The Netter Collection of Medical Illustrations VOLUME 1 Reproductive System

Plate 13-3 Reproductive System

Parasternal nodes

Apical axillary (subclavian) nodes

Interpectoral (Rotter) nodes

Central axillary nodes

Posterior axillary
(subscapular) nodes

Lateral axillary
(humeral) nodes

LYMPHATIC DRAINAGE

The lymphatic distribution of the breast is complex. Anterior
The mammary gland has a very rich network of lymph axillary
vessels, which is separated into two planes, the superfi- (pectoral) nodes
cial or subareolar plexus of lymphatics and the deep or
fascial plexus. Both originate in the interlobular spaces Pathway to
and in the walls of the lactiferous ducts. The lymph anterior
nodes that drain the breast are not linked in a straight mediastinal nodes
line; instead, they are staggered, variable, and fixed
within fat pads. This arrangement complicates lymph Pathways to opposite breast
node removal during breast cancer surgery. Pathways to inferior phrenic (subdiaphragmatic) nodes and liver

Collecting lymph from the central parts of the gland, lymph nodes is often referred to as level I nodes. (Level instances, breast cancer spreads in a predictable way
the skin, areola, and nipple, most of the superficial II nodes are located underneath the pectoralis minor within the axillary lymph node chain based on the loca-
plexus drains laterally toward the axilla, passing first to muscle, and level III nodes are found near the center of tion of the primary tumor and the associated sentinel
the anterior pectoral group of nodes, which are often the collarbone.) Other metastatic routes include lym- nodes. However, lymphatic metastases from one spe-
referred to as the low axillary group of glands. The phatics adjacent to the internal mammary vessels, cific area of the breast may be found in any or all of the
anterior pectoral nodes, four to six in number, lie along allowing direct spread into the mediastinum. groups of regional nodes. Despite this observation, the
the border of the pectoral muscles adjacent to the concept of using a sentinel node to detect spread is still
lateral thoracic artery. The drainage passes thence to Lymph drainage usually moves toward the most adja- useful because in only about 3% of these women does
the central axillary nodes, which lie along the axillary cent group of nodes: this is the basis for the concept of the positive node occur outside of the axilla.
vein, or to the midaxillary nodes. From there, the drain- sentinel node mapping in breast cancer. In most
age is to the subclavian nodes at the apex of the axilla
where the axillary and subclavian veins join. The axilla
contains a varying number of nodes, usually between 30
and 60. Approximately 75% of the breast lymphatic
drainage goes to these axillary regional nodes.

The deep fascial plexus extends through the pectoral
muscles to Rotter lymph nodes, situated beneath the
pectoralis major muscle, and thence to the subclavian
nodes. This is known as Groszman pathway. The rest
of the fascial plexus, for the most part, extends medially
along the internal mammary artery via the internal
mammary nodes to the mediastinal nodes. Other paths
of lymphatic drainage proceed from the lower and
medial portions of the breast. One of these is the para-
mammary route of Gerota, through the abdominal lym-
phatics to the liver or subdiaphragmatic nodes. Another
is a cross-mammary pathway, via superficial lymphatics
to the opposite breast and opposite axilla. Metastases
from one breast across the midline to the other breast
or chest wall occur occasionally via this pathway. From
the lower medial portion of the breast, some lymphatics
of the fascial group drain, passing beneath the sternum,
to the anterior mediastinal nodes situated in front of
the aorta. Lymphatic drainage to the intercostal glands,
which are located posteriorly along the vertebral
column, and to subpectoral and subdiaphragmatic areas
may also occur.

Lymph nodes play a central role in the spread of
breast cancer. The axillary lymph nodes are particularly
important, as they are among the first places that cancer
is likely to metastasize from the breast. This cluster of

286 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 13-4 The Breast

Progesterone

Estrogen

DEVELOPMENTAL STAGES

In a human newborn at birth, in the female as well as Childhood Puberty Maturity
in the male, the mammary glands have developed suf-
ficiently so that they appear as distinct hemispheroidal lobular structure found during the childbearing years. The predictable sequence of breast development
elevations, palpable as movable soft masses. This is This differentiation into a lobular gland is finished brought on during adolescence forms one part of the
especially prominent in postterm infants. Histologi- approximately 1 to 1½ years after the first menstruation, sexual maturation scale (Tanner staging) that is used to
cally, a number of branching channels with layers of but further acinar development continues in proportion assess the degree and sequence of pubertal develop-
lining cells and plugs of basal cells at their ends, the to the intensity of the hormonal stimuli during each ment. In 1969, Marshall and Tanner defined five stages
future milk ducts and glandular lobules, respectively, menstrual cycle and especially during pregnancies. Fat of breast development and pubic hair development that
can easily be recognized. In a great number of infants deposition and formation of fibrous stroma contribute are combined and called Tanner, or pubertal, stages 1
an everted nipple is observed, and in about 10% a to the increasing size of the gland in the adolescent through 5. For most girls, breast budding is the earliest
greatly enlarged gland can be palpated, a condition that period. sign of puberty and menarche the latest.
received the unfortunate name of mastitis neonatorum,
though no signs of inflammation exist. These early
glandular structures may produce a milklike secretion,
the “witch’s milk,” starting 2 or 3 days after birth. All
these neonatal phenomena in the breast are the result
of the very intensive, maternal estrogen–driven devel-
opmental processes in the last stages of intrauterine
life. The changes subside within the first 2 to 3 weeks
of life. It is during this period that the breast undergoes
marked involutional changes leading to the quiescent
stage, which is characteristic of infancy and childhood.
During these periods, the male and the female glands
consist of a few branching rudimentary ducts lined by
flattened epithelium, surrounded by collagenous con-
nective tissue.

For most girls, the first sign of puberty is usually the
appearance of breast budding. In the United States, this
early breast change begins at an average age of 10.8
(±1.1) years of age. With the onset of puberty and
during adolescence, follicular ripening in the ovaries, in
response to follicular-stimulating hormone (FSH) of
the anterior pituitary gland, is accompanied by an
increased output of estrogen. In response to the latter,
the mammary ducts elongate and their lining epithe-
lium reduplicates and proliferates at the ends of the
mammary tubules, forming the sprouts of the future
lobules. This growth of ductal epithelium is accompa-
nied by growth of periductal fibrous tissue, which is
largely responsible for the increasing size and firmness
of the adolescent female gland. During this period, the
areola and nipple also grow and become pigmented.

With the onset of maturity, that is, when ovulation
occurs and the progesterone-secreting corpora lutea are
formed, the second stage of mammary development
occurs. It is essentially concerned with the formation of
the lobules and acinar structures. Although in the adult
woman, progesterone always asserts its influence when
estrogen is simultaneously present, overwhelming
experimental evidence indicates that this beginning
unfolding of the lobules is a specific effect of progester-
one. This gives the mammary gland the characteristic

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Plate 13-5 Reproductive System

FUNCTIONAL CHANGES
AND LACTATION

The maturational changes in hormones from the ante- Pregnancy Lactation
rior pituitary gland and ovary are major factors in the
development and functioning of the mammary gland. ripening and ovulation are suppressed for approxi- and its storage account for one-fifth to one-third of the
Follicle-stimulating and luteinizing hormones are mately 6 months. breast volume.
indispensable for the production of ovarian estrogen
and progesterone, which, in turn, control mammary The secretion of true milk takes place in the epithe- Nipple and breast stimulation can also increase pro-
gland development. These are necessary but not suffi- lial lining of the dilated acini by cuboidal or columnar lactin levels in the nonpregnant woman. Prolactin levels
cient to prepare the breast for lactation. cells with nuclei at their bases or tips. This epithelium normally rise following ingestion of the noonday meal
rests on a narrow band of connective tissue that encloses and may increase in response to exercise, sleep, and
The mammary gland of a nonpregnant woman is thin-walled capillaries. Secretory globules and desqua- stress. For these reasons, prolactin levels normally fluc-
inadequately prepared for secretory activity. Only mated epithelial cells distend the acini and their afferent tuate throughout the day, with maximal levels observed
during pregnancy do those changes normally occur that channels. During the height of lactation, milk secretion during nighttime sleep and in the early afternoon.
make milk production possible. In the first trimester of
pregnancy, the terminal tubules sprouting from the
mammary ducts proliferate in order to provide a
maximum number of epithelial elements for future
acinar formation. In the midtrimester, the reduplicated
terminal tubules are grouped together to form large
lobules. Their lumina begin to dilate, and the acinar
structures thus formed are lined by cuboidal epithe-
lium; occasional acini contain small amounts of colos-
trum secretion. In the last third of pregnancy, the acini
formed in early and midpregnancy are progressively
dilated. The high levels of circulating estrogens and
progesterone during pregnancy are responsible for
these alterations in the breast.

During pregnancy, as estrogen levels increase, there
is a parallel hypertrophy and hyperplasia of the pituitary
lactotrophs. An increase in prolactin occurs soon after
implantation, concomitant with the increase in circu-
lating estrogen. Circulating levels of prolactin steadily
increase throughout pregnancy, peaking at about
200 ng/mL during the third trimester. This rise is in
parallel with the continued increase in circulating estro-
gen levels over this time. Despite these elevated prolac-
tin levels, lactation does not occur because estrogen
inhibits the action of prolactin on the breast (most likely
blocking interaction with the prolactin receptor).

Following childbirth, active secretion begins in the
now maximally dilated acinar structures as a result of
the stimulation by prolactin from the anterior pituitary
gland and by the nursing of the infant. A day or two
following delivery of the placenta, both estrogen levels
and prolactin levels decline rapidly and lactation is initi-
ated. Prolactin levels reach basal concentrations after 2
to 3 weeks in women who do not breastfeed. In nursing
women, basal levels of prolactin decline to the nonpreg-
nant range within 6 months after parturition; after each
act of suckling, prolactin increases markedly.

Lactation, starting 3 to 4 days after delivery, is stimu-
lated and maintained through the mechanical act of
sucking. In addition to prompting a pulse in prolactin,
stimulation of the areola causes the secretion of oxyto-
cin, which is responsible for the letdown reflex and
ductal contraction that expels the milk. Therefore, it is
through these feedback mechanisms that suckling
ensures further milk production.

Prolactin has not been shown to affect the macro- or
microscopic changes in the gland. Its only function
is to stimulate milk secretion after the tissues have
been previously adequately prepared (by estrogen and
progestin). During consistent breastfeeding, follicular

288 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 13-6 The Breast

POLYTHELIA, POLYMASTIA,
HYPERTROPHY

Congenital anomalies of the breast, such as agenesis or Virginal hypertrophy Polythelia
amastia, aplasia, or the absence of nipple and/or areola,
are extremely rare. (Athelia or amastia is sometimes Polymastia The milk lines
associated with Poland syndrome, consisting of absent occurring, respectively, in adolescent or pregnant When this type of hypertrophy occurs in teenage girls,
chest wall muscles, absence of ribs 2 to 5, and deformi- women. Precocious mammary hypertrophy is associated it can have a deeply disturbing effect on a teenager’s
ties of hands or vertebrae.) An increase in the number with endocrine disturbances of the ovary. It is bilaterally self-image and social development. The only effective
of mammae or of nipples only is encountered somewhat symmetric and rarely of a marked degree. Virginal and treatment is reductive mammoplasty.
more frequently. Both these conditions find ready gravid hypertrophies are of unknown origin and may
explanation in the embryologic development of the be bilateral or unilateral, and the affected breast may Some degree of asymmetry of breast development is
breast. During the 6th to the 12th week of fetal life, the grow to enormous size. The enlarging organs are com- common, with roughly 3% of patient examinations
mammary glands first develop as solid down growths of posed of increased amounts of fibrous stroma with notable for asymmetric volume differences relative to
the epidermis that extend into the mesenchyme from hypertrophied ducts, associated at times with lobular the contralateral breast. This asymmetry represented a
the axilla to the inguinal regions—the milk lines. Later, formation. The enlargement, once formed, persists. benign, normal variation unless an associated palpable
these ridges disappear, except in the pectoral area where abnormality is present.
the normal breast develops.

Accessory or supernumerary nipples (polythelia)
occur in about 1% of men and 2% of women. These
cases are sporadic; although familial polythelia is recog-
nized, it is extremely rare. Most supernumerary nipples
resemble a mole or birthmark and are only recognizable
because of their anatomic location. Most often the
supernumerary nipples are found 5 or 6 cm below the
normal pair and toward the midline. They are usually
not associated with significant amounts of underlying
mammary tissue. The accessory nipples without acces-
sory mammary tissue are found anywhere in the course
of the milk lines of the embryo. In the adult, this extends
from the axillary to the inguinal regions. In the regions
below the breast, the milk line runs medially to the
normal nipple; above the breast it runs laterally toward
each axilla. Supernumerary mammary glands (polymas-
tia) situated laterally are more apt to be of considerable
size and to undergo normal lactation compared with
those situated medially. Bilateral axillary breasts that
are of small size may develop during pregnancy and
undergo lactation. They occur in approximately 1% to
2% of women of European descent and 5% to 6% of
Asian women. Accessory breast tissue has been classi-
fied into eight levels of completeness from a simple
patch of hair to a milk-bearing breast in miniature. This
classification is based on the presence of glandular and
fat tissue, a nipple, an areola, or tufts of hair.

Aberrant mammary tissue in the axilla without nipple
formation is more prone to malignant change than is a
supernumerary breast, in which the frequency of tumor
occurrence is seemingly the same as with a normal
single breast. Either benign or malignant tumors can
occur in supernumerary or aberrant tissue. A 2000
American Journal of Cardiology article postulated a pos-
sible relationship with mitral valve prolapse.

Mammary hypertrophy is a common anomaly of the
breast and affects both sexes. In females, the major forms
of mammary hypertrophy are precocious or infantile
hypertrophy and virginal or gravid hypertrophy

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Plate 13-7 Reproductive System

GYNECOMASTIA

Some degree of mammary hypertrophy is normally Hyperplastic duct epithelium and periductal
found in the male breast during adolescence. In two- stroma of prepubertal gynecomastia
thirds of all boys between the ages of 14 and 17 years,
a button-shaped plaque of mammary tissue is palpated Fibroadenomatous form
beneath the nipple. This is known as the puberty node. of gynecomastia in adult
Although gynecomastia is usually bilateral, it can be
unilateral. Normally, this involutes before the age of 21. True gynecomastia (feminization)
Rarely, this adolescent growth of tissue may be two or
three times its normal size and may be persistent. Fibroadenoma of one breast
Sometimes it has been found so discrete and firm that
the observers classified the enlargement as a benign medications associated with gynecomastia, including Testicular deficiency in all its forms may be accompa-
fibroadenoma. Fat deposition without glandular prolif- hormones like estrogen, some antibiotics like metroni- nied by gynecomastia of varying degrees. Mammary
eration is termed pseudogynecomastia. dazole, antihypertensives like spironolactone, antiulcer hypertrophy has been originally described as an integral
medications such as ranitidine, and psychoactive drugs part of Klinefelter syndrome. Only when the underly-
Gynecomastia most frequently happens in newborn, like phenothiazines. Alcohol, especially if associated ing hyalinization process of the tubular apparatus of the
pubertal, and older males. On palpation, the enlarged with cirrhosis, marijuana, methadone and amphet- testes in this condition starts late in puberty is gyneco-
mammary gland may be the seat of increased tissue, amines, has also been associated with gynecomastia. mastia a frequent but not obligatory phenomenon.
both mammary and adipose, feeling like the normal
female breast. Often a discrete, firm mass is felt, which Rather frequently, gynecomastia is found in patients Simple mastectomy, performed through a curved
is composed microscopically of increased amounts of with testicular tumors (especially chorioepithelioma incision following the margin of the areola, remains the
periductal connective tissue surrounding mammary but also teratoma and interstitial cell tumors). most satisfactory treatment.
ducts containing hyperplastic epithelium.

Growth of the mammary gland during puberty is
explained by changes in the endocrine environment
characteristic of this age. Gynecomastia generally
results from an imbalance in the estrogen–androgen
balance, in favor of estrogen (stimulatory) over andro-
gen (inhibitory), or increased breast sensitivity to a
normal circulating estrogen level. Estrogens induce
ductal epithelial hyperplasia, ductal elongation and
branching, proliferation of the periductal fibroblasts,
and an increase in vascularity just as they do in the
female breast: the histologic picture is similar in male
and female breast tissue after exposure to estrogen. The
Leydig cells of the testes, long accepted to be the source
of the androgens, also secrete estrogens. Most estrogen
production in males is from the peripheral conversion
of androgens (testosterone and androstenedione to
estradiol and estrone, respectively) through the action
of aromatase, mainly in muscle, skin, and adipose
tissue. For this reason, overweight adolescent boys are
more likely to undergo these changes or to have more
marked changes than those of normal weight. The
overall prevalence of adolescent gynecomastia ranges
from 4% to 69%.

Gynecomastia in late adolescence and in the adult is,
in many instances, associated with clinical endocrine
disorders that result in estrogen excess or decreased
androgens. Any endocrine disorder that results in hypo-
gonadism, either primary, such as Klinefelter syndrome
(46, XXY), or secondary, such as hypopituitarism due
to an adenoma, can result in gynecomastia. Other
causes include testicular and feminizing adrenal neo-
plasms. Hyperthyroidism is also associated with gyne-
comastia, which is thought to be related to a relative
decrease in circulating free testosterone due to thyroid
stimulated increases in sex hormone binding globulin
as well as increased peripheral aromatization. Genetic
causes of gynecomastia include complete and incom-
plete forms of androgen insensitivity as well as certain
types of congenital adrenal hyperplasia.

Gynecomastia in adult males is often multifactorial.
Increased peripheral aromatization of testosterone to
estradiol and the gradual decrease of testosterone
production in the aging testes probably accounts for
gynecomastia in older men. There are a number of

290 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 13-8 The Breast

PAINFUL ENGORGEMENT, Painful engorgement
PUERPERAL MASTITIS

Painful engorgement of the breast is caused by vascular Subtypes of mastitis
and lymphatic stasis. It usually occurs on the third or Subcutaneous
fourth day postpartum, before the onset of lactation. It
also occurs when lactation, once established, is inter- Subareolar Acute mastitis
rupted. The breasts are heavy, painful, warm, firm and
tender to palpation, with prominent axillary prolonga- Glandular (intramammary)
tions (axillary tail of Spence, part of the mammary gland Retromammary
that extends along the inferolateral edge of the pecto- Locations of breast abscess
ralis major toward the axilla). Fever rarely exceeds 1 or
2 degrees (°F) over normal. The overlying skin may be more lobes are involved, and the abscess may rupture symptoms and signs of acute mastitis may continue for
edematous and the nipple may be so flattened that the spontaneously, giving rise to a sinus tract. In the inter- weeks and months, though to a milder degree. Manage-
baby cannot grasp it. Pumping or manually expressing stitial form the fatty and connective tissues are involved, ment of the chronic form is the same as for the acute.
some breast milk can help reduce engorgement, allow- giving rise to a retromammary abscess overlying the
ing the baby to properly latch and nurse. The degree pectoral fascia, as shown in the illustration. Once signs Rarely, mastitis can occur in women who have not
of engorgement usually lessens with each child; first- of suppuration have developed, efforts to localize the recently delivered as well as in women after menopause.
time mothers often have more engorgement than abscess by heat application should be made, and the Because inflammatory breast cancer has symptoms very
women who are nursing their second or subsequent abscess should be incised and drained. In some cases similar to mastitis, the possibility that carcinoma may
children. In cases where lactation is being discontinued, a chronic mastitis follows the acute condition. All be masked or hide behind an abscess should be kept
the breasts should be firmly bound and ice packs and in mind.
analgesics used as needed for pain relief.

Prevention of infectious mastitis consists of taking
care to wash the hands well (and any other equipment
used) before breastfeeding or breast manipulation.
Additionally, the nipples and the infant’s face should
also be clean before each feeding.

Acute mastitis occurs more frequently during the first
4 months of lactation. Mastitis occurs in approximately
10% of breastfeeding mothers in the United States,
with more than half of these cases occurring in first-
time nursing mothers. The portal of entry for the infec-
tious organisms is usually a cracked or traumatized
nipple allowing entry for organisms from the baby’s
nose and mouth. The signs of onset are fever, leukocy-
tosis, unilateral tenderness, and a zone of induration.
In some cases the infection progresses rather rapidly,
and the body temperature may rise as high as 105° to
106° degrees Fahrenheit (40.5° to 41° C). In such
instances suppuration usually starts within 48 hours.
Abscess formation can usually be avoided if antibiotic
therapy is instituted promptly. For most cases, nursing
need not be stopped. A tight binder supporting the
breasts can improve symptoms, along with ice bags
applied for analgesia. In suppurative cases, dicloxacillin
therapy will treat the infection, but any abscesses
formed should be evacuated. The choice of antibiotic
should be adjusted based on the patient’s history,
allergies (if any), and the prevalence of methicillin-
resistant Staphylococcus aureus. Ciprofloxacin, clinda-
mycin, and trimethoprim/sulfamethoxazole are often
effective against methicillin-resistant S. aureus. However,
trimethoprim/sulfamethoxazole should be avoided in
women breastfeeding infants below the age of 2 months.

