of a vasectomy is male sterilization. After their third child, Frank and his wife decided not to have any more children. Frank's vasectomy reduced his sperm cell count to zero. The male reproductive system produces and maintains the spermatozoa (sing., spermatozoon)—the male sex cells—and also secretes several hormones. The most important of the hormones are androgen (andr/o = male; -gen = producing, forming) and testosterone, which stimulate the development of male characteristics. Sperm cells contain one half of the genetic material that forms each living being.

1.4 Cryptorchidism

Frank recalls that his brother Sam was treated as a boy for undescended testicles. Typically, the testicles descend from the abdominal cavity into the scrotal sac before birth. When one or both of the testes fail to descend, the condition known as cryptorchidism exists (crypt/o = hidden; orchid/o = testis). Cryptorchidism, also called cryptorchism, is the most common congenital testicular condition. Only if the condition is not corrected before puberty does it becomes a risk factor for infertility and testicular cancer.

2.6 Gonorrhea

Gonorrhea is a common STI that is caused by Gonococci bacteria (gon/o = seed; -rrhea = abnormal discharge) and results in inflammation of the genital tract mucosa. Indications of the infection include urethritis; painful urination; a mucopurulent urethral discharge; and itching, burning, or pain around the urethral opening. As with chlamydia, a gonorrheal infection is often asymptomatic.

2.3 Hypospadias and Erectile Dysfunction

Hypospadias is a congenital disorder in which the external opening of the urethra—the urinary meatus—is on the undersurface of the penis, involving the penoscrotal surface area (pen/o + scrot/o + -al = pertaining to penis and scrotum). This disorder, too, can interfere with the flow of urine. Surgery can easily correct this condition. Men of all ages can experience erectile dysfunction (impotence) (ED), that is, difficulty achieving or maintaining an erection. This condition can be improved with the use of drugs such as Viagra (sildenafil citrate), Cialis (tadalafil), and Levitra (vardenafil), which enhance erectile function by increasing blood flow to the penis.

3.7 Fertility Procedures

If, after her fibroid treatment, Jackie had continued to have trouble conceiving, then she and Alan may have to consider a procedure such as in vitro fertilization (IVF), during which ova and sperm are combined in a glass laboratory dish (in vitro). In this procedure, if fertilization is successful, then the fertilized ova are injected into the woman's uterus through the cervix after 2 or 3 days. Between 30% and 50% of all IVF procedures are now associated with intracytoplasmic sperm injection (ICSI), which is the direct injection of sperm into harvested ova.

1.8 Intrauterine Assessment of the Fetus

In addition to amniocentesis, a number of other procedures enable intrauterine assessment of the fetus. Chorionic villus sampling (CVS), which is the aspiration of placental tissue, can be performed to diagnose genetic abnormalities. Fetal monitoring is the continuous recording of the fetal heart rate and maternal uterine contractions to assess fetal status and the progress of labor. Pelvimetry is the process of measuring (-metry) the dimensions of the maternal pelvis (pelv/i) to help evaluate the mother's capacity for a vaginal delivery.

3.7 Progesterone

In addition to estrogen, the corpus luteum also secretes the hormone progesterone. Progesterone stimulates growth of the endometrial lining of the uterus to support the fertilized ovum should pregnancy occur. Production of both estrogen and progesterone is controlled by two hormones released by the pituitary gland.

3.6 Estrogen

In addition to their role as the essential organs of the female reproductive system, the ovaries also perform another important function—hormone secretion. Cells that surround the ovum within the ovarian follicles—follicular cells—secrete the hormone estrogen. Our knowledge about the influences of estrogen continues to grow. Some of estrogen's actions include promoting the development of reproductive organs and secondary sex characteristics and initiating the menstrual cycle.

