The Lower Urinary Tract and Male Genital System - Chapter 21 Flashcards
Describe some of the more common congenital anomalies of the ureter.
Double and bifid ureters – associated with totally distinct double renal pelves or with anomalous development of a large kidney
having a partially bifid pelvis terminating in separate ureters.
Ureteropelvic junction obstruction – results in hydronephrosis.
Diverticula – saccular outpouching of the ureteral wall.
What are the two types of chronic ureteritis?
Ureteritis follicularis and ureteritis cystica
gooogle:
Urethritis is a lower urinary tract infection causing inflammation of the urethra, a fibromuscular tube through which urine exits the body in both males and females and through which semen exits the body in males.
Ureteritis cystica or pyeloureteritis cystica is a benign condition of the ureters representing multiple small submucosal cysts.
Typically, this condition is seen in diabetics with recurrent urinary tract infections. As such, it is most frequently seen in older patients and is more common in women.
The most common benign tumors of the ureter are of _______origin.
Mesenchymal (Fibroepithelial polyp)
The most common primary malignant tumor of the ureter is
Urothelial carcinoma
Describe the derivation of a cystocele.
in middle aged and elderly women, relaxation of the pelvic support leads to prolapse of the uterus pulling with it the floor of the bladder. In this fashion, the bladder is protruded into the vagina, creating a pouch (cystocele) that fails to empty readily with micturition.
Describe the occurrence of and complications from vesicoureteral reflux
Vesicoureteral reflux is the most common and serious anomaly. It is a major contributor to renal infection and scarring
Define and differentiate the two most common forms of urinary bladder diverticula and their etiologies.
Congenital form – due to a focal failure of development of the normal musculature or to some urinary tract obstruction during fetal development
Acquired diverticula are most often seen with prostatic enlargement producing obstruction to urine outflow and marked muscle thickening of the bladder wall.
Bladder diverticula are of clinical significance because
they constitute sites of urinary stasis and predispose to infection and the formation of bladder calculi; may also predispose to vesicoureteral reflux, and rarely, carcinoma.
Describe the occurrence, gross appearance, and complications of exstrophy of the bladder.
Exstrophy of the bladder is a developmental failure in the anterior wall of the abdomen and the bladder, so that the bladder either communicates directly through a large defect with the surface of the body or lies as an open sac. The exposed bladder mucosa may undergo colonic glandular metaplasia and is subject to the development of infections that often spread to upper levels of the urinary system. There is also an increased risk of development of adenocarcinoma in the bladder remnant.
The most common etiologic agents of cystitis are _____ (general), specifically ______,_____,_____ and____.
Coliform
Escherichia coli, Proteus, Klebsiella, and Enterobacter
acronym PEEK
google: Cystitis is inflammation of the bladder, usually caused by a bladder infection. It’s a common type of urinary tract infection (UTI),
the most significant clinical consequence of cystitis is
Bacterial pyelonephritis
google:
Acute pyelonephritis is a bacterial infection causing inflammation of the kidneys and is one of the most common diseases of the kidney.
Define and differentiate the various special forms of cystitis
interstitial cystitis (AKA chronic pelvic pain syndrome) – chronic cystitis occurring most frequently in women and characterized by intermittent, often severe suprapubic pain, urinary frequency, urgency hematuria and dysuria. Cystoscopic findings of fissures and punctate hemorrhages (glomeurlations) in bladder mucosa after luminal distention. Etiology unknown and diagnosis controversial.
Malakoplakia – a chronic inflammatory reaction due to defects in phagocyte function. arises in the setting of chronic bacterial infection, mostly E. coli or Proteus species. Characterized macroscopically by soft, yellow, slightly raised mucosal plaques 3-4 cm in diameter and histologically by infiltration with large, foamy macrophages with occasional multinucleated giant cells and interspersed lymphocytes. Laminated, mineralized concretions (Michaelis-Gutmann bodies) are typically present.
