Pathoma Ch 13-14 Male Genital/Female Genital and Gestational

Question 1

Bartholin Cyst

Answer 1

cystic dilation of bartholin gland that arises unilaterally, painful. In women of reproductive age.

-Lower vestibule adjacent to vaginal canal

Question 2

Condyloma

Answer 2

“Genital Warts”

warty neoplasm of vulvular skin

• Most commonly due to HPV type 6 or 11 (low risk, rarely progress to carcinoma)
• Sexually transmitted

(Remember that HPV chondylomas are characterized by koilocytes, the hallmark of HPV infected cells)

Question 3

Lichen Sclerosis vs Lichen Simplex Chronicus (women)

Answer 3

Lichen Sclerosis: THINNING of epidermis and fibrosis. Presents with white patch (leukoplakia). Parchment-like vulvar skin. Postmenopausal women

Lichen Simplex Chronicus: THICKENING hyperplasia of vulvar squamous epithelium. Presents as Leukoplakia with thick, leathery vulvar skin. Benign. Associated with chronic irritation and scratching

Question 4

Vulvar Carcinoma

Answer 4

Carcinoma arising from sqamous epithelium lining the vulva

• Presents as Leukoplakia…need to differentiate from Lichen sclerosis and Lichen simplex chronicus
• May be HPV related (types 16, 18, the bad ones) or non HPV related from long standing lichen sclerosis

Question 5

Extramammary Paget Disease and what must it be distinguished from and how?

Answer 5

Malignant epithelial cells in the epidermis of the vulva

• Presents as erythematous, pruritic ulcerated vulvar skin
• Represents carcinoma in situ
• Paget disease of nipple is characterized by malignant epithelial cells in the epidermis of the nipple, almost ALWAYS associated with carcinoma

-Must distinguish from melanoma

Paget: PAS+, Keratin +, S100 -

Melanoma: PAS -, Keratin, -, S100 + (classic)

Question 6

Vagina epithelial cell types and what happens if get persistence?

Answer 6

Lower 1/3 stratified squamous epithelium derived from urogenital sinus

Upper 2/3 columnar epithelium from mullerian ducts

During development, squamous epithelium grows upward to replace columnar. If have persistence of columnar –> Adenosis (increased risk with DES exposure)

Question 7

Embryonal Rhabdomyosarcoma

Answer 7

Malignant mesenchymal proliferation of immature skeletal musles

• Presents as bleeding and grape like mass protruding from vagina or penis
• Rhabdomyoblast is characteristic cell, exhibits cytoplasmic cross-striations and positive IHC stain for desmin (intermediate filament in muscle cells) and myogenin (transcription factor skeletal muscle)

Question 8

Hypospadias vs Epispadias

Answer 8

Hypospadias: opening of urethra on inferior surface of penis due to failure of urethral folds to close

Epispadias: opening of urethra on superior surface of penus due to abnormal positioning of genital tubercle. Associated with bladder exstrophy. The female equivalent of the genital tubercle is the glans clitoris

Question 9

Chlamydia trachomatis serotypes

Answer 9

1. Types A, B, and C: Chronic infection, cause blindness due to follicular conjunctivitis in Africa.

ABC = Africa, Blindness, Chronic infection.

2. Types D–K: Urethritis/PID, ectopic pregnancy, neonatal pneumonia (staccato cough) with eosinophilia, neonatal conjunctivitis. Neonatal disease can be acquired during passage through infected birth canal. D-K Everything Else
3. Types L1, L2, and L3: Lymphogranuloma venereum—small, painless necrotising granulomatous ulcers on genitals swollen, painful inguinal lymph nodes that ulcerate (buboes). Heal with fibrosis. Perianal involvement may result in rectal strictures. Treat with doxycycline.

Question 10

Squamous Cell Carcinoma of Penis and 3 precursor in situ lesions

Answer 10

Malignant proliferation of squamous cells of penile skin, associated with high risk HPV (serotypes 16,18, 31,33)

-Can be due to lack of circumcision

-PREcursor in situ lesions

1 . Bowen Disease: in situ carcinoma on shaft of penis presents as leukoplakia. Bowen=Boner=on Shaft

2. Erythroplasia of Queyrat: in situ carcinoma of glans that presents as erythroplakia
3. Bowenoid papulosis- in situ carcinoma that presents as multiple reddish papules. Seen in younger pts. does NOT progress to invasive carcinoma

Question 11

Cryptorchidism

Answer 11

Failure of testicle to descend into the scrotal sac.

• Most common congenital male repro abnormality (seen in 1% of population)
• Most cases resolve spontaneously.
• Orchiopexy is surgery done to repair. Still get increased risk of seminoma (due to higher temp inside body than testicles prefer to be at)

Question 12

Orchitis (causes in young adults vs older adults and other common causes)

Answer 12

Inflammation of testicle

Young adult: Chlamydia (serotype D-K) or Neisseria Gonorrhoeae. Leydig cells spared so libido NOT affected. Incresed risk of sterility

Older Adult: E. Coli and Pseudamonas: UTI pathogens spread to repro tract

Mumps: Parititis, Orchitis, Meningitis. NOT seen kids under 10. increased risk infertility

Autoimmune orchitis: granulomas involving seminiferous tubules (muse r/o TB)

Question 13

Testicular Torsion

Answer 13

Twisting of spermatic cord, thin walled veins become obstructed while arteries continue to pump new blood into testicles.