4.8 Childbirth

In humans, the average pregnancy (gravid/o, -cyesis, -gravida) lasts approximately 9 months. When labor begins, the pregnancy stage is over. Labor begins with strong uterine contractions that cause the cervix to dilate and thin (effacement), which allows the fetus to pass from the uterus through the vagina. After the birth of the child, or parturition (represented by the suffixes -para and -tocia), the placenta, then called the afterbirth, is expelled from the uterus. A woman who is pregnant (-gravida) for the first (primi-) time is a primigravida. A multigravida is a woman who has had more than one (multi-) pregnancy, and a nulligravida is a woman who has had zero (nulli-) pregnancies. Pregnancy, or gravida, is abbreviated G. These prefixes can also be paired with the suffix -para, meaning delivery, to create terms that describe how many children a woman has delivered. Thus a primipara woman (primip) has given birth once, and a multipara woman (multip) has delivered more than one baby (multi- = more than one). A woman's reproductive history is recorded in terms of "para," followed by a series of numbers that lists (1) full term, (2) preterm, (3) aborted, and (4) living biological children. For example, para 2-0-1-1 means that the woman has delivered two babies at full term, no preterm babies, has had one abortion, and has one living biological child.

3.5 Cautery and Cryosurgery

Inflammatory disorders, such as cervicitis, can be treated with oral antibiotics. Cervical dysplasia or erosion may be removed by cautery, or cauterization, or cryosurgery, also called cryocauterization. Cauterization is the destruction of tissue by burning with chemicals (silver nitrate) or an electrically heated instrument. Cryosurgery uses cold temperatures to destroy tissue. A liquid nitrogen probe produces the freezing temperature.

4.7 Hydrocephalus

Interference with the flow of cerebrospinal fluid (CSF)—a protective fluid (hydr/o) circulates throughout the brain and spinal cord—can result in its abnormal accumulation. The resulting condition, known as hydrocephalus, exhibits an enlarged head (cephal/o), an abnormally small face, and eyes that appear to be depressed within their sockets. Treatment consists of the insertion of a tube, called a shunt, to drain the excessive fluid and to relieve pressure on the brain.

Structures of the Female Reproductive System

Its essential organs are the ovaries (gonads).Their male counterparts, as you will see in Module 9, are the testes. The ovaries produce the female sex cell, or egg, called the ovum (pl., ova). The egg or ovum (ov/o, ovul/o, o/o) and the male sex cell, the sperm, are called gametes.

2.5 Threaded Case Study: Lumpectomy

Jackie and Alan visit Dr. Sharp to go over the results of the mammogram. It is determined that Jackie will need a lumpectomy, a procedure during which the tumor and immediate surrounding tissue are removed while preserving the remaining breast tissue. During this procedure, the surgeon will also perform a sentinel node biopsy (SNB) (sentinel lymph node [SLN] biopsy) to determine whether the tumor has spread to the lymph nodes. This procedure involves injecting a blue dye or radioisotope into the site and tracking it to identify the sentinel node(s). The sentinel node(s) are removed for microscopic study to see if they are affected. If they are not, then the procedure stops there; if they are affected, then more nodes are removed to determine the extent of involvement. The surgery is then followed by radiation to the affected tissues to kill any remaining tumor cells.

1.1 Threaded Case Study: Jackie

Jackie reports that her periods are heavier and last longer than they used to be. Jackie's report is a type of dysfunctional uterine bleeding (DUB) or abnormal uterine bleeding (AUB). In her case, her heavy menstrual periods are called menorrhagia (men/o = menstruation; -rrhagia = bursting forth of blood). By contrast, metrorrhagia is uterine (metr/o) bleeding between menses, and menometrorrhagia is excessive uterine bleeding that occurs both during and between menstrual periods. Other abnormal bleeding symptoms can include painful (dys-) menstrual (men/o) discharge (-rrhea), known as dysmenorrhea; amenorrhea is an absence (a-) of menstrual discharge; and oligomenorrhea is light, scarce, or scanty (olig/o) menstrual flow.

4.4 Apgar Score

Jackie was able to deliver her baby with relatively few problems. She received a local anesthetic and, as labor progressed, an episiotomy, a surgical incision (-tomy) in the perineum (the area between the vaginal opening and the anus) to surgically enlarge the space through which the baby is delivered (episi/o = vulva). This procedure is also called a perineotomy. The baby's fetal presentation (position of the baby in relation to the birth canal) was a normal cephalic version—that is, the head (cephal/o) was turned (vers/o) toward the cervix. Immediately after birth, a newborn's physical condition is assessed to determine his or her ability to adapt to life outside of the uterus. The Apgar score, developed by anesthesiologist Virginia Apgar, evaluates five factors that may indicate a need for immediate intervention. These factors include the infant's heart rate, respiration, muscle tone, color, and response to skin stimulation.