According to the site of the mastitis, three types have
been distinguished – the subareolar, the glandular, and
the interstitial forms. In the subareolar type of infec-
tion, the abscess, when it forms, is confined to the area
just beneath the nipple. In the glandular form one or

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Plate 13-9 Reproductive System

Hypothalamic stimulation Pituitary tumor
via sensory pathways or dysfunction

GALACTORRHEA STH

Prolactin
FSH
deficient

Galactorrhea is the spontaneous bilateral discharge of Prolonged suckling Estrogen Acromegaly
milky fluid from the nipples. (Many women, especially (or manipulation) deficient
those who have given birth, can express small amounts Chiari-Frommel
of milky fluid from one or both nipples, and this is not Benign cystic Amenorrhea syndrome; long-
considered abnormal.) Galactorrhea is uncommon but breast disease continued lactation
reports vary from 1% to 30%, depending on the popu- Afferent and amenorrhea
lation studied. Although not inherently dangerous, Herpes zoster nerves after pregnancy
galactorrhea can be the harbinger of significant under-
lying physiologic disruptions and, as such, deserves OxPSyroTtolHaccintinfrom nipple
careful evaluation. cAodrrtiecnoailds
Estrogen
Because galactorrhea represents a symptom, multiple Progesterone
causes can result in the same clinical presentation. Pitu-
itary adenoma or hypothyroidism can result in elevated Endocrine influences
prolactin levels, which can stimulate the breast paren- in normal lactation
chyma and result in milk secretion. Galactorrhea can
also result as a side effect from pharmacologic agents. Psychosis Ahumada-del
Most often this occurs with those drugs that affect Castillo syndrome;
dopamine or serotonin production or metabolism. Chest lactation with no
(Some foods when consumed in excess can mimic this operations preceding
same process, notably licorice.) Some autoimmune dis- pregnancy
eases (sarcoid, lupus) or Cushing disease may result in or acromegaly
the patient’s symptoms. Chronic chest wall irritation
such as from herpes zoster, breast stimulation, or breast Tranquilizer administration (rarely) Adrenal cortical or
irritation may result in the activation of neural pathways Disturbance of hypothalamic function ovarian disorders
normally associated with physiologic milk production.
Chronic stimulation of these neural pathways can result FSH = follicle-stimulating hormone; STH = somatotropic hormone.
in galactorrhea. Physiologic changes during pregnancy
or after childbirth and/or nursing may lead to persistent degrees of galactorrhea, or have macroadenomas. patient’s symptoms may recur when medical therapy is
milk secretion. Most pathologic processes that lead to Unfortunately, medical therapy may be associated with discontinued.
galactorrhea result in an elevation of serum prolactin nausea, orthostatic hypotension, drowsiness, or syncope,
levels. This can be helpful in evaluating the source and hypertension, or seizures, and bromocriptine therapy Rapidly growing tumors, tumors that are large at
threat posed by these symptoms. may interact with phenothiazines or butyrophenones. the time of discovery, or those that do not respond to
bromocriptine therapy may require surgical or radia-
Galactorrhea is often accompanied by other present- Medical therapy is generally effective for patients tion therapy. Surgery can often be accomplished via
ing complaints or conditions: one-third of patients with with hyperprolactinemia. Prolactin levels should be the transsphenoidal approach. Surgical therapy may
an elevated prolactin level experience amenorrhea or measured every 6 to 12 months and visual fields reas- result in complete loss of pituitary function requiring
infertility. Prolonged hypogonadal amenorrhea result- sessed yearly. The pituitary should be reevaluated careful replacement and monitoring of other endocrine
ing from hyperprolactinemia is associated with an every 2 to 5 years, based on the initial diagnosis. The systems, including the thyroid and adrenal.
increased risk of osteoporosis, vaginal and genital atro-
phic changes, dyspareunia, and libidinal dysfunction.

The evaluation of the patient with galactorrhea will,
in part, be dictated by any associated symptoms sugges-
tive of an underlying process. In the absence of other
symptoms, measurement of serum prolactin levels
begins the evaluation process. (Pregnancy should always
be considered if menses are absent.) Prolactin should
be measured in the fasting, resting state because eating
and stress can increase levels. An elevated serum pro-
lactin level suggest the need for radiologic evaluation
of the pituitary. The preferred approach is computed
tomography or magnetic resonance imaging of the sella
turcica. Unfortunately, there is a poor correlation
between serum prolactin levels and the size of a pitu-
itary lesion. Testing of visual fields may be indicated if
there is a pituitary macroadenoma (≥10 mm).

When prolactin levels are low and imaging of the
sella turcica is normal, observation alone may be suffi-
cient. If observation is chosen, periodic reevaluation is
required to check for the emergence of slow-growing
tumors. Treatment with bromocriptine is recommended
for patients who desire pregnancy, have distressing

292 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 13-10 The Breast

Mondor disease results from thrombophlebitis
of thoracoepigastric veins

MONDOR DISEASE

Mondor disease, or superficial angiitis, is a superficial Typical signs include pain over involved Arm elevation stretches involves
thrombophlebitis of the breast, named after Henri vein, erythema, and “dimpling” veins and creates a groove in breast
Mondor (1885-1962), a French surgeon who first Vein may appear cordlike on palpation
described the disease in 1939. This is a very uncommon restriction on physical activity, good mechanical support
clinical entity that may occur during the late reproduc- corresponding to the thrombosed vein may be seen. In with a well-fitting bra or binder improves comfort
tive or early menopausal years. The predominant age rare patients, a biopsy may be required to establish the during vigorous activity. Antibiotics and anticoagulants
for patients with Mondor disease is between 30 and diagnosis. have little effect on the course of the disease and are
60 years. This should not be confused with Paget- not indicated.
Schroetter disease, which refers to deep vein thrombo- Mondor disease is benign and self-limited. The treat-
sis of an upper extremity vein, including the axillary ment of superficial thrombophlebitis of the breast is Subcutaneous penile vein thrombosis (penile Mondor
or subclavian vein often following vigorous activity generally supportive: analgesics and heat reduces symp- disease) has also been described. It appears suddenly as
(though it can also occur spontaneously). toms. The condition generally clears up on its own in almost painless indurations on the penile dorsal surface.
2 to 3 weeks, but it may take 6 weeks or longer to Its pathogenesis is unknown.
Breast phlebitis is most often linked to a recent preg- completely resolve. Although there is generally no
nancy, trauma, or operative procedure but may occur
spontaneously. It most often involves the thoracoepi-
gastric veins of the breast and the lateral thoracic veins.
Rarely, Mondor can present following augmentation
mammoplasty, manifesting as temporary cords extend-
ing from below the breast toward the abdomen. This
occurs in less than 2% of patients. In these patients, the
cords appear at about 3 to 6 weeks, last a few months,
and then usually disappear.

Thrombophlebitis of the breast veins usually pres-
ents with symptoms of pain that is acute and generally
located in the upper outer quadrant of the breast. Dim-
pling of the skin or a distinct cord with erythematous
margins may be found on physical examination. In
addition, a shallow groove may be seen extending
upward toward the axilla when the arm is raised.

Although these symptoms are typical of Mondor
disease, they must be differentiated from those of a
breast abscess or mastitis, ductal ectasia, carcinoma, or
fat necrosis. Mondor disease can be distinguished from
inflammatory cancer of the breast by the presence of
sudden pain, early skin adherence, and progressive
improvement, characteristics that are not present in
these cancers. Scarring from previous surgery (biopsy,
augmentation, or reduction) can result in thickening or
a retraction of the overlying skin, similar to that seen
in Mondor disease but should be readily distinguished
by careful history.

Mondor disease is generally diagnosed by history and
physical examination. On physical examination there
will be accentuation of dimpling, or the formation of a
groove over the affected vein. This often occurs when
the ipsilateral arm is raised during physical examina-
tion. Mammography may be required to rule out other
processes, but the diagnosis is generally established
by physical examination and history. (On mammo-
graphy, a beaded subcutaneous vein may be seen
together with skin retraction. Rarely, the vein calcifies.)
On ultrasonography, a tubular, hypoechoic structure

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Plate 13-11 Reproductive System

Mammography

Position for craniocaudad Usually two exposures When additional breast and rib
projection detail is needed, a mediolateral
at right angles (craniocaudad exposure is also made

BREAST IMAGING and lateral) are made Breast Position for mediolateral
projection
In current medical practice, breast imaging is domi- of each breast compression
nated by two modalities, mammography and ultra-
sonography, for screening and evaluation of suspicious Position for device
breast lesions. Magnetic resonance imaging (MRI) has
demonstrated promise as an adjunct to traditional lateral projection
imaging for selected situations. Other modalities such
as thermal imaging (thermography), molecular breast Coned x-ray
imaging (scintimammography), three-dimensional beam
mammography (tomosynthesis), electrical impedance
imaging (T-scan), and transillumination are either Breast compression device
experimental or have not proven to be effective.
Translucent Connective Prominent ducts and Rib detail shown in this projection
Mammography is the best mode of screening for fatty tissue tissue shadows glandular elements Connective tissue shadows
early lesions currently available. Mammography can
identify small lesions (1 to 2 mm), calcifications, or Vascular shadows
other changes suspicious for malignancy roughly
2 years before a lesion is clinically palpable. More Craniocaudad projection Lateral projection of normal Mediolateral projection of
than one-third of occult breast cancers have calcifica- of normal fatty breast dense glandular breast normal breast
tions, making the otherwise undetected tumors visible
through mammography. Ultrasonography

Widespread use of mammography has been credited Cystic mass visible
with reducing the mortality rate from breast cancer by
up to 30%. Unfortunately, not all women receive sensitive than MRI (detects fewer tumors), it has routinely with a mammogram when screening younger
appropriate screening on a regular basis. The most the advantage of costing less and being more widely women or those with dense breast tissue. A large study
recent breast cancer screening guidelines recommend available. evaluated the use of breast ultrasonography for screen-
that mammography be performed every 1 to 2 years for ing and found that more breast cancers were found
women aged 40 to 49 years and annually thereafter. Breast ultrasound is not routinely used for screening, with the combined modalities compared with mam-
Most guidelines have dropped the suggestion to obtain but rather it is useful in the evaluation of palpable mography alone, but the rate of false-positive studies
routine baseline mammograms in women younger than masses that are mammographically occult, in the evalu- and biopsies also was higher. Ultrasonography is gener-
40 years. Most have recommended annual screening ation of clinically suspected breast lesions in women ally acknowledged to be a highly operator dependent
mammography and clinical breast examination for younger than 30 years, and in the follow-up of abnor- modality that requires a skilled practitioner, high-
women aged 50 years and older. However, published malities seen on mammography. Some studies have quality examinations, and state-of-the-art equipment.
and public controversy about the potential benefits and suggested that it may be helpful to use ultrasound
risks of screening mammography continues.

When the patient has a first-degree relative with pre-
menopausal breast cancer, screening should begin
roughly 5 years before the age at which the relative’s
cancer was diagnosed. For patients at increased risk
for breast cancer (strong family history or genetic
abnormality such as mutations of BRCA-1 or -2),
mammography should be augmented by MRI studies.
MRI should not be used independently for screening
because of its unacceptably high false-positive rate.

Mammography in younger women is more difficult
to interpret than in older women because of the greater
tissue density present during the reproductive years;
breast cancers in these women are more easily missed
for this reason. Overall, mammography is approxi-
mately 85% accurate in diagnosing malignancy, with a
10% to 15% false-negative rate. For this reason, it
provides an adjunct to clinical impressions and the
definitive procedure of biopsy but does not replace
them. Roughly, 10% of mammographic studies require
additional views. Between 1% and 2% of screening
studies necessitate histologic evaluation to establish a
diagnosis. Total mammographic radiation exposure is
minimal (<1 rad).

Ultrasonography has become a valuable tool for use
along with mammography because it is widely available,
noninvasive, and less expensive than other options.
Originally, ultrasonography was primarily used as an
effective method of differentiating cystic breast masses
from solid breast masses, but it also provides valuable
information about the nature and extent of solid masses
and other breast lesions. Although ultrasound is less

294 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 13-12 The Breast

FIBROCYSTIC CHANGE I—
MASTODYNIA

Fibrocystic change (previously called fibrocystic disease) Schema of clinical syndrome: Sagittal section
is a nonspecific term that includes mastalgia (masto- tender, granular swelling
dynia), breast cysts, and nondescript lumpiness. These In very selective patients gonadotropin-releasing
may occur in isolation or together. The breasts gener- Microscopic aspect (stunted lobules hormone agonists may be required. Diuretics must be
ally have a nodular and dense texture and are tender in proliferating fibrous stroma) used with care to avoid fluid and electrolyte distur-
when palpated. Fibrocystic change is responsible for the bances. Bromocriptine may cause hypotension during
most commonly reported breast symptoms. chasteberry have shown efficacy in limited trials but the first several days of therapy. Care should also be
standardization of both therapy and active ingredients exercised with patients who have compromised hepatic
Mastalgia is the nonspecific term used for breast pain in varying preparations limits the ability to fully evalu- or renal function.
of any etiology. Mammary pain may occur in obese, ate these as therapeutic options.
pendulous breasts at or after the menopause when the Whatever therapy is used, it remains essential to con-
weight of the breast stretches the suspensory ligaments Combination oral contraceptives improve symp- sider the possibility of cancer in all cases.
and puts traction on the nerve fibers. These cases are toms for between 70% and 90% of patients. In more-
not true mastodynia and are relieved by a supportive resistant cases, treatment with spironolactone, danazol
brassiere and by weight reduction. Another form of sodium (begun during menstruation or once pregnancy
mammary pain, which does not arise in the paren- has been ruled out), or bromocriptine may be required.
chyma, is due to intercostal neuralgia, which may com-
plicate spondylitis, fatigue, or respiratory infections.

Most women experience breast pain at some point in
their lives, but in most cases it is transient. The most
common cause of persistent breast pain is fibrocystic
change. Breast pain can also arise from rapid hormonal
change (especially a change that involves a rise in estro-
gen levels, such as starting birth control pills, hormone
replacement, or pregnancy). In the absence of obvious
pathologic changes, mastalgia has been attributed to
caffeine consumption and high-fat diets, but hard data
are lacking. Nongynecologic causes include dorsal
radiculitis or inflammatory changes in the costochon-
dral junction (Tietze syndrome), sclerosing adenosis,
chest wall muscle spasms, costochondritis, fibromyal-
gia, and referred pain. Older patients may also suffer
postherpetic neuralgia or neuritis following herpes
zoster infections. This pain may mimic mastalgia.

The pain of fibrocystic change, at first present only
in the premenstruum, becomes progressively more pro-
longed and more severe until it persists throughout the
cycle. The breast affected is usually well developed. A
swollen granular zone of increased density is felt, which
is located far more frequently in the upper lateral quad-
rant than in other parts of the hemisphere. On com-
pressing this swollen area with the examining fingers,
pain is produced. The fibrocystic change is often bilat-
eral. Definitive masses are generally not felt. Unilateral
or localized pain suggests a pathologic process. Mam-
mography may be indicated for other reasons but
seldom directly assists in the evaluation of mastalgia.

When biopsied, the painful breast tissue is found to
be more dense and fibrous than normal. The lobular
tissue stands out as small pink dots in the dense white
stroma, which encloses occasional small cyst forma-
tions. On microscopic examination, the lobules are
stunted or irregular, with minute cystic dilatations. Pro-
liferating immature connective tissue, which stains
poorly, surrounds the epithelial structures.

Mastodynia usually responds to medical therapy and
to reassurance against the fear of cancer. General mea-
sures include analgesics, mechanical support (a well-
fitting brassiere worn day and night), local heat, and
reassurance. A reduction in methylxanthine intake is
often beneficial. Premenstrual restriction of salt or
fluids is recommended for selected patients. The role
of vitamins A and E is unknown. Evening primrose and

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 295

Plate 13-13 Reproductive System

FIBROCYSTIC CHANGE II—
ADENOSIS

Stromal and ductal proliferation that results in cyst Schema of clinical syndrome: cord-like Appearance on
formation, diffuse thickening, cyclic pain, and tender- and nodular with “saucer edge” cross section
ness are the hallmarks of fibrocystic change. The term
fibrocystic change encompasses a multitude of different Dilated acini and epithelial proliferation women who predominantly have these complaints. As
processes and older terms, including fibrocystic disease. a result, ultrasonography may be of more help when
It is the most common of all benign breast conditions, is sometimes difficult, if not impossible, particularly imaging is deemed necessary. If the patient has a cystic
accounting for its linguistic demotion to change from if small, intraductal papillomas have developed in breast mass, needle aspiration with a 22- to 25-gauge
the designation disease. To one extent or another, advanced cases of adenosis. Premenopausal age, multi- needle may be both diagnostic and therapeutic. Fine
fibrocystic change affects 60% to 75% of all women. plicity of more peripherally situated nodules, a brown- needle aspiration or core biopsy may be required if
These changes are most common between the ages of ish rather than a sanguineous discharge from the nipple, malignancy is suspected. When atypia is found in
30 and 50 years, with only 10% of cases in women and the involvement of both sides of the breast favor hyperplastic ducts or apocrine cells, there is a fivefold
younger than 21 years. Methylxanthine intake has been adenosis. increase in the risk of development of carcinoma in
proposed as a causative agent, but hard data are lacking. the future.
There is no evidence that oral contraceptives increase Mammography may be used to assist with the diag-
the risk of these changes. A family history of fibrocystic nosis or to provide a baseline, but it is not necessary for
change is often present, but causality is difficult to diagnosis. Mammography is more difficult in younger
establish.

The cause or causes of fibrocystic change are
unknown, but it is postulated to arise from an exagger-
ated parenchymal response to hormones. A role for
progesterone has been suggested based on the common
occurrence of premenstrual breast swelling and tender-
ness. Other proposed sources for fibrocystic changes
are altered ratios of estrogen and progesterone or an
increased rate of prolactin secretion, but none of these
has been conclusively established.

Adenosis is characterized by the occurrence in one
or both breasts of multiple nodules varying from 1 mm
to 1 cm in size, usually distributed about the periphery
of the upper or outer hemisphere. The breasts affected
tend to be small, dense, and edged like a saucer when
grasped in the hand. Typical findings on physical exam-
ination include multiple cysts and nodules intermixed
with scattered bilateral nodularity, or a ropy thickening,
especially in the upper outer quadrants of the breast.
Pain and tenderness (which vary during the menstrual
cycle) occur as in mastodynia, with the worst symptoms
occurring just before menses. (The pain associated with
fibrocystic change often radiates to the shoulders or
upper arms.) Although pain is the most common com-
plaint, up to 50% of cases of fibrocystic adenosis may
be asymptomatic.

Fibrocystic changes appear in three steps: (1) prolif-
eration of stroma, especially in the upper outer quad-
rants; (2) proliferation of the ducts and alveolar cells
occurs, adenosis ensues, and cysts are formed; and (3)
larger cysts are found and pain generally decreases.
Proliferative changes may be extensive (although
usually benign) in any of the involved tissues. Overall,
the mammary tissue affected contains dense fibrous
tissue, numerous minute cysts, and foci of epithelial
proliferation. Lobule formation is much distorted.
Some of the terminal tubules form solid plugs of basal
cells, which, on cross section, appear as duct adenomas.
Other tubules lead to greatly enlarged lobular struc-
tures, which are penetrated by dense strands of fibrous
tissue giving the appearance of fibrosing adenoma. Dif-
ferential diagnosis of adenosis from fibrosing adenoma

296 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 13-14 The Breast
Corpus albicans
Involuting
follicle

Follicle estrogen efwgfiteeLhcntaidrccatafto-weral

FIBROCYSTIC CHANGE III— Estrogen Effect
CYSTIC CHANGE

Cystic breast masses are frequently encountered in the Solitary “blue dome” cyst
clinical care of women. Sorting out those that represent
a threat from those that may be followed conservatively Mulitple cysts
is the challenge posed by the presence of cysts in the
breasts. Some authors estimate that cysts form in the but it has limited spatial resolution and cannot be used but is also innocuous. Bloody fluid requires further
breasts of roughly 50% of women during their repro- to differentiate benign and malignant tissues.) Needle evaluation. Cytologic evaluation of the fluid obtained
ductive years. Roughly one in four women seek medical aspiration with a 22- to 25-gauge needle may be both is of little value because of unacceptably high false-
attention for some form of breast problem; often this diagnostic and therapeutic. If the cyst disappears com- positive and false-negative results. After aspiration of a
takes the form of a palpable mass. The most common pletely and does not reform by a 1-month follow-up cyst, the patient should be rechecked in 2 to 4 weeks.
cause of a palpable breast cyst is fibrocystic change examination, no further therapy is required. Fluid aspi- Lack of complete resolution at the time of aspiration,
(found in 60% to 75% of all women). Dilation of rated from patients with fibrocystic changes is custom- recurrence of the cyst, or the presence of a palpable
ducts and complications of breastfeeding (galactoceles, arily straw colored. Fluid that is dark brown or green mass should prompt additional evaluation, such as fine-
abscess) may also cause cysts. occurs in cysts that have been present for a long time needle aspiration (FNA) or open biopsy.

