REPRODUCTIVE SYSTEM

OUTLINE

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Review
the
anatomy
of the
male
genitalia

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Review
the
anatomy
of the
external
female
genitalia.

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• There are two basic approaches in the management of STIs.
• Etiologic diagnosis :- using laboratory tests and as the ideal way of diagnosing
disease.
• Syndromic approach:- the choice of approache when there are no laboratory
facilities. And it uses the sign and symptomes.
• Uses flow charts that guide the health worker through logical steps.

• Both classic approaches present with a number of problems.

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• Urethral discharge:- abnormal secretions from the urethra meatus.
• it is the characteristic manifestation of urethritis.

• Urethritis is usually due to STI

• although UTI may produce similar symptoms.

• Urethral discharge:-
• amount and nature of the discharge :- vary according to the causative agents.

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• The appearance of the discharge can be purulent or mucoid, clear, white, or
yellowish-green.

• It may be associated with :-

• dysuria, increased urgency and frequency,
• itching sensation of the urethra.
• Sometimes scrotal swelling and pain which tends to be unilateral.

• If penile discharge is present, assess the amount, its color and consistency,
and any fever, chills, rash, or associated symptoms.

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Cause or etiology of UDS
• The two most common causative agents of the syndrome are
• Neisseria gonorrhea and Chlamydia trachomatis (81% and 36.8% respectively)

• Mycoplasma genitalium, Trichomonas vaginalis, and Ureaplasma

urealyticum.

• Most of the time urethral discharge is due to mixed infection of

Neisseria gonorrhea and Chlamydia trachomatis.
• In some rare cases it can be also the result of non-infectious causes.
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• Common acute complications
• Disseminated gonococci syndrome
• Perihepatitis
• Acute epididymo-orchitis

• Common chronic complications

• Urethral stricture
• Infertility
• Reiter‘s syndrome.

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How we
Diagnosis
UDS

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• Abnormal vaginal discharge in terms of quantity, color or odor
• most commonly as a result of vaginal infections.

• But, it is a poor indicator of cervicitis, especially in young girls

because a large proportion of them are asymptomatic.

• The most common causes of vaginal discharge are:-

• Neisseria gonorrhoeae, Chlamydia trachomati, Trichomonas vaginalis,
• Gardnerella vaginalis (Polymicrobial), Candida albicans.

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• The first three are sexually acquired and the last two are endogenous
infections etiologic agents.

• Bacterial vaginosis (Gardnerella vaginalis) is the leading cause of

vaginal discharge in Ethiopia followed by
• candidiasis,
• trichomoniasis,
• gonococcal and
• chlamydia cervicitis.

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• Cervicitis:-

• Multiple sexual partners in the last 3months.

• New sexual partner in the last 3 months
• Ever traded sex
• Age below 25 years

• NB: The presences of one or more risk factor suggest cervicitis.

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Common clinical manifestations of genital ulcer are:
• Constitutional symptoms such as fever, headache, malaise and muscular pain
• Recurrent painful vesicles and irritations
• Shallow and non-indurated tender ulcers
• Painless indurated ulcer (Chancre)
• Regional lymph adenopathy

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• Common sites :- glance penis, prepuce and penile shaft.

• Common sites :- vulva, perineum, vagina and cervix.

• Genital ulcer facilitates transmission of HIV more than other sexually

transmitted infections.

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Cause or etiology of GUS:-
• Herpes simplex virus (HSV-1 and HSV-2)
• Treponema pallidum
• Haemophilius ducreyi (Chancroid)
• Chlamydia trachomatis serovar L1, L2 & L3 (LGV)
• Klebsiella granulomatis

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• Syphilis: Clinically has three stages (primary, secondary, tertiary).
• The ulcer starts during the primary stage of the disease as papules & rapidly
ulcerate. The ulcer is typically painless, clean base and raised boarder.

• Genital herpes: herpes simplex virus is the most common causes of

genital ulcer worldwide.
• It produces lifelong infection after the primary infection (latency).
• The lesions are painful, erythematous macules which progressively form
vesicles, pustules, ulcer and crusts.

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• Chancroid: is also the common cause of genital ulcer in developing
countries.
• The lesion started as painful papules and pustules which ulcerate with dirty
base and soft edge.
• Inguinal fluctuant adenopathy (buboes) may occur following ulcer.

• Lymphogranuloma veneurum (LGV):

• The disease starts as painless papules that develops an ulcer.
• After a few days painful regional lymphadenopathy develop and associated
systemic symptoms may occur.

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• Granuloma inguinale (Donovanosis):-
• is chronically progressive ulcerative disease without systemic symptoms.
• Presents with non-suppurative painless genital ulcer and beefy-red
appearance.

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• All sexually active women presenting with lower abdominal pain
• carefully evaluated for the presence of upper genital tract infections (tube,
uterus, ovaries, and pelvic cavity).

• In addition, all women with presumptive STI should undergo

thorough bimanual and abdominal examination.
• some women with PID may not complain of lower abdominal pain.

