ERS24 Pathology Of Male Genital Tract Flashcards
Penis, Urethra, Scrotum pathologies
- Congenital anomalies
- Inflammatory lesions
- Tumour
- Tumour-like lesion
- Benign tumours
- Malignant tumours
Congenital abnomalies of Penis, Urethra, Scrotum
- Hypospadia, Epispadia
- Urethral orifice situated on anywhere along ventral / dorsal surface of penis
—> predispose to ***UTI in infancy, childhood
—> interfere with normal ejaculation in later life - Congenital urethral valvular obstruction
- presence of valves at urethra (e.g. membranous flap in Prostatic urethra) - Phimosis (包皮過長)
- orifice of prepuce to small for normal retract —> unable to retract to expose Glans penis
- usually acquired (after inflammatory scarring), congenital (rare)
ALL affect flow of urine, prone to inflammation / infection?
Inflammation: Urethra, Scrotum
Non-specific inflammation (also affect other parts of body)
- Infection of Urinary tract, Prepuce (Posthitis), Glans (Balanitis)
- **Pyogenic bacteria
- **Candida albicans (itchy lesions)
- Mumps (inflammation, swelling of salivary glands + testes)
- TB (affect Epididymis first, then involve Testes)
—> may be affected by immune status - Sexually Transmitted Diseases (smear show many Polymorphs)
—> each with different clinico-pathological characteristics
Specifically sexually transmitted
- ***Syphilis
- ***Gonorrhea
- ***Chlamydial infections
- ***Genital herpes
- Lymphogranuloma venereum
- Granuloma inguinale
- Chancroid
Other infections that can be sexually transmitted
- ***Trichomonas vaginalis (Protozoa, cause severe itchiness in women)
- ***Condylomata acuminata (caused by HPV)
- AIDS
Rmb:
Effects / Complications of STD ***NOT confined to genital tract
—> travel in different routes
—> implications in prevention / diagnosis
Complications of gonorrhoea in male patients
Spread of infection (upwards): Urethra (can lead to fistula, stricture) —> Prostate —> Vas deferens —> Epididymis —> Testes (atrophy, scarring)
Chronic persistent inflammation
—> **Atrophy, **Scarring of structures (e.g. Testes)
—> ***Obstruction of tubular structures due to scarring (e.g. Urethra)
Systemic involvement:
- Endocarditis
- Arthritis
Tumour and Tumour-like lesions of Lower Male genital tract
-
**Condyloma acuminata (Venereal warts)
- tumour-like lesions
- caused by low risk **HPV infection (HPV type 6, 11)
- Gross:
—> single / multiple **warty papillary growth on penis/scrotum
—> may spread locally to wide areas in anogenital region
- Histology:
—> **fibroblastic branching stalk covered by acanthotic squamous epithelium
—> finger-like projections covered by **Stratified squamous epithelium —> **Koilocytes (characteristic of HPV infection) —> ***Perinuclear halo + Smudged nuclei
—> differentiated from squamous carcinoma by mature epithelium - (Squamous) Carcinoma-in-situ
- **white/red discolouration/papules of Glans penis
- smooth, soft red plaques
- may develop into invasive Squamous cell carcinoma
- **NO stromal invasion
- ↑ nucleus/cytoplasmic ratio
- pleomorphic, hyperchromatic nuclei
- frequent mitotic figure -
**Squamous cell carcinoma
- **most common malignant tumour of penis
- 50-70 yo
- Etiology:
—> poor personal hygiene + smegma
—> HPV infection
—> circumcision soon after birth (rare)
- Gross: **Exophytic ulcerated growth / nodular plaques
- Histology: **Stromal invasion
- Spread: Regional ***LN metastasis
HPV and Cancer
- Cervical cancer (strongest association, >99%)
- Anal cancer (85%)
- Penile cancer (50%)
- Oropharyngeal (20% ↑)
- Larynx and Aerodigestive tract (10% ↑)
Prostate pathologies
