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The principal supporting membrane of the female reproductive tract is the broad ligament cheap 200mg red viagra diabetic with erectile dysfunction icd 9 code. The broad ligament is the parietal peri- Knowledge Check toneum that supports the uterine tubes and uterus order 200mg red viagra with amex erectile dysfunction protocol book download. Define ally supported by an ovarian ligament, which is anchored to the menstruation and ovulation. What is the usual span uterus, and a suspensory ligament, which is attached to the of a woman’s reproductive years? Distinguish between the primary sex organs, secondary sex is the thin outermost layer composed of cuboidal epithelial cells organs, and secondary sex characteristics. The principal substance of the ovary is divided into an outer ovarian cortex and a vascular inner ovar- STRUCTURE AND FUNCTION ian medulla, although the boundary between these layers is not distinct. The stroma—the material of the ovary in which folli- OF THE OVARIES cles and blood vessels are embedded—lies in both the cortical The ovary contains a large number of follicles, each of which en- and medullary layers. Some of these follicles mature during the ovarian cycle, and the ova they contain progress to the secondary oocyte Blood Supply and Innervation stage of meiosis. During ovulation, the largest follicle ruptures and releases its secondary oocyte. The ruptured follicle becomes a Blood is supplied by ovarian arteries that arise from the lateral corpus luteum and regresses to become a corpus albicans. These sides of the abdominal aorta,just below the origin of the renal ar- cyclic changes in follicular development are accompanied by teries. An additional supply comes from the ovarian branches of changes in hormone levels. The right ovarian vein empties into the inferior vena cava, Objective 4 Describe the position of the ovaries and the whereas the left ovarian vein drains into the left renal vein. Objective 5 Describe the structural changes in the ovaries that lead to and follow ovulation. Female Reproductive © The McGraw−Hill Anatomy, Sixth Edition Development System Companies, 2001 Chapter 21 Female Reproductive System 729 Ampulla Uterine tube of uterine Suspensory Ovarian ligament tube ligament of Body of uterus ovary Mesovarium Fundus of uterus Ovary Infundibulum of uterine tube Round Fimbriae ligament Egg cell Broad Follicle Endometrium ligament of uterus Myometrium Perimetrium Fornix of vagina Cervix of uterus Vagina Waldrop FIGURE 21. The ovaries have both sympathetic and parasympathetic a newborn girl contain about 2 million oocytes, this number de- innervation from the ovarian plexus. Innervation to the ovaries, clines to 300,000 to 400,000 by the time she enters puberty. On however, is only to the vascular networks and not to the follicu- average, 400 oocytes are ovulated during a woman’s reproductive lar substance within the stroma. Follicle Formation Normal, healthy ovaries usually cannot be palpated either by Primary oocytes that are not stimulated to complete the first vaginal or abdominal examination. If the ovaries become meiotic division are contained within tiny follicles called pri- swollen or displaced, however, they are palpable through the vagina. There are many types of nonmalignant tumors of the ovaries, most of mordial follicles. In response to stimulation by gonadotropic which cause swelling and some localized tenderness. The ovaries at- hormones, some of these oocytes and follicles get larger, and the rophy during menopause, and ovarian enlargement in post- follicular cells divide to produce the follicular epithelium that menopausal women is usually cause for concern. At The germ cells that migrate into the ovaries during early embry- this point, they are called secondary follicles (fig. The mound is called the cumulus oogonia stops at this point and never resumes. Under stimulation of follicle-stimulating of the first meiotic division, and therefore the primary oocytes are still diploid (have 46 chromosomes). Female Reproductive © The McGraw−Hill Anatomy, Sixth Edition Development System Companies, 2001 730 Unit 7 Reproduction and Development Primary follicles Vesicle Secondary follicle (a) Granulosa cells Antrum Corona radiata Secondary oocyte Zona pellucida Cumulus oophorus Theca interna (b) FIGURE 21. In- By about the tenth to the fourteenth day following day 1 of a terestingly, the follicular cells produce estrogen from its precursor menstrual period, usually just one follicle has matured fully to be- testosterone, which is supplied by a layer of cells immediately come a vesicular ovarian (graafian) follicle (fig. This does not form two complete cells, that it forms a bulge on the surface of the ovary. Under proper however, because only one cell—the secondary oocyte—gets al- hormonal stimulation (a sudden burst of luteinizing hormone most all of the cytoplasm. The other cell formed at this time be- from the anterior pituitary, triggered by a peak level of estrogen), comes a small polar body (fig.

