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Showing posts with label Reproductive. Show all posts
Showing posts with label Reproductive. Show all posts

Tuesday, January 5, 2021

LYMPHATIC DRAINAGE—EXTERNAL GENITALIA

LYMPHATIC DRAINAGE—EXTERNAL GENITALIA

LYMPHATIC DRAINAGE—EXTERNAL GENITALIA

A network of lymphatic anastomoses drains the external genitalia, the lower third of the vagina, and the perineum. Bilateral or crossed extension and drainage is common. The superficial femoral nodes are reached through the superficial external pudendal lymphatic vessels, although the superficial external epigastrics may also play a role. From the region of the clitoris, deeper lymphatic vessels may pass direct to the deep femoral nodes, particularly to Cloquet node in the femoral canal, or through the inguinal canal to the external iliac nodes. Cloquet node is thought to be the sentinel node between the superficial and deep inguinal/obturator lymph nodes. Sometimes, intercalated nodes may be encountered in the prepubic area or at the external inguinal ring. The lowermost portion of the vagina, like the vulva, may drain to the femoral nodes. This complex network of lymph nodes is clinically important, for these are the nodes to which cutaneous and vulvovaginal gland malignancies may drain. Regional lymph node dissections are routinely performed in the surgical treatment of vulvar cancer as the status of regional lymph nodes is essential for therapeutic planning and overall prognosis. Superficial nodes in the groin may also become enlarged when significant inflammation is present in vulvar structures (e.g., Bartholin gland infections).

PERINEUM

PERINEUM

PERINEUM

The mons veneris in front, the buttocks behind, and the thighs laterally bound the perineum. More deeply, it is limited by the margins of the pelvic outlet, namely, the pubic symphysis and arcuate ligament, ischiopubic rami, ischial tuberosities, sacrotuberous ligaments, sacrum, and coccyx. A transverse line joining the ischial tuberosities divides the perineum into an anterior urogenital and a posterior anal triangle.

PUDENDAL, PUBIC, AND INGUINAL REGIONS

PUDENDAL, PUBIC, AND INGUINAL REGIONS

PUDENDAL, PUBIC, AND INGUINAL REGIONS

The superficial fascia of the anterior abdominal wall has been cut away, exposing the aponeurosis of the external oblique muscle, with the linea alba in the midline and the linea semilunaris laterally outlining the rectus compartment beneath. Below are the inguinal ligaments, continuous with the fascia lata of the thighs, and the structures of the perineum superficial to the inferior fascia of the urogenital diaphragm. The fascial layers of the canal of Nuck emerge from the superficial inguinal ring and descend toward the lateral margin of the labium majus. These layers are composed of fibers both from the aponeurosis of the external oblique and from the transversalis fascia. The innermost layer is closely applied to the round ligament, which becomes more attenuated as it descends and eventually terminates by fine, fingerlike attachments in the labium majus. Within this sac is a vestigial remnant of peritoneum, the homologue of the tunica vaginalis in the male. The canal of Nuck may persist in the child or the adult in a patent form and may then give rise to inguinal hernias or the so-called hydrocele feminae. Adjacent to the terminal portion of this process on the right side is Colles fascia, attached laterally to the ischiopubic ramus and inferiorly to the fasciae, covering the superficial transverse perineal muscle, which forms the upper margin of the ischiorectal fossa.

EXTERNAL GENITALIA

EXTERNAL GENITALIA

EXTERNAL GENITALIA

The vulva includes those portions of the female genital tract that are externally visible in the perineal region. The mons veneris, overlying the symphysis pubis, is a fatty prominence, covered by terminal sexual (pubic) hair that functions as a dry lubricant during intercourse. From the mons, two longitudinal folds of skin, the labia majora, extend in elliptical fashion to enclose the vulval cleft. They contain an abundance of adipose tissue, sebaceous glands, and sweat glands and are covered by hair on their upper outer surfaces. The anterior commissure marks their point of union at the mons. Posteriorly, a slightly raised connecting ridge, the posterior commissure or fourchette, joins them. Between the fourchette and the vaginal orifice, a shallow, boat-shaped depression, the fossa navicularis, is evident. The labia minora are thin, firm, pigmented, redundant folds of skin, which anteriorly split to enclose the clitoris; laterally, they bound the vestibule and diminish gradually as they extend posteriorly. The skin of the labia minora is devoid of hair follicles, poor in sweat glands, and rich in sebaceous glands. The skin of the labium majus, and to a less extent the labium minus, is subject to most of the same dermatologic pathologies as other areas of skin.

