Exam 4 - Chapter 17

Question 1

Cryptorchidism

Answer 1

Cause
• Testis do not descend normally into scrotum
• Usually retained in abdominal cavity; sometimes in inguinal canal
• Germ cells require a lower-than-normal body temperature
• Interstitial cells function normally at body temperature

Manifestations
• Germ cells destroyed at higher intra-abdominal temperature, Interstitial cells function normally
• Undescended testis more prone to developing testicular cancer
Treatment : Surgically replace testis in scrotum

Question 2

Hypospadias and Epispadias

Answer 2

Development of penis takes place between 9 and 12 weeks of pregnancy occurs in 1 out of every 150-300 boys. It is a condition where the urethral opening does not form completely at the tip of the penis, instead it can be located anywhere along the penis

• Hypospadias is an anomaly in which the urethral meatus opens on the ventral surface of the penis
• Epispadias is an anomaly in which the urethral meatus opens on the dorsal surface of the penis. It is less common than hypospadias

Causes: Less androgen production, No conversion of DHT from Testosterone, Androgen receptor deficiency
Treatment: Never circumcise a child without checking for hypospadias because the foreskin is essential for the repair. It can be corrected surgically using the foreskin.

Question 3

Klinefelter’s Syndrome

Answer 3

It is a chromosomal disorder. Children are born with an extra sex chromosome (47, XXY), which is known as sex chromosome variations (SCV). These children present a significant speech and language delay, which requires formalized speech and language program

Symptoms:
•Individuals are male with different degree of 1o Hypogonadism
•Decrease secretion of gonadotropins (FSH & LH)
•Smaller size gonads, which affect the testicular function
•Gyaecomastia (breast development)
•Azoospermia (absence of sperm)
Common symptoms with school age Children: Curved 5th finger, decreased muscle tone, delayed pubertal development, delayed speech & language skills, long legs and arms, hand tremors and mild to severe developmental delays
Treatment: Hormone replacement therapy (HRT) with Testosterone (AndroGel)

Question 4

Testicular Torsion

Answer 4

Cause
• Abnormal attachment of testis in scrotum
• Predisposes to rotary twisting of testis and spermatic cord
• Shutting off blood supply to testis

Manifestations and treatment
• Acute onset of testicular pain and swelling
• Leads to hemorrhagic infarction unless promptly untwisted

Question 5

Scrotal Abnormalities

Answer 5

Hydrocele
• Excess fluid accumulates in tunica vaginalis of scrotum. Presents as nontender fullness of scrotum
• Treated by aspiration or resection of tunica vaginalis

Varicocele
• Varicose veins in spermatic cord, usually left side of scrotum involved
• Blood collection increases heat and results in infertility
• No treatment required unless varicocele causes discomfort or impairs infertility

Spermatocele
• Collection of sperm within the testes, usually at epididymis
• Usually asymptomatic
• No treatment necessary, just observation

Question 6

Erectile Dysfunction (ED)

Answer 6

Risk factors:

1. Drugs (β-Blockers) e.g. Digoxin
2. Psychological problems
3. Distortion of the penile arteries or tissue
4. Alcohol related liver damage, which interferes with testosterone production
5. Diabetic patients
6. Smoking

Question 7

STD’s and Pathogens

Answer 7

1. Chancroid (Haemophilus ducreyi)
2. Syphilis (Treponema pallidum)
3. Gonorrhea (Neisseria gonorrhoeae)
4. Chlamydia (Chlamydia trachomatis)
5. Herpes (Herpesvirus)
6. Granuloma Inguinale (Calymmatobacterium Granulomatis): Africa, Carribbean & India. Some cases in homosexual men

Question 8

Chancroid

Answer 8

Haemophilus ducreyi

Presents as a soft, painful ulcer. This ulceration makes the site more prone to infection with other organisms or fungi, with the tendency to spread along the penis and groin areas

Question 9

Syphilis

Answer 9

Treponema pallidum - gram negative

3 Stages

Primary stage: Painless, hard chancre (an indurated ulcer) often at the glans, or site of infection. Because this first stage is painless, the patient may not know he has the disease, and could proceed to infect other people

Secondary stage: largest number of organisms in the body, manifesting in a diffuse rash of small red macules, included on the palms, soles and membranes