- Inflammation
- Acute / Chronic type
—> Extend from bladder / urethra
—> Nonspecific infection caused by Coliform bacteria / Gonococci / Chlamydia - Granulomatous type
—> Specific infections e.g. TB / Syphilis
—> Nonspecific inflammatory reaction to inspissated (thickened) secretion / Autoimmune causation
- ***Benign prostatic hyperplasia (Nodular prostate hyperplasia)
- Carcinoma of prostate
Benign prostatic hyperplasia (Nodular prostatic hyperplasia)
Tend to involve ***“inner” / Transitional zone of prostate (urethral (mucosal) / submucosal glands)
- common > 50 yo
Clinical presentation:
-
**Retention of urine
- Bladder distension / hypertrophy of bladder muscle wall (striation of bladder mucosa)
- Hydroureter, Hydronephrosis (∵ obstruction of urine flow)
- **Chronic renal failure (∵ obstruction of urine flow, common in the past) -
**Compression on Prostatic urethra —> **Obstruct urine flow
- Difficulty urination
- Frequency
- Dribbling - ***Superimposed infection
- Prostatitis
- Cystitis - Asymptomatic
Gross:
Distinct **circumscribed grey white nodules in **Periurethral zone
Histology:
- **Proliferation of both Glandular + Fibromuscular stromal elements
- **+/- Infarct, Infection, Squamous metaplasia
- Nodular configuration
(- Double layer of cells preserved (help to diagnose benign nature)
- Cystically dilated glands (some)
- Basal cells (can be highlighted by K903 Immunohistochemistry))
Treatment:
- ***Transurethral resection / curetting
Carcinoma of Prostate
Tend to involve outer zone of prostate (External / Prostatic glands proper)
—> may be ***palpable during rectal examination (hard mass)
↑ incidence in HK, uncommon in orientals
Etiology:
- Role of androgen in growth of tumour
Clinical presentation (Latent / Occult / Overt):
- Clinical symptoms of Prostatism (~BPH)
- ***hard mass found during PR exam - S/S of metastasis (e.g. back pain due to vertebral metastasis)
- Incidental finding by microscopic examination during removal of prostatic tissue for BPH
- Detected during autopsy with no clinical evidence of prostatic cancer
Gross:
- Yellowish, Hard, Gritty tissue
Histology:
- ***Adenocarcinoma, usually microacini
- ***Perineural invasion
Spread:
- Local
- grow inwardly —> obstruct Prostatic urethra
- grow peripherally —> infiltrate adjacent tissue - Lymphatics
- Presacral in pelvis, Iliac, Para-aortic LN - Retrograde venous (**Prostatic venous plexus —> **Vertebral vein)
- Vertebra (unique **osteoblastic lesion rather than destructive lesions, X-ray: **dense lesions —> bone formation) - Bloodstream
- wide spread metastases - Perineural spread (Adenocarcinoma)
Treatment:
- Surgery +/- Hormonal therapy
Tumour marker:
- **Prostatic specific antigen (PSA)
—> Screening of occult / asymptomatic prostate cancer
—> Detection of recurrence
—> Detection of distant metastasis
—> **Identify primary tumour in cases of metastasis of unknown origin (if PSA identified —> Prostate as primary site)
Differential diagnoses of Scrotal mass
- Testicular tumour (infrequent but always malignant)
- ***Germ cell tumours (>90%)
- Sex cord-Stromal tumours
- Mixed germ cell and sex cord-stromal tumours
- Lymphoma
- Metastasis
- Mixed
- Tumours of epididymis
- Unclassified - Tumour-like conditions
- e.g. ***Hydrocele, Haematocele (accumulation of fluid / blood in scrotal sac) - Hernia
- ***Orchitis (inflammation of testes) / Epididymitis
- Non-specific inflammation
- Specific inflammation
—> TB, Gonorrhea (epididymis first, then testes)
—> Syphilis (testes first)
—> Mumps (orchitis complicate 25-30% mumps in postpubertal group)