The pathogenesis is not clear for the most common
types of cyst formation. Cyclic changes in hormones
induce stromal and epithelial changes that may lead to
fibrosis and cyst formation. Cysts may be single or be
found in clusters, with some up to 4 cm in diameter.
Small cysts have a firm character and are filled with
clear fluid, giving the cyst a bluish cast. Larger cysts
may have a brown color resulting from hemorrhage
into the cyst. Inspissated secretions or milk may form a
cystic dilation of ducts (galactocele, ductal ectasia) that
may be palpable as a cystic mass. Variable degrees of
fibrosis and inflammation may be seen in the surround-
ing stroma. (Leakage of cyst fluid into the surrounding
tissue induces an inflammatory response that may alter
physical findings and imitate cancer.) The microscopic
findings associated with breast cysts depend on the
pathophysiologic changes involved.

In fibrocystic change, the cyst makes its appearance
abruptly in a previously normal breast in which the
parenchyma has been largely replaced by fat and is
accompanied by a sticking or stinging sensation. A
serous discharge from the nipple occurs in about 6% of
the patients. On palpation a tense, movable, rounded
mass is felt fluctuating between the fingertips of the
right and left hands if the two hands alternately com-
press the mass. On transillumination, both the breasts
and the tumor transmit the light readily. The cyst
usually occupies a region midway between the nipple
and the periphery of the breast.

On gross examination (when the cyst is exposed at
operation), it has a characteristic blue dome that bulges
into the subcutaneous fat. This cyst has a thin, fibrous
wall, which may have an epithelial lining of duct cells
resembling sweat gland epithelium. On opening the
cyst, a smoky or cloudy straw-colored fluid is evacuated.
Microscopically, the cyst wall is embedded in dense,
fibrous mammary stroma. The gland is poor in acinar
tissue.

The diagnosis and management of cystic masses in
the breast are based on history, physical examination,
and aspiration, with the occasional adjunctive use of
mammography and ultrasonography. (Ultrasonography
is useful in differentiating solid and cystic breast masses,

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 297

Plate 13-15 Fibroadenoma Reproductive System
Tumor in cross section
BENIGN FIBROADENOMA, Tumor being excised
INTRACYSTIC PAPILLOMA from breast

Fibroadenomas are the second most common form of Histology of fibroadenoma and Benign intracystic papilloma
breast disease and the most common breast mass. The papilloma showing well-developed
peak incidence is from 20 through 25 years, with most ducts surrounded by an overgrowth Fibrous
patients younger than 30 years of age. More rapidly of periductal connective tissue stalk
growing tumors may be found during adolescence. Papilloma
The tumors are twice as common in blacks (30% of Discharge within
breast complaints), in patients with high hormone states from nipple breast
(adolescence, pregnancy), and in patients receiving tissue
unopposed estrogen therapy. with either retained bloody fluid within the cyst or
malignant change, which occurs in about 10% of the sanguineous fluid. Smaller papillomas may be found in
Fibroadenomas are generally discovered as firm, cases. Multiple papillomas in one or both breasts are the neighboring ducts or through the ramifications of
painless, mobile, rubbery, solitary breast masses that found in 14% of the cases. On palpation, the benign a group of ducts some distance from the main tumor.
may grow rapidly during adolescence or in high-estro- papilloma is freely movable, soft, and either tense Microscopically, the arborescent epithelial outgrowths
gen states such as pregnancy or estrogen therapy. These (cystic) or fluctuant. rest upon a fibrous stalk with an intact basement mem-
tumors are generally discovered incidentally or during brane. The treatment is simple excision, examination of
breast self-examination and average 2 to 3 cm in diam- Grossly, intracystic papillomas are encapsulated the neighboring ducts for secondary papillomas, and
eter, though they may grow as large as 6 to 10 cm. tumors in which epithelial tufts extend within the cavity excision of these where indicated. Recurrent tumors in
Multiple fibroadenomas are found in 15% to 20% and are bathed by varying amounts of serous or elderly patients warrant simple mastectomy.
of patients, and they are bilateral in 10% to 20% of
patients.

The chief symptom is gradual enlargement of the
mass over a period of months or years, the average
duration being just under 3 years. On palpation, the
tumor is firm, encapsulated, nodular, and freely
movable. Mammography is generally avoided but can
be diagnostic if needed. Breast ultrasonography can
distinguish between solid and cystic masses, although it
is often not required.

The structure of the tumor is lobular. A centrifugal
nodule with sharply circumscribed, fleshy, and homo-
geneous character, usually spherical or ovoid in shape,
characterizes them. Pink or tan-white fibrous whorls
bulge from the surface when cut. Hemorrhagic infarcts
are common. Microscopically, well-developed ducts are
seen, surrounded by a marked overgrowth of periductal
connective tissue. When this connective tissue is pale
staining and loose, and the epithelium of the ducts is
compressed, the tumor is referred to as an intracana-
licular myxoma. When the amounts of fibrous tissue
and duct growth are more evenly balanced, the tumor
is termed a fibroadenoma.

In early adolescence, in pregnancy, or toward the
menopause, when estrogen secretion is increased or
dominant, the growth of fibroadenomas is more rapid.
These are termed giant mammary myxomas. Malignant
change is extremely rare and usually takes the form of
fibrosarcoma occurring in the giant myxoma. After
menopause, fibroadenomas tend to regress and become
hyalinized but may remain unchanged or grow with
estrogen replacement therapy. The treatment is simple
excision, which confirms the diagnosis and suffices for
the cure.

Benign intracystic papillomas are soft epithelial
growths occurring within a mammary duct or cystic
acinar structure. They are about one-half as common
as fibroadenomas and are usually found at or near the
menopause, in the central zone of the breast. The dura-
tion of symptoms is variable, usually from 6 months to
5 years. The symptoms consist of either a sanguineous
discharge from the nipple (in 50% of the cases) or a
lump associated with moderate tenderness. The tumors
are rarely of large size; they range in diameter from 1
to several centimeters. The larger ones are associated

298 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 13-16 The Breast

Sarcoma

GIANT MYXOMA, SARCOMA Sarcoma. Microscopic view showing
numerous crowded spindle cells with
A variety of fibroadenoma growing to immense size and abnormal hyperchromatic nuclei
occurring near the menopause was first described by the
distinguished physiologist of the early 19th century, Tumor ulcerated through skin
Johannes Müller, as “cystosarcoma phyllodes.” This is
a rare, predominantly benign tumor that occurs almost Giant myxoma
exclusively in the female breast. It represents less than
1% of all breast tumors. The duration of the growth Section of breast tissue
extends over a period of 6 or 7 years, with rapid growth containing tumor
toward the end of this period, when these tumors can
significantly increase in size in just a few weeks. The Cyst
benign character of the growth is indicated by the containing
absence of invasion of the skin or of the regional lymph myxoid
nodes. The tumors are heavy, massive, lobulated mass
growths with cystic areas. They have a sharply demar-
cated smooth texture and are typically freely movable. Clinical presentation
Their average weight is between 7 and 8 lb. In spite of of tumor in right breast
the size, the tumor remains movable and encapsulated,
and the nipple is not retracted. Grossly, the tumor Giant myxoma. Microscopic view showing
displays characteristics of a large malignant sarcoma, bland myxoid connective tissue containing
takes on a leaf-like appearance when sectioned, and uniform spindle cells
displays epithelial cystic spaces when viewed histologi-
cally. Because most of these tumors are benign, the stroma of the breast or from the stroma of preexisting asymptomatic for many years and then suddenly may
name may be misleading, leading to the preferred ter- fibroadenomas. The tumors, which may develop at any become painful, giving rise to the rapidly growing and
minology of phyllodes tumor or giant myxoma. age but have their peak incidence between 45 and 55 invading sarcoma.
years of age, are characterized by rapid growth, large
The origin of these growths is in a preexisting intra- size, and a firm consistency. Ulceration of the skin, with Sarcomatous change has also been seen in benign
canalicular myxoma. Dense fibrous tissue in whorls is fungation, may occur. The tremendous size and the myxomas. Grossly, the tumors are solid, fleshy growths,
separated by clefts from polypoid, fibrous, and epithe- absence of axillary node involvement distinguish these which may invade the pectoralis fascia. Microscopically,
lial masses projecting into cystic cavities. Under the growths from mammary carcinomas. Pain and rapid they are composed of tightly packed pleomorphic
microscope, the predominant component is myxoma- growth are the symptoms most commonly noted. A spindle cells. The treatment is radical mastectomy. The
tous connective tissue with intervening dense fibrous preexisting fibroadenoma may have been stationary and lungs are the most common metastatic site, followed by
strands. The majority of the growths are benign, but bone, heart, and liver.
some may be the seat of sarcomatous change in about
10% of cases, particularly when the tumor has existed
for many years. These tumors are best treated by simple
mastectomy with removal of the pectoralis fascia.
Although these benign tumors often do not metastasize,
they do have a reputation of growing aggressively and
recurring locally. The malignant tumors metastasize
hematogenously like other sarcomas. The histologic
appearance does not always predict clinical behavior.
Roughly 30% of patients with malignant phyllodes
tumors will die from their disease. Other than surgery,
there is no cure for phyllodes tumors, as chemotherapy
and radiation therapy are not effective. Current studies
do not support the use of adjuvant radiotherapy for
patients with adequately resected disease.

Mammary sarcoma is relatively rare and represents
between 1% and 2% of breast tumors. Many varieties
of sarcomas, such as osteogenic, lympho-, myo-, lipo-,
and myelosarcomas, have been described. In more than
half of the cases, however, sarcomas of the mammary
gland are of the fibrospindle cell–type arising in the

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 299

Plate 13-17 Reproductive System

Infiltrating carcinoma.
Seen in cross section of breast

BREAST CANCER

Women in the United States have the highest incidence Nipple retraction Stellate,
rates of breast cancer in the world. Worldwide, breast irregular
cancer is the second most common type of cancer after mass
lung cancer (10.4% of all cancer incidence, both sexes
counted) and the fifth most common cause of cancer Slow-growing form. Proliferation of duct
death. Approximately one-third of all forms of female cells with enlarged nuclei and irregular
carcinoma arise in the breast, and more than three- gland pattern
quarters of these are the infiltrating scirrhous type or
lobular carcinoma. Breast cancer accounts for approxi- Rapidly growing form. Proliferation of duct
mately 18% of cancer deaths and results in about the cells with hyperchromatic nuclei in solid
same number of deaths per year as auto accidents. The sheets and no glandular architecture
peak incidence is above 40 years of age; with 85%
occurring after 40 and 75% after 50. Approximately 5% lymph nodes were uninvolved and 20% if there was the disease. It has become apparent that many women
to 10% of breast cancers have a familial or genetic link. lymph node involvement. This has given way to a much with breast cancer have systemic disease at the time of
more nuanced approach that is dependent on a number initial diagnosis. The natural history of the developing
The symptoms that bring the patient under examina- of factors: the tumor’s size; its inherent aggressiveness, breast carcinoma, with an average doubling time of 100
tion are the discovery of the lump (55% to 65% of as determined by the histology of the initial lesion; the days, results in years of growth before its clinical dis-
cases), its increasing size, occasional fleeting pains or presence of positive nodes; and the receptor status of covery. Because occult vascular dissemination is likely
tenderness, and changes in the skin or nipple. Approxi- the tumor. The major impetus for changes in manage- to occur prior to diagnosis, treatment of breast carci-
mately 60% of palpable tumors are located in the upper ment of breast carcinoma over the past two decades has noma now relies upon both local and systemic therapy,
outer quadrant of the breast. An abnormal mammo- come from a changing view regarding the biology of without reliance on radical surgery.
gram without a palpable mass is the second most
common cause for diagnosis (35%). One quarter of all
breast cancers are found during routine examination.

The major clinical findings on examination are the
presence of a single lump in a breast otherwise normal
to palpation in a patient more than 35 years old; the
hard and irregular feeling of the tumor; the apparent
nearness of the tumor to the examining fingers because
of atrophy of overlying fat; the restricted mobility of
the mass; and flattening or retraction of the skin or
nipple on the affected side when arms or breast are
manipulated. Excisional biopsy with or without radio-
graphic control provides the only definitive diagnosis.

Grossly, mammary carcinoma is a dense, yellowish-
white, stellate, indurated mass with a cut surface that
is gritty and concave and that feels like an unripe pear.
Unless secondarily infected, the growth is usually free
of necrosis. It infiltrates the surrounding fatty and
fibrous stroma of the breast. Microscopically, the tumor
cells are of moderate size, with prominent hyperchro-
matic nuclei. The cells grow in small nests or in cords
with prominent intervening fibrous tissue. In the more
slowly growing cancers, the cells grow in scattered
masses and tend to form acinar or tubular structures.
In those more rapidly growing, the cells are scattered
individually without histologic resemblance to normal
structure.

The most common breast cancer histology is the
infiltrating ductal carcinoma, accounting for about 75%
of breast cancers. Scirrhous carcinoma is the most
common subtype: well-demarcated hard nodules con-
sisting of cords and nests of malignant ductal cells char-
acterize it. Medullary and mucinous forms are also
recognized.

At one time, radical mastectomy was the treatment
of choice, yielding 70% 5-year survival if the axillary

300 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 13-18 The Breast

INTRADUCTAL AND
LOBULAR ADENOCARCINOMA

The two main types of breast adenocarcinomas are Mass clinically presenting
ductal carcinomas (85%) and lobular carcinomas. Based in left breast
on the tumor’s histology, these are also sometimes
classed as papillary adenocarcinomas; carcinomas with Mass seen in
gelatinous, mucoid degeneration; or as a kind of intra- cross section
ductal carcinoma that forms plugs in preexisting ducts of breast
and circumscribed rings of carcinoma cells. These
forms of circumscribed adenocarcinomas bulge out- Papillary adenocarcinoma. Sheets Duct cancer (comedo- Gelatinous carcinoma. Clusters
wardly from the chest wall rather than retract inwardly of tumor cells with hyper- carcinoma). Nests of tumor of malignant cells (arrows)
as in the infiltrating form. Skin adherence or ulceration chromatic nuclei from a large cells with central foci of embedded in thick gelatinous
and axillary node involvement occur much later in the growth with papillary projections necrosis (arrow) material
course of the disease than in the ordinary scirrhous (see cross section above)
form. The tumors progress slowly to an immense size.
The most common type of adenocarcinoma is ductal plasma cells. Colloid or gelatinous carcinomas have a and to involve both breasts more often than infiltrating
carcinoma, which begins in the cells of the ducts. similar soft consistency, with extensive deposition of ductal carcinoma. On palpation, these growths feel
Lobular carcinoma begins in the lobes or lobules and extracellular mucin. boggy and semimovable and are dependent and heavy
is more often found bilaterally than are other types of when the breast is moved upward. The papillary carci-
breast cancer. The cancer is classified based on the Infiltrating lobular carcinomas are histologically nomas may contain a cystic cavity with blood. The
predominant histologic cells; however, several cellular notable for the uniformity of the small, round neoplas- intraductal carcinomas form plugs (comedones), which
patterns may be found in any one tumor. tic cells. Histologic subdivisions of infiltrating lobular may be expressed from the ducts. On cross section the
carcinoma include small cell, round cell, and signet cell gelatinous carcinomas contain a characteristic slimy,
In intraductal carcinoma in situ, the cellular abnor- carcinomas. Often the malignant epithelial cells infil- gray, mucoid material that spills from the tumor, which
malities are limited to the ductal epithelium and have trate the stroma in a single file fashion. This cancer is honeycombed with this substance.
not penetrated the basement membrane of the duct. It tends to have a multicentric origin in the same breast
is most common in perimenopausal and postmeno-
pausal women. Because the disease does not produce a
definitive mass, intraductal carcinoma in situ is not
usually detected by palpation. The histologic diagnosis
of intraductal carcinoma in situ includes a heteroge-
neous group of tumors with varying malignant poten-
tial. Carcinoma develops in approximately 35% of
women with this disease within 10 years of initial diag-
nosis, and 5% to 10% of women will have a simultane-
ous invasive carcinoma in the same breast at the time
of biopsy.

Unlike intraductal carcinoma in situ, lobular carci-
noma in situ should not be treated as a cancer or cancer
precursor but rather as a marker for an increased breast
cancer risk. It has a much greater tendency to be bilat-
eral and to present as multifocal disease. Three of four
patients with lobular carcinoma in situ are in the pre-
menopausal age group. The latent period to the devel-
opment of invasive carcinoma is longer than with
intraductal carcinoma in situ; often more than 20 years
will elapse before infiltrating carcinoma develops.
Approximately 20% of women with this disease eventu-
ally develop invasive breast carcinoma. Paradoxically,
most of these subsequent carcinomas are ductal, not
lobular.

In cases of infiltrating ductal carcinoma, nonuniform
malignant epithelial cells of varying sizes and shapes
infiltrate the surrounding tissue. The degree of fibrous
response to the invading epithelial cells determines the
firmness to palpation and texture during biopsy. Often
the stromal reaction may be extensive. Approximately
10% of infiltrating ductal carcinomas are of a uniform
histologic picture and are classified as medullary,
colloid, comedo, tubular, or papillary carcinomas. In
general, the specialized forms are grossly softer, mobile,
and well delineated. They are usually smaller and have
a more optimistic prognosis than the more common
heterogeneous variety. Medullary carcinomas are soft,
with extensive stromal infiltration by lymphocytes and

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Plate 13-19 Reproductive System
Inflammatory carcinoma

INFLAMMATORY CARCINOMA

Inflammatory or acute carcinoma, formerly designated Invasion of dermal lymphatics Inflamed skin
as carcinomatous mastitis, is more often observed in
patients with obese breasts or during pregnancy and Carcinoma forming Recurrent cancer
lactation, from which is derived another older term, along surgical wound
lactation cancer. Inflammatory carcinomas comprise trastuzumab) for patients whose tumors overexpress
approximately 1% to 5% of all breast cancers. This symptoms are usually less than 4 months in duration. the HER-2 tumor protein.
form is recognized clinically as a rapidly growing, Treatment consists of chemotherapy, targeted surgery,
highly malignant carcinoma, with infiltration of malig- radiation therapy, and hormonal therapy, but 5-year Tissue sections through a region with inflammatory
nant cells into the lymphatics of the skin, which pro- survival is only in the range of 25% to 50% with recur- cancer exhibit relatively few signs of acute inflamma-
duces a clinical picture that simulates a skin infection. rences common. This is significantly lower than for tion. The paramount characteristic is the blockage of
There is not a specific histologic cell type. In the TNM patients with other types of breast cancer. Chemother- lymphatics and superficial blood vessels with invading
staging system for breast cancer, inflammatory cancer apy is generally the first treatment followed by targeted cancer cells. This same metastatic process into the sub-
has its own classification, T4d, and by definition, is surgery. Additional treatments may include additional cutis is seen in preparations from a lenticular cancer, or
staged as stage IIIb or above. (Stage IIIB breast cancers chemotherapy, hormonal therapy, or the recently carcinoma en cuirasse, where the invasion proceeds
are locally advanced; stage IV breast cancer is cancer added modality of special targeted therapy (such as more slowly, more diffusely, and without edema.
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.

Inflammatory breast cancer tends to be diagnosed in
younger women compared to other breast cancers, and
it occurs more frequently and at a younger age in blacks
than in whites. Like other types of breast cancer,
inflammatory breast cancer can occur in men, but
usually at an older age than in women. There is some
early evidence for an association between family history
of breast cancer and inflammatory cancers, but more
studies are needed.

