13.12: Abnormal and Disease Conditions - Incidence, Risk Factors, Consequences, Prevention, and Treatment

Several abnormal and disease conditions affect the reproductive systems and become especially common or serious with advancing age.

For short videos on topics on interest, search Blausen. For Internet images of normal reproductive system structures or diseases, search the Images section of http://www.google.com/ for the name of a particular structure or disease. For diseases, I highly recommend searching WebPath: The Internet Pathology Laboratory, the excellent complete version of which can be purchased on a CD.

Benign Prostatic Hypertrophy

In men, one of these conditions is benign prostatic hypertrophy (BPH), which is a noncancerous enlargement of the prostate gland.

Recall that the prostate gland surrounds the urethra immediately below the urinary bladder (Figure 13.2). Though the prostate of most 40-year-old men has begun to shrink, in some men of this age it enlarges because of increases in fibrous material and muscle cells.

By age 40 few prostate glands have grown enough to cause problems. However, the percentage of men with substantially enlarged prostates increases with age so that approximately 90 percent of all men who reach age 80 have a prostate large enough to cause significant problems.

Causes

The causes of this abnormal growth are unknown, though age-related changes in sex hormones and increased binding of testosterone by the prostate are suspected to be contributing factors.

Consequences

Benign prostatic hypertrophy is a serious disorder primarily because the enlarged gland compresses the urethra. The resulting partial or complete blockage of urine flow is especially harmful to the urinary system because it promotes difficult and painful urination; enlargement and weakening of the bladder; bladder spasms; urinary incontinence; urinary tract infections; urinary stone formation; kidney malfunction; kidney damage; and impotence (see below). All these effects can reduce the quality of life, and most of them diminish the ability of the urinary system to maintain homeostasis.

Prevention and Treatment

Nothing can be done to prevent the initial abnormal enlargement of the prostate gland in men with BPH. However, BPH develops gradually and can be detected in the early stages. Once it has been discovered, treatments to prevent the adverse effects can be initiated.

The simplest method for early detection of BPH is to include evaluation of the prostate in an annual physical examination. Other conditions suggesting the development of BPH include (1) slow urine flow, (2) difficulty starting, continuing, or stopping urine flow, (3) discomfort or pain during urination, (4) frequent need to urinate, and (5) urinary incontinence.

Some cases of BPH can be treated by regulating dietary fluid intake and with medications. Many cases are treated surgically. One of the simpler surgical procedures, transurethral resection of the prostate (TURP), involves using surgical instruments to remove the inner region of the prostate piecemeal through the urethra. More advanced cases require more involved surgical procedures. Though these procedures rarely affect sexual functioning directly, their negative psychological consequences may adversely affect sexual activity.

Impotence

The essential feature of impotence is an inability to engage in sexual intercourse because the penis is not sufficiently erect (not stiff enough) to be inserted into the vagina. In some cases (primary impotence) adequate erection is not achieved in spite of significant amounts of sexual stimulation; in other cases (secondary impotence) an adequate erection is achieved but subsides before insertion of the penis. See videos in Figure 13.6.

Occasional incidents of impotence occur in many men at every age and are not considered abnormal. Impotence is considered abnormal only when it occurs in a high percentage of attempts at sexual intercourse. Opinions vary widely regarding what rate of impotence constitutes an abnormal frequency. Identifying abnormal impotence in older men is complicated because the refractory period may last for several days.

Abnormal impotence seems to be present in far less than 10 percent of men under age 40. Its incidence increases slowly between ages 40 and 50, though it seems to remain below 10 percent. The incidence rises slightly more rapidly after age 50, reaching perhaps 15 percent by age 60. Thereafter the incidence rises more rapidly, and impotence may be present in more than 50 percent of men over age 80.

