Pathology of the Testis, Epididymis and Penis

Question 1

What is cryptorchidism?

Answer 1

“hidden testis” caused by either absent, ectopic or undescended testis

Question 2

How are ectopic and undescended testicles different?

Answer 2

Undescended stop short on their way to scrotum

Ectopic diverted to an aberrant position

Question 3

What percentage of full term babies have cryptorchidism?

Answer 3

5% have undescended testicles

1% at one year old

10% are bilateral

Question 4

What happens to testis if they are undescended?

Answer 4

They do not form spermatozoa and look irregular on histology

Question 5

What are potential complications of cryptorchidism?

Answer 5

Inguinal hernia

Testicular torsion

Subfertility

Malignant transformation

Question 6

What is epididymo-orchitis and what causes it?

Answer 6

Inflammation of testis or epididymis

Trauma

Autoimmune diseases

Most commonly caused by:

It is caused by infections mostly (neisseria gonorrhoeae and chlamydia trachomatis <35yo, Ecoli, other coliforms, and pseudomonas in >35)

Question 7

What are the symptoms of epididymo-orchitis?

Answer 7

Localised testicular pain

Tenderness and swelling

Scrotal wall erythema

Hydrocoele

If untreated can form abscess and testicular infarction

Question 8

How does tuberculosis manifest in the genital tract?

Answer 8

Forms a caseous mass

Question 9

What happens if testicular torsion is left untreated?

Answer 9

Haemorrhagic infarction can result

Question 10

What happens if testicular torsion is left untreated?

Answer 10

Haemorrhagic infarction can result

Can result in irreversible damage after 12 hours of ischaemia

Can also be damage the other testis as anti-sperm antibodies can form -> infertility

Question 11

What are the symptoms of testicular torsion?

Answer 11

Acute onset moderate to severe pain

Profound diffuse tenderness and swelling

Absent cremasteric reflex

Nausea and vomiting

Asymmetrically high rising testis

Long axis is transverse rather than horizontal

Testicular swelling with hydrocoele

Question 12

How is testicular torsion confirmed?

Answer 12

Ultrasound and referred to surgeon urgently

Question 13

What is the 5 year survival rate of testicular cancer?

Answer 13

In 2017 it was 95% which is an improvement from the 1970s where it was 64%

Question 14

What ages is testicular cancer most common?

Answer 14

15 to 35

Question 15

What are the most common types of tumours that arise in the testis?

Answer 15

Germ cell tumours (95% of all testicular tumours)

Question 16

What are the types of germ cell tumours?

Answer 16

Seminoma and non-seminoma (embryonal carcinoma, yolk sac tumour, choriocarcinoma, and teratoma)

Question 17

Where are germ cell tumours most common?

Answer 17

Increasing incidence seen in Western countries like Scandinavia and Switzerland

Question 18

What are the risk factors for germ cell tumours of the testis?

Answer 18

Caucasian men

Undescended testis

Previous germ cell tumour

Inguinal hernia

Family history

Question 19

How do germ cell tumours present?

Answer 19

Painless testicular swelling

Feels heavy

Hormonal manifestations like gynaecomastia

Symptoms of metastasis (abdominal pain, retroperitoneal metastases, haemoptysis, etc)

Question 20

What causes seminomas?

Answer 20

Strongly associated with cryptorchidism

Question 21

What ages are men more prone to seminomas?

Answer 21

30 to 50

Question 22

What is the most common type of germ cell tumour?

Answer 22

Seminoma

Question 23

How is a seminoma treated? What is its prognosis?

Answer 23

Orchidectomy

Sensitive to chemo and radiotherapy

Spreads to lymph nodes particularly para-aortic nodes.

Question 24

What does a seminoma look like on histology?

Answer 24

Background lymphocytes

Clear cells

Nuclear atypia

Nucleoli

Question 25

What percentage of testicular cancers are non-seminomatous germ cell tumours?

Answer 25

~33% of testicular cancers They may also be combined with seminoma

Question 26

What aged people get non-seminomatous germ cell tumours?

Answer 26

20s to 30s

Question 27

What are the types of non seminomatous germ cell tumours? What hormones are they associated with?

Answer 27

Embryonal carcinoma Teratoma Yolk sac tumour: Associated with elevated serum AFP Choriocarcinoma: Associated with elevated serum bHCG

Question 28

What do teratomas look like on histology?

Answer 28

Random cells of all types can appear here

Question 29

What work is done for suspected testicular tumour?

Answer 29

Scrotal ultrasound Measurement of serum tumour markers (AFP, bHCG, LDH) Abdominal CT scan and CXR looking for metastases to the retroperitoneal lymph nodes and lungs. Orchidectomy

Question 30

How is a tumour staged?

Answer 30

TNM system. T1 limited to testes T2 limited to testes with LVSI or tumour spread into hiilar soft tissue/epididymis/tunica albuginea T3 invades spermatic cord T4 invades scrotum N0 N1 or N2 presence or absence of regional lymph node metastasis and size of metastasis M0 or M1 presence or absence of distant metastasis

Question 31

How are germ cell tumours treated?

Answer 31

Surgery If early stage seminoma orchidectomy may be adequate If early stage NSGCT treatment depends on presence of poor prognostic factors like LVSI, predominance of embryonal carcinoma, T3 or T4 disease In advanced disease options are chemo, radiotherapy, surgery to metastatic deposits.

Question 32

Summary of testicular tumours:

Answer 32

Most are germ cell tumours Most common malignancy in men 15 to 35 Very high cure rate Present with painless testicular mass

Question 33

What is hypospadias/epispadias?

Answer 33

Malformation of the urethral groove and urethral canal (an abnormal urethral opening on the ventral surface of the penis (Hypospadias) or on the dorsal surface (epispadias) Formed in 1:300 live births

Question 34

What is condyloma acuminata?

Answer 34

Caused by HPV infection. Usually low risk HPV subtypes. It is common and increased risk with immunosuppression.

Question 35

What is prognosis like in condyloma acuminata?

Answer 35

It tends to recur but only rarely can progress to malignancy

Question 36

What are the histological features of condyloma acuminata?

Answer 36

Papillomatosis Acanthosis Hyperkeratosis Koilocytosis

Question 37

What is carcinoma of the penis? Which cancer type is most common?

Answer 37

A rare condition that presents as a painless lump or ulcer. SCC is most common

Question 38

Where is SCC of the penis most common? What age group?

Answer 38

Africa, Asia, and South America (can be up to 20% of cancers in men) Older men, 60+

Question 39

What are the risk factors for SCC of the penis?

Answer 39

High risk HPV (16 and 18) Phimosis Men not circumcised in childhood (smegma) HIV infection Smoking

Question 40

What does carcinoma of the penis look like?

Answer 40

Red patches Painless lumps Ulcers

Question 41

What is the prognosis of carcinoma of the penis?

Answer 41

Often slow growing They often metastasize to inguinal lymph nodes Prognosis related to stage