The appearance of a rapidly widening area of
inflamed skin usually occurs early in the disease and
may precede the discovery of the underlying tumor.
The dermal spread is caused by retrograde extension of
the cancer cells through the lymphatics of the skin. The
majority of cases are of the primary form, that is, when
the patient has noted a small tumor in the breast or
axilla only a few weeks prior to the appearance of
inflammatory signs. The presence of the tumor in the
secondary form antedates the skin inflammation by
months. The tumor might already have reached a large
size, or the skin changes may fall upon a mastectomy
scar. The changes in the skin are characterized by a
reddish or purplish discoloration and edema producing
the characteristic orange peel effect. Multiple small
nodules may also be present. The inflamed discolor-
ation may extend up the neck and down the arm on the
affected side, or across to the opposite breast and shoul-
der. A low-grade fever, enlarged axillary nodes, and an
elevated leukocyte count, which may reach 15,000,
accompany the carcinomatous invasion of the skin.
Adenopathy may extend to the groin, and the skin over
the abdomen may be inflamed; hence the term erysip-
eloid cancer has also been used. In a typical case the

302 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 13-20 The Breast

Generation
I

II

III

IV

Squares represent males and circles represent females, diagonal lines indicate
decreased, shaded individuals are affected, arrow indicates the proband.

HEREDITARY BREAST DISEASE

Approximately 5% to 10% of breast cancers have a any associated clinical syndrome have not yet been to 35 years. They made no recommendation for or
familial or genetic link. In these families, breast cancer determined. against prophylactic surgery in these patients. Although
tends to occur at a younger age and there is a higher there is good evidence suggesting that tamoxifen can
prevalence of bilateral disease. The association between Presently, management recommendations for women significantly reduce the risk of breast cancer in women
inherited breast and ovarian cancer has lead to the term with BRCA mutations vary from earlier and increased at high risk, there are still no conclusive data on the use
hereditary breast ovarian cancer syndrome (HBOC). interval screening tests to prophylactic measures such of tamoxifen in a population of patients with a BRCA
as chemoprevention with tamoxifen, mastectomy, and gene mutation. There are currently no effective screen-
Hereditary breast ovarian cancer syndrome is char- oophorectomy. A task force has recommended breast ing techniques for the early detection of ovarian cancer.
acterized by an early age of onset of breast cancer (often self-examination beginning by age 20, annual or semi- For this reason, some women at high risk choose to
before age 50). In affected families, there is a family annual clinical examination beginning at ages 25 to 35 undergo prophylactic oophorectomy.
history of both breast and ovarian cancer and an years, and annual mammograms beginning at ages 25
increased chance of bilateral cancers or an individual
with both breast and ovarian cancer. Pedigrees will
demonstrate an autosomal dominant pattern of inheri-
tance (vertical transmission through either the mother’s
or father’s side of the family). Members of these families
also have an increased incidence of tumors of other
organs, such as the fallopian tube or prostate. Families
with cases of male breast cancer and families of
Ashkenazi Jewish ancestry are at increased risk for this
syndrome (greater than 10-fold increase).

At least two genes have been found in which muta-
tions can cause this pattern of inherited breast and/or
ovarian cancer. It appears that germline mutations of
the BRCA1 tumor suppressor gene on chromosome
17q are responsible for a large proportion of these
hereditary cancers. However, not all families in which
hereditary breast or ovarian cancer is suspected are
found to have mutations in either BRCA1 or BRCA2.
Having a single mutation in one of these genes does not
appear to be sufficient to have a tumor develop. It is
generally thought that mutations in both alleles, due to
chemical, physical, or biologic environmental expo-
sures, or chance errors in cell replication, must occur
for tumor development. To date, hundreds of unique
mutations have been identified in both BRCA1 and
BRCA2, most due to sporadic mutations unique to the
individual or family. Specific recurring mutations have
been found in individuals of Ashkenazi Jewish descent
and persons from the Netherlands, Iceland, and
Sweden. Mutations in the BRCA family of genes confer
a lifetime risk of breast cancer that approaches 85%,
though the risk of ovarian cancer is variable depending
on the location of the mutation. The average lifetime
risk of ovarian cancer is approximately 40% to 50%.

The BRCA2 gene resides on chromosome 13, and the
DNA sequence was determined in 1995. A woman with
a BRCA2 gene mutation also has an 85% lifetime risk
of breast cancer and a 15% to 20% lifetime risk of
ovarian cancer. This mutation is associated with male
breast cancer, conferring a 5% to 10% lifetime risk
for a male with the mutation. BRCA3 gene has been
recently mapped to chromosome 8, but the details of

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Plate 13-21 Reproductive System

Eczematous type of Paget disease

PAGET DISEASE OF THE NIPPLE

Paget disease of the breast is rare, comprising between Ulcerating type of Paget disease Duct invasion
1% and 2% of breast carcinomas. It is a malignant
process that involves the nipple and areola. Rarely, it Paget cells in epidermis (arrows) on palpation. Although biopsy of the nipple should
may also involve the skin of the vulva. This lesion has be avoided whenever possible, a study of the tissue
an innocent appearance that looks like eczema or der- Therapy is focused on treatment of the underlying becomes imperative in certain cases, for example, when
matitis of the nipple. The clinical picture is produced malignancy and is most commonly surgical. When the skin lesion does not heal within a matter of days
by an infiltrating ductal carcinoma that invades the epi- limited to the nipple, breast conservation may be pos- under hygienic measures or on application of pet-
dermis. Paget disease has an excellent prognosis. sible. Adjunctive hormonal or chemotherapy is often rolatum. Even if the gland does not appear to be
recommended based on cell type and stage. Radiation involved, it is important that the biopsy specimens
Paget carcinoma is characterized by invasion of the therapy is a common adjuvant therapy following breast- obtained from such patients should contain not only
nipple or areola and the mouths of the larger ducts by conserving surgery. skin but also a representative portion of the mammary
large malignant cells resembling those seen in transi- ducts.
tional cell carcinoma of the mucous membranes else- The differential diagnosis from benign lesions of the
where in the body. It is thought to arise in the nipple, such as keratosis and ulcers, depends largely
dermoepidermal junction from multipotent cells that on the discovery of a mass in the underlying tissue
can differentiate into either glandular or squamous
cells. The average age at diagnosis is 62 for women and
69 for men. The duration of symptoms, which is
approximately 3 years, and the symptoms, referable to
the nipple, are characteristic clinical features of the
disease. Paget disease is almost always associated with
infiltrating or intraductal carcinoma in deeper parts of
the breast (95% of cases). In most of the cases, involve-
ment of the nipple precedes a definite tumor of the
breast, but in a few instances the lump in the breast may
be noted first. The disease is bilateral in less than 5%
of the cases. Mammography is usually used to detect
deeper lesions and lesions in the contralateral breast. In
addition, a touch smear obtained by softening the crust
with saline and gently scraping the surface often dem-
onstrate the characteristic Paget cells.

The involved nipple has either a red granular appear-
ance or is crusted and eczematous. After an interval of
a few months, both the eczematous and the granular
types undergo ulceration. Serum or blood oozes from
the denuded region. A small amount of blood may be
obtained on manipulation. In early stages, the zone
immediately surrounding the nipple is indurated,
whereas in later stages both the central zone and the
periphery may be involved by a hard mass. Palpable
axillary nodes are found in about 50% of the cases.

Grossly, besides the changes in the nipple, the larger
ducts are dilated and filled with blood or inspissated
secretion. Microscopically, large cells with deep stain-
ing or vesicular nuclei and pale-staining cytoplasm are
found in the epidermis of the nipple. Mitotic figures are
frequent. Dermal infiltrates of large neoplastic cells
(Paget cells) are defining features of this condition.
These cells have abundant clear cytoplasm with mucin
and irregular prominent nucleoli. Most often, these
cells arise from infiltrating ductal carcinoma. In cases
where the cells in the nipple have infiltrated beyond the
basement membrane, they invade both the larger ducts
and the breast tissue.

304 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Plate 13-22 The Breast

MALIGNANCIES OF MALE BREAST

Carcinoma of the male breast is a rare disease and Sarcoma Ulcerating scirrhous carcinoma
represents only about 0.1% of all-site malignancy and
is approximately 100 times less common than breast breast cancer has a worse prognosis may stem from the Although rare, various types of sarcomas of the male
cancer in women, accounting for about 1% of all breast tendency of these tumors to be diagnosed at a later breast have been reported. The majority are either
cancers. In the United States, male breast cancer stage. Prognostic factors such as the size of the lesion fibrospindle or lymphosarcomas. These are rapidly
accounts for fewer than 2000 cases per year and fewer and the presence or absence of lymph node involvement growing tumors with early attachment to the overlying
than 500 deaths. The mean age at diagnosis is between correlate well with prognosis. Whether ploidy and skin and are highly malignant. Simple mastectomy is
60 and 70 years, though men of any age can be affected number of cells in S phase correlate with survival awaits employed. If lympho- or liposarcoma is disclosed by
with the disease. The average duration of symptoms more definitive data. Estrogen-receptor and progester- histologic examination, postoperative irradiation should
before diagnosis approximates 2 years. This long dura- one-receptor status and HER2/neu gene amplification be given.
tion is probably explained by the disregard of this rudi- are also being evaluated.
mentary 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.

Because of the small amount of fatty stroma and
glandular tissue in the male breast, ulceration of the
skin or involvement of the nipple is an almost regular
symptom of onset. Pain and trauma are often given as
the reasons for consulting the doctor. The tumor is
hard, irregular, and firmly attached to the overlying and
underlying structures. Ulceration is common. The axil-
lary lymph nodes are usually enlarged.

Differential diagnosis from gynecomastia can be
made with fair certainty, taking the age of the patient
into account. Nodular tumors in the middle-aged man
should be excised and examined histologically. Even
though a fibroadenoma, an intracystic papilloma, a
lipoma or a benign epidermoid cyst usually leaves the
skin over the nodule freely movable in contrast to car-
cinoma, and though these nodules are also softer than
cancer, it is not recommended to exclude a malignant
growth based only on these clinical signs.

On cross section, the neoplasm is firm, white, and
infiltrating. A higher percentage of these growths are
low-grade adenocarcinomas, probably arising in the
developmental anomalies of the sweat glands or
mammary epithelial structures. Pathologically, most
carcinomas of the male breast resemble the infiltrating
form found in the female breast, with infiltrating ductal
cancer the most common tumor type. Lobular cancer
has been described as well. Inflammatory carcinoma and
Paget disease of the nipple have also been seen in men,
but lobular carcinoma in situ has not. Lymph node
involvement and the hematogenous pattern of spread
are similar to those found in female breast cancer. The
TNM staging system for male breast cancer is identical
to the staging system for female breast cancer.

Overall survival is similar to that of women with
similar stage breast cancers. The impression that male

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 305

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SELECTED REFERENCES

Section 1 AUA Clinical Practice Guideline: Report on the Evaluation Polycystic ovary syndrome. ACOG Practice Bulletin No. 108.
of the Azoospermic Male. http://www.auanet.org/content/ American College of Obstetricians and Gynecologists. Obstet
Reproductive Tract Development guidelines-and-quality-care/clinical-guidelines/main-reports/ Gynecol 2009;114:936-9.
azoospermicmale.pdf. 2001.
Balen, AH, Creighton SM, Davies MC, MacDougall J, Stanhope Section 11
R, eds. Paediatric and Adolescent Gynaecology: A Multidisci- AUA Clinical Practice Guideline: Report on the Management
plinary Approach. Cambridge, UK: Cambridge University Press; of Obstructive Azoospermia. http://www.auanet.org/content/ The Ovum and Reproduction
2004. guidelines-and-quality-care/clinical-guidelines/main-reports/
obstructiveazoospermia1.pdf. 2001. Bagshawe A, Taylor A. ABC of Subfertility. Counselling. BMJ
Section 2 2003;327(7422):1038-40.
Turek PJ, Cha I, Ljung B-M, Conaghan J. Diagnostic findings from
The Penis and Male Perineum testis fine needle aspiration mapping in obstructed and non- Smith S, Pfeifer SM, Collins JA. Diagnosis and management of
obstructed azoospermic Men J Urol 2000;163:1709-16. female infertility. JAMA 2003;290:1767-70.
Lue TF. Erectile Dysfunction. N Engl J Med 2000;342(24):
1802-13. Masters V, Turek PJ. Ejaculatory Physiology and Dysfunction. Frey KA, Patel KS. Initial evaluation and management of infer-
Urol Clin North Am 2001;28:363. tility by the primary care physician. Mayo Clin Proc 2004;79:
AUA Clinical Practice Guidelines: Management of Erectile Dys- 1439-43.
function. http://www.auanet.org/content/guidelines-and-quality- Smith JF, Turek PJ. Ejaculatory Duct Obstruction. Urol Clin
care/clinical-guidelines/main-reports/priapism/online.pdf. 2006. North Am 2008;35:221-7. Lobo RA. Infertility. In: Katz VL, Lentz GM, Lobo RA,
Gershenson DM, eds. Comprehensive Gynecology, 5th ed.
AUA Clinical Practice Guidelines: Management of Priapism. Section 6 Philadelphia: Mosby/Elsevier; 2007. p. 1030-2.
http://www.auanet.org/content/guidelines-and-quality-care/
clinical-guidelines/main-reports/priapism/online.pdf. 2008. The Vulva Rowell P, Braude P. Assisted conception. I—general principles.
BMJ 2003;327(7418):799-801.
Section 3 Diagnosis and management of vulvar skin disorders. ACOG Prac-
tice Bulletin No. 93. American College of Obstetricians and Section 12
The Scrotum and Testis Gynecologists. Obstet Gynecol 2008;111:1243-53.
Pregnancy
Frenkl T, Potts J. Sexually transmitted diseases. In: Wein AJ, Vaginitis. ACOG Practice Bulletin No. 72. American College of
Kavoussi L, Novick AC, Partin AW, Peters CA, editors. Campbell- Obstetricians and Gynecologists. Obstet Gynecol 2006;107: Diagnosis and treatment of gestational trophoblastic disease.
Walsh Urology, 9th ed. Philadelphia: Saunders; 2007, p. 371-85. 1195-06. ACOG Practice Bulletin No. 53. American College of Obstetri-
cians and Gynecologists. Obstet Gynecol 2004;103:1365-77.
Link RE. Cutaneous diseases of the external genitalia. In: Wein AJ, Vulvodynia. ACOG Committee Opinion No. 345. American
Kavoussi L, Novick AC, Partin AW, Peters CA, editors. College of Obstetricians and Gynecologists. Obstet Gynecol Management of alloimmunization during pregnancy. ACOG Prac-
Campbell-Walsh Urology, 9th ed. Philadelphia: Saunders; 2007. 2006;108:1049-52. tice Bulletin No. 75. American College of Obstetricians and
p. 405-35. Gynecologists. Obstet Gynecol 2006;108:457-64.
Section 7
Schlegel PN, Hardy MP, Goldstein M. Male reproductive physiol- Medical management of ectopic pregnancy. ACOG Practice
ogy. In: Wein AJ, Kavoussi L, Novick AC, Partin AW, Peters The Vagina Bulletin No. 94. American College of Obstetricians and Gyne-
CA, editors. Campbell-Walsh Urology, 9th ed. Philadelphia: cologists. Obstet Gynecol 2008;111:1479-85.
Saunders; 2007. p. 577-608. Centers for Disease Control and Prevention. Toxic-shock syn-
drome United States. MMWR 1990;39:421-4. Postpartum hemorrhage. ACOG Practice Bulletin No. 76. Ameri-
Schneck FX, Bellinger ME. Abnormalities of the testes and scrotum can College of Obstetricians and Gynecologists. Obstet Gynecol
and their surgical management. In: Wein AJ, Kavoussi L, Novick Eckert LO, Lentz GM. Infections of the lower genital tract. In: 2006;108:1039-47.
AC, Partin AW, Peters CA, editors. Campbell-Walsh Urology, Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Compre-
9th ed. Philadelphia: Saunders; 2007. p. 3761-98. hensive Gynecology, 5th ed. Philadelphia: Mosby/Elsevier; 2007. Vaginal birth after previous cesarean delivery. Practice Bulletin No.
p. 596-8. 115. American College of Obstetricians and Gynecologists.
Sigman M, Jarow J. Male infertility. In: Wein AJ, Kavoussi L, Obstet Gynecol 2010;116:450-63.
Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh Section 8
Urology, 9th ed. Philadelphia: Saunders; 2007. p. 609-53. Section 13
The Uterus and Cervix
Turek PJ. Practical approach to the diagnosis and management of The Mammary Gland
male infertility. Nat Clin Pract Urol 2005;2:1-13. American College of Obstetricians and Gynecologists. Chronic
pelvic pain. ACOG Practice Bulletin No. 51. Obstet Gynecol Breast cancer screening. ACOG Practice Bulletin No. 42. American
Section 4 2004;103:589-605. College of Obstetricians and Gynecologists. Obstet Gynecol
2003;101:821-32.
The Seminal Vesicles and Prostate American College of Obstetricians and Gynecologists. Medical
Management of Endometriosis. Washington, DC: ACOG; 1999. Elective and risk-reducing salpingo-oophorectomy. ACOG Prac-
AUA Best Practice Statement: PSA. http://www.auanet.org/ ACOG Practice Bulletin 11. tice Bulletin No. 89. American College of Obstetricians and
content/guidelines-and-quality-care/clinical-guidelines/main- Gynecologists. Obstet Gynecol 2008;111:231-41.
reports/psa09.pdf. 2009. Turek PJ. Practical approach to the diagnosis and management of
male infertility. Nature Clin Pract Urol 2005;2:1-13. Hereditary breast and ovarian cancer syndrome. ACOG Practice
AUA Clinical Practice Guidelines: Management of Clinically Bulletin No. 103. American College of Obstetricians and Gyne-
Localized Prostate Cancer. http://www.auanet.org/content/ Section 9 cologists. Obstet Gynecol 2009;113:957-66.
guidelines-and-quality-care/clinical-guidelines/main-reports/
priapism/online.pdf. 2006. The Fallopian Tubes Rajaratnam K, Kumar PD, Sahasranam KV. Supernumerary nipple
as a cutaneous marker of mitral valve prolapse in Asian Indians.
Turek PJ. Seminal Vesicle and Ejaculatory Duct Surgery. In: Eckert LO, Lentz GM. Infections of the upper genital tract. In: Am J Cardiol 2000;86(6):695-7, A9.
Graham SD, ed. Glenn’s Urologic Surgery, 6th ed. Philadelphia: Katz VL, Lentz GM, Lobo RA, Gershenson DM. Comprehen-
Lippincott, Williams & Wilkins; 2004. p. 439-45. sive Gynecology. 5th ed. Philadelphia: Elsevier; 2007. p. 607-32.

Section 5 Section 10

Sperm and Ejaculation The Ovaries

WHO Laboratory Manual for the Examination and Processing of Management of adnexal masses. ACOG Practice Bulletin No. 83.
Human Semen. 5th ed. Cambridge, UK: Cambridge University American College of Obstetricians and Gynecologists. Obstet
Press; 2010. Gynecol 2007;110:201-14.