MALIGNANCIES OF MALE BREAST

MALIGNANCIES OF MALE BREAST

MALIGNANCIES OF MALE BREAST

Carcinoma of the male breast is a rare disease and represents only about 0.1% of all-site malignancy and is approximately 100 times less common than breast cancer in women, accounting for about 1% of all breast cancers. In the United States, male breast cancer accounts for fewer than 2000 cases per year and fewer than 500 deaths. The mean age at diagnosis is between 60 and 70 years, though men of any age can be affected with the disease. The average duration of symptoms before diagnosis approximates 2 years. This long duration is probably explained by the disregard of this rudimentary organ by the male adult and by the examining physician. Predisposing risk factors are thought to include radiation exposure, estrogen administration, and diseases associated with hyperestrogenism, such as cirrhosis or Klinefelter syndrome. An increased risk of male breast cancer has been reported in families, with an increased incidence seen in men who have a number of female relatives with breast cancer and those in whom a BRCA2 mutation on chromosome 13q is present. When there is a mutation in this gene, it confers a 5% to 10% lifetime risk for male breast cancer.

Monday, January 4, 2021

PAGET DISEASE OF THE NIPPLE

PAGET DISEASE OF THE NIPPLE

PAGET DISEASE OF THE NIPPLE

Paget disease of the breast is rare, comprising between 1% and 2% of breast carcinomas. It is a malignant process that involves the nipple and areola. Rarely, it may also involve the skin of the vulva. This lesion has an innocent appearance that looks like eczema or dermatitis of the nipple. The clinical picture is produced by an infiltrating ductal carcinoma that invades the epidermis. Paget disease has an excellent prognosis.

HEREDITARY BREAST DISEASE

HEREDITARY BREAST DISEASE

HEREDITARY BREAST DISEASE

Approximately 5% to 10% of breast cancers have a familial or genetic link. In these families, breast cancer tends to occur at a younger age and there is a higher prevalence of bilateral disease. The association between inherited breast and ovarian cancer has lead to the term hereditary breast ovarian cancer syndrome (HBOC).

INFLAMMATORY CARCINOMA

INFLAMMATORY CARCINOMA

INFLAMMATORY CARCINOMA

Inflammatory or acute carcinoma, formerly designated as carcinomatous mastitis, is more often observed in patients with obese breasts or during pregnancy and lactation, from which is derived another older term, lactation cancer. Inflammatory carcinomas comprise approximately 1% to 5% of all breast cancers. This form is recognized clinically as a rapidly growing, highly malignant carcinoma, with infiltration of malignant cells into the lymphatics of the skin, which pro- duces a clinical picture that simulates a skin infection. There is not a specific histologic cell type. In the TNM staging system for breast cancer, inflammatory cancer has its own classification, T4d, and by definition, is staged as stage IIIb or above. (Stage IIIB breast cancers are locally advanced; stage IV breast cancer is cancer that has spread to other organs.) Because of the rapid growth of these tumors, the physical appearance of the breast is often different from that of patients with other stage III breast cancers.

INTRADUCTAL AND LOBULAR ADENOCARCINOMA

INTRADUCTAL AND LOBULAR ADENOCARCINOMA

INTRADUCTAL AND LOBULAR ADENOCARCINOMA

The two main types of breast adenocarcinomas are ductal carcinomas (85%) and lobular carcinomas. Based on the tumor’s histology, these are also sometimes classed as papillary adenocarcinomas; carcinomas with gelatinous, mucoid degeneration; or as a kind of intraductal carcinoma that forms plugs in preexisting ducts and circumscribed rings of carcinoma cells. These forms of circumscribed adenocarcinomas bulge out-wardly from the chest wall rather than retract inwardly as in the infiltrating form. Skin adherence or ulceration and axillary node involvement occur much later in the course of the disease than in the ordinary scirrhous form. The tumors progress slowly to an immense size. The most common type of adenocarcinoma is ductal carcinoma, which begins in the cells of the ducts. Lobular carcinoma begins in the lobes or lobules and is more often found bilaterally than are other types of breast cancer. The cancer is classified based on the predominant histologic cells; however, several cellular patterns may be found in any one tumor.

