Male genitalia path

Question 1

Penis: MalformationsHypospadias and epispadias

Answer 1

Urethral opening
-below tip of penis (ventral) = hypospadias
-above tip of penis (dorsal) = epispadias
may be associated with other genital abnormalities
the urethral orifice may be constricted, causing complications from urinary tract obstruction

Question 2

Penis: InflammationsBalanitis

Answer 2

local inflammation of the glans penis
+ overlying prepuce = balanoposthitis
usually due to smegma accumulation, typically under the foreskin of uncircumcised males
-smegma = sweat, debris, desquamated epithelial cells
distal penis is red, swollen, and tender; may have purulent discharge

Question 3

Penis: InflammationsPhimosis

Answer 3

Inability to retract the foreskin of uncircumcised penis because of scarring or adhesions, usually secondary to balanoposthitis
Interferes with cleanliness; smegma accumulation favors the development of secondary infections and possibly carcinoma

Question 4

Penis: InflammationsParaphimosis

Answer 4

Forcible retraction of foreskin with phimosis leads to painful swelling that can obstruct the urethra
-severe cases may cause urinary retention

Question 5

Penis:Neoplasms

Answer 5

uncommon; most originate from squamous epithelium (squamous cell carcinomas)
most cases occur in uncircumcised patients >40 yoa
risk factors:
-phimosis
-poor hygiene
-infection with HPV types 16 and 18

Question 6

Penis:Squamous Cell Carcinoma

Answer 6

usually preceded by 1 of 3 variants of carcinoma in situ

• Bowen disease
• erythroplasia of Queryat
• bowenoid papulosis

Question 7

Bowen disease

Answer 7

Appears as a solitary, plaque-like lesion on the shaft of the penis
most common >30 yoa
~1/3 of patients develop visceral cancers

Question 8

Erythroplasia of Queyrat

Answer 8

variant of Bowen disease

erythematous patch on the glans penis and other mucosal surfaces

Question 9

Bowenoid papulosis

Answer 9

venereally transmitted viral (HPV 16) lesion of the penile shaft
Patients typically younger than seen in Bowen disease
Presents with multiple reddish-brown pigmented papules (may be verrucoid)
Histologically indistinguishable from Bowen disease
virtually never develops into invasive carcinoma and may spontaneously regress

Question 10

Penis:Squamous cell carcinoma

Answer 10

SCC of the penis is uncommon in the U.S. (<1% of male cancers)
-In some parts of Asia, South America, and Africa it comprises 10-20% of male malignancies
Usually found in patients between 40-70 yo
Is extremely rare in populations that practice circumcision
-better genital hygiene?
-decreases likelihood of HPV infection?

Question 11

SSC clinical course

Answer 11

SCC is slowly growing, locally invasive, and probably present for a year or more before brought to medical attention
-In early stage metastasize to inguinal and iliac lymph nodes
-Widespread dissemination is uncommon, but occurs late in disease
Not painful until they undergo ulceration (may bleed) and infection
Prognosis is related to tumor stage
-In limited lesions without inguinal node involvement, there is a 66% 5-year survival rate
-Metastasis to a lymph node results in only a 27% 5-year survival rate

Question 12

Cryptorchidism

Answer 12

Represents a complete or incomplete failure of testicular descent into the scrotal sac
-involves right testis more commonly than the left, but bilateral in 25%
-usually results in testicular atrophy and hyalinization by puberty
*4x increased risk of malignancy (less risk in the normally-descended testis)
*may result in sterility
usually occurs as an isolated anomaly, but may be associated with other malformations such as hypospadias or other congenital syndromes (e.g., Prader-Willi syndrome)
diagnosis is uncertain before 1 year of age (complete descent isn’t universally present at birth)

Question 13

Epididymitis and orchitis

Answer 13

Commonly related to infections of the urinary tract (cystitis, urethritis, genitoprostatitis) that spread to the testis via the vas deferens and spermatic cord lymphatics
Cause varies with age
-In childhood associated with congenital abnormality and Gram Negative Bacteria
-In sexually active men 35 yo, common UT pathogens: Escherichia coli and Pseudomonas sp.
May lead to sterility if testis involved and inflammation not resolved in a timely fashion

Question 14

Gonorrhea

Answer 14

neglected infection extends from posterior urethra to the prostate → seminal vesicles → epididymis
-results in abscesses that may destroy the epididymis
may spread to testis and produce a suppurative orchitis

Question 15

Mumps

Answer 15

testicular involvement uncommon in school-age children, but produces orchitis in 20-30% of postpubertal males
-usually develops ~1 wk after swelling of parotid glands

Question 16

Tuberculosis

Answer 16

believed epididymitis results from spread via prostate and seminal vesicles
caseating granulomas

Question 17

Testicular Atrophy causes

Answer 17

Progressive atherosclerotic narrowing of the blood supply (old age)
End stage of inflammatory orchitis (by any cause)
Cryptorchidism
Hypopituitarism
Generalized malnutrition or cachexia
Irradiation
Prolonged exposure to female sex hormones