Causes

The age-related increase in abnormal impotence occurs because of the age-related increase in both the incidence and severity of many factors that contribute to this condition. Since proper functioning of the nervous and circulatory systems is essential for erection, factors that adversely affect these systems contribute substantially to impotence. The highest ranking among these factors are medications, especially neuroactive drugs and drugs that reduce blood pressure; diabetes mellitus; and atherosclerosis. Other common contributing factors are nervous system diseases (e.g., strokes, dementia), surgery of reproductive or adjacent structures (e.g., prostate, rectum), and alcoholism. Less common contributing factors include hormone imbalances (e.g., inadequate testosterone production), malnutrition (e.g., inadequate zinc), and other diseases (e.g., emphysema, kidney disease). Many older men have more than one contributing factor. Aging of arteries in the penis may augment the effects of these contributing factors.

Probably more than 50 percent of all cases of abnormal impotence result primarily from one or more of these physical factors, though psychological factors may also contribute. Psychological conditions are the primary cause of all other cases of abnormal impotence, though some degree of physical impairment may also be present. Relevant psychological conditions include anxiety, depression, fear of aggravating a physical problem such as heart disease, boredom, lack of confidence (e.g., fear of repeated impotence), and poor self-image.

Note that virtually none of these factors are age changes. Therefore, contrary to a common stereotype of older men, becoming impotent is not an inevitable part of becoming old but an abnormal condition. Recall that unless abnormal or disease conditions develop, the male reproductive system retains the ability to perform its reproductive functions and its operations in sexual activity throughout life.

Consequences

The onset of abnormal impotence is of concern to many aging adults because it can cause extensive adverse psychological and social effects, including the breakdown of a relationship. Therefore, preventing, ameliorating, or eliminating abnormal impotence can provide a much higher quality of life.

Obviously, preventing impotence means avoiding or minimizing factors that contribute to its development. Chaps. 4, 6, 7, and 14 describe methods for avoiding or minimizing many relevant physical factors (e.g., diabetes mellitus, atherosclerosis, strokes). Good physical health, positive social interactions, and economic security also help prevent or minimize some contributing psychological factors.

When abnormal impotence occurs, identifying the specific contributing factors is the first step in establishing treatment strategies. Once the principal factors have been identified, appropriate treatments can be applied. This may involve reducing or removing the cause, which may include modifying medications, repairing blood vessels surgically, administering hormones, or instituting counseling or psychotherapy.

When reducing or removing the cause is impossible or unsuccessful, other techniques can be used. One involves injecting a vasodilating drug (e.g., papaverine) into vessels in or near the penis when erection is desired. External pumps that draw blood into the penis can be used to achieve erection. Various prostheses, pumps, and other devices that provide temporary or permanent erection can be surgically implanted into the penis or surrounding areas. Both the number and extent of treatments attest to the seriousness with which this disorder is regarded.

The drug sildenafil is a recent addition to treatments for impotence. Sildenafil is produced by Pfizer Labs and is sold under the brand name Viagra. The drug helps produce and sustain vasodilation of vessels in the penis by assisting the actions of nitric oxide (*NO).

During sexual stimulation and arousal, neurons stimulate the production of *NO in the penis and elsewhere in the body. The *NO causes smooth muscle cells in penile arteries to produce a special form of nucleotide - cyclic GMP (cGMP). The cGMP causes the smooth muscle cells to relax, allowing blood pressure to expand the arteries and produce erection. Eventually the cGMP is broken down by an enzyme (i.e., cGMP phosphodiesterase), the smooth muscle contracts, and the penis returns to the flaccid condition.

Sildenafil helps develop and sustain erection by inhibiting the enzyme the breaks down cGMP. By inhibiting the enzyme, more cGMP can accumulate and it can last longer, so erection occurs easier and lasts longer. When sildenafil is taken orally as the drug Viagra, it is absorbed within minutes. The sildenafil is slowly removed from the blood by the liver, so it becomes ineffective within a few hours.