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INDEX

A Amniotic fluid Azoospermia, 70
pulmonary embolism by, 260 diagnostic procedures for, 105
Abdominal aorta, 159 volume of, 245 from excurrent duct obstruction, 103
Abdominal pregnancy, 251 genetic causes of, 102
Abdominal testis, 15, 64 Anal canal, 154 microsurgery for, 104
Abortion Anal (rectal) nerve, 115, 263
Anal pit, 4 B
complete versus incomplete, 252 Anal sphincter muscle, external, 20, 22, 23, 111, 112, Balanitis, 40
of ectopic pregnancy, 250 Balanitis xerotica obliterans, 40, 46
during first trimester, 243 114, 130, 132, 154 Barrier devices, contraceptive, 240
inevitable, 252 Anal triangle, 24, 112 Bartholin abscess, 121
missed, 252 Anal tubercle, 4 Bartholin duct, 110, 135
recurrent, 238 Anaphylactoid syndrome of pregnancy, 260 Bartholin gland
during second trimester, 244 Androgen. See also Testosterone.
septic, 178, 252 cancer of, 135
threatened, 252 in delayed puberty, 69 cyst of, 124
Abruptio placentae, 258 in gonadal function, 5, 6 endometriosis in, 149
Abscess in gynecomastia, 290 primordium of, 3
appendiceal, 228 in hypergonadotropic hypogonadism, 65 topographic relationships of, 110, 112, 114, 130, 135
Bartholin, 121 in hypogonadotropic hypogonadism, 66, 67 Bartholinitis, 121
of breast, 291 in Klinefelter syndrome, 68 Basal cell carcinoma, of vulva, 126
of Douglas pouch, 194 maternal use of, virilism from, 18 Battledore placenta, 256
parametrial, 191, 192 in menopausal/postmenopausal period, 206 Bed rest, for cervical insufficiency, 253
of prostate, 80 in polycystic ovary syndrome, 221 Birth. See Delivery.
of testis, 71 in prostate development, 77 Bisphenol A, precocious puberty from, 14
tuboovarian, 194, 197, 211 secretion of, by Sertoli-Leydig cell tumors, 219 Bladder
Acne, 8 Androgen deprivation therapy blood supply of, 25
Acrosomal reaction, in fertilization, 233 in polycystic ovary syndrome, 221 complications of, in benign prostatic hyperplasia,
Activin, in gonadal function, 5, 6 in prostate cancer, 87
Adeno-acanthoma in puberty abnormalities, 10-12 84
of ovary, 225 Androgen insensitivity syndrome, 17 distended, 228
of uterine corpus, 185 Androstenedione, 7 endometriosis of, 210
Adenocarcinoma in polycystic ovary syndrome, 221 exstrophy of, epispadias with, 33
of breast, 301. See also Breast, carcinoma of. Anejaculation, 107 infection of, in pregnancy, 272
of cervix, 173 Anemia, in erythroblastosis fetalis, 279 nerve supply of, 29
of uterine corpus, 185 Anesthesia prolapse of, 144
of vagina, 150 for cesarean section, 269 reconstruction of, 93, 94
of vulva, 126 for labor pain, 263 rupture of, 78
Adenofibroma Angiokeratoma, 63 topographic relationships of, 20, 78, 130, 134, 154,
of breast, 290, 298, 299 Angioneurotic edema, of vulva, 118
of ovary, 214 Annular lesions, syphilitic, 61 155, 156, 157, 159
Adenoma. See also Nodules. Anococcygeal body, 111, 112, 131, 132 Bladder neck hyperplasia, 82
adrenal, 219 Anococcygeal nerve, 115 Blastodermis vesicle (blastocyst), 242
of spermatic cord, 97 Anorchia, 65 Bleeding. See Hemorrhage.
of vulva, 125 Anorgasmia, male, 107
Adenomyosis, 177 Antibiotics menstrual. See Menstruation.
Adenosis, of breast, 296 for mastitis, 291 uterine. See Uterine bleeding.
Adnexa for toxic shock syndrome, 142 vaginal. See Vaginal bleeding.
testicular, mesothelioma of, 97 Antidepressants, for vulvar vestibulitis, 120 Blindness, cortical, in preeclampsia/eclampsia, 274
uterine, 160 Antimüllerian hormone, in sexual differentiation, 2, 3 Blood supply. See also named arteries and veins.
Antisperm antibody test, 101 of bladder, 25
torsion of, 217 Anus, 4, 21, 23, 110, 154 of breast, 285
Adolescents, hormonal influences in, 205 Aorta, abdominal, 25, 27, 51, 155, 156, 159 of endometrium, 162
Adrenal adenoma, 219 Aortic lymph node, 28, 158 of genitalia, 25, 26
Adrenal feminizing neoplasms, gynecomastia in, Aortic (intermesenteric) plexus, 30, 159, 263 of pelvic viscera, 156
Aorticorenal ganglion, 29, 263 of pelvis, 25
290 Aphallia, 16 of perineum, 26, 114
Adrenal hyperplasia, congenital Appendiceal abscess, 228 of testis, 27, 51
Appendicitis, 195 of uterus, 156, 162
precocious puberty in, 11-12 Appendix epididymidis, 3, 50 of vagina, 130
sexual ambiguity from, 18 Appendix testis, 3, 50 of vulva, 114
Adrenal rests, 12 torsion of, 59 Blood volume, maternal, 245
tumors of, 219 Appendix vesiculosa, 3 Body composition, gender differences in, 9
Adrenocorticotropic hormone (ACTH) Arcuate artery, 162 Boil, scrotal, 60
in precocious puberty, 11-12 Arcuate ligament of pubis, 24 Bone growth, gender differences in, 9
in sex hormone production, 7 Areola, 284 Bone scan, in prostate cancer, 86
Albarran subcervical glands, 77 Areolar glands, 284 Bowel, endometriosis of, 210
Allantois, 2 Arteries. See Blood supply; named arteries. Bowen disease, 46
Allergic eczema, scrotal, 55 Arteriovenous anastomosis, 247 Bowenoid papulosis, 46
Alpha-adrenergic blocking agents, for benign prostatic Ascites, 223, 229 Brachial artery, 285
Asherman syndrome, 178 Brachial plexus, 285
hyperplasia, 84 Aspermia, 107 Brain lesions, in preeclampsia/eclampsia, 275
Alveolar carcinoma, of ovary, 225 Autonomic nervous system, 29, 159 Braxton-Hicks contractions, 245
Amenorrhea Avulsion, of scrotum or penis, 57 BRCA mutations
Axillary lymph node, 286 in hereditary breast ovarian cancer syndrome, 303
hypogonadal, from hyperprolactinemia, Axillary vein, 285 in male breast cancer, 303
292 Axoneme, 100 in tubal carcinoma, 199

in ovarian dysgenesis, 208 309
Amniocentesis, 243, 254
Amniochorionic membrane, 245
Amnion, 242, 246, 247, 256

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Breast, 284-305 Bulbospongiosus reflex, 30 Index
abscess of, 291 Bulbourethral (Cowper) gland, 3, 20, 24, 31, 76
accessory tissue of, 289 Buschke-Lowenstein tumors, 46 Cesarean section
adenocarcinoma of, 301 scar from, uterine rupture in, 270
adenosis of, 296 C technique of, 268-269
anatomy of, 284-286 Calcification, in fibroids, 180
areola of, 284 Calculi, prostatic, 81 Chancre, 42, 61, 122, 140, 170
blood supply of, 285 Camper fascia, 21, 111 Chancroid, 43, 123
budding of, 287 Cancer. See also Carcinoma; Sarcoma. Chimney sweeps’ cancer, 63
cancer screening for, 294 Chlamydia trachomatis, 43, 123, 171
carcinoma in situ of, 301 Bartholin gland, 135 Chlamydial infection, salpingitis in, 191, 194
carcinoma of, 300-305 paraffin, 63 Chocolate cyst, 210
clinical findings in, 300 testicular, 73-74 Cholesterol, 7
colloid, 301 urethral, 48 Chordee, 37
comedo, 301 Carcinoma. See also specific types, e.g., Squamous cell Chorioangioma, 261
ductal, 301 Choriocarcinoma (chorioepithelioma), 262
forms of, 300, 301 carcinoma.
gelatinous, 301 of cervix, 151, 158, 172-174 metastatic, 151
hereditary, 303 of clitoris, 126 of testis, 74
histology of, 300 of endometrium, 184-185 theca lutein cyst associated with, 220
incidence of, 300 of fallopian tube, 195, 199 of uterus, 151
infiltrating, 300, 301 of ovary. See Ovary, carcinoma of. Chorion, 242, 247, 256
inflammatory, 302 of prostate, 77, 85-87 Chorion frondosum, 246
lobular, 301 renal cell, metastatic, 126, 151 Chorion laeve, 246
in male, 303, 305 of scrotum, 63 Chorionic gonadotropin, human. See Human chorionic
management of, 300 of sigmoid colon, 229
medullary, 301 of vagina, 150 gonadotropin.
Paget, 304 of vulva, 126 Chorionic plate, 247
papillary, 301 Carcinoma in situ Chorionic villi, 246
congenital anomalies of, 289 of breast, 301 Chorionic villus sampling, 243
cysts of, 297 of testis, 74 Chromosome(s)
development of, 8, 287 of uterine corpus, 185
asymmetry in, 289 Carcinosarcoma, of prostate, 88 abnormalities of
in male, 290 Cardiac output, maternal, 245 azoospermia from, 102
premature, 13 Cardinal (transverse cervical or Mackenrodt) ligament, gonadal dysgenesis associated with, 208
engorgement of, painful, 291 recurrent abortion associated with, 238
fascia of, 284 133, 155, 161, 166
fatty tissue in, 284 Cardinal movements of fetus, 264 sex, 2
fibroadenoma of, 290, 298, 299 Caruncle, urethral, 125 sperm, 101
fibrocystic changes in, 295-297 Cavernous artery of penis, 26, 31 Y, defects in, 102
glandular tissue in, 284 Cavernous nerve, 30, 76 Circumcision, 36
hormonal influences on, 205, 287, 288 Cavernous venous plexus, 134 female, 127
hypertrophy of Cecum, low-lying, 228 for penile cancer, 47
in male, 68, 290 Celiac ganglion, 29, 263 Circumflex iliac vein node, 113
precocious, 289 Cerclage, for cervical insufficiency, 253 Clavicle, 284
virginal, 289 Cervical glands, infection of, 171 Clear cell carcinoma
imaging of, 294 Cervical os, stricture of, 169 of ovary, 225
infection or inflammation of, 291 Cervical pregnancy, 251 of uterine corpus, 185
innervation of, 284 Cervicitis, 170, 171 of vagina, 150
during lactation, 288 Cervix Climacteric period, 206
lobules of, 284, 287 Climax, male, 107
lymphatic drainage of, 286 anatomy of, 154, 160 Clitoral index, 110
milk secretion by, 288 carcinoma of, 151, 172-174 Clitoridectomy, 127
milky fluid discharge from, 292 Clitoris
myxoma of, giant, 298, 299 ACS classification of, 171 absence of, 16
neonatal phenomena in, 287 cytology of, 171 artery of, 114
nipple of, 284 extension and metastasis of, 174 carcinoma of, 126
accessory, 289 sentinal lymph node biopsy for, 158 crus of, 133
Paget disease of, 304 staging of, 172, 174 hypertrophy of, 18, 219
supernumerary, 289 treatment of, 173, 174 tear of, obstetric, 266
nodules in, 296 types of, 173 topographic relationships of, 4, 110, 112, 130
pain in, 291, 295, 296 chancre on, 170 Clitoromegaly, 18
papilloma of, intracystic, 298 chlamydial infection of, 171 Cloaca, 2
during pregnancy, 288 contraceptive barrier devices for, 240 Cloquet lymph node, 113
sarcoma of, 299, 305 dilation of, 264 Clunial nerve, 115
size of, 284 pain associated with, 263 Coccygeus (ischiococcygeus) muscle, 131, 132, 159
structure of, 284 duplication of, 165 Coccyx, 23, 24, 112, 131
thrombophlebitis of, 293 endometriosis in, 149 Colles (dartos) fascia, 20, 21, 22, 23, 24, 26, 39, 50, 114,
ultrasonography of, 294, 296 erosion of, 170
eversion of, congenital, 170 130, 133, 134
Breastfeeding, 288 gonorrhea of, 171 Colliculus, 76, 77
breast engorgement before, 291 insufficiency of, 253 Colon
mastitis during, 291 at introitus, 167
preparation for, 245 laceration of, 169, 266 pelvic, 154
lymphatic drainage of, 158 sigmoid, 155, 159
Brenner (transitional cell) tumor of ovary, 222 moniliasis in, 170
Broad ligament, 130, 133, 154, 155, 160 polyps of, 169 carcinoma of, 229
Bromocriptine, for galactorrhea, 292 retention cysts of, 170 redundant, 228
Buck fascia, 20, 21, 22, 23, 25, 26, 39 ripening of, 264 Compressor urethrae muscle, 112, 114, 130, 132,
Bulbocavernosus muscle, 111, 112, 114 sarcoma of, 150 133
Bulbocavernosus reflex, 30, 32 stricture of, 169 Computed tomography
Bulbospongiosus muscle, 20, 22, 26, 133, 134 topographic relationships of, 133, 155 in cervical cancer, 174
trichomoniasis in, 170 in prostate cancer, 86
310 Cesarean hysterectomy, 270 Condylomata acuminata, 61, 125, 148
Condylomata lata, 61, 122
Congenital anomalies
of breast, 289
of fallopian tube, 189-190
of ovary, 207, 208
in Turner syndrome, 207

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Index

Congenital anomalies (Continued) Cyst (Continued) Ductus deferens, 29
of uterus, 137, 165 urachal, 228 artery to, 25, 51
of vagina, 137, 138 of vagina, 148
of vulva, 124 Ductus epididymidis, 52
Contraception, 240. See also specific types, e.g., Oral of wolffian duct, 34 Ductus plexus, 29
contraceptives. Dwarf, pituitary, 66
Cystadenocarcinoma, of ovary, 224 Dysgerminoma, of ovary, 222
Convulsions, in eclampsia, 273 Cystadenofibroma, of ovary, 214 Dysmenorrhea, 164
Corona radiata, 202 Cystadenoma, of ovary, 212, 213, 215
Corpora amylacea, 81 Cystic degeneration, in fibroids, 182 E
Corpus albicans, 204 Cystic fibrosis, male infertility in, 97, 103 Echinococcus (hydatid) cyst, 200, 220
Cystitis, in pregnancy, 272 Eclampsia. See Preeclampsia/eclampsia.
cyst of, 209 Cystocele, 144, 167 Ectoderm, primitive, 242
Corpus cavernosum, 20, 21, 22, 23, 31 Cystoma, of ovary, 212 Eczema, scrotal, 55
Cytogenetic analysis, 102 Edema
rupture of, 38
Corpus luteum, 160, 203 D angioneurotic, of vulva, 118
Dartos (Colles) fascia, 20, 21, 22, 23, 24, 26, 39, 50, 114, in preeclampsia/eclampsia, 273
cyst of, 209 of scrotum, 4, 57
hematoma of, 209 130, 133, 134 Ejaculate, 76
hormone production by, 232, 243, 248 DAX1 gene, in sexual differentiation, 2 Ejaculation disorders, 107
involution of, 204, 232 Decidua, abnormal formation of, placenta accreta in, 259 Ejaculatory duct, 31, 76, 77, 108
mature, 204 Decidua basalis, 242, 246 obstruction of, 103, 108
of pregnancy, 204 Decidua basalis compacta, 247 transurethral resection of, 108
Decidua basalis spongiosa, 247 Elephantiasis
cystic, 209 Decidua capsularis, 242, 246 of scrotum, 62
ruptured hemorrhagic, 209 Decidua marginalis, 246, 247 of vulva, 118
structure of, 202 Decidua vera, 246 Embryonal carcinoma, of testis, 73
Corpus spongiosum, 20, 22, 23, 31 Decidual septum, 247 Embryonal teratoma, of ovary, 216
Cortical blindness, in preeclampsia/eclampsia, 274 Decidual vessels, lipid deposition in, 277 Embryonic development, 243
Cortical necrosis, in preeclampsia/eclampsia, 275 Defeminization, in Sertoli-Leydig cell tumors, 219 Embryonic pole, 242
Corticotropin (adrenocorticotropic hormone; ACTH) Deferential artery, 27, 50, 51 Embryonic reawakening theory of benign prostatic
in precocious puberty, 11-12 Del Castillo syndrome, 70
in sex hormone production, 7 Delivery hyperplasia, 83
Cotyledon, 247, 255 Endocervix, polyps of, 169
Couvelaire uterus, 260 cesarean, 268-269 Endoderm, primitive, 242
Cowper gland, 3, 20, 24, 31, 76 of placenta, uterine inversion after, 271 Endodermal sinus (yolk sac) tumor, of testis, 73
Cremasteric artery, 27 preterm, in multiple gestation, 254 Endometrial (chocolate) cyst, 210
Cremasteric fascia, 50 vaginal Endometrial glands, within myometrium, 177
Cremasteric muscle, 50 Endometrioid tumors, in ovary, 225
Cremasteric vein, 27 after cesarean section, 269 Endometriosis, 149
Cremasteric vessels, 51 lacerations during, 266-267
Cryptorchidism, 54, 64, 237 normal, 264 extrauterine, 177, 210
Cumulus oöphorus, 202, 233 operative, 265 pelvic, 210
Curettage Denonvilliers (rectoprostatic) fascia, 20, 76 sites of, 210
Asherman syndrome after, 178 Dermatitis, scrotal, 55 Endometritis, 171, 179
uterine perforation during, 168 Dermatophytes, scrotal, 55 postpartum, 281
Cutaneous nerve Dermatoses, of vulva, 116 septic, 281
lateral femoral, 29, 30 Dermoid cyst Endometrium
perforating, 115 of ovary, 216, 217 biopsy of, in infertility evaluation, 236
posterior femoral, 30, 115 of spermatic cord, 97 blood supply of, 162
Cyst Desmoid tumors, 228 carcinoma of, 184-185
of Bartholin gland, 124 Detrusor muscle of bladder wall, 134 cyclic changes in, 163, 164, 175, 176, 203, 205
of breast, 297 Dexamethasone, for polycystic ovary syndrome, 221 dyssynchronous, 176
of corpus albicans, 209 DHEA (dehydroepiandrosterone), 7 hormonal influences on, 161, 162, 175, 176, 205
of corpus luteum, 209 DHEA=S (dehydroepiandrosterone sulfate), in polycystic hyperplasia of, 175, 176, 179
dermoid ovary syndrome, 221 polyps of, 169, 179
Diabetic vulvitis, 119 topographic relationships of, 162, 175
of ovary, 216, 217 Diaphragm. See Pelvic diaphragm; Urogenital diaphragm. tuberculosis of, 179
of spermatic cord, 97 Diaphragmatic ligament, 3 Endopelvic fascia, 155
echinococcus (hydatid), 200, 220 Diethylstilbestrol, fallopian tube defects associated with, Endosalpingitis, tuberculous, 198
endometrial, 149 190 Endosalpinx, 188
epoöphoron, 3, 160, 200 Dihydrotestosterone (DHT) Endotheliosis, glomerular capillary, in preeclampsia/
of follicle, 209 in benign prostatic hyperplasia, 83
of Gartner duct, 148 in sexual differentiation, 2, 5, 6 eclampsia, 275
of genitalia, 34 Disorders of sexual development (DSD), 15-18 Enterocele, 145, 167
inclusion Diverticulitis, 229 Entodermal tube, 242
of vagina, 148 Diverticulum, of urethra, 34, 35 Epididymis, 3, 50, 52
of vulva, 124 Donovan bodies, in granuloma inguinale, 44
mesenteric, 229 Donovanosis (granuloma inguinale), 44, 123 absence of, 97
of müllerian duct, 34 Dorsal artery histology of, 52
Nabothian, 170 of clitoris, 114, 130 infection of, 71
of Nuck canal, 124 of penis, 24, 25, 26, 27, 51 nerve supply of, 30
of ovary. See Ovary, cysts of. Dorsal nerve obstruction of, 103
paraovarian, 228 of clitoris, 115, 130, 263 sperm retrieval from, 106
perisalpingeal, of uterus, 189 of penis, 24, 26, 29, 30 tumors of, 97
pilar, of scrotum, 63 Dorsal vein Epididymitis, 71
of prostate, 79 of clitoris, 130, 131, 132, 154 syphilitic, 72
retention of penis, 20, 21, 25, 26, 27, 51 tuberculous, 72
of cervix, 170 Douches, vaginitis from, 141 Epididymo-orchitis, 57, 71
of prostate, 79 Douglas (rectouterine) pouch, 130, 154, 155, 160 tuberculous, 72
of scrotum, 63 abscess of, 194 Epididymovasostomy, 104
sebaceous Ductuli efferentes, 52 Epidural anesthesia, for labor pain, 263
of scrotum, 63 Epigastric artery, 156
of vulva, 124 Epigastric vein node, 113, 156
theca lutein, 220
tuboovarian, 197, 211, 229 311