Question 18

Testicular Torsion

Answer 18

Twisting of the spermatic cord may cut off venous drainage and arterial supply to testis
-Infarction may follow

Question 19

Testicular Torsion clinical course

Answer 19

presents as sudden pain
intense congestion and widespread extravasation of blood into interstitial tissues
one of the few urologic emergencies
-need to be surgically resolved in <6 hours to retain testicular viability

Question 20

Testicular torsion

Answer 20

sudden onset
extreme pain
elevated testicle
absent cremasteric reflex
age <20

Question 21

Epididymitis

Answer 21

Hx urethritis
pyuria
tenderness, swelling
age <35

Question 22

Varicocele

Answer 22

dilated vein within the spermatic cord
cause of infertility
-left testicle more commonly involved
-A rapidly developing variocele is suspicious for renal cell carcinoma

Question 23

Hydrocele

Answer 23

accumulation of clear serous fluid in the tunica vaginalis causing enlargement of the scrotal sac
-may be mistaken for testicular enlargement
often occur spontaneously without any apparent cause
Diagnostic technique to detect a hydrocele = transillumination

Question 24

Testicular neoplasms

Answer 24

neoplasms of the scrotal sac are unusual, but don’t forget the association of scrotal squamous cell carcinoma with chimney sweeps
We’ll focus here on testicular neoplasms, which are derived from -germ cells (95% of cases)
Some trends you should notice:
germ cell tumors are usually very aggressive cancers
-sex cord or stromal tumors are usually benign, but can elaborate steroids that cause interesting endocrinologic syndromes
most commonly present with painless enlargement of the testis

Question 25

Biopsy of testicular neoplasm?

Answer 25

Biopsy of a testicular neoplasm is associated with a risk of tumor spillage which would necessitate excision of the scrotal skin in addition to orchiectomy Standard management of a solid testicular mass is radical orchiectomy based on the presumption of malignancy!

Question 26

Testicular Cancer Risk Factors

Answer 26

Cryptorchidism (3x-5x fold increase) Family history (brothers 8x-10x fold increase) Testicular dysgenesis -feminization -Klinefelter syndrome Age range: 20-54, peak at 15-34 Caucasian NO ASSOCIATION with lifestyle (smoking, obesity, etc.) Development of cancer in one testis is associated with a markedly increase risk in contralateral testis

Question 27

Testicular cancers

Answer 27

``` Seminoma Spermatocytic Seminoma Embryonal Carcinoma Yolk Sac Tumor Choriocarcinoma Teratoma Mixed Germ Cell Tumors ```

Question 28

Seminoma

Answer 28

50% of germ-cell tumors 40-50 yoa Large, soft, well-demarcated tumors may have coagulation necrosis, but no hemorrhage identical to ovarian dysgerminomas large cells with clear, glycogen-rich cytoplasm; conspicuous nucleoli Tumor marker: 10 % of patients have elevated hCG 7-24% have syncytiotrophoblast-like giant cells

Question 29

seminoma prognosis

Answer 29

late metastases very radiosensitive chemosensitive excellent prognosis

Question 30

Spermatocytic Seminoma

Answer 30

``` larger than classic seminoma but uncommon pale gray, soft, mucoid cysts affects elderly (> 65 years ) best prognosis mixture of large & small tumor cells rarely metastasize ```

Question 31

Embryonal Carcinoma

Answer 31

smaller than seminomas, but poorly demarcated contains foci of hemorrhage or necrosis poorly differentiated, pleomorphic cells in sheets or cords cellular pleomorphism and nuclear atypia present in the tumor cells

Question 32

Embryonal Carcinoma prognosis

Answer 32

more aggressive than seminomas not radiosensitive chemosensitive early metastases

Question 33

Yolk Sac Tumor

Answer 33

nonencapsulated, yellow-white, mucinous tumor most common testicular tumor <3 (good prognosis) Adult yolk sac tumors are often seen admixed with embryonal carcinoma

Question 34

Yolk Sac Tumor cells

Answer 34

reticular network of poorly differentiated cuboidal or columnar cells 50% contain Schiller-Duval bodies

Question 35

Choriocarcinoma

Answer 35

do not cause testicular enlargement, but metastasize rapidly hemorrhage and necrosis common rarest type (~1%) 20-30 yoa 100% have elevated BhCG -The detection of βhCG after orchiectomy is an indicator of metastatic disease. Primary tumors are small, nonpalpable lesions

Question 36

Choriocarcinoma prognosis

Answer 36

very early and rapid metastases not radiosensitive or chemosensitive poor prognosis

Question 37

Teratoma

Answer 37

large, with solid, sometimes cartilaginous, and cystic areas in child, benign in adult, always regarded as malignant local resection for cure

Question 38

Mixed Germ Cell Tumors

Answer 38

Mixed germ-cell tumors account for ~60% of testicular germ-cell neoplasms most common is a combination of teratoma, embryonal carcinoma, and yolk sac tumors nonseminomatous mixed germ cell tumor with various textures and colors is displayed