The body contains at least six forms of the enzyme that breaks down cGMP. Different cells have different proportions of these enzyme forms. Sildenafil has a much greater effect on enzyme form 5, the form that predominates in penile vessels. Therefore, sildenafil has little effect in other parts of the body. However, since sildenafil has some effect on other forms of the enzyme, it may cause extra vasodilation in other vessels. For example, sildenafil affects vessels in the retina, leading to side effects in vision such as altered perception of blue and green colors. If sildenafil affects many body vessels, it can cause widespread vasodilation and low blood pressure. Blood pressure can become abnormally low if the effects from sildenafil are amplified by other medications. Examples include medications that promote *NO formation and medications for vasodilation that contain nitrates (e.g., nitroglycerine).

Prostate Cancer

Like all cancers, prostate cancer consists of cells whose relentless reproduction and spreading are not stopped by the body's normal regulatory mechanisms. See videos in Figure 13.6.

Prostate cancer occurs rarely before age 50; its incidence rises steadily afterward. In men, the incidence of prostate cancer is second only to that of lung cancer. Prostate cancer ranks second to melanoma as a cause of death in men from cancer. For men over age 55, it is the third leading cause of death from cancer, exceeded only by lung cancer and colorectal cancer. The fact that cancer ranks second only to heart disease in causing deaths among older men highlights the importance of these statistics.

Causes

Since the causes of prostate cancer are not known, the specific reasons for the age-related increase are also unclear. The development of prostate cancer is not related to having BPH. Since prostate cancer is 50 percent more common in black males than in white males, a genetic factor may be involved.

Consequences

At first the cancerous cells remain within the prostate gland. As the mass of cells enlarges, the prostate compresses the urethra. Since this obstructs urine flow, the consequences are similar to those of BPH.

The cancer eventually spreads out of the prostate and usually invades the pelvic region first. Because cancer cells can be carried by blood and lymph, they also spread to other regions. Common sites include the vertebrae and other bones, the lungs, and the liver. Several organs may be invaded simultaneously.

The cancer destroys the normal structure and functioning of every part of the body it enters. The ability to sustain homeostasis deteriorates, illness develops, and death ensues. Three examples will be presented. First, prostate cancer weakens bones, causing pain and leading to fractures and their complications. Second, prostate cancer in the lungs may block airways, thicken membranes, fill air spaces, and cause hemorrhaging, significantly reducing respiratory functioning. Third, prostate cancer can severely impair many of the numerous functions of the liver and may cause problems similar to those caused by cirrhosis of the liver.

Prevention and Treatment

Since the causes of prostate cancer are not known, virtually nothing can be done to prevent its onset. However, as with BPH, early detection can lead to early treatment, which may prevent, delay, or minimize the effects. Unfortunately, prostate cancer produces few signs and symptoms until it is well developed. Since some cases can be detected by feeling the prostate during a rectal exam, such an examination should be part of an annual physical exam, especially for men over age 40. A newer and more convenient method involves evaluating blood samples for the presence of prostate-specific antigen (PSA). The PSA test is more accurate than other diagnostic procedures and is used to test many men. Ultrasound imaging (sonograms) is used to test for prostate cancer, and small pieces of the prostate can be removed and tested for the presence of cancer cells.

Sometimes the best treatment is to retest periodically to see how the disease is progressing. Prostate cancers that grow very slowly may require no further treatment. Sometimes prostate cancer is treated with radiation therapy, surgery, or medications that suppress testosterone production.

Vaginal Infections

In aging women changes in the vagina increase the risk of developing vaginal infections. Perhaps the most common type of vaginal infection which results from the age-related decrease in vaginal acidity is yeast infection. This type of infection often causes intense itching and is usually accompanied by excessive vaginal discharge.

Wearing underwear made of cotton and avoiding clothing that fits tightly in the genital area reduce the risk of developing vaginal infections. Yeast infections can be treated effectively with antibiotic creams or suppositories.