Polypoid cystitis (image in question)- inflammatory lesion resulting from irritation of the bladder mucosa. Indwelling catheters are the most common cause. Urothelium is thrown into broad bulbous polypoid projections as a result of marked submucosal edema. May be confused with papillary urothelial carcinoma both clinically and histologically. (p. 962-963)
Brunn nest are a result of ?
Nests of urothelium
Inbudding of the surface epithelium
Describe the metaplastic lesions of the bladder
Cystitis glandularis and cystitis cystica – common lesions of the urinary bladder in which Brunn nests grow downward into the lamina propria and undergo transformation of their central epithelial cells into cuboidal or columnar epithelium (cystitis glandularis) or retract to produce cystic spaces lined by flattened urothelium (cystitis cystica). In one variant, goblet cells are sometimes present and the epithelium resembles intestinal mucosa.
Squamous metaplasia - as a response to injury, urothelium is replace by nonkeratinizing squamous epithelium.
Nephrogenic adenoma - results from the implantation of shred renal tubular cells at sites of injured urothelium. The overlying urothelium may be focally replaced by cuboidal epithelium which can assume a papillary growth pattern. May mimic malignant processes (p.963-964)
The majority of neoplasms of the bladder are of ______ origin.
Epithelial (95%, remaining 5% are mesenchymal)
List two systems of grading of urothelial transitional cell carcinomas.
WHO/ISUP consensus
Urothelial papilloma
Urothelial neoplasm of low malignant potential Papillary urothelial carcinoma, low grade Papillary urothelial carcinoma, high grade WHO Grade
Urothelial papilloma
Urothelial neoplasm of low malignant potential Papillary urothelial carcinoma, grade 1 Papillary urothelial carcinoma, grade 2 Papillary urothelial carcinoma, grade 3 (p. 964)
google:
Bladder cancer cells are divided into 3 grades.
Grade 1
The cancers cells look very like normal cells. They are called low grade or well differentiated. They tend to grow slowly and generally stay in the lining of the bladder.
Grade 2
The cancer cells look less like normal cells (abnormal). They are called moderately differentiated. They are more likely to spread into the deeper (muscle) layer of the bladder or to come back after treatment.
Grade 3
The cancer cells look very abnormal. They are called high grade or poorly differentiated. They grow more quickly and are more likely to come back after treatment or spread into the deeper (muscle) layer of the bladder.
The cancer cells look very abnormal. They are called high grade or poorly differentiated. They grow more quickly and are more likely to come back after treatment or spread into the deeper (muscle) layer of the bladder.
Low grade and high grade
Bladder cancer can also be described as either low grade or high grade.
Low grade bladder cancer means that your cancer is less likely to grow, spread and come back after treatment. High grade means your cancer is more likely to grow spread and come back after treatment.
For example, if you have early (non muscle invasive) bladder cancer but the cells are high grade, you’re more likely to need further treatment after surgery. This is to reduce the risk of your cancer coming back.
Low grade is the same as grade 1. High grade is the same as grade 3. Grade 2 can be split into either low or high grade. Carcinoma in situ (CIS) tumours are high grade.
World Health Organisation (WHO) grades
This is another grading system. It is sometimes used for early bladder cancer. This divides bladder cancers into 4 groups:
urothelial papilloma means it is a non cancerous (benign) tumour
papillary urothelial neoplasm of low malignant potential (PUNLMP) means it is a very slow growing tumour that is unlikely to spread
low grade papillary urothelial carcinoma is a slow growing cancer that is unlikely to spread
high grade papillary urothelial carcinoma is a quicker growing cancer that is more likely to spread
Describe the pathologic T staging of bladder carcinomas.
AJCC/U1CC
Depth of invasion
Noninvasive, papillary Ta
Carcinoma in situ, flat Tis
Lamina propria invasion T1
Muscularis propria invasion T2
Microscopic extra-vesicle invasion T3a
Grossly apparent extra-vesicle T3b
invades adjacent structures T4
Describe the etiology/pathogenesis of squamous cell carcinoma and adenocarcinoma of the bladder.
Squamous cell carcinomas represent about 3%-7% of bladder cancers in the US, but in countries endemic for urinary schistosomiasis ( a disease caused by parasitic worms. ), they occur much more frequently.
