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Flashcards in Male Pathology Deck (17)
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What results in hypospadias? Epispadias? Which is more common?

- hypospadius: failure of the urethral folds to close
- epispadius: (rare) abnormal positioning of genital tubercle (becomes the glans penis); associated with bladder exstrophy


What is the major cancer that arises in the penis? What are the three main precursor lesions?

- Bowen disease: in situ carcinoma of the shaft, presents as leukoplakia
- erythroplasia of Queyrat: in situ carcinoma of the glans, presents as erythroplakia
- Bowenoid papulosis: in situ carcinoma presenting as reddish papules; it does NOT usually progress


What is the most common male congenital abnormality? What are some major complications that may arise without resolution?

- cryptoorchidism (undescended testicle)
- most resolve spontaneously, or will be surgically fixed if it fails to do so by age 2 due to risk of complications
- complications: testicular atrophy and infertility*, increased risk for seminoma
- *the necrotic testis loses its immunological privilege and therefore the body is able to develop antibodies against sperm, so the other testicle will also be affected!


Which organisms can cause orchitis? What can cause a granulomatous orchitis?

- Chlamydia trachomatis, Neisseria gonorrhoeae, E. coli, Pseudomonas, Mumps virus (note that these are the same causes of prostatitis)
- granulomatous inflammation: TB (necrotizing) and autoimmune orchitis (non-necrotizing)


What is testicular torsion? How do patients present?

- testicular torsion is the twisting of the spermatic cord; the thin-walled vein gets compressed and the thick-walled artery remains open, resulting in hemorrhagic infarction; this is a medical emergency
- patients are usually adolescents with sudden onset testicular pain and no cremasteric reflex


What is a varicocoele?

- the dilation of spermatic vein due to impaired draining (left side is much more common)
- scrotal swelling and "bag of worms" appearance


What is a hydrocoele and how can it arise in infants? How about in adults?

- hydrocoele is a collection of fluid in the tunica vaginalis; this resulting mass will transilluminate because it is not solid
- infants: due to incomplete closure of the processus vaginalis
- adults: due to blocked lymphatic drainage


What are the two broad types of testicular tumors? How common is each? Which are mainly malignant? How do testicular tumors present and how do we biopsy them?

- germ cell tumors (95%) and sex-cord stromal tumors (5%)
- all germ cell tumors are malignant, most sex-cord stromal tumors are usually benign
- firm, painless mass that does NOT transilluminate (advanced can present with back pain)
- right teste is more commonly involved
- we do NOT biopsy for confirmation! we use ultrasound and then jump straight into removing the testicle because biopsy increases risk of seeding the malignancy into the scrotum


What are the risk factors for germ cell tumors? What is the general classification for these tumors?

- RFs: aged between 15-40, cryptorchidism, Klinefelter syndrome, gonadal dysgenesis, family history
- classified as either seminoma or non-seminoma
- seminomas respond well to radiotherapy, they metastasize late, and have an excellent prognosis
- non-seminomas are variable
- (remember all male germ cell tumors are malignant)


What are the five types of germ cell testicular tumors?

- seminoma: MC (65%), large cells with clear watery cytoplasm and central nuclei ("fried egg"); female equivalent is dysgerminoma; *homogenous tumor with NO hemorrhage or necrosis*; 10% beta-hCG
- embryonal carcinoma: immature, primitive cells; *hemorrhagic and necrotic (painful)* with glandular morphology; AFP and beta-hCG
- yolk sac tumor: MC testicular tumor in kids, contains Schiller-Duval bodies (resembles glomeruli); AFP
- choriocarcinoma: may present as hyperthyroidism and gynecomastia because of beta-hCG; mimics placental tissue and so has an early hematogenous spread
- teratoma: mature fetal tissue (these are malignant in men, benign in women)


What are the two types of sex-cord stromal cell testicular tumors?

- Leydig cell tumor: androgen producing (precocious puberty, gynecomastia); Reinke crystals on histo
- Sertoli cell tumor: usually clinically silent


What is the most common testicular cancer in older men?

- testicular lymphoma
- this is NOT a primary malignancy, but arises from lymphoma
- it's usually DLBCL


What is BPH and where does it occur? How do patients present?

- BPH is the hyperplasia of both stromal and glandular tissue (vs. carcinoma, which only involves the glands) that is driven by DHT
- it occurs in the periurethral/transitional zone of the prostate
- patients present with urinary retention, nocturia, difficulty starting and stopping, dysuria; microscopic hematuria; can lead to smooth muscle hypertrophy of the bladder wall and eventual hydronephrosis


How do we treat BPH?

- if patient is also hypertensive: give an alpha-1 antagonist (terazosin) to relax smooth muscle of prostate
- if patient is normotensive: give an alpha-1a specific* antagonist (tamsulosin, alfuzosin)
- give finasteride (5-alpha-reductase inhibitor); this may increase risk of breast cancer
- *1a innervates prostate and bladder neck; 1b innervates vasculature


How common is prostate cancer? What are the risk factors? Where does it usually arise? How do we screen for/monitor prostate cancer? What imaging is recommended to detect?

- prostatic adenocarcinoma is the most common cancer in men and the 2nd most common cause of cancer death
- RFs: age, diet high in saturated fats, ethnicity (blacks more common than whites more common than Asians)
- 85% of cases arise in the posterior lobe/posterior periphery (this does not affect the urethra in early stages, and is clinically silent)
- PSA greater than 10 warrants investigation (follow-up with MRI, very good at detecting prostate cancer)
- note that the cancer secretes bound-PSA, so the percentage of free-PSA will decrease despite the overall increase in PSA


Where does prostatic adenocarcinoma commonly spread to in later stages? How do we treat localized disease? Metastatic disease?

- commonly causes osteoBLASTIC metastases in the lumbar spine, femur, and pelvis (so sclerotic lesions, not lytic ones); patients develop back pain and increased serum ALP
- treat local with radical therapy (acute surveillance, prostatectomy if younger, radical radiotherapy with external beam or brachytherapy if older)
- treat advanced with watchful waiting, continuous leuprolide (GnRH analog) with flutamide (androgen receptor antagonist), and chemo with taxotene and bisphosphonates (palliative)


What are the major differentiating features of acute prostatitis versus chronic prostatitis?

- both have dysuria
- acute more likely to have fever
- chronic is highly associated with pelvic or lower back pain
- both will have WBCs in prostatic secretions, but only acute will have a positive culture