Patients must be motivated to learn; if they are not ready buy discount red viagra 200 mg line erectile dysfunction doctor singapore, education should be delayed purchase red viagra 200mg young living oils erectile dysfunction. Outcomes of education: Patient should be able to: ✧ describe rationale of therapy ✧ correctly reconstitute and administer medication ✧ manage side effects ✧ identify and use resources to obtain further information 9. Promoting adherence: establish a trusting relationship consistent and clear education advocate for access to treatment reinforcement of the multidisciplinary team ongoing patient and family contact ADDITIONAL READING Burk JS, Johnson KP, eds. Best practices in nursing care: Disease management, pharma- cological treatment, nursing research. Chapter 11 The Symptom Chain in Multiple Sclerosis Objectives: Upon completion of this chapter, the learner will: Describe the most common symptoms of MS Cite effective management strategies of MS symptoms Discuss the nurse’s role in symptomatic managementMultiple sclerosis is a complex and dynamic disease. Symptoms have to be recognized, understood, and discussed with the healthcare team by the patient and family. Management should be individualized and flexible in light of the dynamic nature of MS. Paresthesias 51 52 NURSING PRACTICE IN MULTIPLE SCLEROSIS: A CORE CURRICULUM TABLE 11. Other causes: depression, deconditioning, medications, concommitant medical conditions (thyroid dysfunction, cardiovascular disease), sleep disturbance C. The most common cause of MS-related disability 54 NURSING PRACTICE IN MULTIPLE SCLEROSIS: A CORE CURRICULUM D. Question about other symptoms (pain, spasticity, bowel or bladder dysfunction) 7. Encourage the use of appropriate use of assistive devices (scooters, walkers, wheelchairs, transfer equipment) 3. Encourage the initiation of symptom management—pain, spasticity, bowel, bladder dysfunction 6. Medications used to manage MS-related fatigue: CNS stimulants (methylphenidate) aminopyridines (currently being studied in research) amantidine (SE: headache, dizziness, rash) modafinil (SE: headache, tachycardia, palpitations, con- traindicated in LMVP) pemoline (liver cautions) SSRI antidepressants unique antidepressants—buprioprion (Wellbutrin®) (SE: seizure risk) 9. Pain inadequately defined, identified, or measured by an observer CHAPTER 11: THE SYMPTOM CHAIN IN MULTIPLE SCLEROSIS 55 C. Acute pain trigeminal neuralgia tonic spasms lightning-like extremity pain painful Lhermitte’s sign optic neuritis and retrobulbar pain 2. Chronic pain with insidious onset dysesthetic extremity pain bandlike pain in torso or extremities back pain with radicolopathy headache F. Trigeminal neuralgia probably arises from transmission of nerve impulses in areas of demyelination. In the chronic phase, anticonvulsants such as carbamaze- pine and gabapentin are used. Less common is the painful tetanic posturing of an arm or leg, usually on one side of the body. Treatment consists of carbamazepine, clonazepam, tizanidine, and baclofen. Lightning-like extremity pain can be treated with carbamazepine, gabapentin, and phenytoin. Lhermitte’s sign responds to the above medications and also to tricyclic antidepressant medications. Headache has been reported to be causally related to demye- linating lesions. When associated with a relapse, treatment with steroids may cause resolution of headache. Optic neuritis is due to inflammation and demyelination occurring in and around pain-sensitive meninges surrounding the optic nerve. Gabapentin—useful in dysesthetic and paroxysmal pain; better SE profile than phenytoin 3. Accentuation of DTR and clonus occurs, with exaggeration of flexor reflexes C. Spasms and stiffness are common in the quadriceps, hamstrings, and gastrocnemious muscles D. May be heightened during an exacerbation, with underlying infection, and with noxious stimuli E.