Breast Cancer

In aging women as in aging men, reproductive system cancers are common and serious disorders. The most common cancer of the female reproductive system is breast cancer. See videos in Figure 13.12.

In women, the incidence of breast cancer is exceeded only by that of lung cancer. Breast cancer occurs in 10 percent of all women at some time. The rate of new cases increases with age throughout life, with the most rapid increase occurring between ages 45 and 65. For women over age 55, breast cancer is second only to heart disease as a cause of death.

Risk Factors

A woman's chances of developing breast cancer are increased by many risk factors besides age. One of the strongest factors is having a mother or sister with breast cancer, especially if it occurred during early adulthood or in both breasts. Other risk factors include using oral contraceptives containing estrogen, undergoing estrogen replacement therapy, drinking alcoholic beverages, being exposed to high doses of radiation, having no children, and, possibly, consuming a high-fat diet.

Consequences

Though the dozen or more types of breast cancer have various effects on the breasts, the most dangerous ones are those which tend to spread easily to other parts of the body. Spreading usually occurs through lymph and blood vessels. The structures more frequently invaded include certain bones (skull, vertebrae, ribs, pelvis), the lungs, the liver, and the kidneys. The loss of homeostasis resulting from fractures or inadequate functioning of other vital organs leads to illness and death.

Prevention and Treatment

In spite of the serious threat posed by breast cancer, most of the complications, illnesses, and deaths it causes can be prevented by early detection and treatment. Knowing and routinely checking for signs of breast cancer can be helpful. These signs include (1) a thickening or lump in the breast, (2) changes on the breast skin, areola, or nipples (e.g., wrinkling, puckering, sores), (3) enlarged lymph nodes near the armpits, and (4) irregularly shaped or asymmetrical breasts. These signs can be detected by monthly breast self-examination and by having a breast examination as part of a routine physical examination. However, the most effective way to detect breast cancer in the early stages is to receive mammograms (x-rays of the breast). An annual mammogram is especially recommended for women over age 45 because the risk of developing breast cancer increases markedly after that age.

Another important aspect of prevention is minimizing risks from estrogen intake by limiting the amount of estrogen used for oral contraception or estrogen replacement therapy, administering estrogen on a cyclic basis rather than continuous one, and including progesterone along with the estrogen.

When breast cancer is suspected, the preliminary diagnosis can be confirmed or negated by examining a sample of the tissue (biopsy). If cancer is present, the specific type and its extent are determined. Depending on the results of these investigations, treatment plans designed to cure the cancer or reduce the effects by slowing its progress are developed. Such treatment plans may involve surgery, radiation therapy, chemotherapy, and hormone therapy.

Endometrial Cancer

Endometrial cancer is cancer of the uterine lining. It has the highest incidence among cancers of the female reproductive structures, occurring in slightly more than 2 percent of all women. New cases develop most frequently between ages 50 and 64. Risk factors include eating excess calories in the diet, having a lowered glucose tolerance, having no children, having relatives with endometrial cancer, and receiving estrogen therapy.

The risk of developing endometrial cancer can be reduced by avoiding overeating and adjusting estrogen therapies in ways similar to those recommended for preventing breast cancer. Once initiated, endometrial cancer reveals its presence by causing bleeding from the vagina between menstrual periods or after menopause. This type of cancer is not as dangerous as others because it is usually detected early. The most common indicator is abnormal bleeding from the reproductive system. Because endometrial cancer is usually detected early, it is easily and effectively treated by surgery and hormone therapy.

Ovarian Cancer

Ovarian cancer ranks fifth in occurrence among cancers in women and in older women, it ranks second among cancers of the female reproductive structures. Ovarian cancer causes more deaths than any other female reproductive system cancer and is the fifth leading cause of death for women.

Risk factors include never being pregnant, inhaling cigarette smoke, and estrogen replacement therapy. Avoiding or minimizing these factors can help reduce the incidence of this cancer. However, little can be done to prevent it from spreading and destroying other organs because it is difficult to detect before it is well established in many areas. Surgery, radiation, and chemotherapy usually can only slow its destructive progress somewhat.