• Usually due to congenital failure of testes to attach to the inner lining of the scrotum (via processus vaginalis)
• Presents in adolescents with sudden testicular pain and absent cremasteric reflex

Question 14

Varicocele vs Hydrocele

Answer 14

Varicocele: dilation of spermatic vein due to impaired drainage. Presents as scrotal swelling with “bag of worms” appearance due to veins being pushed to surface. Usually LEFT sided (testicular vein drains into renal vein, where common to see RCC spread hematogenously)

Hydrocele: fluid collection within tunica vaginalis (serous membrane that covers testicle as well as internal surface of scrotum). Incomplete closure of processus vaginalis leading to communication with peritoneal cavity or blockage of lymphatic drainage. CAN be transilluminated (just fluid)

Question 15

Testicular Tumor overview

Answer 15

Arise from germ cells or sex cord-stroma

-Present as firm, painless testicular mass that CANNOT be illuminated

NOT biopsied due to risk of seeding in scrotum.

MOST are malignant germ cell tumors (95%)

Question 16

Germ Cell Tumor Overview (Male testicle tumors)

Answer 16

Most common type (95% of all testicular tumors)

Malignant by definition

14-40 years of age (older, more likely get Diffuse Large B-cell Lymphoma)

Risks: cryptorchidism and Klinefelter syndrome

Divided into

1. Seminoma (55%): highly responsive to radiotherapy, metastasize late, excellent prognosis
2. Non-seminoma (45%): variable response to treatment, metastasize early

Question 17

Seminoma

Answer 17

Most common testicular tumor, NEVER in infancy

Malignant tumor comprised of large cells with clear cytoplasm and central nuclei

NO hemorrhage or necrosis, painless

Good prognosis

Rarely produce beta-hCG (usually choriocarcinoma that does this)

Question 18

Non-seminoma Germ Cell Tumors of Testicle (4)

*Remember ALL are malignant by definition*

Answer 18

1. Embryonal Carcinoma: forms hemorrhagic mass with necrosis. Agressive with EARLY hematogenous spread. Chemo may make change to Teratoma
2. Yolk Sac tumor: resembles yolk sac elements. Most common tumor in children.Schiller-Duval bodies, look like glomerulus on histology. AFP characteristically elevated
3. Choriocarcinoma: tumor of syncytiotrophoblast (produce beta-hCG), and cytotrophoblasts (placenta-like tissue). May lead to hyperthyroidism or gynecomastia (since B-hCG alpha subunit is similar to LH, FSH, TSH)
4. Teratoma: tumor of mature fetal tissue derived from two or three embryonic layers. MALIGNANT in MALES, benign in females.

Question 19

Sex Cord-Stromal Tumors (2)

Answer 19

The other category of Testicular tumors that are NOT Germ Cell Tumors.

Two types

1. Leydig cell tumor: produces androgen, causes precocious puberty in children or gynecomastia in adults
2. Sertoli Cell tumor: comprised of tubules and is clinically silent Sertoli=Silent

Question 20

Acute Prostatitis vs Chronic Prostatitis

Answer 20

Acute:

Young adults: Chlamydia and Gonorrea are main cuases

Older adults: E. Coli and Pseudamonas

Presentation: dysuria with f/c

Prostate is tender and “boggy” on digital rectal exam

Cultures are positive, increased WBC

Chronic:

dysuria with pelvic or low back pain

cultures are NEGATIVE, increased WBC

Question 21

Benign Prostatic Hyperplasia (BPH)

Answer 21

HYPERPLASIA (not hypertrophy) of prostatic stroma and glands

• Present in most men by age 60, NO increased risk for cancer
• Related to dihydrotestosterone (DHT). Acts on androgen receptor of stromal and epithelial lining to result in hyperplastic nodules.
• Occurs in central periurethral zone of prostate.
• Problems stopping/starting. See Hypertrophy of bladder wall.
• PSA slightly elevated

Tx: 1) alpha1 antagonist (terazosin) to relax smooth muscle. 2) selective alpha1a antagonist (tamsulosin) used in normotensive pts. 3) 5alpha reductase inhibitor (finesteride)

Question 22

Prostate Adenocarcinoma (Prostate cancer)

Answer 22

Most common cancer in men, 2nd most common cause of cancer death in medn (Lung)

• Often clinically silent, usually arises in peripheral, posterior region of the prostate and does NOT produce any urinary sx
• Screening begin age 50 with DRE and PSA (>10 is worrisome)
• Biopsy REQUIRED to confirm dx
• Gleason scale used, based on ARCHITECTURE alone. (two areas graded separately, scores added)
• Spreads to lumbar spine or pelvis is common, results in osteoBLASTic activity, thus see an increase in Alk Phos, PSA, PAP
• Prostectomy is preferred tx early, advanced treat with hormone surpression to reduce DHT, T (Leuprolide, Flutamide)