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There is no response to bic hair order red viagra 200 mg otc erectile dysfunction treatment protocol, which are androgen-dependent red viagra 200 mg lowest price erectile dysfunction drugs uk, are scarce or ab- clomiphene, but intermittent treatment with GnRH can sent. Testosterone levels are normal or elevated, estradiol produce sexual maturation and full spermatogenesis. The inguinally located testes nadism, panhypopituitarism or pituitary failure, can oc- usually have to be removed because of an increased risk of cur before or after puberty and is usually accompanied by cancer. After orchiectomy, patients are treated with estra- a deficiency of other pituitary hormones. REVIEW QUESTIONS DIRECTIONS: Each of the numbered (D) Failure of the hypothalamus to (A) Storage and transport of mature sperm items or incomplete statements in this respond to testosterone (B) Initiating the development of section is followed by answers or by (E) Increased number of FSH receptors spermatozoa completions of the statement. Select the in the testis (C) Secretion of estrogens ONE lettered answer or completion that is 2. The major function of follistatin is (D) Production of inhibin BEST in each case. A major causal factor in some cases of (B) Inhibit the production of seminal 4. The production of mature spermatozoa hypogonadism is fluid from spermatogonia (A) Reduced secretion of (C) Reduce testosterone secretion by (A) Takes 32 days gonadotropin-releasing hormone Leydig cells (B) Takes 70 days (GnRH) (D) Stimulate the production of (C) Takes 150 days (B) Hypersecretion of pituitary LH and spermatogonia (D) Is unaffected by Kallmann’s FSH as the result of increased GnRH (E) Bind activin and thus decrease FSH syndrome (C) Excess secretion of testicular secretion (E) Is independent of testicular activin by Sertoli cells 3. A major function of the epididymis is temperature (continued) 666 PART X REPRODUCTIVE PHYSIOLOGY 5. The first enzymatic reaction, which is (C) Decreases the half-life of SUGGESTED READING the rate-limiting step, in the testosterone Burger H, DeKretser D. New production of testosterone (D) Stimulates the secretion of inhibin York: Raven Press, 1989. Sertoli cells, immediate derivative (A) Sertoli cell follistatin function. Testosterone is (C) Activin but not LH New York: Academic Press, (A) Bound to high-density lipoprotein (D) Leydig cell, Sertoli cells, LH, and 1999;371–380. The Encyclopedia of Repro- in the prostate (A) Estrogens stimulate the growth of duction. The Leydig (E) Metabolized by cholesterol side- closure of the long bones Cell. Vienna, IL: Cache River Press, chain cleavage enzyme (C) Reduced androgen and estrogen 1996. Sex hormone-binding globulin (SHBG) delays epiphyseal closure in long Redman JF. Male reproductive system, (A) Binds testosterone with a higher bones human. The formation of a functional corpus luteum requires the and FSH, which enhance follicular development, steroido- presence of an LH surge, adequate numbers of LH recep- genesis, ovulation, and formation of the corpus luteum. LH and FSH, in coordination with ovarian theca and granu- terone secretion. Ovulation occurs as the result of a positive feedback of fol- terone, such that estradiol induces proliferation of the uter- licular estradiol on the hypothalamic-pituitary axis that in- ine endometrium, whereas progesterone induces differen- duces LH and FSH surges. Follicular development occurs in distinct steps: primordial, distinct products. Follicular rupture (ovulation) requires the coordination of creasing quantities of GnRH, which increases LH and FSH appropriately timed LH and FSH surges that induce in- secretion, enhances ovarian function, and leads to the first flammatory reactions in the graafian follicle, leading to ovulation. Follicular atresia results from the withdrawal of go- ment and estradiol secretion. The tive-feedback effects on the hypothalamus and on pituitary Trelease from the ovary of a mature female germ cell or gonadotrophs, generating the cyclic pattern of LH and ovum occurs at a distinct phase of the menstrual cycle. The FSH release characteristic of the female reproductive sys- secretion of ovarian steroid hormones, estradiol and prog- tem. Since the hormonal events during the menstrual cycle esterone, and the subsequent release of an ovum during the are delicately synchronized, the menstrual cycle can be menstrual cycle are controlled by cyclic changes in LH and readily affected by stress and by environmental, psycho- FSH from the pituitary gland, and estradiol and proges- logical, and social factors. The cyclic changes in steroid hor- The female cycle is characterized by monthly bleeding, mone secretion cause significant changes in the structure resulting from the withdrawal of ovarian steroid hormone and function of the uterus in preparing it for the reception support of the uterus, which causes shedding of the super- of a fertilized ovum.

