Pathology of Male Genital System

1. Pathology of Male Genital System Doç. Dr. Işın DOĞAN EKİCİ

4. Disorders of the male genital system include: • a variety of malformations, • inflammatory conditions, and • neoplasms involving the penis and scrotum, prostate, and testes.

5. DEVELOPMENTAL DISORDERS

6. HYPOSPADIAS • Abnormal opening of the urethra onto the ventral surface of the penis or scrotum. • This results from failure of fusion of the urethral folds, i.e., it is a form of feminization. Occurs 1 in 250 male alive births. • There is often associated cryptorchidism, ureterovesical reflux, inguinal hernia, and/or other developmental problems. • Right now there is a pop claim that hypospadias has doubled in frequency in the past twenty years, and the cause is chemical pollutants acting as "endocrine disruptors".

7. The urethral meatus may open on the ventral surface of the penis, at the base of the penis or the perineum. • This infant with ambiguous genitalia was a genetic male. The arrow points to the urethral orifice that opens unto the perineum.

8. PHIMOSIS • Present when the preapuce can not be retracted over the corona. • Phimosis may be congenital, the orifice of the prepuce being too small. • More often, phimosis is due to poor hygiene, resulting in chronic inflammation and scarring, which sets up a vicious cycle requiring circumcision. • Such an ongoing infection of the glans and prepuce is called balanoposthitis. • Paraphimosis results when a tight foreskin is forcibly retracted, and edema of the glans prevents its replacement. This can quickly lead to acute urinary retention and even gangrene of the glans.

9. EPISPADIAS • Abnormal opening of the urethra on the dorsal surface of the penis. • Epispadias is a form of extrophy of the urinary bladder. • There is usually an associated separation of the pubic bones and inadequacy of the urinary sphincters. • Incontinence and bladder infections are usual. • Epispadias is fortunately less common than hypospadias and more difficult to correct surgically.

10. PRIAPISM • A persistent, non-pleasurable erection. • "Priapus" was the classical-era Greek god of erections. • Most cases of priapism are probably due to obstruction of the deep dorsal vein of the penis. • Causes: • idiopathic • sickle cell disease • leukemia • metastatic cancer • papaverine treatment of impotence (rare) • trauma.

11. INFLAMMATION of Male Urogenital Tract • Balanoposthitis • Urethritis • Cystitis • Prostatitis • Epididymitis • Orchitis

12. Fournier’s gangrene Necrotizing fasciitis of genitalia and perineum Usually due to Staph or Strep in children; gram negative rods or anaerobic bacteria in adults Affects Buck’s fascia and foreskin, sparing glans Risk factors: trauma, burns, anorectal disease, diabetes, leukemia, alcoholic cirrhosis

13. URETHRITIS

14. Gonorrheaand “non-gonococcal urethritis” (“urethral syndrome”) • Due to chlamydia, mycoplasma, trichomonas, perhaps others, • Important sexually-transmitted diseases. • Gonorrhea tends to come on fast after the contact, while chlamydia comes on insidiously. • Gonorrhea tends to have a more purulent discharge.

16. Reiter's syndrome The triad of • (1) arthritis involving many joints, • (2) conjunctivitis, and • (3) urethritis. • It is a male’s disease and lasts for several months. • The urethritis is usually (if not always) chlamydia, and one new study finds chlamydial RNA in the synovium; if the initial episode of urethritis is treated appropriately, • As with other "reactive arthropathies", there's an impressive proliferation of T-cells specific for chlamydia within the affected joints. • Patients with Reiter's syndrome are likely to have circinate balanitis, keratoderma blennorrhagica of soles, ulcers of the mouth, iritis, or even ankylosing spondylitis.

17. Peyronie’s Disease • Proliferation of dense fibrous tissue involving a portion of the fascia. • This leads to curvature of erection. • Other names: • "painful erection in the wrong direction", • "squint of the cock". • This is one of several abnormal hyperplasias of fibrous tissue which are sometimes called "fibromatoses“. • Another common one is palmar fibromatosis (Dupuytren's contracture of the hand) which often occurs with Peyronie's disease. • Metaplastic ossification and calcification are common. • Treatment for Peyronie's disease is not very satisfactory, and many patients eventually require a penile prosthesis.