3.8 Cesarean Section (Animation)

Jackie's baby, Phoebe, was vaginally delivered and presented in a normal cephalic position, with the head exiting the vagina first. Sometimes, however, complications arise during labor and surgical intervention is required. The most common intervention is a cesarean section (C-section). In this procedure, a surgical incision is made across the belly just above the pubic area. The uterus and amniotic sac are opened, and the baby is delivered. Medical reasons for an emergency C-section include fetal distress, fetal developmental problems such as hydrocephalus or spina bifida, placenta abruptio, placenta previa, umbilical cord prolapse, stalled labor, preeclampsia, or an active genital herpes infection in the mother.

2.3 Threaded Case Study: Staging Breast Cancer

Jackie's mammogram looks suspicious, so Dr. Sharp requests a follow-up breast ultrasound, which confirms the presence of a mass and suggests the possibility that the mass is breast cancer, or carcinoma of the breast. Alan comes with Jackie to her next appointment and is the first to speak. "How serious is this?" Alan asks. Dr. Sharp explains that, similar to other types of cancer, carcinoma of the breast is classified in terms of its growth and progression using a method called staging. In the earliest stage of cancer, the tumor is localized or confined to a duct or lobe within the breast. As the disease advances, the tumor invades the surrounding breast tissue and is carried—either by lymphatic drainage or systemic circulation—to other sites in the body.

4.1 Mastectomy

Jackie's surgeon explains to her that if a lumpectomy cannot reach far enough to eradicate malignant tissue, then a mastectomy may be necessary. A mastectomy is the surgical removal of one or both breasts (mast/o). A radical mastectomy is the removal of the breast, lymph nodes, and adjacent chest wall muscle if the lymph nodes are involved. In a modified radical mastectomy, the pectoral muscles are preserved. Adjuvant chemotherapy (treatment with chemical agents or drugs) is given after a lumpectomy or mastectomy procedure if any lymph nodes were found to have been involved. Jackie requires mastectomy of her left breast with adjuvant chemotherapy.

4.1 Ovulation, Fertilization, and Implantation (Animation)

Let's review the process of fertilization. After the ovum is released from the ovary, the fimbriae guide it into the fallopian tube. If coitus (sexual intercourse) has occurred, then sperm cells deposited in the vagina will be carried through the uterus and into the fallopian tube. The seminal fluid that is ejaculated during intercourse and the flagellating tail-like projections of the sperm cells help propel the sperm toward the ovum. If the sperm and ovum unite—that is, if fertilization takes place—then the fertilized ovum will lodge, or implant, in the nutrient-rich and highly vascular uterine wall.

1.8 Cervicitis

Now let's turn our attention to disorders of the cervix (cervic/o) and vagina (vagin/o). Perhaps one of the most common disorders is cervicitis, an inflammation (-itis) of the lower necklike portion of the uterus that protrudes into the vaginal cavity. This condition may be either acute or chronic and can sometimes produce a white or yellowish pus-filled discharge from the vagina called leukorrhea (leuk/o = white; -rrhea = discharge, flow). Inflammation of the vagina is called vaginitis. Vaginitis is usually caused by bacteria and yeasts. The use of antibiotic therapy may cause a loss of normal vaginal bacteria, which creates an environment that allows yeast to grow. Inflammation of the vulva is called vulvitis, and inflammation of both the vulva and the vagina is called vulvovaginitis. Vulvodynia is chronic pain (-dynia) with no identifiable cause that affects the vulvar area—labia, clitoris, and vaginal opening.

2.2 Ovarian Cysts and Ovarian Carcinoma

Ovarian cysts are globular sacs filled with fluid or semisolid material that develop in or on the ovaries. Ovarian carcinoma, a malignant neoplasm of the ovaries, is the most deadly gynecologic cancer among women in the United States because it tends not to be diagnosed until it is far advanced. The cause of the condition is not well understood, but its development is associated with hereditary, environmental, and dietary factors. Early stages of the disease produce few, if any, symptoms. As it progresses, ovarian cancer may cause ascites (accumulation of fluid in the abdominal cavity), weight loss, abnormal bleeding, and pelvic pain. Some ovarian cysts are lined with tumor cells that must be removed to distinguish between malignant (cystadenocarcinomas) and benign (cystadenomas) growths. Two types of ovarian cancer are most common: serous (clear fluid) and mucinous (thick, pasty fluid) cystic adenocarcinomas.