—> Granulomatous orchitis (reaction to extravasated sperms, middle-aged men, simulate TB orchitis / testicular tumour) - Torsion of Testes, Epididymis (Vascular lesions)
- surgical emergency
- twisting of spermatic cord —> interfere with venous drainage —> Engorgement + Haemorrhagic infarct - Tumour / Tumour-like conditions of spermatic cord, testicular appendages
Germ cell tumours of Testes
Etiology:
1. Genetic
- strong familial predisposition
- ***Cryptorchidism
- Abdominal vs Inguinal
- Undescended vs Contralateral descended
- Orchiopexy (may reduce risk of Germ cell tumours) vs No orchiopexy
***Heterogenous group of tumours (combinations may occur in a patient):
1. Seminoma
2. Embryonal carcinoma
3. Teratoma
4. Yolk sac tumour / Endodermal sinus tumour —> AFP
5. Choriocarcinoma —> HCG
Histogenesis:
Germ cell (Spermatogonia / Oogonia —> Seminoma)
—> Totipotent cell
—> (Embryonal carcinoma: transition state between primitive / differentiated tumour)
—> Extra-embryonic tissue
1. Trophoblast (placenta) (Choriocarcinoma)
2. Yolk sac / Endodermal sinus (Yolk sac tumour / Endodermal sinus tumour)
OR
—> Embryonic tissue (i.e. Ectoderm, Mesoderm, Endoderm) (***Teratoma)
Age and incidence:
- Neonate / infant —> Yolk sac tumour / Choriocarcinoma / Teratoma
- Middle-age —> Seminoma
- Adolescents / young adult —> Embryonal CA
- > 60 —> Lymphoma
Presentation:
- Testicular enlargement / pain
- Distant metastasis
**Spread:
1. **Seminoma / Dysgerminoma —> Lymphatics
2. ***Choriocarcinoma —> Blood
3. Embryonal carcinoma, Yolk sac tumour, Teratoma —> Lymphatics / Blood
Treatment:
1. Surgery
2. Radiation
3. Chemotherapy
Cryptorchidism
Congenital anomalies of Testes
Complete / Incomplete failure of intraabdominal testes to descend into scrotal sac
Histology of undescended testes (Depend on age / duration of undescended testes):
- Interstitial fibrosis
- Shrinkage of organ
- Disappearance / ↓ of specialised spermatogenic cells (only Sertoli cells present)
- Progressive degenerative changes (Sertoli cells may disappear eventually)
Complications of undescended testes:
- Infertility if bilateral (∵ affect spermatogenesis)
- ***Inguinal hernia
- ***Testicular Germ cell tumours
- Risk of trauma (if inside inguinal canal)
- Testicular atrophy (at / after puberty)
Seminoma
“Potato tumour”
Gross appearance:
- well-demarcated tan-white ***homogeneous mass (“Potato-like”) composed of uniform cells separated by fine stroma
Histology:
- Large, round polyhedral tumour cells
- Abundant clear cytoplasm
- Large central hyperchromatic nuclei
- Prominent nucleoli
- Sharp cell border
- ***Abundant cytoplasmic glycogen
Spread:
- ***Lymphatics
Treatment:
- ***Radiosensitive
- favourable prognosis after Orchidectomy + Post-surgical irradiation
Embryonal carcinoma
- ***Highly malignant tumour
- Variable pattern
Histology:
- Cells resemble ***anaplastic epithelial cells
Spread:
- Lymphatics + Blood
Prognosis:
- ***Poor
Teratoma (畸胎瘤)
- Histologically complex tumour composed of tissue derived from >=1 of Ectodermal, Mesodermal, Endodermal elements
- Mature / Immature
—> postpubertal males: capable of metastasis even if appear entirely mature
—> infants / small children: differentiated mature, usually ***benign
Ectodermal differentiation
- Skin, appendages (e.g. hair)
- Choroid plexus (neuroectodermal differentiation)
- Neuroepithelium (immature tissue e.g. neuroblast arranged in tubes)
Mesodermal differentiation
- Cartilage
- Bone
- Smooth muscle
Endodermal differentiation
- Intestinal mucosa
- Bronchial mucosa
- Thyroid
Spread:
- Lymphatics + Blood