Tertiary stage: gummas form (which are basically granulomas with giant cells, inflammation of the vessels and necrosis). If this stage is left untreated, the infection may progress to involve the heart and nervous system; occurs 2 to 20 years later

Diagnostic Tests: Demonstration of treponemas/spirochetes in chancre. Serologic tests (antigen-antibody reactions in a test tube)
Treatment: Antibiotics

Question 10

Gonorrhea

Answer 10

Neisseria gonorrhoeae - gram negative (also a cause for pelvic inflammatory disease)

Symptoms:

1. Urethritis (inflammation of passage through which urine is discharged from bladder)
2. Cervicitis (inflammation of cervix)
3. Pharyngitis (inflammation of pharynx)
4. Infection of rectal mucosa (proctitis)

Diagnosis: Culture of organisms from sites of infection
Treatment: Antibiotics

Question 11

Chlamydia

Answer 11

Chlamydia trachomatis - gram negative. Most common STD. #2 cause of PID

Symptoms: Cervitis & Urethritis. It can also cause epididymitis. Chlamydial infection should be suspected when bacteria are not demonstrated in a purulent urethral discharge
Diagnosis: Detection of chlamydial antigens in cervical/urethral secretions or Cultures
Treatment: Antibiotic

Question 12

Herpes

Answer 12

Herpes Simplex Virus (HSV) type 2 infection accounts for the majority of genital herpes cases (although HSV type 1 is also capable of causing genital infections) and is spread by sexual contact

Symptoms: Small painful vesicles and shallow ulcers that can involve the penis, cervix, vagina, clitoris, vulva, urethra, and perianal skin
Pathology: Multinucleated giant cells with viral inclusions are found in cytologic smears from lesions. Three “Ms”: multinucleation, nuclear molding, and margination of the chromatin
Diagnosis: Tzanck smear
Treatment: Acyclovir, Valacyclovir, Famciclovir

Question 13

Granuloma Inguinale

Answer 13

Calymmatobacterium (Donovania) granulomatis - gram negative

Donovan bodies, which are multiple organisms filling large histiocytes, are characteristic. An infection appears initially as a papule, which becomes superficially ulcerated. It progresses by adjacent lesions to form large genital or inguinal ulcerations, sometimes with lymphatic obstruction or genital distortion

Question 14

Trichomoniasis (Yeast Infection)

Answer 14

Not an STD

Vulvovaginitis
Profuse, foul-smelling, purulent, frothy discharge

Question 15

Orchitis

Answer 15

Inflammation of the Testes

• When bacterial, orchitis is often associated with epididymitis. Orchitis may be caused by syphilis
• When viral, orchitis is most often due to mumps virus. Bilateral, orchitis may result in sterility due to atrophy of the seminiferous tubules. Serum testosterone is decreased, whereas pituitary FSH and LH are increased.

Question 16

Epididymitis

Answer 16

More common than orchitis. Causes most often include: Neisseria gonorrhoeae, Chlamydia trachomatis, Escherichia coli & Mycobacterium tuberculosis

Question 17

Testicular Tumors

Answer 17

These are rare tumors but important because they affect men 25 to 45 years of age
• Most tumors are of germ cell origin
• Most tumors are malignant but can be successfully treated by surgery combined with chemotherapy or radiation therapy
• Mortality was high before, but now more than 90% of patients survive

Question 18

Serum Markers for Testicular Cancer

Answer 18

• Human chorionic gonadotropin, or HCG, is usually synthesized and secreted by the placental syncytiotrophoblast
• Alpha-fetoprotein (AFP) is the major serum protein of the early fetus and is synthesized by the fetal gut, liver cells, and yolk sac. It is usually undetectable after the first year of life
• LDH (lactate dehydrogenase) is useful in following the tumor burden, since its level is proportional to the mass of tumor cells. However, it is produced in a number of tissues, so increased levels are not specific for testicular tumors

Question 19

Seminoma

Answer 19

These are the most common type of germ cell tumor. The occurrence peaks in men in their 30s, and account for about half of the germ cell tumors

