Pathology-Male Reproductive Path Flashcards
A boy is born and as you are about to perform the circumcision, you note that the urethra is on the inferior surface of the penis. What causes this condition?
He has hypospadias. This is due to failure of the urethral folds to close. Normally, the urethral folds (beneath the genital tubercle) grow outward and “zipper up” which closes the urethra of the penis.
A boy is born and as you are about to perform the circumcision, you note that the urethra is on the superior surface of the penis. What causes this condition?
He has epispadias. This is due to abnormal positioning of the genital tubercle.
A boy is born and as you are about to perform the circumcision, you note that the urethra is on the superior surface of the penis. What other condition is this condition associated with?
Epispadias is associated with bladder exstrophy (abnormal formation of the lower abdomen so bladder wall is exposed)
A 26 year old man presents with a warty growth on the skin of his genitalia. Biopsy of the growth is shown below. What is your diagnosis?
This patient has a condyloma acuminatum. This is due to HPV 6 or 11. Note the characteristic koilocytic change (nuclei appear like raisins)
What long term complication are patients at risk for who are infected with chlamydia trachomatis serotypes 1-3?
This bug can initially cause lymphogranuloma venereum (necrotizing granulomatous inflammation of inguinal lymphatics). Eventually this resolves and causes fibrosis and rectal strictures if the perianal region was involved.
How does chlamydia infection occur?
It enters mucosal surfaces as elementary bodies. It then replicates within cells as reticulate bodies, which are then released again as elementary bodies to infect further cells.
What are risk factors for squamous cell carcinoma of the penis?
2/3 of cases have high risk HPV (16, 18, 31, 33). Lack of circumcision.
Bowen disease
In situ carcinoma that presents as leukoplakia on the shaft of the penis. Precursor to squamous cell carcinoma.
Erythroplasia of Queyrat
In situ carcinoma that presents as erythroplakia on the glans of the penis. Precursor to squamous cell carcinoma.
Bownoid papulosis
In situ carcinoma that presents as reddish papules on the skin of the penis that do not usually invade.
What is the most common abnormality in the male reproductive system?
Cryptoorchidism. This is a failure of testicles to descend into the scrotal sac.
A mother is referred to you after she finds out that her newborn baby’s testicles failed to descend. How do you treat this child?
Most cases resolve spontaneously. If it is not resolved by the age of 2 you do surgery and bring them into the testicular sac. This will decrease the risk of testicular atrophy, infertility and risk of seminoma (germ cell tumor).
What microbes can cause orchitis in young adults? Kids > 10 years old?
Young adults: chlamydia trachomatis (D-K), neisseria gonorrhoeae. Older adults: E. coli, pseudomonas (both common UTIs). Kids > 10 years: mumps and autoimmune orchitis.
What organs are often targets of inflammation by the mumps virus?
Parotids, meningitis, pancreatitis and orchitis.
What things are on your differential if you see granulomas in the testicles? What further testing might you do?
Autoimmune orchitis and Tb. Look for acid-fast bacilli to rule out Tb. Look for necrotizing granulomas to rule out Tb.
A 14 year old boy presents with sudden testicular pain and an absent cremaster reflex. On physical exam you note increased swelling of the right testicle. What is causing his condition?
Testicular torsion. This leads to closure of the vein, so the artery is still pumping in blood and none is draining out, resulting in hemorrhagic infarction of the testicle. The torsion can occur because of a congenital failure of the testes to attach to the inner lining of the scrotum.
Why does the cremasteric reflex not work when someone has a testicular torsion?
The nerve and blood supply to the cremaster are twisted and no longer work.
A 67 year old man presents with scrotal swelling. On physical exam the scrotum looks like a bag of worms. What side is most likely affected and why?
The left side. On the left side, the spermatic vein first goes into the renal vein, then the renal vein drains into the inferior vena cava. On the right side, the spermatic vein goes directly into the inferior vena cava. This condition is associated with renal cell carcinoma because it likes to invade the renal vein, which can block off the left spermatic vein and present as a varicocele.
Why are varicoceles prevalent in infertile males?
Blood pooling up within the spermatic veins warms the testicles and impedes on the cooler environment requires for spermatogenesis.
A 5 month old boy presents with scrotal swelling. On physical exam you can transluminate the fluid in the scrotum. What is causing his condition? What if it was a 50 year old man?
Hydrocele. This is due to incomplete closure of the processus vaginalis and peritoneal fluid collection within the tunica vaginalis. In adults this is due to blockage of lymphatic drainage.