Pure squamous cell carcinomas are nearly always associated with chronic bladder irritation and infection. Adenocarcinomas of the bladder are rare. Some arise from urachal remnants or in association with extensive intestinal metaplasia. (p. 967)
Describe the clinical symptoms associated with bladder tumors and list the best way of clinically evaluating the urinary tract system.
Bladder tumors classically produce painless hematuria. Frequency, urgency, and dysuria occasionally accompany the hematuria. Cystoscopy and biopsy are the mainstays of diagnosis. Cytologic examinations, FISH, and new urine tests are also of value.
What are the two sarcomas of the urinary bladder?
The most common sarcoma in infancy and childhood is embryonal rhabdomyosarcoma. The most common sarcoma in the bladder in adults is leiomyosarcoma.
The most common secondary tumors of the bladder are malignancies arising in
Cervix, uterus, prostate, and rectum
acronym : R CUP
Males -Prostate gland enlargement due to nodular hyperplasia
Females - cystocele of the bladder
congenital strictures of the urethra, inflammatory urethral strictures, inflammatory fibrosis and contraction of the bladder ,
bladder tumors - either benign or malignant, invasion of the bladder neck by growths arising in contiguous organs,
mechanical obstructions caused by foreign bodies and calculi, injury to the nerves of the bladder (neurogenic bladder)
The most common etiologic agent in nongonococcal urethritis is_
Various strains of Chlamydia
Describe the clinical occurrence, gross appearance, and histologic appearance of a caruncle.
Urethral caruncle is an inflammatory lesion presenting as a small, red painful mass about the external urethral meatus in the older female patient. The lesion consists of inflamed granulation tissue covered by an intact but friable mucosa which may ulcerate and bleed at the slightest
trauma.
The distal urethra is the most common location for
Squamous cell carcinoma
Define hypospadias and epispadias.
Hypospadias – abnormal urethral openings on the ventral surface of the penis.
Epispadias – abnormal urethral openings on the dorsal surface of the penis.
Epispadias and hypospadias are anomalies most commonly associated with ____ and ____ and can result in what clinical consequences?
Failure of normal descent of the testes and with malformation of the urinary tract
Urinary tract obstruction and increased risk of ascending UTIs; possible sterility in men
Define phimosis and list some of its possible causes and clinical consequences.
When the orifice of the prepuce is too small to permit its normal retraction, the condition is designated phimosis. Such an abnormally small orifice may result from anomalous development but is more frequently the result of repeated attacks of infection that causes scarring of the preputial ring. Phimosis is important because it interferes with cleanliness and permits the accumulation of secretions and detritus under the prepuce, favoring the development of secondary infections and possibly carcinoma.
The most common specific infections of the penis include
syphilis, gonorrhea, chancroid, granuloma inguinale, lymphopathia venerea, and genital herpes
SGGGCL
The most frequent neoplasms of the penis are _____ and _____.
Carcinomas and condyloma acuminatum
List two carcinoma in situ lesions of the penis.
Bowen disease and bowenoid papulosis
google:
Bowen’s disease is a very early form of skin cancer that’s easily treatable. The main sign is a red, scaly patch on the skin. It affects the squamous cells, which are in the outer layer of skin, and is sometimes referred to as squamous cell carcinoma in situ
Bowenoid papulosis is an uncommon sexually transmitted condition that occurs in both males and females. It is characterized by multiple well-demarcated red-brown to violaceous papules in the genital area. (pic in question)
Describe the gross appearance of seminoma.
Seminomas produce bulky masses, sometimes 10 times the size of the normal testis.
The typical seminoma has a homogeneous, gray-white cut surface, usually devoid of hemorrhage or necrosis. The tunica albuginea is not penetrated, but occasionally extension to the epididymis, spermatic cord, and scrotal sac occurs.
google:
The mass lesion seen here in the testis is a seminoma. Germ cell neoplasms are the most common types of testicular neoplasm. They are most common in the 15 to 34 age range. They may have more than one of several histologic components: seminoma, embryonal carcinoma, teratoma, choriocarcinoma. The one that is most likely to be of a single histologic type is seminoma, as in the testis seen here
Describe the gross appearance of embryonal carcinoma.