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Index

Epigastric vessels, 25, 27, 51 Fallopian tube (Continued) Fine-needle aspiration mapping
Episiotomy, 265, 266 isthmic, 188 for azoospermia, 105
Epispadias, 33 nodular enlargement of, 199 sperm retrieval guided by, 106
Epithelial tag, 4 spasm of, 195
Epithelioma, 63 lymphatic drainage of, 158 Fistulae
Epithelium mucosa (endosalpinx) of, 188 urethrorectal, 34
occlusion of, 192, 196, 198 vaginal, 146
germinal, 202 paraphimosis of, 196
urethral, 31 phimosis of, 196 Foley balloon, in prostatectomy, 90, 91
vaginal, 135, 136, 147 rudimentary, 189 Follicle
Epoöphoron, 3, 160, 200 supernumerary, 190
Erection topographic relationships of, 3, 130, 133, 154, 155, atresia of, 202
dysfunctional, 32 156, 159, 161 cyst of (hydrops folliculi), 209
penile, 32 tuberculosis of, 191, 198 cystic hematoma of, 209
prolonged, 37 tumors of, 199 graafian, 203, 204, 232
Erysipelas, of scrotum, 60 wall of, 188
Erythrasma, 55 ruptured, 209
Erythroblastosis fetalis, 279 Fascia. See also named fascia. primordial, 202
Estradiol, 7 of breast, 284 stages of, 202, 203, 204
in gonadal function, 5, 6 cremasteric, 50 Follicle stimulating hormone (FSH). See also
in ovarian failure, 206 dartos, 20, 21, 22, 23, 24, 26, 39, 50, 114, 130, 133, 134
Estriol, 7 endopelvic, 155 Gonadotropins.
Estrogen extraperitoneal (subserous), 159 in gonadal function, 5, 6
bioavailability of, 7 lata, 21, 111, 113, 133 lifelong influences of, 205
in breast development, 287 obturator, 112, 132, 133, 155 in menopausal/postmenopausal period,
deficiency of pectoral, 284
of pelvic diaphragm, 26, 111, 112, 132, 155 206
age-related. See Menopause/postmenopause. of penis, 21-23 in ovarian cycle, 203
ovarian failure from, 207, 208 perineal in ovarian failure, 206
in endometrial cancer, 184 deep, 20, 21, 22, 23, 111, 132, 133, 134 in puberty, 8
endometrial hyperplasia and, 176 superficial, 20, 21, 22, 23, 24, 26, 39, 50, 114, 130, in puberty abnormalities, 10-14
excess of 133, 134 Folliculitis, of vulva, 116
in granulosa cell tumors, 219 rectal, 111, 155 Folliculogenesis, 203, 204
in neonatal theca cell tumors, 218 rectoprostatic, 20, 76 Forceps-assisted delivery, 265, 267
in fibroid development, 180 of scrotum, 21 Foreign bodies, in vagina, 141
in gonadal function, 5, 6 spermatic, external, 20, 21, 22, 23, 26 Fossa
in gynecomastia, 290 transversalis, 20, 111 ischioanal, 111, 112, 133
lifelong influences of, 205 umbilical prevesical, 20 ischiorectal, 112
in ovarian cycle, 203, 204, 232 urogenital, 20, 21, 22, 111 navicular, 20, 31, 110
in pregnancy, 247, 248, 288 uterovaginal, 111, 133, 155 pararectal, 155
prolactin inhibition by, 288 vesical, 20, 111, 155 paravesical, 155
in puberty abnormalities, 13-14 vestibular, 110
supplementation of Fasciitis, necrotizing, of scrotum, 60 Fournier gangrene, of scrotum, 60
for Asherman syndrome, 178 Feminization, 290 Fraser syndrome, 18
for menopausal symptoms, 206 Feminizing neoplasms, 218 Frei test, in lymphogranuloma venereum,
for ovarian dysgenesis, 208 Femoral lymph node, 113
in postmenopausal women, 7 Femoral nerve, 29 43
for Turner syndrome, 207 Femoral testis, 64 Frenulum, 23
synthesis of, 7 Femoral thrombophlebitis, 281 Fundiform ligament, 20
uterine development and, 161 Femoral vessels, 27, 51, 113 Furuncle, of scrotum, 60
vaginal epithelium and, 136, 147 Fertility. See also Infertility. Furunculosis, of vulva, 116
Eunuchoidal habitus, 65, 66
Exotoxins, in toxic shock syndrome, 142 male, evaluation of, 101 G
Extraperitoneal (subserous) fascia, 159 Fertilization, 233, 242 Galactorrhea, 292
Galludet (deep perineal) fascia, 20, 21, 22, 23, 111, 132,
F inhibitors of, 240
Fallopian tube, 188-200 in vitro, 239 133, 134
Fetal membranes, 246, 256 Ganglion
abscess of, tuboovarian, 194, 197, 211 Fetus
absence of, 189 cardinal movements of, 264 aorticorenal, 29, 263
accessory ostia of, 190 early development of, 243 celiac, 29, 263
adhesions of, 192, 193, 195, 196, 197, 198 during first trimester, 243 mesenteric, 29, 263
adnexal torsion of, 217 genetic evaluation of, 243 Gangrene, of scrotum, 60
ampulla of, 188 growth-restricted, 254, 278 Gangrenous balanitis, 40
heart rate monitoring of, during delivery, 264 Gartner duct, 3
accessory, 190 movements of, 244, 245 cysts of, 148
anatomy of, 160, 188 during second trimester, 244 Genital cord, 3
blood supply of, 188 syphilitic, 280 Genital ducts
carcinoma of, 195, 199 during third trimester, 245 development of, 3
congenital anomalies of, 189-190 Fibroadenoma masculinization of, 4
contrast materials in, 196 of breast, 290, 298, 299 Genital mutilation, female, 127
cyst of of ovary, 214 Genital ridge, 2
Fibroids. See Myoma. Genital tubercle, 2, 4
paraovarian (epoöphoron), 3, 160, 200 Fibroma Genital ulcers
tuboovarian, 197, 211, 229 of ovary, 223 chancroid, 43
cystic dilation (hydrosalpinx) of, 193, 196, of vagina, 148 in granuloma inguinale, 44
of vulva, 125 in lymphogranuloma venereum, 43
229 Fibrosarcoma Genital warts, 46, 48, 125
development of, 189 of ovary, 223 Genitalia
ectopic pregnancy in, 195, 249, 250, 251 of prostate, 88 ambiguous, 15-18
hematosalpinx of, 193 Filarial elephantiasis, of scrotum, 62 congenital cysts of, 34
hypoplasia of, 190 Fine-needle aspiration delayed development of, 69
infantile, 190 of breast cysts, 297 external
infection of. See Salpingitis. in fibrocystic adenosis, 296
intramural (interstitial), 188 anatomy of, 110
blood supply of, 25, 26
312 homologues of, 4
innervation of, 115
lymphatic drainage of, 113

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Genitalia (Continued) Gumma, 72, 122 Index
internal Gynecomastia, 290
blood supply of, 26 Hydrocele
homologues of, 3 in Klinefelter syndrome, 68 communicating, 54, 58
innervation of, 159 with hernia, 58
lymphatic drainage of, 158 H infantile, 58
male Haemophilus ducreyi, 43, 123 simple, 58
innervation of, 29-30 Hair of spermatic cord, 58
lymphatic drainage of, 28
growth of, gender differences in, 8, 9 Hydromucocolpos, 138
Genitofemoral nerve, 29, 115 in hypogonadal men, 67 Hydronephrosis
Germ cells male-pattern, in women. See Hirsutism.
pubic, 8, 9 in benign prostatic hyperplasia, 84
aplasia of, in azoospermia, 70 Heat therapy, for dysmenorrhea, 164 in pregnancy, 272
primordial, 3 HELLP syndrome, 273 Hydrops fetalis, 279
tumors of, 73-74 Hematocele, 59 Hydrops folliculi, 209
Germinal epithelium, 202 Hematocolpos, 138 Hydrops tubae profluens, 193
Gerota pathway, 286 Hematoma Hydrosalpinx, 193, 196, 229
Gestation, multiple, 232, 233, 242, 254, 256, of corpus luteum, 209 Hydroureter
cystic, of follicle, 209 in benign prostatic hyperplasia, 84
277 of placenta, 261 in pregnancy, 272
Gestational age, small for, 278 of rectus abdominis muscle, 229 Hymen, 110
Gestational trophoblastic disease, 262 of scrotum, 57 caruncle of, 133
Glans, 4, 23, 31 of vulva, 118 fibrous, 138
Hematometra, 138 imperforate, 138
clitoridis, 4 Hematosalpinx, 138, 193 Hypergonadotropic hypogonadism, in male,
penis, 4, 20, 23, 40 Hematuria, in benign prostatic hyperplasia, 84
Glanular hypospadias, 33 Hemolytic disease of newborn, 279 65
Gleason grading scale for prostate cancer, 85 Hemorrhage. See also Uterine bleeding; Vaginal Hypernephroma, metastatic, 126, 151
Glomerular capillary endotheliosis, in preeclampsia/ Hyperprolactinemia, 292
bleeding. Hypertension
eclampsia, 275 in abruptio placentae, 258
Gluteal artery, 25 in placenta previa, 257 essential
Gluteus maximus muscle, 22, 23, 112, 115 in preeclampsia/eclampsia, 274, 275 ophthalmic changes in, 274
Gonad(s). See also Ovary; Testis. retinal, 274 preeclampsia superimposed on, 277
in tunica vaginalis, 59
development of, 2-4 uterine, pregnancy-related, 175 in preeclampsia/eclampsia, 273
disorders of, 15-18 Hemorrhoidal artery, 114 in pregnancy, 258, 273
hypothalamic-pituitary-gonadal (HPG) axis in, Hemorrhoidal nerve, 30, 115 Hyperthecosis, 220
5-6 Hereditary breast ovarian cancer syndrome, 303 Hypogastric lymph node, 157
Hermaphroditism Hypogastric nerve, 29, 30, 159, 263
dysgenesis of, 16, 207, 208 pseudo-, 16, 17, 18 Hypogastric plexus, 29, 30, 107, 159, 263
streak, 16, 208 true, 15 Hypogastric vessels, 157
Gonadal hormones. See Estrogen; Progesterone; Hernia Hypogonadism
hydrocele with, 58 hypergonadotropic, in male, 65
Testosterone. inguinal, 17, 64 hypogonadotropic
decreased production of. See Hypogonadism. Hernia uteri inguinale, 3
Gonadarche, 9 Herpes genitalis, of vulva, 116 in female, 13
Gonadotropin-releasing hormone (GnRH) Herpes simplex virus infection in male, 10, 66, 67
deficiency of, 10, 13, 66 balanitis in, 40 Hyponatremia, dilutional, 92
excess of, 10, 11, 13 of vulva, 116 Hypopituitarism, 66
in gonadal function, 5, 6 Hindgut, 2 Hypospadias, 16, 33, 237
hypothalamic regulation of, 232 Hirsutism Hypotension, in toxic shock syndrome, 142
ovarian feedback modulation of, 232 with luteinization of ovaries, 220 Hypothalamic-pituitary-gonadal (HPG) axis,
in puberty, 8 in polycystic ovary syndrome, 221 5-6
Gonadotropin-releasing hormone (GnRH) agonists, for virilism with, 18 Hypothalamus
Histiocytoma, malignant fibrous, of prostate, 88 gonadotropin regulation by, 232
adenomyosis, 177 Hormonal therapy hormones of, 5, 6
Gonadotropins, 5, 6. See also Follicle stimulating for fibroids, 182 Hysterectomy
for ovarian dysgenesis, 208 abdominal, urinary tract fistulae after, 146
hormone (FSH); Human chorionic gonadotropin; Hormones. See also specific hormones, e.g., Estrogen. cesarean, 270
Luteinizing hormone (LH). feedback loops with, 5 Hysterosalpingography, 196
in azoospermia, 70 of hypothalamic-pituitary-gonadal (HPG) axis, in recurrent abortion, 238
in delayed puberty, 69
in Klinefelter syndrome, 68 5-6 I
in pregnancy, 248 types of, 5 Icterus, in erythroblastosis fetalis, 279
in puberty abnormalities, 10-14 Human chorionic gonadotropin Iliac artery, 156, 159
in testicular failure, 66, 67 challenge test with, in delayed puberty, 69 Iliac lymph nodes, 28, 113, 157, 158
Gonorrhea for cryptorchidism, 64 Iliac plexus, 159
of cervix, 171 for hypogonadism, 67 Iliac spine, anterior superior, 21, 111
epididymitis in, 71 lifelong influences of, 205 Iliac vein node, circumflex, 113
salpingitis in, 191, 192, 194 in pregnancy, 248 Iliac vessels, 20, 25, 27, 51, 113, 133, 154
urethritis in, 41 structure of, 248 Iliococcygeus muscle, 131, 132
vaginitis in, 140 Human papillomaviruses Iliohypogastric nerve, 29, 263
of vulva, 121 cervical cancer and, 173 Ilioinguinal nerve, 29, 115, 263
Granuloma, syphilitic, 72 genital warts from, 46, 48, 125 Iliolumbar artery, 25
Granuloma inguinale, 44, 123 penile cancer from, 47 Impalement injury, to vagina, 143
Granulosa cells, 7, 202 vulvar vestibulitis and, 120 Implantation
tumors of, 14, 219 Humeral lymph node, 286
Granulosa lutein cells, 202 Hydatid (echinococcus) cyst, 200, 220 of ovum, 233, 242
Greater sciatic foramen, 131 Hydatid of Morgagni, 160 inhibitors of, 240
Greater vestibular gland. See Bartholin gland. Hydatidiform mole, 262
Growth chart, for preterm infants, 278 Hydradenoma, of vulva, 125 of placenta, abnormal, 257
Growth hormone In vitro fertilization, 239
deficiency of, testicular failure and, 66, 67 Incisions, for cesarean section, 268-269
for ovarian dysgenesis, 208 Inclusion cyst
Growth restriction, intrauterine, 278
in multiple gestation, 254 of vagina, 148
Grozman pathway, 286 of vulva, 124
Gubernaculum, 3, 54 Incontinence, stress, 144

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS 313

Index

Infarction Kraurosis vulvae, 117 Lymphogranuloma venereum, 43, 123
of placenta, 261 Krukenberg tumors of ovary, 226 Lymphosarcoma, of prostate, 88
causes of, 277
in preeclampsia/eclampsia, 276, 277 L M
of prostate, 79
Labia majus, 4, 110, 130, 133, 134, 154 Mackenrodt ligament, 133, 155, 161, 166
Infertility sarcoma of, 126 Macula cerulea, 56
age-related, 235 Magnetic resonance imaging, in prostate cancer, 86
female Labia minus, 4, 110, 130, 133, 134, 135, 154 Mammary artery, 285
causes of, 235 Labial artery, 114 Mammary gland. See Breast.
evaluation of, 236 Labial nerve, 115, 263 Mammary papilla. See Nipple.
in fibroids, 180 Labial tear, obstetric, 266 Mammography, 294, 296
in ovarian dysgenesis, 208 Labioscrotal swelling, 4 Manometry, in ejaculatory duct obstruction, 108
pelvic inflammatory disease and, 194 Labor Marginal sinus, 247
tubal damage and, 196 Masculinization
male, 70. See also Azoospermia. cervical ripening prior to, 264
causes of, 235 pain pathways in, 263 with diffuse luteinization of ovaries, 220
in cystic fibrosis, 97, 103 stages of, 264 of genital ducts, 4
from ejaculatory duct obstruction, 103, 108 Lacerations neoplasms causing, 219
evaluation of, 101, 237 of cervix, 169, 266 Mastitis, puerperal, 291
microsurgery for, 104 obstetric, 266-267 Mastodynia, 291, 295, 296
treatment of, 239 of uterus, 169 Masturbation, self-instrumentation injuries associated
unexplained, 237 of vagina, 143, 266, 267
Lactation, 288 with, 143
Infibulation, 127 breast engorgement before, 291 May-Thurner syndrome, 156
Infundibulopelvic ligament. See Suspensory ligament. mastitis during, 291 Mayer-Rokitansky-Küster-Hauser syndrome, 17, 18, 137,
Inguinal fold, 3 Lactiferous duct, 284
Inguinal hernia, 17, 64 Lactiferous sinus, 284 165
Inguinal ligament, 21, 22, 111, 113, 132 Lactotrophs, pituitary, hyperplasia of, 288 McCune-Albright syndrome, 13-14
Inguinal lymph nodes, 28, 113, 158 Lamina propria, 135 Median bar obstruction, 82
Inguinal lymphadenectomy, for penile cancer, 47 Langhans cells, 242 Mediastinal lymph node, 286
Inguinal lymphadenopathy, in syphilis, 122 Laparoscopic radical prostatectomy, 95 Medullary carcinoma
Inguinal region, anatomy of, 111 Leiomyomata, uterine, 180-182. See also Myoma.
Inguinal ring, 111, 155 Leiomyosarcoma, of prostate, 88 of ovary, 225
Inhibin, in gonadal function, 5, 6 Leptin, in puberty, 8 of vulva, 126
Insulin-like-3, in sexual differentiation, 2 Leukocytes, seminal, 101 Meigs syndrome, 223
Insulin resistance, in polycystic ovary syndrome, 221 Leukoplakia Meiosis, 53, 232, 234
Intercostal artery, 285 carcinoma on, 126 Melanoma, of vagina, 150
Intercostal muscle, 284 of penis, 46 Menarche, 9
Intercostal nerve, 284 of vulva, 117 Mendelian inheritance, 234
Intercostal vein, 285 Levator ani muscle, 22, 23, 111, 112, 131, 132, 133, 134, Menopause/postmenopause, 206
Intercostal vessels, 284 breast changes during, 287
Intercourse, timing of, 239 154 changes during, 206
Interferon, for vulvar vestibulitis, 120 levator plate (median raphe) of, 131, 132 hormonal influences in, 205
Intermesenteric (aortic) plexus, 30, 159, 263 tendinous arch of, 131, 132, 133 management of, 206
Intersex disorders, 2, 3, 15-18 Leydig cells, 2, 3, 7, 53 vaginal changes during, 136, 147
Interstitial pregnancy, 251 Lice, 56 Menorrhagia, 175
Intertrigo, 55, 116 Lichen planus, 55 Menstrual cycle, 163
Intervillous space, 247 Lichen sclerosis, 40 endocrine relations during, 203
Intracytoplasmic sperm injection, 239 Lichenification, of vulva, 117 ovarian changes during, 204
Intrauterine device, 240 Lidocaine, for vulvar vestibulitis, 120 Menstruation, 175
Ligaments. See also named ligaments. fluid retention during, 162
for Asherman syndrome, 178 suspending uterus, 166 painful, 164
dysmenorrhea from, 164 Linea terminalis, 133 pathologic, 175
uterine perforation with, 168 Lipoma, of vulva, 125 process of, 163
Intrauterine growth restriction, 278 Liquor folliculi, 204 Mesenteric artery, 27, 51, 156
in multiple gestation, 254 Littré glands, 31 Mesenteric cyst, 229
Intrauterine insemination, 239 Liver, lesions of, in preeclampsia/eclampsia, 275 Mesenteric ganglion, 29, 263
Ischemic priapism, 37 Lung, 284 Mesoderm, primitive, 242
Ischial spine, 115, 131, 132 Lutein, 203 Mesometrium. See Broad ligament.
Ischial tuberosity, 22, 23, 24, 30, 111, 112, 115, 131 Luteinization, of ovary, 220 Mesonephric duct. See Wolffian duct.
Ischioanal fossa, 111, 112, 133 Luteinizing hormone (LH). See also Gonadotropins. Mesonephric tubules, 3
Ischiocavernosus muscle, 22, 23, 26, 111, 112, 114, 130, in gonadal function, 5, 6 Mesonephros, 3
lifelong influences of, 205 Mesosalpinx, 155, 160
133, 154 in menopausal/postmenopausal period, 206 Mesothelioma, of testis adnexa, 97
Ischiococcygeus (coccygeus) muscle, 131, 132, 159 in ovarian cycle, 203, 204, 232 Mesovarium, 133, 160
Ischiopubic ramus, 20, 21, 22, 23, 24, 76, 111, 112, 133 in polycystic ovary syndrome, 221 Metanephric duct and tissue, 2
Ischiorectal fat, 21 in puberty, 8, 69 Metformin, for polycystic ovary syndrome, 221
Ischiorectal fossa, 112 in puberty abnormalities, 10-14 Methylxanthine intake, breast fibrocystic changes and,
Ischium, inferior ramus of, 24 Lymph nodes. See Lymphatic drainage; named lymph
296
K nodes. Micropenis, 16
Kallman syndrome, 10, 16, 66 Lymph scrotum, 62 Microsurgery, reproductive, 104
Karyotyping, 102 Lymphadenectomy, pelvic, for penile cancer, 47 Microtubules, sperm, 100
Lymphadenopathy, inguinal, in syphilis, 122 Milk
in ovarian dysgenesis, 208 Lymphangiectasis, of scrotum, 62
in recurrent abortion, 238 Lymphatic drainage breast, 288
Kidney, 156 witch’s, 287
lesions of, in preeclampsia/eclampsia, 275 of breast, 286 Milk lines, 289
pelvic, 229 of genitalia Milky fluid discharge, from breast, 292
polycystic, 103, 229 Miscarriage, 243. See also Abortion.
Kisspeptin, in puberty, 8 external, 113 Mitochondria, sperm, 100
Klebsiella granulomatis, 44, 123 internal, 158 Mitosis, 53
Klinefelter syndrome, 10-11, 16, 68, 102 male, 28 Molar pregnancy, 262
of pelvis, 28, 157 Mondor disease, 293
of uterus, 158 Monilia albicans, 139