2.2 Balanitis

Penile disorders are not always, of course, sexually transmitted. For example, balanitis is simply an inflammation of the glans penis, caused by an overgrowth of either yeast or bacteria.

3.3 Placenta Previa

Placenta previa is a condition in which the placenta has developed in the lower portion of the uterus in such a way as to partially or completely cover the cervical opening.

1.9 Prostate Cancer and Benign Prostatic Hyperplasia (BPH)

Prostate cancer is the most common cancer in men. It is a slow-growing, malignant tumor of the prostate gland that affects many men older than 50 years of age. However, it is possible that Frank has benign prostatic hyperplasia (BPH), a noncancerous condition also common in men 50 years old and older. BPH is characterized by the enlargement of portions of the prostate gland (hyper- = excessive; -plasia = development or formation). Because the urethra passes through the prostate gland, an enlarged prostate can compress the urethra and obstruct urinary flow. Other symptoms of BPH include a decrease in the urinary stream, urgency, blood in the urine, incomplete emptying of the bladder, and infection as a result of urinary retention. Notice how similar these signs are to Frank's symptoms.

3.1 Ectopic Pregnancy

Several conditions that occur during the course of pregnancy can threaten both maternal and fetal health. Obstruction of the fallopian tubes can lead to an ectopic pregnancy—implantation outside of the uterus—and to infertility. Tubal pregnancy, as it is also called, constitutes a surgical emergency, as continued development of the embryo within the fallopian tube can lead to rupture. Other sites of ectopic pregnancy, which also require surgical intervention for removal of the implant, include the ovaries, cervix, and the abdominal cavity.

1.1 Gynecology, Obstetrics, and Neonatology

Several specialty medical fields are related to the female reproductive system. For example, gynecology (GYN) is the study (-logy) of the female (gynec/o) reproductive organs, including the breasts. Obstetrics (OB) is the branch of medicine concerned with pregnancy and childbirth (obstetr/o), and neonatology concentrates on the care of the neonate or newborn (nat/i = birth; neo- = new).

2.5 Threaded Case Study: Sexually Transmitted Infections (STIs)

Sexually transmitted infections (STIs), previously known as STDs, affect both men and women and, as the term implies, are communicated by intimate sexual contact. In this module, we will review several types of STIs. Acquired immunodeficiency syndrome (AIDS), which can also be sexually transmitted, is described in Module 14. Because Frank has had an infection in the urinary tract, it is possible that he could have chlamydia. Chlamydia, caused by the bacteria Chlamydia trachomatis, is currently believed to be the most prevalent STI in the United States. In men, the presence of the disease may be indicated by urethritis—recognized by painful or burning sensation on urination and urethral discharge. Signs of the infection in women include frequent and/or painful urination and cervical discharge. The disease is often asymptomatic. Urethritis that is not caused by an STI is referred to as nonspecific urethritis (NSU).

1.5 Testicular Torsion

You may recall that many testicular disorders tend to be age related. Adolescence can increase the chances for certain disorders. For instance, testicular torsion involves the twisting of the spermatic cord, which contains the blood vessels supplying the testis and epididymis. This condition, most often seen in adolescent boys, is characterized by severe pain and acute swelling. Testicular torsion represents a surgical emergency that, if left untreated, can lead to atrophy of the testis (a- = no, without; -trophy = development).

1.2 Testicular Tumors

Testicular neoplasms are categorized as either germinal or nongerminal. Germinal neoplasms arise from embryonic, or germ, cells in the testes. Approximately 90% of testicular carcinomas are germ cell (germinal) cancers. A seminoma (see figure) is a germinal tumor that forms in the seminiferous (semin/i) tubules. Nonseminomatous germ cell tumors (NSGCTs) are germ cell tumors that contain embryonal stem cells. The four types of NSGCTs include: (1) embryonal carcinoma, (2) yolk sac tumor, (3) choriocarcinoma, and (4) teratoma. Teratomas in the testes are malignant.