18. INFERTILITY • Female causes 50% • Male causes 50% • Pretesticular • Testicular • Post testicular

20. Focal testicular atrophy

21. Testicular atrophy

22. Spermatogenesis can be temporarily diminished or even stopped by a host of factors ranging from heavy drinking to anabolic steroid abuse to alcoholism to bicycling. • Obstruction of the sperm passages may be more amenable than the above to surgical help.

23. CRYPTORCHIDISM (cryptorchism) • Incomplete descent of the testis into the scrotal sac. • Unilateral or bilateral cryptorchidism occurs in around 4% of prepubertal boys. • Cryptorchid testes may be found anywhere along the normal route of descent (abdomen, inguinal canal, prepubic). • The epididymis is likely to be malformed or at least elongated. • Ectopic testis is less common; it may stray into the superficial inguinal region, penis, or femoral sheath.

24. Failure of the testes to descend into the scrotum causes problems: • The tubules will undergo atrophy and fibrosis, beginning in infancy and advanced around puberty. • There is an increased risk of torsion of the spermatic cord and gangrene of the testis. • The risk of germ cell cancer (usually seminoma) in undescended testes is around 30x greater than normal. • Most cryptorchidism is idiopathic. • It may be accompanied by • other developmental abnormalities, • diethyl-stilbestrol exposure, • poorly-understood anatomic and hormonal problems.

25. EPIDIDYMITIS and ORCHITIS • Non-specificinfections of the contents of the scrotum are usually complications of urinary tract infection, instrumentation or prostate surgery. • Gonorrhea: the infection often spreads to the epididymis, less often the testis. • Mumps: orchitis is common in adolescents and adults. It usually follows the onset of parotitis by a week or so, and may cause atrophy of the germinal epithelium and infertility. The Leydig cells are spared. • Tuberculosis: granulomas involving the epididymis; may spread to the testis. • Syphilis: gummas involving the testis; may spread to the epididymis.

26. TORSION OF SPERMATIC CORD ("torsion of the testis") • Twisting of the spermatic cord is likely to result in venous infarction and gangrene in a few hours. • This is quite common, especially in children and adolescents. • The involved testis is painful and elevated; the cord is typically twisted. • There may or may not be a history of trauma (often minor, as in baseball or break dancing. • The underlying problem may be abnormal fixation of the testis or cryptorchidism.

28. Hydrocele Hematocele Spermatocele

29. HYDROCELE • Fluid in the tunica vaginalis. • Usually idiopathic • A hydrocele may contain 100 cc or more of serous fluid. • If ascites is present and the patient has a patent processus vaginalis, a hydrocele will appear and disappear as the patient changes position. • One can distinguish a hydrocele from a tumor mass by trans-illuminating it with a bright flashlight in a dark room.

31. Hematocele • Blood in the tunica vaginalis. • May follow trauma, or a sing of an underlying testicular cancer. • Chylocele • Accumulation of lymphatic fluid in the tunica. • Spermatocele • A cystic lesion up to 1 cm or so in the area of the rete testis, filled with fluid and dead sperms. VARICOCELE • Varicosities of the pampiniform plexus, • Usually on the left side. • This is common in young men, may cause fertility problems by warming the testes. • A new varicocele in an old man often indicates occlusion of the vein by renal cell carcinoma.

32. PROSTATE

33. PROSTATITIS • Acute and chronic prostatitis are uncomfortable problems, and are common in • sexually-transmitted urethritis • lower urinary tract infections. • E.coli is the most common etiologic agent of both acute and chronic prostatitis. • The diagnosis depends on physical and lab exams. • In acute prostatitis the gland is exquisitely tender. • Gonorrhea is an important cause of acute prostatitis (secondary to urethritis; it can also cause epididymitis). • In chronic prostatitis the gland is somewhat tender and the prostatic fluid contains WBC's and bacteria.

35. Granulomatous prostatitis may be due to • Tbc (hematogenous spread from the lungs), • "idiopathic" (no Tbc, no caseation, no clues as to the etiology). • The histiocytes may resemble cancer cells. • In "non-bacterial prostatitis", the findings are as in chronic prostatitis, but no organisms grow, probably; • Chlamydia • Trichomonas • Autoimmunity • Heroic abstinence.

