MALE GENITAL SYSTEM

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MALE GENITAL SYSTEM

• PENIS
• SCROTUM, TESTIS, EPIDIDYMIS
• PROSTATE
• Robbins Basic Pathology
• KUMAR, Abbas, Fausto, and Mitchell
• 8th Edition, CH 18

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PENIS

• MALFORMATIONS
• INFLAMMATORY LESIONS
• NEOPLASMS

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MALFORMATIONS OF THE PENIS

• ABNORMAL LOCATION OF URETHRAL ORIFICE ALONG
  PENILE SHAFT
• HYPOSPADIAS (VENTRAL ASPECT)
• MOST COMMON (1/250 LIVE MALE BIRTHS)
• EPISPADIAS (DORSAL ASPECT)

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Hypospadias (ventral)
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Epispadias (dorsal)
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HYPOSPADIAS AND EPISPADIAS

• MAY BE ASSOCIATED WITH OTHER GENITAL
  ABNORMALITIES
• INGUINAL HERNIAS
• UNDESCENDED TESTES
• CLINICAL CONSEQUENCES
• CONSTRICTION OF ORIFICE
• URINARY TRACT OBSTRUCTION
• URINARY TRACT INFECTION
• IMPAIRED REPRODUCTIVE FUNCTION

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INFLAMMATORY LESIONS OF THE PENIS

• SEXUALLY TRANSMITTED DISEASES
• BALANITIS (BALANOPOSTHITIS)
• INFLAMMATION OF THE GLANS (PLUS PREPUCE)
• ASSOCIATED WITH POOR LOCAL HYGIENE IN
  UNCIRCUMCISED MEN
• SMEGMA
• DISTAL PENIS IS RED, SWOLLEN, TENDER
• /- PURULENT DISCHARGE

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INFLAMMATORY LESIONS OF THE PENIS

• PHIMOSIS
• PREPUCE CANNOT BE EASILY RETRACTED OVER GLANS
• MAY BE CONGENITAL
• USUALLY ASSOCIATED WITH BALANOPOSTHITIS AND
  SCARRING
• PARAPHIMOSIS (TRAPPED GLANS)
• URETHRAL CONSTRICTION

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INFLAMMATORY LESIONS OF THE PENIS

• FUNGAL INFECTIONS
• CANDIDIASIS
• ESPECIALLY IN DIABETICS
• EROSIVE, PAINFUL, PRURITIC
• CAN INVOLVE ENTIRE MALE EXTERNAL GENITALIA

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NEOPLASMS OF THE PENIS

• SQUAMOUS CELL CARCINOMA (SCC)
• EPIDEMIOLOGY
• UNCOMMON LESS THAN 1 OF CA IN US MEN
• UNCIRCUMCISED MEN BETWEEN 40 AND 70
• PATHOGENESIS
• POOR HYGIENE, SMEGMA, SMOKING
• HUMAN PAPILLOMA VIRUS (16 AND 18)
• CIS FIRST, THEN PROGRESSION TO INVASIVE SQUAMOUS
  CELL CARCINOMA

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Squamous Cell Carcinoma
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SCC OF THE PENIS

• CLINICAL COURSE
• USUALLY INDOLENT
• LOCALLY INVASIVE
• HAS SPREAD TO INGUINAL LYMPH NODES IN 25 OF
  CASES AT PRESENTATION
• DISTANT METS RARE
• 5 YR SURVIVAL
• 70 WITHOUT LN METS
• 27 WITH LN METS

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LESIONS INVOLVING THE SCROTUM

• INFLAMMATION
• TINEA CRURIS (JOCK ITCH)
• SUPERFICIAL DERMATOPHYTE INFECTION
• SCALY, RED, ANNULAR PLAQUES, PRURITIC
• INGUINAL CREASE TO UPPER THIGH
• SQUAMOUS CELL CARCINOMA
• HISTORICAL SIGNIFICANCE
• SIR PERCIVAL POTT, 18TH CENTURY ENGLISH PHYSICIAN
• CHIMNEY SWEEPS

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LESIONS INVOLVING THE SCROTUM