BREAST CANCER

BREAST CANCER

BREAST CANCER

Women in the United States have the highest incidence rates of breast cancer in the world. Worldwide, breast cancer is the second most common type of cancer after lung cancer (10.4% of all cancer incidence, both sexes counted) and the fifth most common cause of cancer death. Approximately one-third of all forms of female carcinoma arise in the breast, and more than three- quarters of these are the infiltrating scirrhous type or lobular carcinoma. Breast cancer accounts for approximately 18% of cancer deaths and results in about the same number of deaths per year as auto accidents. The peak incidence is above 40 years of age; with 85% occurring after 40 and 75% after 50. Approximately 5% to 10% of breast cancers have a familial or genetic link. The symptoms that bring the patient under examination are the discovery of the lump (55% to 65% of cases), its increasing size, occasional fleeting pains or tenderness, and changes in the skin or nipple. Approximately 60% of palpable tumors are located in the upper outer quadrant of the breast. An abnormal mammogram without a palpable mass is the second most common cause for diagnosis (35%). One quarter of all breast cancers are found during routine examination.

Sunday, January 3, 2021

GIANT MYXOMA, SARCOMA

GIANT MYXOMA, SARCOMA

GIANT MYXOMA, SARCOMA

A variety of fibroadenoma growing to immense size and occurring near the menopause was first described by the distinguished physiologist of the early 19th century, Johannes Müller, as “cystosarcoma phyllodes.” This is a rare, predominantly benign tumor that occurs almost exclusively in the female breast. It represents less than 1% of all breast tumors. The duration of the growth extends over a period of 6 or 7 years, with rapid growth toward the end of this period, when these tumors can significantly increase in size in just a few weeks. The benign character of the growth is indicated by the absence of invasion of the skin or of the regional lymph nodes. The tumors are heavy, massive, lobulated growths with cystic areas. They have a sharply demarcated smooth texture and are typically freely movable. Their average weight is between 7 and 8 lb. In spite of the size, the tumor remains movable and encapsulated, and the nipple is not retracted. Grossly, the tumor displays characteristics of a large malignant sarcoma, takes on a leaf-like appearance when sectioned, and displays epithelial cystic spaces when viewed histologically. Because most of these tumors are benign, the name may be misleading, leading to the preferred terminology of phyllodes tumor or giant myxoma.

BENIGN FIBROADENOMA, INTRACYSTIC PAPILLOMA

BENIGN FIBROADENOMA, INTRACYSTIC PAPILLOMA

BENIGN FIBROADENOMA, INTRACYSTIC PAPILLOMA

Fibroadenomas are the second most common form of breast disease and the most common breast mass. The peak incidence is from 20 through 25 years, with most patients younger than 30 years of age. More rapidly growing tumors may be found during adolescence. The tumors are twice as common in blacks (30% of breast complaints), in patients with high hormone states (adolescence, pregnancy), and in patients receiving unopposed estrogen therapy.

FIBROCYSTIC CHANGE III— CYSTIC CHANGE

FIBROCYSTIC CHANGE III— CYSTIC CHANGE

FIBROCYSTIC CHANGE III— CYSTIC CHANGE

Cystic breast masses are frequently encountered in the clinical care of women. Sorting out those that represent a threat from those that may be followed conservatively is the challenge posed by the presence of cysts in the breasts. Some authors estimate that cysts form in the breasts of roughly 50% of women during their reproductive years. Roughly one in four women seek medical attention for some form of breast problem; often this takes the form of a palpable mass. The most common cause of a palpable breast cyst is fibrocystic change (found in 60% to 75% of all women). Dilation of ducts and complications of breastfeeding (galactoceles, abscess) may also cause cysts.

FIBROCYSTIC CHANGE II—ADENOSIS

FIBROCYSTIC CHANGE II—ADENOSIS

FIBROCYSTIC CHANGE II—ADENOSIS

Stromal and ductal proliferation that results in cyst formation, diffuse thickening, cyclic pain, and tenderness are the hallmarks of fibrocystic change. The term fibrocystic change encompasses a multitude of different processes and older terms, including fibrocystic disease. It is the most common of all benign breast conditions, accounting for its linguistic demotion to change from the designation disease. To one extent or another, fibrocystic change affects 60% to 75% of all women. These changes are most common between the ages of 30 and 50 years, with only 10% of cases in women younger than 21 years. Methylxanthine intake has been proposed as a causative agent, but hard data are lacking. There is no evidence that oral contraceptives increase the risk of these changes. A family history of fibrocystic change is often present, but causality is difficult to establish.