Pathology: Made of sheets of uniform cells. Better prognosis than NSGCT
Symptoms: Large tumors which can grow to ten times the size of a normal testicle. They do not secrete markers. It does not transiluminate on a flash light
Treatment: Radiotherapy, chemo

Question 20

Embryonal Carcinoma

Answer 20

Second most common. These are more aggressive than seminomas and generally occur in 20-30 year olds

Pathology: Secretes hCG and AFP. Tubular cells
Symptoms: Painful mass often with metastasis
Treatment: Surgery, abdominal lymph node dissection and chemotherapy

Question 21

Choriocarcinoma

Answer 21

Highly malignant form of testicular tumor that is composed of mixed germ cells. It is the most aggressive of the NSGCT

Pathology: These tumors are usually small and are found by palpation of a small testicular nodule
Symptoms: Testicular enlargement is rare, but hemorrhage & necrosis common
Treatment: Surgery, abdominal lymph node dissection and chemotherapy

Question 22

Teratoma

Answer 22

Mature teratomas are found in adults and immature teratomas are found in children. 30% of all tumors

Pathology: Random arrangement of mesodermal (muscle, cartilage, adipose tissue), ectodermal (neural tissue, skin), and endodermal (gut, bronchial epithelium) tissue
Symptoms: Painful lump
Treatment: Surgery, abdominal lymph node dissection and chemotherapy

Question 23

Testicular Cancer Stages

Answer 23

Stage I means the tumor is confined to the testis, epididymis, or spermatic cord
Stage II cancer means distant spread is limited to retroperitoneal lymph nodes below the diaphragm
Stage III cancer means there is metastasis outside the peritoneal nodes or above the diaphragm

Question 24

Benign Prostate Hyperplasia (BPH)

Answer 24

BPH is the most frequent cause of urinary tract obstruction. BPH is extremely common (almost universal) in older men

Causes: Increase in estradiol levels
Pathology: BPH is directly related to the action of dihydrotestosterone (DHT), a testosterone metabolite. DHT is synthesized from testosterone by the action of 5 α-reductase, type 2, and inhibition of this enzyme is one approach to the treatment of BPH. Rubbery, nodular enlargement of the gland, affecting the inner groupings of glands (periurethral and transitional zones)
Diagnosis: Increased total PSA (prostate specific antigen) with proportional increase in free PSA
Symptoms: Polyuria, nocturia, dysuria
Treatment: Finasteride (5 α-reductase inhibitor) or Cialis,
α-blockers, Tamsulosin and TURP (Transurethral Resection of Prostate)

Question 25

Prostate Carcinoma (General Information)

Answer 25

This is the most common cancer of internal organs in males—more than 100,000 new cases per year. This is the third most common cause of cancer-related deaths in males. It is a tumor of old age, and the prolongation of human life has been accompanied by an overall increased incidence of prostate carcinoma.
No effective treatment exists.
The cause remains unknown.
No major risk factors have been identified.

The course may be indolent or aggressive; this can be predicted by the very useful Gleason system of grading, based on differentiation

Question 26

Prostate Cancer (Pathology, Diagnosis, and Treatment)

Answer 26

Pathology:
• The tumor is often well differentiated with small invasive glands with prominent nucleoli
• The tumor arises most often from the peripheral group of glands

Diagnosis:
• Done by rectal examination
• Prostate cancer is associated at an early stage with an increase in serum PSA. Elevations of PSA reflect a complexed form (bound to α1-anti-chymotrypsin), which becomes elevated with prostatic cancer, and a free form, which increases with BPH. Thus, an increased total PSA with a decreased fraction of free PSA suggests malignancy
• A number of other approaches to PSA measurement (e.g., serial PSA, PSA velocity, PSA density) are used to increase the predictive value of this procedure
• Prostate cancer is characterized by increased serum prostatic acid phosphatase when the tumor penetrates the capsule into adjacent tissues

Treatment: Prostatectomy, radiotherapy, da Vinci Si robotic system, GnRH analogues, anti-androgens and chemotherapy

Question 27

Penile Carcinoma

Answer 27

This is rare in the United States, affecting 1 to 2 men per 100,000. It is more common in some parts of the world, like South America. Tumors are squamous cell carcinomas. Metastases occur first to inguinal lymph nodes. Prognosis depends on the stage of tumor. Treatment: Surgery