Question 39

Tumors of Sex Cord or Stroma

Answer 39

Leydig Cell Tumors Sertoli Cell Tumors Testicular Lymphoma

Question 40

Leydig Cell Tumors

Answer 40

may elaborate androgens, estrogens, even corticosteroids most common 20-60 yoa adults → gynecomastia; children → sexual precocity excellent prognosis ~90% are benign

Question 41

Steroli Cell Tumors

Answer 41

insufficient quantities of estrogens or androgens to cause masculinization or feminization, but sometimes gynecomastia excellent prognosis ~90% are benign

Question 42

Testicular Lymphoma

Answer 42

not a primary tumor, but discussed here because they account for ~5% of testicular neoplasms most common form of testicular neoplasm in men >60 yoa most common type = diffuse large-cell type Non-Hodgkin Lymphoma

Question 43

Prostate

Answer 43

Nodular Hyperplasia | Adenocarcinoma

Question 44

Nodular Hyperplasia

Answer 44

aka, benign prostatic hypertrophy (BPH) but misnomer Extremely common disorder in men > 50 yo Characterized by hyperplasia of stromal and epithelial cells resulting in the formation of large, discrete nodules in the periurethral (central) region of the prostate- postvoid dripping When sufficiently large, can obstruct the urethra Well-circumscribed, white-tan, rubbery hyperplastic nodules symmetrically on either side of the compressed urethra

Question 45

Adenocarcinoma

Answer 45

Most common form of cancer in men and second leading cause of cancer death Typically a disease of men > 60 yoa Uncommon in Asians; higher incidence in African-Americans In contrast to nodular hyperplasia, arises from the peripheral glands no postvoid dripping

Question 46

AdenocarcinomaRisk factors

Answer 46

Age, race, family history, hormone levels, and environmental influences Incidence rises as people from areas of low risk move to areas of higher risk (change of diet, environmental carcinogens, etc.) Androgens and estrogens believed to play a role (inhibition of these tumors occurs with orchiectomy) In ~10% of white American men, prostate cancer has been linked to germ-line inheritance -Men with one first-degree relative have a 2X higher risk of developing prostate cancer, and those with 2 first-degree relatives have a 5X higher risk

Question 47

Adenocarcinoma diagnostic approach

Answer 47

Digital rectal exam suffers from low sensitivity and low specificity -Imaging studies (transurethral unltrasonography [TRUS], etc.) are also of poor specificity and sensitivity -Transperitoneal or transrectal biopsy is required for confirmation Prostate specific antigen (PSA)

Question 48

Prostate specific antigen (PSA)

Answer 48

Elevated blood levels occur in association with localized as well as advanced cancer -In most labs, 4 ng/mL is the upper limit of normal Caveats: -PSA is organ specific but NOT cancer specific -Nodular hyperplasia, prostatitis, infarct, instrumentation, and ejaculation increase serum PSA -only ~2/3rds of men with localized prostate cancer have increased PSA (compared to 95% of metastatic)

Question 49

Refinements in the interpretation of PSA values

Answer 49

The recommended age-specific upper reference ranges for serum PSA are 2.5 ng/mL for men 40-49 yoa 3.5 ng/mL for men 50-59 yoa 4.5 ng/mL for men 60 -69 yoa 6.5 ng.mL for men 70-79 yoa Men with prostate cancer demonstrate an increased rate of rise in PSA compared to men without prostate cancer -suspicious for prostate cancer if >0.75 ng/mL/y measure 3x over 1.5 years

Question 50

PSA controversy

Answer 50

serum PSA by itself cannot be used for early detection of prostate cancer considerable controversy about continuing to promote PSA testing as a cancer screening tool: recent studies show that it does NOT reduce prostate cancer mortality (evidence that screened men actually have higher morbidity and mortality, likely due to treatment side effects) despite this evidence, the American Urological Association (April 2009) changed their recommendation to start PSA testing earlier (now at 40 yoa instead of 50 yoa) in October 2011, the USPSTF released its draft recommendation that PSA screening be discouraged

Question 51

Adenocarcinoma clinical course

Answer 51

Microscopic cancers found incidentally at autopsy or biopsies for nodular hyperplasia are asymptomatic -Their long term significance is not clear *autopsy studies have shown that 30% of men >50 yoa and 70% of men >70 yoa have occult prostate cancer Prostate cancer that is local/regional has excellent prognosis!

Question 52

Adenocarcinoma clinical course

Answer 52

Patients with clinically localized disease do not have urinary symptoms -The lesion is discovered by digital rectal exam and/or PSA testing Patients with clinically advanced disease have symptoms -Some patients come to medical attention because of back pain -The finding of osteoblastic bone disease is virtually diagnostic for this form of cancer in men can have osteoblastic metastases from prostatic adenocarcinoma -Osteoblastic bone disease is virtually diagnostic for prostate cancer!

Question 53

hyperplasia vs adenocarcinoma location

Answer 53

Nodular hyperplasia typically occurs periurethrally, while adenocarcinoma tends to occur peripherally.