FIBROCYSTIC CHANGE I-MASTODYNIA

FIBROCYSTIC CHANGE I-MASTODYNIA

FIBROCYSTIC CHANGE I-MASTODYNIA

Fibrocystic change (previously called fibrocystic disease) is a nonspecific term that includes mastalgia (mastodynia), breast cysts, and nondescript lumpiness. These may occur in isolation or together. The breasts generally have a nodular and dense texture and are tender when palpated. Fibrocystic change is responsible for the most commonly reported breast symptoms.

Tuesday, December 1, 2020

EJACULATORY DUCT OBSTRUCTION

EJACULATORY DUCT OBSTRUCTION

EJACULATORY DUCT OBSTRUCTION

Ejaculatory duct obstruction (EDO) underlies 1% to 5% of male infertility. Although originally described in azoospermic men with complete blockage, it is now clear that EDO is a more complex anatomic condition that can take several forms.

EJACULATORY DISORDERS

EJACULATORY DISORDERS

EJACULATORY DISORDERS

Although commonly viewed as a single event, ejaculation is actually two separate processes, termed emission and ejaculation. During emission, the semen is “loaded” into the prostatic urethral chamber. After this, ejaculation is the forcible expulsion of semen from the penis in a series of spurts caused by rhythmic contractions, about 1 second apart, of the pelvic muscles. Ejaculation is different from orgasm or climax, the latter being an event that is centered in the brain that is closely associated with ejaculation.

THERAPEUTIC SPERM RETRIEVAL

THERAPEUTIC SPERM RETRIEVAL

THERAPEUTIC SPERM RETRIEVAL

Sperm retrieval techniques collect sperm from organs within the male genital tract. Developed in 1985, ten years before the description of intracytoplasmic sperm injection (ICSI), sperm retrieval combined with in vitro fertilization (IVF) and ICSI allow severely infertile men the opportunity for fatherhood. Candidate organs for sperm retrieval include the vas deferens, epididymis, and testicle in obstructed men and the testis in nonobstructive azoospermic men. Although it is not difficult to retrieve sperm from men with normal sperm production, it can be very difficult to find sperm in men with testicular failure and nonobstructive azoospermia.

AZOOSPERMIA IV: DIAGNOSTIC PROCEDURES

AZOOSPERMIA IV: DIAGNOSTIC PROCEDURES

AZOOSPERMIA IV: DIAGNOSTIC PROCEDURES

The evaluation of the infertile, azoospermic man involves a direct assessment of spermatogenesis. This provides definitive evidence of either obstructive or nonobstructive azoospermia. The testis biopsy is most commonly used to assess sperm production. The technique involves a small, open incision in the scrotal wall and testis tunica albuginea under local anesthesia. A small wedge of testis tissue is removed, examined histologically, and seminiferous tubule architecture and cellular composition are assessed (for patterns, see Plate 3-21). Alternatively, percutaneous sampling of testis tissue with a biopsy gun can be used, similar to that employed for prostate biopsy. Although several excellent descriptions of testis seminiferous epithelium histology have been reported, no individual classification has been uniformly adopted as a standard approach.

AZOOSPERMIA III: REPRODUCTIVE MICROSURGERY

AZOOSPERMIA III: REPRODUCTIVE MICROSURGERY

AZOOSPERMIA III: REPRODUCTIVE MICROSURGERY

The role of microsurgery in the treatment of male infertility is well established and cost-effective when compared to assisted reproduction, including in vitro fertilization and intracytoplasmic sperm injection. Surgery also attempts to reverse specific pathology and, as such, allows for conception at home rather than in the laboratory. The rise of microsurgery as a surgical discipline followed three advances: (1) refinements in optical magnification, (2) the development of more precise microsuture and microneedles, and (3) the ability to manufacture smaller and more refined surgical instruments. In urology, microsurgery was first applied to renal transplantation and vasectomy reversal. Techniques evolved quickly from humble beginnings using borrowed forceps from the local jewelry store (the “jeweler’s forceps”) and using human hair for fine suture material, to its current highly refined state.

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