4.6 Meconium Aspiration and Hyaline Membrane Disease

The Apgar test is only the beginning of a newborn's monitoring. Several conditions can be already present in a newborn; two are respiratory disorders. Meconium aspiration syndrome occurs when the fetus' lungs become blocked by meconium, the first stools of a fetus or newborn. At birth the lungs fail to expand, causing respiratory distress. Hyaline membrane disease (HMD), also known as respiratory distress syndrome (RDS) of the newborn, is an acute lung disorder often associated with prematurity and low birth weight. This condition is caused by a lack of surfactant, a substance formed from protein and produced by special cells in the lungs. Surfactant allows the easy movement of air in and out of the lungs. Without this substance, small air sacs within the lungs collapse because of increased tension, a problem indicated by the baby's labored breathing. Treatment includes measures to maintain adequate oxygenation.

2.3 The Breasts

The breasts, or mammary glands (mamm/o, mast/o), are accessory structures of the female reproductive system that lie on the upper chest between the second and sixth ribs. The primary function of the mammary glands is lactation—the production and secretion of nutrient-rich milk (lact/o, galact/o) for the newborn. The breasts are composed of glandular, fatty, and fibrous tissue. They are attached to the overlying skin and to the muscles of the chest wall by suspensory ligaments.

1.6 Vas Deferens

The epididymis runs down the length of the testis, turns upward, and then tapers into an inferior tail portion that is continuous with the vas deferens (vas/o). The vas deferens is a narrow tube on each side that carries sperm from the epididymis toward the urethra. This structure is also known as the ductus deferens. Encased in the spermatic cord, the vas deferens extends into the abdominal cavity, over the ureters, and behind the urinary bladder. It then enters the base of the prostate gland (prostat/o) to join with the seminal vesicles and to form the ejaculatory duct.

2.1 External Female Genitalia

The external structures of the female reproductive system are collectively known as the vulva (vulv/o, episi/o). These structures include the Bartholin glands, mons pubis, labia majora and labia minora, clitoris, and the openings—called orifices —of the vagina and the urethra. Please note that the vagina is an internal female organ. The female genitalia that are external and visible are the vulva. The Bartholin glands (bartholin/o) are two small, mucus-secreting organs that lie to the left and right of the vaginal orifice. The Bartholin glands are also called the greater vestibular glands because their ducts open into an area of the vulva known as the vestibule. The mons pubis is a rounded, skin-covered pad of fatty tissue that overlies the connection of two pubic bones—the symphysis pubis. After puberty (the arrival of adolescence), the mons pubis is covered with an inverted triangular pattern of pubic hair.

3.8 GnRH, FSH, and LH

The hypothalamus is an area of the brain that produces hormones that control, among other things, the release of hormones from many glands in the body, including the pituitary gland. A gonadotropin is any hormone that stimulates the gonads, especially the pituitary hormones that stimulate the function of the ovaries. Gonadotropin-releasing hormone (GnRH) is a hormone made by the hypothalamus that causes the pituitary gland to release follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSH induces the development of ovarian follicles and their secretion of estrogen. LH causes the mature follicle to rupture and release its ovum. LH also stimulates the maturation of the ovum and the formation of the corpus luteum. Sustained high blood levels of estrogen and progesterone, which occur during pregnancy and with the use of contraceptive birth control pills, suppress the production of the pituitary gland hormones and prevent ovulation.

2.2 External Female Genitalia (cont'd)

The labia majora are two elongated folds of fatty tissue on each side of the vaginal orifice that extend back from the mons pubis. They are thicker in front and gradually become thinner and flatter as they merge with other tissues in the perineum (perine/o), which is the area between the vagina and the anus. Two smaller folds of tissue, the labia minora, lie parallel to, and are sometimes concealed by, the labia majora. These smaller, hairless folds contain sebaceous glands. The urethral and vaginal orifices are located within the vestibule, which lies between the labia minora. The clitoris is a small, rounded organ that is situated near the anterior folds of the labia minora. The clitoris is composed of erectile tissue, which serves as a sensitive receptor of sexual stimulation.