36. Prostatodynia • is a stress-related pain syndrome in which there are no WBC's in the prostatic fluid. • Other exacerbating factors include • constipation, • smoking, • coffee, • spices.

37. PROSTATIC HYPERPLASIA • Benign prostatic hypertrophy or hyperplasia, BPH. • Most men over about age 50; 10% of men living to age 80 will need prostate surgery. • The normal prostate weighs around 20 gm. Old men's prostates enlarge to 60-200+ gm. • The increased tissue is nodular overgrowth of periurethral glands and stroma. • Press upon the prostatic urethra. • The hyperplasia most often involves the lateral and median lobes. • Median lobe hyperplasia by itself produces a "median bar", obstruction without an enlarged gland.

38. The etiology of prostatic hyperplasia is obscure. • Hormonal imbalance with ageing. • Estrogen sensitive peri-urethral glands. • Accumulation of dihydrotestosterone in the prostate and its growth-promoting androgenic effect. • Heroin abuse is also rumored to be a risk factor. • The most interesting work right now focuses in a nerve-growth factor-like protein produced by the stromal cells which causes hyperplasia of both glands and stroma

39. Microscopy • Nodular prostatic hyperplasia consists of nodules of glands and intervening stroma (mostly glands) • The glands variably sized, with larger glands have more prominent papillary infoldings. • Nodular hyperplasia is NOT a precursor to carcinoma.

41. Prostatism (This is a clinical term) • frequency (i.e., only small amounts are voided at a time), • nocturia (urinating at night, same reason), • difficulty starting and stopping urination, • incontinence (dribbling), • dysuria (painful urination), • hernias (from straining), • acute urinary retention (emergency) • hematuria (due to stretching of veins), • bladder hypertrophy and trabeculation (accentuation of the normal muscles), • bladder diverticula, bladder stones, • hydronephrosis, • renal failure

43. The TUMORS of the MALE REPRODUCTIVE SYSTEM

44. Penis Tumors

45. WARTS Condyloma acuminatum • A papillary, keratinizing lesion caused by the sexually-transmitted "human papilloma virus" (usually strain 6). • In males, it commonly occurs in the urethral meatus, which is a mess. Condyloma latum • Groups of flat-topped lesions which may ooze serous fluid • caused by secondary syphilis. • Typically occur in skin folds. Pearly penile papules • Little bumps, sometimes hairy, which pop up in young adults, especially on the corona. • Each is a single big dermal papilla. No need to treat.

46. PREMALIGNANT LESIONS OF THE PENIS • Erythroplasia of Queyrat • A raised, velvety plaque on the uncircumcised glans or prepuce. • Histologic study shows dysplasia of the squamous epithelium. • A minority of cases (5-10%) develop into squamous cell carcinoma if not removed. • Bowen's disease • Carcinoma in situ of the skin, most often on the penis or scrotum in men. • Some cases (maybe 10%) develop into invasive squamous cell carcinoma. • In many cases, the appearance of Bowen's disease on the skin heralds the growth of another malignancy internally. • Bowen's disease tends to spare the sweat glands and involve the hairs.

47. Bowenoid papulosis • Multifocal intraepithelial neoplasia, caused by HPV-16. • The atypia is mild. • Bowenoid papulosis tends to spare the hairs and involve the sweat glands. • Bowen's disease tends to spare the sweat glands and involve the hairs. • Giant condyloma of Buscké-Lowenstein • verrucous carcinoma • HPV-related, cauliflower-like lesion.

48. CARCINOMA of PENIS • Almost all are variations on squamous cell carcinoma • This is a disease of older men (~60 years) • It originates on glans and prepuce. • Only 1% of cancers among American men begin on the penis; the figure is as high as 18% in the Orient.

49. Risk factors : • phimosis, • smegma, • balanoposthitis, • infection with HPV (notably HPV-16). • Males circumcised as infants almost never get cancer of the penis. The incidence is much lower in those circumcised at a later age than among the uncircumcised. • Carcinoma of the penis spreads to the inguinal lymph nodes. • Five year survival is around 50% overall.

50. Scrotal squamous cell carcinoma is the subject of the famous chimney sweep story. • Many older men get a few angiokeratomas (hemangiomas with each dermal papilla stretched wide by a single ectatic blood vessel), especially on their scrotums.