Grossly, the tumor is smaller than seminoma and usually does not replace the entire testis. On cut surface, the mass is often variegated, poorly demarcated at the margins, and punctuated by foci of hemorrhage or necrosis
Describe choriocarcinoma and its unique gross features.
Highly malignant form of testicular cancer, often with no testicular enlargement, rarely larger than 5 cm in diameter. Hemorrhage and necrosis are extremely common.
Define the two types of testicular tumors arising in sex cord-gonadal stroma, paying particular attention to their gross appearance.
Leydig cell tumors – elaborate androgens or androgens and estrogens, and some have elaborated corticosteroids. Most occur between 20 and 60 years of age. Most common presenting feature is testicular swelling or gynecomastia. In children hormonal effects, manifested primarily as sexual precocity, are the dominating features. These neoplasms form circumscribed nodules, usually less than 5 cm in diameter and have a distinctive golden brown homogeneous cut surface. (pic in answer)
Sertoli cell tumors – Most are hormonally silent and present as a testicular mass. These neoplasms appear as firm, small nodules with a homogeneous gray-white to yellow cut surface. (pic in question:
google:
matching part to pic in question/sertoli cell tumor
Most Sertoli cell tumors of the testis are small (2-5 cm), solid, firm, and well-circumscribed with a tan-yellow or white cut surface.
Review the gross anatomy of the prostate.
The prostate is a retroperitoneal organ encircling the neck of the bladder and urethra and is devoid of a distinct capsule. The adult has 4 biologically and anatomically distinct zones or regions; central, transitional, peripheral, and periurethral. The types of proliferative lesions are different in each region. Hyperplasias arise in the transitional zone, whereas most carcinomas originate in the peripheral zone.
describe the incidence, etiology and gross morphology of nodular hyperplasia
Histologic evidence of nodular hyperplasia can be seen in approximately
20% of men 40 years of age, and
70% by age 60 to
90% by age 80.
Only 50% of those who have microscopic evidence of nodular hyperplasia have clinically detectable enlargement of the prostate and of these individuals, only 50% develop clinical symptoms. Nodules weigh between 60-100 gm.
Nodular hyperplasia originates almost exclusively in the inner aspect of the prostate gland, in the transitional and periurethral zones. The nodules are yellow-pink with a soft consistency, and a milky white prostatic fluid oozes out of these areas when due to glandular proliferation. If the lesion is pale gray, tough, and does not exude fluid, then there is fibromuscular stroma involvement.
describe Gleason grading of prostate cancers
5 Grades- Grade 1 represents the most well differentiated tumors, in which the neoplastic glands are uniform and round in appearance and are packed into well-circumscribed nodules. By contrast, Grade 5 tumors show no glandular differentiation, and the tumor cells infiltrate the stroma in the form of cords, sheets, and nests. Most prostate tumors contain more than one pattern; a primary grade is assigned to the dominant pattern and a secondary grade to the second most common pattern. The two scores are then added to produce the Gleason grade or score (ranges from 1+1=2 up to 5+5=10). Gleason scores 2-4 are small tumors often found incidentally in TURP performed for symptoms of BPH. Potentially treatable tumors detected by needle biopsy have scores of 6 through 7. Gleason scores 8 through 10 tend to be advanced cancers that are less likely to be cured.
List the staging of prostate cancers.
TNM staging:
T1 Clinically inapparent lesion by palpation/imaging
T1a: involves ≤5% of resected tissue
T1b: involves >5% of resected tissue
T1c: carcinoma present on needle biopsy (following elevated PSA) T2 Palpable or visible cancer confined to prostate
T2a: involves ≤5% of one lobe
T2b: involves >5% of one lobe, but unilateral
T2c: involves both lobes
T3 Local extraprostatic extension
T3a: extracapsular extension
T3b: seminal vesicle invasion
T4 Invasion of contiguous organs and/or supporting structures including bladder neck, rectum, external sphincter, levator muscles, or pelvic floor