5.3 Mastitis and Galactorrhea

The most common disorder of the breast is mastitis, an inflammation of the breast (mast/o), which can affect women who are nursing. It is characterized by swelling, redness, and pain. In this same category is galactorrhea, which is an abnormal discharge of milk (galact/o) from the breasts.

1.6 The Ovaries

The ovary (ovari/o, oophor/o) is the gamete-producing organ of the female reproductive system. The ovaries and other major organs of the female reproductive system are located in the pelvic cavity. The ovaries are paired, almond-shaped organs that form part of the internal genitalia. Each ovary weighs approximately 3 grams and has a puckered, uneven appearance, caused by its contents—thousands of small sacs, called graafian follicles, or ovarian follicles, which contain the ova (sing., ovum).

4.5 Chorion and Placenta

The outermost layer of the membranes surrounding the embryo is called the chorion (chori/o). Along with the endometrial lining of the uterus, the chorion gives rise to the placenta, a highly vascular organ that serves as a bridge to the maternal circulation for the exchange of nutrients and wastes. The embryo—which after the sixth to eighth week of pregnancy is called a fetus (fet/o)—is anchored to the uterine wall by the placenta. The placenta is connected to the embryo by the umbilical cord.

1.7 Fallopian Tubes and Adnexae

The ovaries are connected to another major reproductive organ, the pear-shaped uterus (uter/o, metr/o, hyster/o), by bands of fibrous tissues called the utero-ovarian ligaments. There are two fallopian tubes (salping/o, -salpinx), or oviducts. One end of each tube attaches to the uterus, and the other end curves over the top of an ovary and opens into the abdominal cavity. After the expulsion of the ovum from the ovary during the process known as ovulation, fringelike projections on the outer end of each fallopian tube—called fimbriae (sing., fimbria)—catch the egg. Once the egg is inside the tube, the cilia, small hairs in the tube's lining, help move the ovum toward the uterus. The fallopian tubes also serve as a passageway for sperm cells to move toward the ovary. Together, the fallopian tubes, the ovaries, and the supporting ligaments are known as adnexae uteri—accessory structures of the uterus.

2.1 Phimosis

The penis may also be affected by structural abnormalities. Phimosis occurs when a boy (usually age 4 years or older) with an uncircumcised penis cannot retract his foreskin (prepuce) behind the head of his penis (phim/o = to muzzle). This condition can obstruct the flow of urine and can also lead to infection when secretions accumulate under the foreskin. When phimosis develops in an uncircumcised adult who was previously able to retract his foreskin, it is nearly always attributable to a pathologic cause.

4.6 Human Chorionic Gonadotropin

The placenta secretes a hormone called human chorionic gonadotropin (hCG). hCG is the chemical component present in the urine of a pregnant woman, which is detected by pregnancy tests. hCG promotes the continued secretion of estrogen and progesterone by the corpus luteum until around the third month of pregnancy, when the placenta itself assumes that function.

2.2 Prostate Gland

The prostate gland (prostat/o) lies under the bladder near the rectal wall. It is a doughnut-shaped exocrine gland approximately the size of a chestnut, and encircles the upper portion of the urethra. The prostate gland secretes an alkaline substance that, as part of the seminal fluid, helps protect the sperm from urethral and vaginal acidity and enhances sperm motility.

3.10 Hormone Replacement Therapy (HRT)

The reduced estrogen production that accompanies menopause is associated with a number of common complaints. These include hot flashes—transient sensations of warmth caused by a disturbance in the body's temperature-regulating mechanism—and thinning of the vaginal wall. Hormone replacement therapy (HRT)—particularly estrogen replacement therapy (ERT)—is sometimes recommended to relieve these discomforts. Low estrogen replacement appears to contribute to improved cardiovascular health and prevents the loss of bone mass that occurs with aging; however, it may increase a woman's risk for stroke and thromboembolism. Estrogen is also believed to increase the risk of breast and endometrial cancers. A physician can help determine whether the benefits outweigh the risks for an individual patient.