314 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Moniliasis, 119, 170 Obturator internus muscle, 131, 132, 133 Index
Mons pubis, 110 Obturator membrane, 133
Montgomery glands, 284 Obturator nerve, 156, 157 Ovary (Continued)
Morgagni, hydatid of, 160 Obturator node, 157, 158 Meigs syndrome of, 223
Morgagni lacunae, 31 Obturator vessels, 25 papilloma of, surface, 214
Morula, 242 Oligospermia, 102 polycystic, 209, 221
Müllerian duct Oocytes, 202, 232, 233, 234, 244 rudimentary, 207
Oogenesis, 234 senile, 202, 204
cysts of, 34 Oophoritis, 211 structures of, 202
development of, 3 Ophthalmologic changes, in preeclampsia/eclampsia, succenturiate, 207
dysgenesis of, 17, 18, 137, 165 supernumerary, 207
persistent, 3 274 teratoma of, 216, 217
Müllerian inhibiting substance. See Antimüllerian Oral contraceptives, 240 topographic relationships of, 3, 130, 133, 154, 155,
156, 159, 160
hormone. for adenomyosis, 177 torsion of, 217
Mumps orchitis, 71 for dysmenorrhea, 164 tuberculosis of, 211
Muscles. See also named muscles. for ovarian cysts, 227 tumors of
for polycystic ovary syndrome, 221 adrenal rest, 219
of pelvic diaphragm, 131, 132 vulvar vestibulitis and, 120 Brenner (transitional cell), 222
of perineum, 112 Orchidopexy, 64 conditions simulating, 228-229
of urogenital diaphragm, 22 Orchitis cystic, 212-216
of uterus, 161 mumps, 71 diagnosis of, 227
Myoma syphilitic, 72 endometrioid, 225
in cervix, 182 Orgasm (climax), male, 107 feminizing, 218
sarcomatous degeneration of, 183 Ovarian artery, 156, 159 granulosa cell, 14, 219
in uterus, 180-182, 228 Ovarian cycle, 203, 204 masculinizing, 219
in vagina, 148 Ovarian ligament, 130, 133, 154, 160, 161 precocious puberty from, 14, 218
Myomectomy, for fibroids, 181 Ovarian plexus, 159 Sertoli-Leydig cell tumor of, 219
Myometrium, 162, 247 Ovarian pregnancy, 251 stromatogenous, 223
endometrial glands within, 177 Ovarian vein, 156 unicornuate, 15
Myosarcoma, of prostate, 88 Ovary, 202-229
Myxoma, giant, 298, 299 abscess of, tuboovarian, 194, 197, 211 Ovotestis, unicornuate, 15
absence of, 207 Ovulation, 203
N accessory, 207
Nabothian cysts, 170 adeno-acanthoma of, 225 detection of, 236, 239
Navicular fossa, 20, 31, 110 adenofibroma of, serous, 214 failure of
Necrotizing fasciitis, of scrotum, 60 adnexal torsion of, 217
Neisseria gonorrhoeae, 41. See also Gonorrhea. bipartite, 207 causes of, 235
Neonate cancer of, hereditary, 303 endometrial hyperplasia and, 176
carcinoma of in polycystic ovary syndrome, 221
breast of, 287 induction of, 221, 239
estrogen effects on, 205 cystic, 224 inhibitors of, 240
growth-restricted, 278 metastatic, 226 onset of, 9
hemolytic disease of, 279 solid, 225 process of, 232
syphilis in, 280 clear cell carcinoma of, 225 uterine bleeding during, 204
Nephritis, ophthalmic changes in, 274 congenital anomalies of, 207, 208 Ovum
Nephrosis, in preeclampsia/eclampsia, 275 cystadenocarcinoma of, 224 division of, 204
Nerve supply. See also named nerves. cystadenofibroma of, 214 early development of, 242
of bladder, 29 cystadenoma of, 212, 213, 215 fertilization of, 233, 242
of breast, 284 cystoma of, 212 inhibitors of, 240
of genitalia, 29-30 cysts of in vitro, 239
dermoid, 216 implantation of, 233, 242
external, 115 endometrial (chocolate), 210 inhibitors of, 240
internal, 159 neoplastic, 212-216 primordial, 202
of pelvic viscera, 159 nonneoplastic, 209 stages of, 202
of perineum, 115 oral contraceptives for, 227 Oxytocin, 288
Nipple, 284 paraovarian (epoöphoron), 3, 160, 200
accessory, 289 as physiologic variations, 209 P
Paget disease of, 304 theca lutein, 220 Paget disease of nipple, 304
supernumerary, 289 tuboovarian, 197, 211, 229 Paget-Schroetter disease, 293
Nitric oxide, in erection, 32 descent of, 202 Pain
Nodules. See also Adenoma. development of, 202
of breast, 296 displacements of, 207 breast, 291, 295, 296
of placenta, 261, 276 dysgenesis of, 207, 208 with cervical dilation, 263
of prostate, 82, 83, 87, 88-92 dysgerminoma of, 222 labor, 263
of uterus, 189 ectopic, 207 menstrual, 164
Nonsteroidal antiinflammatory drugs (NSAIDs) endometriosis of, 149, 210 scrotal, 30
for adenomyosis, 177 estrogenic hormone production by, 7 with vaginal bleeding, 164
for dysmenorrhea, 164 failure of Pampiniform venous plexus, 25, 27, 50, 51,
Nuck canal age-related. See Menopause/postmenopause.
cyst of, 124 diagnosis of, 206 59
persistence of, 111 in Turner syndrome, 207, 208 Papanicolaou (Pap) smear, 171
fibroma of, 223 Papilla, mammary. See Nipple.
O fibrosarcoma of, 223 Papillary carcinoma
Obesity follicle of. See Follicle.
gonadotropin modulation by, 232 of breast, 301
delayed puberty and, 69 hormonal influences on, 5, 6, 205 of uterine corpus, 185
in hypogonadal men, 67 hypoplastic, 18 Papilloma
in polycystic ovary syndrome, 221 infant, 202 of breast, intracystic, 298
Oblique muscle, external, 21, 22, 111, 284 infections of, 211 of ovary, surface, 214
Obstetric lacerations, 266-267 luteinization of, 220 of urethra, 48
Obturator artery, 25, 155, 156 lymphatic drainage of, 158 of vagina, 148
Obturator canal, 132, 155 mature, 202 Papillomaviruses, human. See Human
Obturator fascia, 112, 132, 133, 155
papillomaviruses.
THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS Papule, syphilitic, 61
Papulosis, Bowenoid, 46
Paraffin cancer, 63

315

Index

Paramesonephric duct. See Müllerian duct. Perineal fascia, 20, 21, 22, 132 Placenta membranacea, 246
Parametrial abscess, 191, 192 deep (Galludet), 20, 21, 22, 23, 111, 132, 133, 134 Placenta percreta, 259
Parametritis, 191, 192, 195 superficial (Colles), 20, 21, 22, 23, 24, 26, 39, 50, 114, Placenta previa, 257
Paraovarian cysts, 228 130, 133, 134 Plaques, penile, 37
Paraphimosis, 36, 196 Plexus
Pararectal fossa, 155 Perineal ligament, 20, 26
Parasternal lymph node, 286 Perineal membrane, 20, 23, 26, 111, 112, 114, 130, 132, aortic (intermesenteric), 30, 159, 263
Parasympathetic nervous system, 29, 30, 159 brachial, 285
Paratesticular tumors, 97 133, 134, 154 ductus, 29
Paraurethral duct. See Skene duct. Perineal muscle, transverse, 20, 22, 23, 24, 26, 111, 112, hypogastric, 29, 30, 107, 159, 263
Paravesical fossa, 155 iliac, 159
Paroöphoron, 3 114, 130, 154 ovarian, 159
Parturition, neuropathways in, 263 Perineal nerve, 30, 115, 130 pelvic, 30, 159
Pectineal ligament, 132. See also Inguinal ligament. Perineal nerve block, for labor pain, 263 prostatic, 30
Pectoral fascia, 284 Perineal raphé, 4, 110 rectal, 30, 159
Pectoral lymph node, 286 Perineal space, 20, 26, 114, 130, 133 spermatic, 29, 30
Pectoralis major muscle, 284 Perineal testis, 64 uterovaginal, 159, 263
Pediculosis pubis, 56 Perineal vein, 26 venous
Pelvic diaphragm Perineum
cavernous, 134
fascia of, 26, 111, 112, 132, 155 anatomy of, 112 pampiniform, 25, 27, 50, 51, 59
female, 130, 131, 132, 133 blood supply of, 26, 114 prostatic, 25
muscles of, 131, 132 endometriosis in, 149 retropubic (vesical), 25
topographic relationships of, 20, 154 innervation of, 115 vesical, 30, 159, 263
Pelvic inflammatory disease, 211 interdigitating fibers of, 131 Podoconiosis, of scrotum, 62
infertility and, 194 lymphatic drainage of, 113 Poland syndrome, 289
tuberculous, 198 muscles of, 112 Polar body, 232, 233, 234
Pelvic kidney, 229 obstetric lacerations of, 266, 267 Polycystic kidney disease, 103, 229
Pelvic lymph nodes, 157 surface topography of, 24 Polycystic ovary syndrome, 209, 221
Pelvic lymphadenectomy, for penile cancer, 47 Perioophoritis, 211 Polyhydramnios, 277
Pelvic nerve, 30 Perisalpingitis, 192 Polymastia, 289
Pelvic plexus, 30, 159 Peritoneum Polyps
Pelvic tuberculosis, 211 adhesions of, 195 of cervix, 169
Pelvic viscera mucinous tissue on, 215 of endometrium, 169, 179
blood supply of, 156 topographic relationships of, 20, 78, 111, 130, 154, of urethra, 48
female, 130, 131, 132, 133, 154, 155 of uterus, 169
innervation of, 159 156, 157, 160 Polythelia, 289
support of, 155 Peritonitis, tuberculous, 198 Postcoital analysis, 236
Pelvioperitonitic abscess. See Tuboovarian abscess. Pessaries, 167 Posterior urethral valves, 34
Pelvis Preaortic lymph node, 158
adhesions of, 195 for cervical insufficiency, 253 Preeclampsia/eclampsia
anatomy of vaginitis from, 141 abruptio placentae in, 258
Peyronie disease, 37 ophthalmologic changes in, 274
in female, 130, 131, 132, 133, 154, 155 Phimosis, 36, 40, 196 placental infarcts in, 276, 277
in male, 20 Phlebitis, of breast, 293 symptoms of, 273
blood supply of, 25 Phrenic lymph node, 286 visceral lesions in, 275
bony, trauma to, 78 Phthalates, precocious puberty from, 14 Pregnancy. See also Delivery; Fetus; Labor.
fracture of, 38 Phyllodes tumor, 298, 299 anaphylactoid syndrome of, 260
hydatid (echinococcus) cyst in, 200 Pilar cysts, of scrotum, 63 breast changes during, 288
lymphatic drainage of, 28, 157 Piriformis muscle, 131, 132, 159 disorders of, uterine bleeding in, 175
renal, dilation of, in pregnancy, 272 Pituitary gland ectopic
retroperitoneal neoplasms in, 229 gonadotropin secretion by. See Gonadotropins. abdominal, 251
Penectomy, for penile cancer, 47 hormones of, 5, 6 abortion of, 250
Penile vein thrombosis, 293 cervical, 251
Penis lifelong influences of, 205 interstitial, 251
absence of, 16 hypofunction of, 66 ovarian, 251
anatomy of, 21, 23, 31 Pituitary lactotrophs, hyperplasia of, 288 ruptured, 250
angiokeratoma of, 63 Placenta
avulsion of, 57 Battledore, 256 with hematocele, 228
blood supply of, 25, 26 bipartite, 256 tubal, 195, 249, 250, 251
chancre of, 42 circulation in, 247 first trimester of, 243
development of, 4 circumvallate, 256 hormonal fluctuations in, 248
epispadias of, 33 color of, 255 hormonal influences in, 205
fascial relationships in, 21-23 cystic degeneration of, 261 hypertension in, 258, 273
glans, 4, 20, 23, 40 delivery of interdiction of, 240
hypospadias of, 33 loss of. See Abortion.
lymphatic drainage of, 28 in cesarean section, 268 molar, 262
nerve supply of, 29 uterine inversion after, 271 multiple, 232, 233, 242, 254, 256, 277
paraphimosis of, 36 development of, 246 preeclampsia/eclampsia in. See Preeclampsia/eclampsia.
Peyronie disease of, 37 in erythroblastosis fetalis, 279 prevention of, 240
phimosis of, 36 fetal aspect of, 245, 255 second trimester of, 244
precancerous lesions of, 46 form and structure of, 255 tests for, 243
strangulation of, 36 hematoma of, 261 third trimester of, 245
structures of, 23 hormone production by, 243, 247, 248 toxemia of. See Preeclampsia/eclampsia.
trauma to, 38 implantation of, abnormal, 257 urinary complications of, 272
warts of, 46 infarction of, 261 uterine rupture during, 168
Penoscrotal hypospadias, 33 causes of, 277 vagina in, 136
Penoscrotal raphé, 4 in preeclampsia/eclampsia, 276, 277 Pregnanediol, 6
Peptide hormones, 5 maternal aspect of, 255 Pregnenolone, 7
Periaortic lymph nodes, 157 maternal circulation to, decreased, causes of, 277 Premature ejaculation, 107
Perineal artery, 25, 26, 114, 133 nodular lesions of, 261, 276 Prepuce, 4, 20
Perineal body, 20, 22, 23, 24, 26, 111, 112 number of, 256 Preputial (Tyson) gland, 23
premature separation of, 258, 260, 277 Presacral nerve, 159
316 succenturiate, 256
in syphilis, 280
thrombus of, 261
Placenta accreta, 257, 259, 270
Placenta increta, 259

THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS

Preterm delivery, in multiple gestation, 254 Prostatomembranous urethra, injury to, 78 Index
Preterm infants, fetal-infant growth chart for, 278 Proteinuria, in preeclampsia/eclampsia, 273
Priapism, 23, 37 Prurigo, 55 Rectum, 20, 130, 131, 132, 154, 156, 159
Processus vaginalis, persistence of, 54 Pseudocryptorchidism, 64 Rectus abdominis muscle, 20, 111
Procidentia, 167 Pseudofollicular hydrosalpinx, 193
Progesterone, 7 Pseudogynecomastia, 290 hematoma of, 229
Pseudohermaphroditism Rectus sheath, 111
in breast development, 287 Regional anesthesia
in gonadal function, 5, 6 female, 18
lifelong influences of, 205 male, 16, 17 for cesarean section, 269
in ovarian cycle, 203, 232 Psoas major muscle, 156 for labor pain, 263
in pregnancy, 247, 248, 288 Psoriasis, of vulva, 116 Reifenstein syndrome, 17
supplementation of, in postmenopausal women, 7 Pseudomyxoma peritonei, 215 Renal cell carcinoma, metastatic, 126, 151
tumors secreting, precocious puberty from, 14 Pthirus pubis, 56 Renal pelvis, dilation of, in pregnancy, 272
for Turner syndrome, 207 Pubarche, 8 Renal vessels, 27, 51, 156
Prolactin premature, 13 Reproduction
in galactorrhea, 292 Puberty assisted, 239
in gonadal function, 5, 6 abnormal, 10-14 genetics of, 234
in lactation, 288 breast development at, 287, 290 Rete testis, 52
lifelong influences of, 205 delayed, 10-11, 12-13 Retention cysts
normal fluctuations in, 288 of cervix, 170
Promontorial nodes, 158 in male, 69 of prostate, 79
Prostaglandin F2α, dysmenorrhea and, 164 normal, 8-9 Retina, in preeclampsia/eclampsia, 274
Prostaglandins, menorrhagia and, 175 precocious, 11-12, 13-14 Retrograde ejaculation, 107
Prostate Retroperitoneal pelvic neoplasms, 229
abscess of, 80 from ovarian neoplasms, 14, 218 Retropubic (vesical) venous plexus, 25
acini of, 76 timing of, 10 Retzius, space of, 76
anatomy of, 76 Puberty node, 290 Rh sensitization, 279
biopsy of, transrectal, 87 Pubic bone, 24, 131, 132 Rhabdomyosarcoma
blood supply of, 25 Pubic hair, development of, 8, 9 of prostate, 88
calculi of, 81 Pubic ligament, 20, 131, 132 of vagina, 150
carcinoma of, 77, 85-87 Pubic ramus, 20, 23, 24, 130, 154 Rib
Pubic region, anatomy of, 111 second, 284
diagnosis of, 86 Pubic symphysis, 20, 24, 111, 131, 132, 154, 159 sixth, 284
epidemiology of, 85 Pubic tubercle, 23, 111 Robotic radical prostatectomy, 95
grading of, 85 Pubococcygeus muscle, 131, 132 Rotter’s lymph node, 286
metastasis of, 85, 86 obstetric lacerations of, 267 Round-cell sarcoma, 183
palliation of, 86 Puboprostatic ligament, 76 Round ligament, 3, 111, 113, 130, 133, 134, 154, 155,
screening for, 85 Puborectalis muscle, 131, 132
staging of, 85 Puboscrotal testis, 64 156, 157, 161, 166
surgical treatment of, 87, 93-95 Pudendal artery, 25, 26, 114, 130
treatment of, 86 Pudendal canal, 26 S
cysts of, 79 Pudendal cleft, 110 Sacral artery, 25, 156
development of, 77 Pudendal lymph node, 113 Sacral crest, 131
histology of, 76 Pudendal nerve, 30, 115, 159, 263 Sacral foramen, 131
hyperplasia of, benign, 77 Pudendal nerve block, 115 Sacral lymph node, 28, 157, 158
calculi in, 81 for labor pain, 263 Sacral nerve, 30, 115
complications of, 84 Pudendal region, anatomy of, 111 Sacral promontory, 132, 154, 155, 159
etiology of, 82, 83 Pudendal vein node, 113
histology of, 82 Pudendal vessels, 26, 27, 51 node of, 157
infarction in, 79 Puerperal infection, 280 Sacral vessels, 25, 155
medical treatment of, 84 Pulmonary embolism, by amniotic fluid, 260 Sacrococcygeal ligament, 132
sites of, 83 Pyelonephritis, in pregnancy, 272 Sacrospinous ligament, 131
surgical treatment of, 89-92. See also Prostatectomy. Pyosalpinx, 192, 193 Sacrotuberous ligament, 112, 115, 131
infarction of, 79 Sacrouterine (uterosacral) ligament, 154, 155, 157, 160,
lobes of, 77 Q
lymphatic drainage of, 28 Queyrat erythroplasia, 46 161, 166
malignant fibrous histiocytoma of, 88 Saddle anesthesia, for labor pain, 263
primordium of, 3 R Salpingitis
sarcoma of, 88 Radial artery, 162
secretions of, 76 Radiation therapy, for prostate cancer, 87 acute, 191-192
topographic relationships of, 3, 20, 22, 31 Rami communicantes, 159, 263 chronic, 195-196
transurethral resection of, 92 Rape injury, 143 gonorrheal, 191, 192, 194
trauma to, 78 Rapid plasma reagin (RPR) test, 122 hydrosalpinx in, 193
tuberculosis of, 81 Rash, in syphilis, 42 nodular isthmic, 199
tubules of, 77 Rectal artery, 25, 26, 114, 156 pelvic peritonitis from, 194
Prostate-specific antigen (PSA), in prostate cancer, 85 Rectal fascia, 111, 155 peri-, 192
Prostatectomy Rectal (anal) nerve, 115, 263 pyosalpinx in, 192, 193
laparoscopic, 95 Rectal plexus, 30, 159 risk factors for, 191
perineal Rectocele, 145, 167 routes of bacterial infection in, 191
benign, 91 tuberculous, 191, 198
radical, 94 postpartum, 267 Saphenous lymph node, 113
retropubic Rectocervical space, 155 Sarcoma
benign, 90 Rectoprostatic (Denonvilliers) fascia, 20, 76 of breast, 299, 305
radical, 93 Rectourethral fistula, 34 of cervix, 150
robotic, 95 Rectouterine peritoneal reflection, 155 of labium majus, 126
suprapubic (transvesical), benign, 89 Rectouterine pouch (of Douglas), 130, 154, 155, 160 myoma degeneration to, 183
transurethral, benign, 92 of ovary, 223
Prostatic plexus, 30 abscess of, 194 of prostate, 88
Prostatic utricle, 3 Rectovaginal fistulae, 146 of uterus, 183
Prostatic venous plexus, 25 Rectovaginal septum, endometriosis in, 149 of vagina, 150
Prostatitis, 80 Rectovaginal space, 155 of vulva, 126
Rectovesical pouch, 20 Sarcoma botryoides, 183
Sarcoptes scabiei, 56
THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS Scabies, 56
Scarpa fascia, 21, 22, 39, 111
Sciatic foramen, greater, 131