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• Other suggestive symptoms:-
• pain during intercourse, vaginal discharge, abnormal vaginal bleeding ,
• painful urination, pain during menstruation, fever and sometimes nausea and
vomiting.

• PID becomes highly probable when one or more of the above

symptoms are seen in a woman with :-
• adnexal tenderness,
• vaginal discharge and
• cervical motion tenderness.

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• Cause or etiology of PID:-
• [Link],
• C. trachomatis,
• Anaerobic bacteria.
• Facultative Gram-negative rods and
• Mycoplasma hominis.

• The first three are the most common

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• Usually manifests with acute onset of unilateral testicular swelling:-
• Often with tenderness of the epididymis and vas deferens
• Occasionally with erythema and edema of the overlying skin

• When it occurs in young male (<35 years old) accompanied with urethral
discharge it is usually due to gonococcal or chlamydial infections.
• In older people the etiologic agent may be non-STIs such as E. coli, Klebsiella
spp. or Pseudomonas.
• TB orchitis is generally accompanied by an epididymitis

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Differenti
al
diagnosis
of a
scrotal
mass

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• This is a painful, fluctuant, swelling of the lymph nodes in the inguinal
region (groin).
• Buboes are usually caused by either chancroid or LGV.
• In many cases of chancroid, but not all, an associated ulcer is visible.

• Infection of the lower limb and other non-STIs like TB can also cause
swelling of the inguinal lymph nodes.

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• Cause or etiology of :-
• Chlamydia trachomatis (L1, L2 and L3) (causes LGV)
• Klebsiella granulomatis (donovanosis)
• Treponema pallidum (causes syphilis)
• Haemophilius ducreyia (causes chancroid)

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• Amenorrhea: No menstruation for 3 months or more.
• Primary amenorrhea - (absence of menses by age 16)
• Kallman's Syndrome: Primary GnRH deficiency
• Turner's Syndrome: XO
• Testicular Sensitization Syndrome: Androgen insensitivity.
• Imperforate hymen
• Congenital malformations of GU tract: Uterine agenesis, vaginal
malformations.

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• Secondary amenorrhea (cessation of menses after previously normal
menstruation).
• Environmental Factors:
• Weight-reduction amenorrhea: Anorexia and related disorders, malnutrition.
• Psychogenic amenorrhea
• Exercise-induced amenorrhea
• Post-pill amenorrhea

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• Pituitary Disease:
• Prolactinoma
• Sheehan Syndrome

• Premature ovarian failure: Menopause occurring before age

35.
• Polycystic Ovary Syndrome
• Asherman's Syndrome: Amenorrhea caused by intrauterine
adhesions.
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• Pregnancy

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PHYSICAL EXMINTION
 Exmining the male genitalia:-

• Inspecting the penis:-

• The skin:-
• The prepuce (foreskin).
• The glans.

Phimosis, Paraphimosis, Balanitis (inflammation of the glans), balanoposthitis

(inflammation of the glans and prepuce), lice or scabies, Hypospadias,

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• Palpatation:-
• palpate any abnormality of the penis,
• tenderness or induration.
• Induration along the ventral surface of the penis suggests a urethral
stricture or possibly a carcinoma.

• Tenderness of such an indurated area suggests periurethral

inflammation secondary to a urethral stricture.

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• Inspecting the Scrotum and Its Contents:-
Inspect the scrotum:-
• The skin.
• The scrotal contours.

• Note any swelling, lumps, or veins.

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• Palpetation:-
• Palpate each testis and epididymis between your thumb and first two
fingers.

• Cryptorchidism (an undescended testicle), indirect inguinal hernias,

hydroceles, and scrotal edema.
• Acute epididymitis, acute orchitis, torsion of the spermatic cord, or a
strangulated inguinal hernia.

• Any painless nodule in the testis must raise the possibility of testicular cancer,

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Exmining the female genitalia:-

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• External examination:-
• Assess pubic hair, its character and distribution.
• Excoriations or itchy or lice at the bases of the pubic hairs.
• Note any inflammation, ulceration, discharge, swelling, or nodules.
• If there are any lesions, palpate them.
• If there is a history or an appearance of labial swelling, check Bartholin’s
glands.

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• Internal examination:-
• Bulging from a cystocele or rectocele.
• Bulges and Swelling of Vulva, Vagina, and Urethra
• Discharge on the endocervical swab suggests a mucopurulent cervicitis.
• Pain on movement of the cervix, together with adnexal tenderness, suggests
PID.

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• Bimanual Examination:
• Abnormalities and Positions of the Uterus.
• Uterine enlargement suggests pregnancy or benign or malignant tumors.
• Nodules on the uterine surfaces suggest myomas.

• Adnexal masses:-
• ovarian cysts, tumors, and abscesses, also the swollen fallopian tube(s) of pelvic
inflammatory disease, and a tubal pregnancy.

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• Pregnancy

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