• SCROTAL ENLARGEMENT
• HYDROCELE - MOST COMMON CAUSE
• ACCUMULATION OF SEROUS FLUID WITHIN TUNICA
  VAGINALIS
• INFECTIONS, TUMOR, IDIOPATHIC
• HEMATOCELE
• CHYLOCELE
• FILIARIASIS - ELEPHANTIASIS
• TESTICULAR DISEASE

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Hydrocele
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LESIONS OF THE TESTES

• CONGENITAL
• INFLAMMATORY
• NEOPLASTIC

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CRYPTORCHIDISM AND TESTICULAR ATROPHY

• FAILURE OF TESTICULAR DESCENT
• EPIDEMIOLOGY
• ABOUT 1 OF MALES (AT 1 YR)
• RIGHT gt LEFT, 10 BILATERAL
• PATHOGENESIS
• HORMONAL ABNORMALITIES
• TESTICULAR ABNORMALITIES
• MECHANICAL PROBLEMS

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Atrophic testes secondary to cryporchidism
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CRYPTORCHIDISM AND TESTICULAR ATROPHY

• CLINICAL COURSE
• WHEN UNILATERAL, MAY SEE ATROPHY IN CONTRALATERAL
  TESTIS
• STERILITY
• INCREASED RISK OF MALIGNANCY (3-5X)
• ORCHIOPEXY
• MAY HELP PREVENT ATROPHY
• MAY NOT ELIMINATE RISK OF MALIGNANCY

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OTHER CAUSES OF TESTICULAR ATROPHY

• CHRONIC ISCHEMIA
• INFLAMMATION OR TRAUMA
• HYPOPITUITARISM
• EXCESS FEMALE SEX HORMONES
• THERAPEUTIC ADMINISTRATION
• CIRRHOSIS
• MALNUTRITION
• IRRADIATION
• CHEMOTHERAPY

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INFLAMMATORY LESIONS OF THE TESTIS

• USUALLY INVOLVE THE EPIDIDYMIS FIRST
• SEXUALLY TRANSMITTED DISEASES
• NONSPECIFIC EPIDIDYMITIS AND ORCHITIS
• SECONDARY TO UTI
• BACTERIAL AND NON-BACTERIAL
• SWELLING, TENDERNESS
• ACUTE INFLAMMATORY INFILTRATE

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INFLAMMATORY LESIONS OF THE TESTIS

• MUMPS
• 20 OF ADULT MALES WITH MUMPS
• EDEMA AND CONGESTION
• CHRONIC INFLAMMATORY INFILTRATE
• MAY CAUSE ATROPHY AND STERILITY
• TUBERCULOSIS
• GRANULOMATOUS INFLAMMATION
• CASEOUS NECROSIS
• AUTOIMMUNE GRANULOMATOUS ORCHITIS
• RARE FINDING IN MIDDLE AGED MEN

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TESTICULAR NEOPLASMS

• EPIDEMIOLOGY
• MOST IMPORTANT CAUSE OF PAINLESS ENLARGEMENT OF
  TESTIS
• 5/100,000 MALES, WHITES gt BLACKS (US)
• INCREASED FREQUENCY IN SIBLINGS
• PEAK INCIDENCE 20-34 YRS
• MOST ARE MALIGNANT
• ASSOCIATED WITH GERM CELL MALDEVELOPMENT
• CRYPTORCHIDISM (10)
• TESTICULAR DYSGENESIS(XXY)

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TESTICULAR NEOPLASMS

• PATHOGENESIS
• 95 ARISE FROM GERM CELLS
• ISOCHROMOSOME 12, i(12p), IS A COMMON FINDING
• INTRATUBULAR GERM CELL NEOPLASMS
• RARELY ARISE FROM SERTOLI CELLS OR LEYDIG CELLS
• THESE ARE OFTEN BENIGN
• Lymphoma
• men gt 60 yo

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WHO CLASSIFICATION OF TESTICULAR TUMORS