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It occurs in about 3% of male infants and should be treated before the infant has reached the age of 5 to reduce the likelihood of infertility or other complications buy 200 mg red viagra overnight delivery erectile dysfunction when drunk. The causes of impotence may be physical generic red viagra 200mg amex erectile dysfunction treatment surgery, involving, for example, ab- normalities of the penis, vascular irregularities, neurological dis- Pelvic cavity orders, or certain diseases. Occasionally, the cause of impotence 1 is psychological, and the patient requires skilled counseling by a sex therapist. The most common 3 cause of male infertility is inadequate production of viable sperm. This may be due to alcoholism, dietary deficiencies, local injury, Penis variococele, excessive heat, hormonal imbalance, or excessive exposure to radiation. Many of the causes of infertility can be Scrotum treated through proper nutrition, gonadotropic hormone treat- (c) ment, or microsurgery. If these treatments are not successful, it may be possible to concentrate the spermatozoa obtained FIGURE 20. Turner, American endocrinologist, pelvic wall, (2) at the root of the penis, or (3) in the perineum, in the 1892–1970 thigh alongside the femoral vessels. Male Reproductive © The McGraw−Hill Anatomy, Sixth Edition Development System Companies, 2001 Developmental Exposition Externally, by the sixth week a swelling called the genital The Reproductive System tubercle is apparent anterior to the small embryonic tail (future coccyx). The mesonephric and paramesonephric ducts open to the outside through the genital tubercle. The genital tubercle EXPLANATION consists of a glans, a urethral groove, paired urethral folds, and paired labioscrotal swellings (see exhibit II). As the glans portion Sex Determination of the genital tubercle enlarges, it becomes known as the phallus. Early in fetal development (tenth through twelfth week), sexual Sexual identity is initiated at the moment of conception, when distinction of the external genitalia becomes apparent. The male, the phallus enlarges and develops into the glans of the ovum is fertilized by a spermatozoon containing either an X or a Y penis. The urethral folds fuse around the urethra to form the body sex chromosome. The urethra opens at the end of the glans as the ure- it will pair with the X chromosome of the ovum and a female thral orifice. The labioscrotal swellings fuse to form the scrotum, child will develop. A spermatozoon carrying a Y chromosome re- into which the testes will descend. In the female, the phallus sults in an XY combination, and a male child will develop. The urethral groove is retained as a longitudinal cleft sex hormones during late embryonic and early fetal development known as the vestibule. Descent of the Testes Embryonic Development The descent of the testes from the site of development begins be- The male and female reproductive systems follow a similar pattern of tween the sixth and tenth week. Descent into the scrotal sac, development, with sexual distinction resulting from the influence of however, does not occur until about week 28, when paired in- hormones. A significant fact of embryonic development is that the guinal canals form in the abdominal wall to provide openings sexual organs for both male and female are derived from the same from the pelvic cavity to the scrotal sac. The process by which a developmental tissues and are considered homologous structures. The gonadal ridge continues to testis descends, it passes to the side of the urinary bladder and an- grow behind the developing peritoneal membrane. It carries with it the ductus defer- week, stringlike masses called primary sex cords form within the ens, the testicular vessels and nerve, a portion of the internal enlarging gonadal ridge. The primary sex cords in the male will abdominal oblique muscle, and lymph vessels. All of these struc- eventually mature to become the seminiferous tubules.