2.1 Seminal Vesicles

The seminal vesicles are two saclike structures that lie between the bladder and the rectum. These glands secrete a thick, yellowish substance that serves to nourish the sperm and, together with the sperm cells and secretions from the prostate, form the seminal fluid, or semen (semin/i). The ejaculatory ducts are short tubes that begin at the base of the prostate gland, pass through the gland, and end in the prostatic portion of the urethra. Semen is discharged from the urethra during ejaculation.

3.2 Sperm Cell

The sperm cell is approximately 1/500 of an inch long and resembles a tadpole in its appearance. It consists of a head, a cylindrical midpiece, and an elongated tail region. The tail region consists of a hairlike projection called the flagellum (pl., flagella), which aids the cell's motility. Within the head, or acrosome, of the sperm is the nucleus, the carrier of genetic information. Although approximately 300 million sperm cells are released into the female reproductive tract with each ejaculation, only 50 to 100 actually reach the ovum, and only one can penetrate and fertilize a single egg.

4.3 Threaded Case Study: Jackie's Prognosis

The surgeon feels confident that Jackie's chances for a complete recovery are excellent. Jackie had opted for breast reconstruction surgery if, indeed, a mastectomy is necessary. This helped save Jackie from an additional surgery later. The positive prognosis for Jackie's complete recovery is comforting and encouraging to both Jackie and Alan. Their usual positive, supportive, and united approach to such challenges makes them responsive to the surgeon's offer to put them in touch with a breast cancer survivors' support group.

4.2 Reconstructive Surgery

The term mammoplasty refers to any type of surgical repair (-plasty) of the breast (mamm/o). After a mastectomy, breast reconstruction is an option many women will choose. This figure illustrates reconstruction performed with the use of tissue flaps from the back or lower abdomen. This procedure is called a TRAM flap because the transrectus abdominis musculocutaneous tissue is used for the reconstruction.

1.9 The Uterus

The uterus is a small, but very strong, fibromuscular organ that lies between the urinary bladder and the rectum. It normally tilts forward and slightly upward. The uterus consists of two main parts: a wide upper portion called the body or corpus and a narrow lower "neck" called the cervix (cervic/o), abbreviated Cx. The body of the uterus rounds into an upper prominence known as the fundus. The walls of the uterus are made up of three layers: the endometrium, an inner (endo-) lining of uterine (metri/o) mucous membrane or tissue (-ium); the myometrium, a thick, muscular (my/o, myom/o) middle layer; and the perimetrium, or uterine serosa, an external (peri-) membranous layer. Each month that conception does not occur, the endometrial lining that has built up in preparation for pregnancy is shed in the process called menstruation, or menses (men/o). Menstruation occurs on average every 28 days.

1.10 The Vagina

The vagina (vagin/o, colp/o), is an expandable muscular tube that extends from the uterine cervix to the vaginal opening. It is 3 to 4 inches in length and is part of the internal genitalia, lying between the urinary bladder and the rectum. Sometimes the vaginal opening is covered by a fold of mucous membrane called the hymen. The vagina is the organ through which sperm travel to unite with the ovum and through which the fetus travels during childbirth. For this reason, the vagina is also called the birth canal in the context of pregnancy.

3.3 Ovulation (Animation)

Throughout a woman's reproductive lifetime, her body repeatedly prepares itself for conception. Each month, one or more of the ovarian follicles matures and ruptures, releasing a developed ovum. Because of its fatty content, the ruptured follicle develops a golden appearance, earning it the name corpus luteum, meaning "yellow body." If fertilization does not occur, then the corpus luteum becomes nonfunctional and disappears.

3.5 Threaded Case Study: Ovulatory Cycle

To help in both assessing her cycle and in optimizing conditions for conception, Dr. Sharp tells Jackie to maintain a daily record of her body temperature, charting its fluctuations in relation to the ovulatory cycle. This record helps plan the timing of sexual intercourse, or coitus, to increase the likelihood that pregnancy (gravid/o, -cyesis, -gravida) will occur.