Cervical Cancer

Cervical cancer ranks third in older women among cancers of the female reproductive structures. Recall that the cervix is the lower part of the uterus and protrudes into the upper part of the vagina ((Figs. 13.7, Figure 13.8, Figure 13.9). Cervical cancer occurs in 2 to 3 percent of all women before age 80. Most new cases develop between ages 40 and 60.

Risk Factors

The most important risk factor for cervical cancer is having sexual intercourse soon after sexual maturation. Other risk factors include having many male sex partners; having male sex partners who have had sexual intercourse with other women with cervical cancer; inhaling cigarette smoke; using oral contraceptives; and having sexually transmitted diseases such as human papillomavirus. This virus sometimes causes genital warts and often occurs together with genital herpes and chlamydia. Hence, the incidence of cervical cancer is higher in women with these diseases.

Consequences

Once present, cervical cancer usually spreads by infiltrating nearby organs. Later, it is carried to more distant organs by the lymphatics. Like other reproductive system cancers, it causes illness and death by destroying the structure and functioning of any organ it invades.

Prevention and Treatment

A primary strategy in the prevention of cervical cancer is avoiding or minimizing behaviors that increase its risk factors. Once cervical cancer begins, it provides few indications of its presence, though it may cause slight bleeding or a watery discharge from the vagina between menstrual periods or after menopause. However, cervical cancer can be easily detected in the early stages by a Pap smear, which involves examining a sample of cells scraped off the cervix. It is recommended that younger women and women with abnormal cervical cells have a Pap smear as part of an annual physical examination. Older women who repeatedly have normal Pap smears may require smears at 2- to 3-year intervals rather than annually. As with most cancers, early detection and treatment can prevent the development of complications, illness, and death.

If a Pap smear reveals the presence of cervical cancer, one or a combination of treatments (e.g., surgery, radiation therapy, chemotherapy) may be used to cure it or slow its progress.

Uterine Fibroids

One type of growth in the female reproductive system that becomes less of a problem as age increases after menopause is uterine fibroids, or leiomyomas. A uterine fibroid consists of a spherical mass of smooth muscle within the muscular wall of the uterus.

Uterine fibroids may begin to develop during or after puberty and may continue to grow until menopause. They occur in various sizes and sometimes become larger than a grapefruit. They usually develop in the upper part of the uterus, though they may occur anywhere in its wall. Uterine fibroids occur in 20 percent to 25 percent of women beyond age 35, and affected women often have more than one. Since uterine fibroids do not invade neighboring regions or metastasize, they are not cancerous.

Most women with uterine fibroids suffer no adverse effects. However, some fibroids cause excessive bleeding during menstrual periods, and unusually large ones may cause problems such as constipation, frequent urination, and kidney disease by putting pressure on adjacent structures. Finally, fibroids occasionally become painful. Treatment may consist of removing the fibroids and the affected part of the uterus or removing the entire uterus (hysterectomy).

Women with uterine fibroids who do not experience significant problems before menopause rarely develop fibroid-related problems afterward because fibroids shrink when blood levels of estrogen and progesterone decline. However, postmenopausal women on estrogen replacement therapy may develop fibroid-related problems because this therapy can cause fibroids to enlarge.

Sexually Transmitted Diseases

Both male and female reproductive systems are affected by sexually transmitted diseases (STDs). Commonly encountered examples include bacterial types (e.g., gonorrhea, syphilis, chlamydia) and viral types (e.g., herpes type II, human papillomavirus, AIDS). The incidence of STDs is much lower among older people than among younger adults, perhaps because older people have sexual encounters with fewer partners. However, increasing age seems to have little impact on the causes, effects, methods of prevention, and treatments for STDs. Therefore, these diseases are not discussed in this book.