A 30 year old man presents with a firm, painless testicular mass that cannot be transilluminated. You broke the rules and biopsied the dang thing. Your results are shown below. What is your diagnosis? What is his prognosis?
He has a seminoma. Note the malignant proliferation of cells with clear cytoplasm and central nuclei. Note that there is no hemorrhage or necrosis and that the mass is homogenous. He has a good prognosis and is likely to respond to radiotherapy.
A 30 year old man presents with a firm, painless testicular mass that cannot be transilluminated. You broke the rules and biopsied the dang thing. Your results are shown below. What is your diagnosis?
He has embryonal carcinoma, a non-seminoma. Note the malignant proliferation immature, primitive cells (embryonal) that are forming GLANDS. Note the HEMORRHAGIC mass w/NECROSIS. These tumors are aggressive with early hematogenous spread and prognosis is poor.
A 5 year old boy presents with a firm, painless testicular mass that cannot be transilluminated. You broke the rules and biopsied the dang thing. Your results are shown below. How do you make the diagnosis?
Yolk sac tumor, note the Schiller-Duval body (a glomeruloid-like structure) characteristic of these tumors. Note that AFP will be elevated and can be measured. Also note that it is the most common testicular tumor in children.
A 5 year old boy presents with a firm, painless and small testicular mass. He has massive tumors all over his body. He also presents with hyperthyroidism and gynecomastia. You broke the rules and biopsied the dang thing. Your results are shown below. How do you make the diagnosis?
This is choriocarcinoma. It is a malignant tumor of synctiotrophoblasts and cytotrophoblasts (but no papillae) because it is a tumor of placental-like tissue. Synctiotrophoblasts make beta-hCG and it will be elevated. The alpha subunit of beta-hCG is similar to LH, FSH and TSH which explains the child’s symptoms of hyperthyroidism and gynecomastia. Finally, synctiotrophoblasts and cytotrophoblasts were made to find blood and metastasize early, explaining large body tumors and a small testicular mass.
A 7 year old boy presents with a deepening voice and hair on his face. He also has a firm, painless testicular mass that cannot be transilluminated. His father had a similar testicular mass but had gynecomastia as an adult. What would you expect to see on histology of both of their tumors?
Leydig cell tumors typically produce androgen and can cause precocious puberty in children and gynecomastia in adults. On histology you would see proliferation of Leydig cells and Reinke crystals.
What type of sex cord tumor is typically silent?
Sertoli cell tumors, they will be comprised of tubules.
What region of the male reproductive tract was this biopsy taken from? Why are there glands?
Note the glands (inner lumenal layer and an outer basal layer) in a fibromuscular connective tissue. This is the prostate, it has glands because it secretes an alkaline fluid with the semen.
How can the kidney be damaged in patients with BPH?
Dilatation of the ureter and dilatation and atrophy of the kidney due to hydronephrosis from urine build up beyond the bladder.
A 60 year old African American man presents with fatigue and low back pain. Physical exam reveals a mass on DRE. Labs show PSA > 10ng/dL, decreased percentage of free-PSA, increased Alk Phos and prostate acid phosphatase (PAP). His prostate biopsy is shown below. What is your diagnosis?
He has prostate adenocarcinoma. This is a malignant proliferation of prostatic glands (note infiltration of small glands with cells that have prominent nucleoli). It is the most common cancer in men and 2nd most common cause of cancer death in men. Note that prostatic adenocarcinoma makes bound PSA. PAP is also a tumor marker for prostate cancer.
What is the most common location of prostatic adenocarcinoma?
Posterior periphery of the prostate. This is why you do not see urinary symptoms until very late in the disease.
What does prostate cancer typically do when it metastasizes to the lumbar spine?
It produces osteoblastic metastasis, so instead of getting lytic lesions, you get sclerotic lesions of the bone. Note that this will result in increased Alk Phos because this indicates osteoblast laying down of bone.
A 60 year old African American man presents with fatigue and low back pain. Physical exam reveals a mass on DRE. Labs show PSA > 10ng/dL, decreased percentage of free-PSA, increased Alk Phos and prostate acid phosphatase (PAP). His prostate biopsy is shown below. How do you treat him?
Prostatic adenocarcinoma is treated with prostatectomy if local, continuous GnRH analogues like leuprolide (GnRH shuts down hypothalamus -> reduces FSH and LH. This reduces the prostate cancer’s ability to thrive because it is androgen dependent) and androgen-receptor inhibitors.