317

Scirrhous carcinoma, of ovary, 225 Spermarche, 53 Index
Scrotal artery, 25, 26 Spermatic artery, 25, 27, 29, 50, 51
Scrotal nerve, 29, 30 Spermatic cord, 22 T
Scrotum Tamoxifen, for hereditary breast ovarian cancer
anomalies of, 97
abscess of, 60 hydrocele of, 58 syndrome, 303
angiokeratoma of, 63 nerve supply of, 30 Tampons
avulsion of, 57 torsion of, 59
carcinoma of, 63 tumors of, 97 toxic shock syndrome from, 142
cysts of, 63 Spermatic fascia, external, 20, 21, 22, 23, 26, 50 vaginitis from, 141
edema of, 4, 57 Spermatic nerve, 50 Tanner staging of puberty, 8, 9, 287
elephantiasis of, 62 Spermatic plexus, 29, 30 Teratoma
erysipelas of, 60 Spermatic vein, 27, 51 of ovary, 216, 217
fascia of, 21 Spermatic vessels, 51 of vagina, 150
fetal remnants in, 50 Spermatids, 53, 100 Testis
furuncle of, 60 Spermatocele, 58 abdominal, 15
gangrene of, 60 Spermatocytes, 53, 100 abscess of, 71
hematocele of, 59 Spermatogenesis, 53, 100, 101, 234 adnexa of, mesothelioma of, 97
hematoma of, 57 Spermatogenic failure, 70 appendix, 3, 50
hydrocele within, 58 Sphincter muscle
hypospadias of, 33 anal, external, 20, 22, 23, 111, 112, 114, 130, torsion of, 59
lymph, 62 atrophy of, 65
lymphangiectasis of, 62 132, 154 biopsy of
lymphatic drainage of, 28 urethral, 24, 25, 111, 112, 132, 133, 134,
masses of, 97 in azoospermia, 70, 105
nerve supply of, 30 154 sperm retrieval by, 106
referred pain to, 30 urethrovaginal, 111, 112, 132 blood supply of, 27, 51
septum of, 21, 50 vaginal, 112 carcinoma in situ of, 74
skin of, 50 Spinal anesthesia, for labor pain, 263 choriocarcinoma of, 74
Spinal nerve, 159, 263 descent of, 54
diseases of, 55-56 Spindle cell sarcoma, 183 development of, 53
infection of, 55-56, 60 of ovary, 223 ectopic, 64
syphilis of, 42, 61 of prostate, 88 embryonal carcinoma of, 73
teratomatous rests in, 12 Spiral arteriole, 162, 247 enlargement of, during puberty, 9
topographic relationships of, 4, 20, 26 Splanchnic nerve, 29, 159, 263 failure of
varicocele of, 51, 59 Squamous cell carcinoma classification of, 65
wall of, 50 of cervix, 173 delayed puberty in, 69
Sebaceous cyst of penis, 46, 47 infertility and, 70
of scrotum, 63 of scrotum, 63 Klinefelter syndrome in, 68
of vulva, 124 of urethra, 48 physical habitus associated with, 65, 66, 67, 68, 69
Semen analysis, 101, 236, 237 of uterine corpus, 185 primary, 10-11, 65
Seminal vesicle of vagina, 150 secondary, 66-67
anatomy of, 76 of vulva, 126 femoral, 64
ejaculatory duct and, 108 SRY gene, in sex determination, 2, 3 histology of, 52
pathology of, 96 Staphylococcal infection hormonal influences on, 5, 6
surgical approaches to, 96 salpingitis in, 191 hypoplasia of, 15
topographic relationships of, 3, 20 toxic shock syndrome from, 142 infection and abscess of, 71
Seminiferous tubules, 52 Stem cell theory of benign prostatic hyperplasia, infertility evaluation of, 237
Seminoma, of testis, 73 lymphatic drainage of, 28
Septa, 52 83 nerve supply of, 30
Serratus anterior muscle, 284 Sterilization, 240 perineal, 64
Sertoli cell only syndrome, 70 Steroid hormones, 5 puboscrotal, 64
Sertoli cells, 2, 3 Straddle injury, 38 rete, 52
Sertoli-Leydig cell tumor, 219 Straight arteriole, 162, 247 retractile, 64
Sex chromosome, 2 Streptococcal infection, salpingitis in, 191 seminoma of, 73
Sex determination, genetics of, 2 Stress incontinence, 144 sperm retrieval from, 106
Sexual ambiguity, 2, 3, 15-18 Strictures syphilitic lesions of, 72
Sexual differentiation, 2-4 teratoma of, 74
disorders of, 15-18 cervical, 169 testosterone production by, 7
Sexual trauma, 143 urethral, 45 topographic relationships of, 3, 20, 50, 52
Skene duct, 3, 110, 134 Subchorial space, 247 torsion of, 59
Skene gland, primordium of, 3 Subclavian artery, 285 tuberculosis of, 72
Skenitis, 121 Subclavian lymph node, 286 tumors of
Skin fungi, scrotal, 55 Subcostal nerve, 29, 263 endodermal sinus (yolk sac), 73
Skin graft, for scrotal avulsion, 57 Suspensory ligament germ cell, 73-74
Skin rash, in syphilis, 42 of breast, 284 gynecomastia in, 290
Spence, axillary tail of, 284, 285 of clitoris, 111, 112 precocious puberty from, 12
Sperm of ovary, 133, 154, 155, 156, 157, 160 undescended. See Cryptorchidism.
anatomy of, 100 of penis, 20 Testosterone. See also Androgen.
antisperm antibody test of, 101 Swyer syndrome, 16 bioavailability of, 7
capacitation of, 233 Sympathetic nervous system, 29, 159 in gonadal function, 5, 6
in fertilization, 233 Sympathetic trunk, 263 in polycystic ovary syndrome, 221
intracytoplasmic injection of, 239 Symphysis, pubic, 20, 24, 111, 131, 132, 154, in prostate development, 77
intrauterine insemination of, 239 in puberty abnormalities, 10-12
laboratory analysis of, 101 159 in sexual differentiation, 2, 3, 4
low count of. See Azoospermia; Oligospermia. Synechia, uterine, 178 supplementation of
morphology of, 101 Syphilis, 42, 61, 122 for hypogonadism, 67
production of in older men, 7
defects in, 102 of cervix, 170 synthesis of, 7
evaluation of, 105 congenital, 280 Theca cells, 7, 203, 232
onset of, 9 diagnosis of, 42, 61, 122 tumors of, 218
retrieval of, 106 orchitis in, 72 Theca externa, 202
of penis, 42 Theca interna, 202
318 of scrotum, 42, 61 luteinization of, 220
of testis, 72 Theca lutein cells, 202
vaginitis in, 140 Theca lutein cysts, 220
of vulva, 122
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Thelarche, 8 Tumors (Continued) Index
premature, 13 of testis
endodermal sinus (yolk sac), 73 Urethra (Continued)
Thoracic artery, 285 germ cell, 73-74 posterior, injury to, 78
Thoracoepigastric veins, thrombophlebitis of, 293 gynecomastia in, 290 reconstruction of, 93, 94
Thrombophlebitis precocious puberty from, 12 rupture of, 38
theca cell, 218 trauma to, 38
of breast, 293 of vagina
femoral, 281 benign, 148 Urethral artery, 26, 114
Thrombus, of placenta, 261 malignant, 150-151 Urethral folds, 4
Thrush of vulva Urethral glands, 134
genital, 55 benign, 125 Urethral meatus, 4, 110
vaginal, 119 malignant, 126
Tinea cruris, 55, 116 external, 20, 23
Tinea versicolor, 55 Tunica albuginea, 21, 22, 50, 52, 202 Urethral sphincter muscle, 24, 25, 111, 112, 132, 133,
Toxic shock syndrome, 142 rupture of, 38
Transcoccygeal approach to seminal vesicle surgery, 134, 154
Tunica dartos, 50. See also Colles (dartos) fascia. Urethral valves, posterior, 34
96 Tunica vaginalis, 50, 52 Urethritis, 41, 121
Transitional cell tumor of ovary, 222
Transperineal approach, to seminal vesicle surgery, 96 hemorrhage in, 59 in pregnancy, 272
Transrectal ultrasound (TRUS)–guided prostate biopsy, Turner syndrome, 12-13, 207, 208 Urethrocele, 144
TURP syndrome, 92 Urethrorectal fistulae, 34
87 Twin-twin transfusion syndrome, 256 Urethrovaginal fistulae, 146
Transurethral resection Twins, 232, 233, 242, 254, 256 Urethrovaginal meatus, hypertrophy of, 18
Tyson gland, 23 Urethrovaginalis sphincter muscle, 111, 112, 132
of ejaculatory ducts, 108 Urinary bladder. See Bladder.
of prostate, 92 U Urinary extravasation, 38, 39
Transversalis fascia, 20, 111 Ulcers, genital Urinary frequency, in benign prostatic hyperplasia, 82, 84
Transverse ligament Urinary incontinence, 144
cervical, 133, 155, 161, 166 chancroid, 43 Urinary tract fistulae, 146
pelvic, 24 in granuloma inguinale, 44 Urinary tract infection
perineal, 26 in lymphogranuloma venereum, 43
Transverse septum of vagina, 137 Ultrasonography bacterial, 80
Transvesical approach of breast, 294, 296 in pregnancy, 272
to prostatectomy, 89 in cervical insufficiency, 253 Urinary tract symptoms, lower, 82
to seminal vesicle surgery, 96 in fibrocystic adenosis, 296 Urogenital diaphragm
Trauma in recurrent abortion, 238 anatomy of, 24
to penis and urethra, 38 Umbilical artery, 25, 156, 247 blood supply of, 26
to prostate, 78 Umbilical cord, 245, 247, 256 muscles of, 22
sexual, 143 Umbilical fold, 155, 156 topographic relationships of, 76, 78, 112, 133
to vagina, 141, 143 Umbilical ligament, 25, 156 Urogenital fascia, 20, 21, 22, 111
Treponema pallidum, 42 Umbilical prevesical fascia, 20 Urogenital sinus, 3, 4
Treponemal antibody test, 122 Umbilical vein, 247 Urogenital slit, 4
Trichilemmal (pilar) cysts, of scrotum, 63 Urachal cyst, 228 Urogenital triangle, 24
Trichomonas vaginalis, 139 Urachus, 20, 111 Uterine artery, 156, 157, 162
Trichomoniasis Ureter embolization of, for fibroids, 182
cervical, 170 dilation of Uterine bleeding. See also Menstruation; Vaginal bleeding.
urethral, 41 causes of, 175
vaginal, 119, 139 in benign prostatic hyperplasia, 84 during climacteric period, 206
Trigone, 31 in pregnancy, 272 dysfunctional, 176
Trophoblast. See Chorion. nerve supply of, 29 endometrial hyperplasia and, 176
Trophoblastic disease, gestational, 262 orifice of, 134 in fibroids, 180
Tubal ligation, 240 topographic relationships of, 20, 25, 27, 51, 76, 130, during ovulation, 204
Tubal pregnancy, 195, 249, 250, 251 Uterine synechia, 178
Tube, fallopian. See Fallopian tube. 133, 154, 155, 156, 157, 159, 160 Uterine vessels, 133, 155
Tubercle Ureteral node, 157 Uterosacral ligament, 154, 155, 157, 160, 161, 166
anal, 4 Ureteric bud, 2 Uterovaginal fascia, 111, 133, 155
genital, 4 Ureteric fold, 155 Uterovaginal plexus, 159, 263
pubic, 23, 111 Ureteritis, in pregnancy, 272 Uterus, 3, 133, 154-185
Tuberculosis Ureterovaginal fistulae, 146 absence of, 137, 165
of endometrium, 179 Urethra adenomyosis of, 177
of fallopian tube, 191, 198 adnexa of, 160
genital, 72, 198 caruncle of, 125
pelvic, 211 epithelium of, 31 torsion of, 217
prostatic, 81 female anatomy of, 154, 155, 160
vaginitis in, 140 anteflexion of, 166
Tuberosity, ischial, 22, 23, 24, 30, 111, 112, 115, anatomy of, 134 aplasia of, 165, 189
duct system of, 134 bicornuate, 165, 228
131 histology of, 134 bleeding from. See Uterine bleeding.
Tuboovarian abscess, 194, 197, 211 musculofascial extensions to, 131, 132 blood supply of, 156, 162
Tuboovarian cyst, 197, 211, 229 prolapse of, 144 carcinoma of, 184-185
Tubular sclerosis, in azoospermia, 70 support of, 134 cervix of. See Cervix.
Tumors. See also Cancer. topographic relationships of, 112, 131, 132, 154 chorioepithelioma of, 151
male, 77 congenital anomalies of, 137, 165
Buschke-Lowenstein, 46 accessory or duplicated, 35 contraction of
desmoid, 228 anatomy of, 20, 31
of epididymis, 97 cancer of, 48 in abortion, 252
of fallopian tube, 199 diverticulum of, 34, 35 after delivery, 264
germ cell epispadias of, 33 during pregnancy, 245
hypospadias of, 33 development of, 161
intratubular, 74 polyps of, 48 displacements of, 166
testicular, 73-74 strictures of, 45 endometrium of. See Endometrium.
of ovary. See Ovary, tumors of. topographic relationships of, 3, 24, 76 gravid, 228
paratesticular, 97 warts of, 48 hormonal influences on, 161, 162
phyllodes, 298, 299 orifice of, 110, 130, 134, 154 infertility-related disorders of, 235
retroperitoneal pelvic, 229 perforation of, urinary extravasation after, 39 inversion of, after delivery, 271
of spermatic cord, 97 laceration of, 169
ligaments suspending, 166
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319

Index

Uterus (Continued) Vaginal bleeding (Continued) Visceral metastasis, of prostate cancer, 86
lymphatic drainage of, 158 painful, 164 Visual disturbances, in preeclampsia/eclampsia, 274
musculature of, 161 in uterine inversion, 271 Voice, changes in, during male puberty, 9
myoma (fibroid) of, 180-182, 183, 228 Voiding symptoms
myometrium of, 162, 177, 247 Vaginal delivery
nodules of, 189 after cesarean section, 269 with aging, 82
perforation of, 168 lacerations during, 266-267 in benign prostatic hyperplasia, 82, 84
perisalpingeal cysts of, 189 normal, 264 Vulva, 110-127
polyps of, 169 operative, 265 adenoma of, 125
positional variations of, 166 anatomy of, 110-112
prolapse of, 145, 167 Vaginal sphincter muscle, 112 angioneurotic edema of, 118
retrodisplacements of, 166, 194 Vaginitis atrophy of, 117
rudimentary, 189 blood supply of, 114
rupture of, 168 atrophic, 147 carcinoma of, 126, 151
during forceps-assisted delivery, 267 bacterial, 139 chancroid of, 123
during labor, 270 chemical, 141 condylomata acuminata of, 125
during pregnancy, 270 fungal, 139 cysts of, 124
sarcoma of, 183 gonoccocal, 140 dermatoses of, 116
senile, 161, 168 Monilia, 139 elephantiasis of, 118
septate, 165 syphilitic, 140 endometriosis in, 149
subseptate, 165 traumatic, 141 fibroma of, 125
support of, 155 Trichomonas, 139 gonorrhea of, 121
topographic relationships of, 154, 155 tuberculous, 140 granuloma inguinale of, 123
tuberculosis of, 198 Vaginosis, bacterial, 139 hematoma of, 118
Varicocele, 27, 51, 59, 237 histology of, 135
Uterus didelphys, 165 Varicose veins, vulvar, 118 lacerations of, obstetric, 266
Utricle, 31, 76, 77 Vas aberrans, 52 lichenification of, 117
Vas deferens, 3, 20, 50, 52, 76 lipoma of, 125
V ampulla of, 76 lymphogranuloma venereum of, 43, 123
Vacuum-assisted delivery, 265 artery of, 27, 50, 51 sarcoma of, 126
Vagina, 130-151 blood supply of, 25, 27 syphilis of, 122
congenital absence of, 97, 103 tumors of
absence of, 137 course of, 20
anatomy of, 130 histology of, 52 benign, 125
atrophy of, 147 nerve supply of, 30 malignant, 126
bleeding from. See Vaginal bleeding. obstruction of, 103 varices of, 118
blood supply of, 130 sperm retrieval from, 106 Vulvar atypia, 117
carcinoma of, 150 Vasa efferentia, 3, 52 Vulvar itching, 119
condylomata acuminata in, 148 Vasectomy, 240 Vulvar vestibulitis, 120
congenital anomalies of, 137, 138 ductal obstruction after, 103 Vulvitis
cystocele in, 144 reversal of, 104 atrophic, 117
cysts of, 148 Vasoconstriction, in preeclampsia/eclampsia, 275 diabetic, 119
cytology of, 136 Vasovasostomy, 104 herpetic, 116
development of, 4, 137 Veins. See Blood supply; named veins. Vulvovaginal infections, 119
double, 137 Vena cava, inferior, 25, 27, 51, 156, 159 Vulvovaginitis, 119
endometriosis in, 149 Venereal Disease Research Laboratory (VDRL) test, 122 of childhood gonorrhea, 121
enterocele in, 145 Venereal (genital) warts, 46, 48, 125
epithelium of, 135, 136, 147 Venous plexus W
fibroma in, 148 cavernous, 134 Walthard’s cell rests, 189
fistulae in, 146 pampiniform, 25, 27, 50, 51, 59 Warts
foreign bodies in, 141 prostatic, 25
fornix of, 154 retropubic (vesical), 25 urethral, 48
histology of, 135 Verumontanitis, 35 venereal (genital), 46, 48, 125
hormonal influences on, 205 Verumontanum, 31 Weight gain, in preeclampsia/eclampsia, 273
lacerations of, 143 disorders of, 35 Weight loss, for polycystic ovary syndrome, 221
Vesical artery, 25, 51, 156 Wharton jelly, 256
obstetric, 266, 267 Vesical fascia, 20, 111, 155 Witch’s milk, 287
lymphatic drainage of, 113, 158 Vesical plexus, 30, 159, 263 WNT4 gene, in sexual differentiation, 2
melanoma of, 150 Vesical (retropubic) venous plexus, 25 Wolffian duct
during menopause and postmenopause, 136, 147 Vesicle cysts of, 34
metastasis and extension to, 151 blastodermis, 242 development of, 3
musculofascial extensions to, 131 seminal. See Seminal vesicle. Wuchereria bancrofti, 62
in neonate, 136 Vesicocervicovaginal fistulae, 146
orifice of, 110, 130, 134, 154 Vesicouterine peritoneal reflection, 155 X
in pregnancy, 136 Vesicouterine pouch, 130, 154, 155 X chromosome, 2
rectocele in, 145 Vesicovaginal fistulae, 146 XYY syndrome, 102
sarcoma of, 150 Vesicular appendix (hydatid of Morgagni), 160
support of, 130, 131, 132, 133 Vestibular fossa, 110 Y
teratoma of, 150 Vestibular gland Y chromosome, 2
topographic relationships of, 3, 110, 112, 154, 156, 157 major. See Bartholin gland.
transverse septum of, 137 minor, 135 defects in, 102
trauma to, 141, 143 Vestibule, 4, 133 Yolk sac, 246
tumors of bulb of, 112, 114, 133, 134
stalk of, 2
benign, 148 artery to, 130, 133 tumor of (testicular), 73
malignant, 150-151 Vestibulitis, vulvar, 120 Young retractor, in prostatectomy, 91
urethrocele in, 144 Villi Young syndrome, 103
wall of, 130, 133, 135, 161
Vaginal artery, 130, 133, 156 chorionic, 243, 246 Z
Vaginal bleeding. See also Uterine bleeding. placental, 242, 247, 255 Zona pellucida, 202, 233
in abortion, 252 Villous stem, 247 Zygote, 233, 242
in abruptio placentae, 258 Virilism, 18
at implantation, 243 in polycystic ovary syndrome, 221
in Sertoli-Leydig cell tumors, 219
Visceral lesions, in preeclampsia/eclampsia, 275

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