• ONE HISTOLOGIC PATTERN (60)
• SEMINOMAS (50)
• EMBRYONAL CARCINOMA
• YOLK SAC TUMOR
• CHORIOCARCINOMA
• TERATOMA
• MULTIPLE HISTOLOGIC PATTERNS (40)
• EMBRYONAL CA TERATOMA
• CHORIOCARCINOMA OTHER
• OTHER COMBINATIONS

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HISTOGENESIS OF TESTICULAR NEOPLASMS (PEAK
INCIDENCE)
GERM CELL PRECURSOR
GONADAL DIFFERENTIATION
TOTIPOTENTIAL DIFFERENTIATION (NONSEMINOMA)
SEMINOMA (40-50 Y)
EMBRYONAL CA (UNDIFFERENTIATED) (20-30 Y)
SOMATIC DIFFERENTIATION
TROPHOBLASTIC DIFFERENTIATION
YOLK SAC DIFF
TERATOMA (ALL AGES)
MATURE IMMATURE MALIGNANT TX
YOLK SAC TUMOR (lt 3 Y) AFP
CHORIOCARCINOMA (20-30 Y) hCG
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Seminoma, with focal hemorrhage and necrosis
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Normal testicular tissue
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Seminoma
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Seminoma
Syncytiotrophoblast
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Dermoid Cyst
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Immature Teratoma
With Embryonal Carcinoma
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CLINICAL COURSE OF TESTICULAR TUMORS

• USUALLY PRESENT WITH PAINLESS ENLARGEMENT OF
  TESTIS
• MAY PRESENT WITH METASTASES
• NONSEMINOMAS (MORE COMMON)
• LYMPH NODES, LIVER AND LUNGS
• SEMINOMAS
• USUALLY JUST REGIONAL LYMPH NODES
• TUMOR MARKERS (hCG AND AFP)
• TREATMENT SUCCESS DEPENDS ON HISTOLOGY AND STAGE
• SEMINOMAS VERY SENSITIVE TO BOTH RADIO- AND
  CHEMOTHERAPY

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DISEASES OF THE PROSTATE

• PROSTATITIS
• NODULAR HYPERPLASIA
• CANCER

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PROSTATITIS

• ACUTE BACTERIAL PROSTATITIS
• CHRONIC BACTERIAL PROSTATITIS
• CHRONIC ABACTERIAL PROSTATITIS

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ACUTE BACTERIAL PROSTATITIS

• ETIOLOGY
• SAME ORGANISMS THAT CAUSE UTI
• E coli, OTHER GNR
• PATHOGENESIS
• ORGANISMS ASCEND FROM URETHRA AND URINARY BLADDER
• RARELY, HEMATOGENOUS SPREAD

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ACUTE BACTERIAL PROSTATITIS

• MORPHOLOGY
• ACUTE INFLAMMATION, ESPECIALLY IN THE GLANDS,
  WITH MICROABSESSES
• CONGESTION, EDEMA
• CLINICAL COURSE
• DYSURIA, FREQUENCY, LOW BACK PAIN, PELVIC PAIN
• ENLARGED, EXQUISITELY TENDER
• /- FEVER OR LEUKOCYTOSIS
• USUALLY RESOLVES WITH WITH AB RX

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CHRONIC PROSTATITIS

• ETIOLOGY
• MAY FOLLOW ACUTE PROSTATITIS
• MAY DEVELOP INSIDIOUSLY
• CULTURE POSITIVE (BACTERIAL)
• SAME ORGANISMS THAT CAUSE AP
• CULTURE NEGATIVE (ABACTERIAL)
• MAY BE RELATED TO
• CHLAMYDIA TRACHOMATIS
• UREAPLASMA UREALYTICUM
• MOST COMMON FORM OF CP

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CHRONIC PROSTATITIS

• MORPHOLOGY
• LYMPHOCYTIC INFILTRATE
• NEUTROPHILS AND MACROPHAGES
• SOME EVIDENCE OF TISSUE DESTRUCTION
• CLINICAL COURSE
• SIMILAR TO AP
• LESS ACUTE SYMPTOMS
• MORE RESISTANT TO AB RX
• CBP OFTEN ASSOCIATED WITH RECURRENT UTI