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Van De Graaff: Human Back Matter Appendix A: Answers to © The McGraw−Hill Anatomy buy 200mg red viagra mastercard erectile dysfunction 2014, Sixth Edition Objective Questions with Companies buy cheap red viagra 200 mg on-line impotence 22 year old, 2001 Explanations Appendix A Answers to Objective Questions with Explanations 797 10. The permanent dentition adenohypophysis of the pituitary the footplate of the stapes and the pumping blood at 25 days following includes 8 incisors, 4 canines, 8 gland. An surface for physically handling to excessive TSH secretion, which diagnostic of infections or diseases adenoidectomy is the removal of food. The papillae also support results from low levels of thyroxine within the body. Bile and impulse to be conducted to the and inferior vena cavae and the three lobes, the left lung has only a pancreatic juice enter the lumen of cerebrum of the brain. The space between the parietal nutrients from digested food enter heavy pressures. During this interval, causing a decrease in the air the sphincter of ampulla would 4. Air prohibit the entry of these pain are consistent from one systole and blood is being ejected flows through the respiratory tract, products. If a spermatozoon passes effective barrier against diseases of the renal medulla. Ejaculation is stratum functionale layer after physiological changes, including the transitional epithelium that the forceful discharge of semen each menstruation. The vagina is an internal and helps to maintain a constant role in forcing urine from the containing either an X or a Y reproductive organ. The Y chromosome, male derive from the embryonic have a lower basal metabolic rate. This may account, in part, for the throughout the fetal period, with subsequent production of longer life span of females. This means that the testosterone maintains male develop and enters into the cavity functions, including the exchange particular recessive trait is not sexuality, including production of of the uterus about 3 days after of gases and other molecules physically apparent. In addition, it serves as a particular genotype is one in four determination of sex drives. Van De Graaff: Human Back Matter Appendix B: Answers to © The McGraw−Hill Anatomy, Sixth Edition Clinical Practicum Companies, 2001 Questions Appendix B Answers to Clinical Practicum Questions Clinical Practicum 5. The seat belt fixes this portion of the body (L1–L3) and causes it to become 1. This rash has the classic appearance and history for poison oak exposure. These pathogens are deposited as the focused at this spot leads to compression and fracture of the vertebral body. This is a compound comminuted fracture of the distal radius and ulna with 2. Exposure to poison oak deposits allergic pathogens on the skin which incite dorsal displacement and angulation. The cells of the immune system already within there are multiple fragments in each fracture. It is an open fracture because the skin release locally acting cytokines which result in recruitment of other the fractured bones are exposed to the outside of the body through a soft inflammatory cells to the area as well as increased permeability of the blood tissue defect. The fracture fragments are displaced dorsally because of the vessels in the area. This type of fracture of the distal radius is classically inflammatory cells results in the local pruritis (itching). In an open fracture the ends of the fracture fragments are exposed to the intercellular spaces particularly within the stratum spinosum. This exposes the bone marrow cavity intracellular fluid in this area may cause blistering. The bone marrow is a good growth reaction to the allergic pathogen requires recruitment of additional medium for bacteria. These fractures are at greater risk of developing inflammatory cells, appearance of symptoms is delayed approximately 24 infection within the bone which may interfere with healing. Considering the amount of displacement seen on the radiographs, vascular 3. Topical steroids are the basis of treatment for poison oak to inhibit the and nervous injuries associated with the bony trauma would be quite possible. Often antihistamine medications are given to Vascular injury may be manifest as a pulseless cold hand.

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