GU Pathophysiology

Question 1

Congenital genitourinary abnormalities of the ureters

Answer 1

Double and bifid ureters

Ureteropelvic junction (UPJ) obstruction (most common cause of hydronephrosis in infants/children)

Diverticula of the ureters

Question 2

Congenital genitourinary abnormalities of the bladder

Answer 2

Vesicoureteral reflux (backwards flow of urine from the bladder to the kidneys due to incompetent vesicoureteral valve)

Diverticula –> predispose to stasis, infection, and formation of stones. Only congenital if due to abnormal development of the musculature of the bladder wall, but can also be acquired.

Exstrophy of the bladder where it communicates with outside the body or lies in an opened sac.

Urachal anomalies- bladder remains connected to the umbilicus by urachus.

Question 3

Cystitis risk factors

Answer 3

Female
Calculi
Urinary obstruction
Instrumentation
Immune deficiency
Diabetes

Question 4

What are the most common infectious agents that cause cystitis

Answer 4

E coli!
Proteus
Klebsiella
Enterobacter

Other: Candida, mycobacterium tuberculosis, shistosoma, BCG (bladder CA treatment)

Question 5

Cystitis clinical features

Answer 5

Classic triad of symptoms: Urinary frequency, lower abdominal pain, dysuria

Major complication is risk of pyelonephritis.

Question 6

Interstitial cystitis

Answer 6

Severe suprapubic pain, urinary frequency, dysuria, and hematuria.

Unknown cause that is diagnosed in the absence of other possible etiologies (diagnosis of exclusion)

Fissures and punctate hemorrhages in the bladder mucosa with luminal distension –> late disease can cause transmural fibrosis and contracted bladder.

Question 7

Cystitis: Malakoplakia

Answer 7

Chronic inflammation due to chronic bacterial infection with acquired defects in phagocyte function (bacteria are not destroyed effectively by macrophages)

On histology you will see macrophages with abundant granular cytoplasm and large phagosomes. Black dots with von Kossa stain.

Most common in immunosuppressed patients.

Question 8

Bladder cancer risk factors

Answer 8

Cigarette smoking!! long term analgesic use, long term exposure to immunosuppressant (cyclophosphamide)

Question 9

What are the two distinct precursor lesions to invasive urothelial carcinoma

Answer 9

1. Noninvasive papillary tumors
2. Noninvasive flat urothelial carcinoma

**in 50% of patients the cancer is already invasive at presentation and these are not seen.

Question 10

Bladder cancer is a highly _____ cancer after excision

Answer 10

Recurrent

Question 11

Bladder cancer clinical features

Answer 11

Most common presenting symptom is painless hematuria but is can progress to frequency, urgency, and dysuria.

Question 12

Bladder cancer treatment

Answer 12

Low grade: diagnostic transurethral resection

High grade: intravesicular instillation of attenuated Mycobacterium bovis strain called bacillus Clamette-Guèrin (BCG) to destroy tumor

Invasive cancer/refractory to BCG: radical cystectomy

Question 13

Prostate

Answer 13

Encircles neck of bladder and urethra

An androgen-dependent organ

Question 14

Most hyperplasia of the prostate (BPH) arises from the ________ which most carcinoma arises in the _______

Answer 14

1. Transitional zone

2. Peripheral zone

Question 15

Prostatitis

Answer 15

Inflammation of the prostate
Can be acute bacterial, chronic bacterial, chronic abacterial (most common), and granulomatous

It is common to find histologic evidence of chronic or acute inflammation in the prostate of men with no symptoms.

Question 16

Benign prostatic hyperplasia (BPH)

Answer 16

Extremely common nodular hyperplasia of prostatic stroma and epithelial cells of transition zone.

Not a premalignant lesion.

Hyperplasia thought to be due to decreased cell death not increased proliferation.

Question 17

BPH clinical features

Answer 17

Major clinical problem is urinary obstruction which leads to increased risk of UTI and pyelonphritis.

Urgency, nocturia, difficultly starting/stopping flow, dysuria, dribbling.

Elevated PSA is often present.

Question 18

Prostate cancer

Answer 18

Prostatic adenocarcinoma is the most common cancer in US men. It has a

It is androgen dependent

Precursor lesions is prostatic intraepithelial neoplasia (PIN)

Question 19

Gleason system of prostate cancer grades

Answer 19

5 grades with grade 1 being most differentiated and grade 5 having no glandular differentiation.

Give two scores for most frequent and second most frequent pattern to form the gleason score.

Question 20

Most common site of prostate cancer metastasis is ______-

Answer 20

bone

Usually osteoblastic

Question 21

Screening for prostate cancer

Answer 21

Rectal exam

Prostate specific antigen (PSA) levels. Neither are very specific.

Question 22

Testicular cancer

Answer 22

Most common tumor of 15-34 year old males.

Two major categories include: Germ cell tumors (95% of the time)
Sex cord-stromal tumors

Question 23

Testicular germ cell tumors and precursor lesions

Answer 23

Most testicular germ cell tumors arise from a precursor lesion called intratubular germ cell neoplasia (ITGCN)

They are thought to arise in utero and then remain dormant until puberty when it progresses. They retain expression of genes important in maintaining pluripotency of stem cells.

Question 24

Seminomas

Answer 24

50% of germ cell tumors
They are the most common and less aggressive.

They tend to form a bulky homogenous mass in the testes that has a uniform appearance.

Question 25

Non-seminomas

Answer 25

More aggressive and heterogenous
Can be embryonal carcinoma (epithelial appearance), yolk sac tumor (glandular appearance) choriocarcinoma (multinucleate giant cytotrophoblasts) or teratoma

Usually a mixture of these types.