1.1 Threaded Case Study: Pap Smear

Today, Jackie has come in for a routine Pap smear. The Pap (Papanicolaou) smear, or Pap test, is a diagnostic tool for detecting abnormal changes in the cells of the cervix. The Pap test can detect infections, abnormal cervical cells (dysplasia), or cervical cancer. During a Pap test, the physician collects a small sample of cells from the cervix using a swab and smears the sample onto a microscope slide. The slide is sent to a laboratory where it is examined for changes in the cells that could indicate cancer or a precancerous condition.

3.1 Threaded Case Study: Treatment of Fibroids

You may recall that Jackie had uterine fibroids that interfered with her ability to get pregnant. Treatment of fibroids depends on the presence and severity of symptoms. Asymptomatic fibroids may warrant only monitoring. Drug therapy—the route that worked for Jackie—may help reduce levels of circulating estrogen, which helps shrink the size of the tumors. Surgical interventions include myomectomy—excision (-ectomy) of the fibroids (myom/o = muscle tumor)—and hysterectomy.

3.2 Hysterectomy and Salpingectomy

Treatment of endometriosis may range from pharmacologic management to surgical removal of the endometrial lesions. Hysterectomy (Fig. B)—the surgical removal of the uterus—may be necessary if the condition does not respond to drug therapy. Two kinds of hysterectomy procedures are most common: (1) total abdominal hysterectomy (TAH), in which the uterus and cervix are removed through an abdominal incision, and (2) total vaginal hysterectomy (TVH), in which the uterus is removed through the vagina. When a laparoscope is used to perform this procedure, the procedure is called laparoscopically assisted vaginal hysterectomy (LAVH). Treatment for ovarian cancer is often a total abdominal hysterectomy with a bilateral salpingo-oophorectomy and removal of the omentum, followed by chemotherapy. A salpingectomy is the resection of a fallopian tube; total abdominal hysterectomy with a bilateral salpingo-oophorectomy (TAH-BSO) is a procedure involving the surgical removal of the fallopian tubes (salping/o) and ovaries (oophor/o) on both sides (bi- = two; later/o = side).

3.14 Menopause

Unlike other body systems, the female reproductive system has a limited period during which it engages in its primary function, namely reproduction. Between 30 and 40 years after menarche, a woman's reproductive life comes to a close during what is known as menopause or the climacteric. Menopause is marked by decreased estrogen production, which gradually causes ovulation and menstruation to become less frequent. Once a woman has not menstruated for 12 consecutive months, she is said to be menopausal.

3.3 D&C and Pelvic Exenteration (Animation)

We learned earlier that dilation and curettage (D&C) is a useful diagnostic procedure, but this procedure is sometimes therapeutically used. One therapeutic use of D&C is when the contents of the uterus need to be removed as, for example, in the case of an incomplete spontaneous abortion (miscarriage) or if fetal or placental tissue is not completely expelled from the uterus during childbirth. Treatment of cervical cancer depends on the degree to which the disease has progressed but may involve the administration of medications, irradiation, surgery, or a combination of these therapies. Surgical interventions may range from hysterectomy to pelvic exenteration. Exenteration is the removal of the contents of a body cavity. Pelvic exenteration involves the removal of all the organs and adjacent structures of the pelvis. Pelvic exenteration is usually performed to surgically destroy cancer involving the urinary bladder, uterine cervix, and rectum.

4.2 Threaded Case Study: Development of the Embryo

When an ovum is fertilized, it signals the beginning of pregnancy, or gestation. Fertilization is the union of sperm and ovum to form a zygote. A zygote is a single cell with a complete set of chromosomes that will develop into an embryo. After fertilization, the zygote continues its journey through the fallopian tube until it implants in the uterine wall, approximately 10 days after fertilization. The corpus luteum helps support the implanted fertilized ovum, now called an embryo.

3.9 IUD and Tubal Ligation

When conception is not desired, women can choose from a variety of methods of birth control, ranging from a pharmaceutical contraceptive agent to an intrauterine device (IUD) (intra- = within; uter/o = uterus; -ine = pertaining to). An IUD prevents implantation of an embryo. Birth control pills work by preventing ovulation. For women who want a more permanent contraceptive, tubal ligation is a surgical option. Tubal ligation is the cutting, burning, or tying off (ligation) of the fallopian tubes, which prevents ova from entering the fallopian tubes and prevents sperm from reaching an egg. This procedure effectively sterilizes the woman.