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PROLIFERATIVE LESIONS OF THE PROSTATE
PERIURETHRAL AND TRANSITIONAL ZONES
URETHRA
PERIPHERAL ZONE
NORMAL PROSTATE
NODULAR HYPERPLASIA
CARCINOMA
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NODULAR HYPERPLASIA

• OTHER TERMS USED
• GLANDULAR AND STROMAL HYPERPLASIA
• BENIGN PROSTATIC HYPERTROPHY (HYPERPLASIA)
• EPIDEMIOLOGY
• OCCURS IN 20 OF MEN OVER 40
• OCCURS IN 90 OF MEN OVER 70

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PATHOGENESIS OF NODULAR HYPERPLASIA

• PROLIFERATION OF BOTH EPITHELIAL AND STROMAL
  ELEMENTS
• BOTH ANDROGENS AND ESTROGENS MAY PLAY A ROLE
• NOT SEEN IN MALES CASTRATED BEFORE PUBERTY
• INHIBITORS OF TESTOSTERONE METABOLISM USEFUL IN
  TREATMENT
• RELATIVE INCREASE IN ESTROGENS IN OLDER MEN MAY
  INCREASE DHT RECEPTORS IN PROSTATE

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CLINICAL COURSE OF NODULAR HYPERPLASIA

• SYMPTOMS OCCUR IN ONLY 10 OF MEN WITH NODULAR
  HYPERPLASIA
• HESITANCY
• URINARY RETENTION
• URGENCY, FREQUENCY, NOCTURIA, UTI
• TREATMENT
• MEDICAL
• SURGICAL
• COMMON CAUSE FOR ELEVATED PROSTATE SPECIFIC
  ANTIGEN (PSA)

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CARCINOMA OF THE PROSTATE

• EPIDEMIOLOGY
• MOST COMMON VISCERAL CANCER
• ABOUT 70/100,000 MEN IN US
• 200,000 NEW CASES/YR IN US
• 20 ARE LETHAL
• SECOND MOST COMMON CAUSE OF CANCER DEATH IN MEN
• PEAK INCIDENCE OF CLINICAL CANCER IS 65-75 YO
• LATENT CA IS EVEN MORE PREVALENT
• gt50 IN MEN gt 80 YO

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CARCINOMA OF THE PROSTATE

• PATHOGENESIS
• HORMONAL FACTORS
• DOES NOT OCCUR IN EUNUCHS
• ORCHIECTOMY AND/OR ESTROGEN TREATMENT INHIBITS
  GROWTH
• GENETIC FACTORS
• INCREASED RISK IN FIRST ORDER RELATIVES
• BLACKS gt WHITES (SYMPTOMATIC CA)
• ENVIRONMENTAL FACTORS
• GEOGRAPHIC DIFFERENCES IN INCIDENCE OF CLINICAL
  CANCER (NOT OF LATENT CA)
• CHANGE IN INCIDENCE WITH MIGRATION

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CARCINOMA OF THE PROSTATE

• CLINICAL COURSE
• OFTEN CLINICALLY SILENT
• DIGITAL RECTAL EXAM (DRE)
• PROSTATE SPECIFIC ANTIGEN (PSA)
• gt 4 ng/ml IN PERIPHERAL BLOOD
• FREE PSA lt 25
• TRANSRECTAL ULTRASOUND
• NEEDLE BIOPSY
• PROSTATISM (LIKE BPH)
• METASTASES
• OSTEOBLASTIC
• TREATMENT- SURGERY, RADIATION, HORMONES, CHEMO

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Needle bx of prostate
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CARCINOMA OF THE PROSTATE

• STAGING
• A (T1) MICROSCOPIC ONLY
• B(T2) MACROSCOPIC (PALPABLE)
• C(T3 T4) EXTRACAPSULAR
• D(N1-3,M1) METASTATIC
• PROGNOSIS DEPENDENT ON STAGE AND HISTOLOGIC GRADE
• 90 10 YR SURVIVAL FOR A AND B
• 10-40 10 YR SURVIVAL FOR C AND D

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Hydronephrosis