Male Genital System Pathology (Pathoma)

Question 1

Testicular Tumor Basics

Answer 1

Arise from germ cells or sex-cord stroma

Presents as a firm, painless testicular mass that cannot be transilluminated

Not biopsied due to risk of seeding scrotum and most are germ cell tumors (thus malignant); removed via radical orchiectomy

Question 2

Germ Cell Tumors

Answer 2

MC type of testicular tumors

Usually occur between 15-40 years of age

Risk factors: cryptoorchidism (undescended testicle) and Klinefelter syndrome

Divided into seminoma and nonseminoma

All are malignant

Question 3

Seminoma

Answer 3

Malignant tumor of large cells w/ clear cytoplasm and central nuclei

Homogenous mass w/ no hemorrhage or necrosis

Rare cases may produce B-hcg

Good prognosis –> response to radiotherapy (doesn’t metastasize often)

Question 4

Embryonal Carcinoma

Answer 4

Malignant tumor of immature, primative cells that may form glands

Hemorrhage mass w/ necrosis

Aggressive w/ early hematogenous spread

Chemotherapy may result in differentiation (i.e. become teratoma)

Increased AFP or B-hCG may be present

Question 5

Yolk Sac Tumor

Answer 5

Malignant tumor that resembles yolk sac elements

MC testicular tumor in children

AFP is elevated

Schiller-Duval body is characterisitic (glomeruloid structure)

Question 6

Choriocarcinoma

Answer 6

Malignant tumor of synctiotrophoblasts (makes B-hCG) and cytotrophoblasts

Spreads early via blood (synctiotrophoblasts are programmed to find blood vessels) –> big tumors in body; small tumor in testicle

B-hcg is characteristically elevated; may lead to hyperthyroidism or gynecomastia (Due to alpha subunit of B-hcg stimlating TSH, FSH, LH receptors)

Don’t get villi –> only synctio and cytotrophoblasts

Question 7

Teratoma

Answer 7

Tumor of mature fetal tissue

Derived from two to three embryonic layers

Malignant in males (benign in females)

AFP or B-hCG may be increased

Question 8

Mixed Germ Cell Tumors

Answer 8

Germ cell tumors are usually mixed

Prognosis is based on the worst component

Question 9

Sex-Cord Stromal tumor

Answer 9

Tumors resemble sex cord-stromal tissue

Usually benign.

Question 10

Leydig Cell Tumor

Answer 10

Usually produce androgen

Precocious puberty in children or gynecomastia in adults

*Characteristic Reinke crystals seen on histology

Question 11

Sertoli Cell Tumor

Answer 11

Compised of tubules

Usually clinically silent

Question 12

Lymphoma

Answer 12

MCC of testicular mass in males >60; often bilateral

Usually diffuse large B-cell lymphoma

Question 13

Hypospadias

Answer 13

Opening of urethra on inferior surface of penis

Due to failure of urethral folds to close**

Question 14

Epispadias

Answer 14

Opening of urethra on superior surface of penis

Much more rare than hypospadias

Due to abnormal positioning of genital tubercle

Associated w/ exxtrophy of bladder

Question 15

Conyloma Acuminatum

Answer 15

Benign warty growth of of genital skin

HPV 6 and 11

Characterized by karyocytic change (raisin appearing nuclei)

Question 16

Lymphogranuloma Venereum

Answer 16

Necrotizing granulomatous inflammation of inguinal lymphatics and lymph nodes

STD cause by Chlamydia trachomatis (L1-L3)

Eventually heads w/ fibrosis; perianal involvement may result in rectal strictures.

Question 17

Squamous Cell Carcinoma of the Penis

Answer 17

Malignant proliferation of squamous cells of penile skin

Risk factors: High risk HPV (2/3 of cases); lack of circumcision w/ improper maintenance

Precursor lesions (SCC in situ): Bowen disease (Shaft); Erythroplasia of Queyrat (glans); Bowenoid papulosis (reddish papules)

Question 18

Cryptoorchidism

Answer 18

Failure of testicle to descend into scrotal sac.

MC congenital male reproductive abnormality (1%)

Most cases resolve spontaneously

Complications include testicular atrophy w/ infertility (increased temp) and increased risk for seminoma

Orchiplasty (tach testicle into scrotum) if not resolved by age 2

Question 19

Orchitis

Answer 19

Inflammation of testicle

Chlamydia trachomatis (D-K) or Neisseria

E. coli and Pseudomonas (UTI in older folks)

Mumps virus

Autoimmune orchitis (granulomas of testicles –> ddx vs. TB)

Question 20

Testicular torsion

Answer 20

Twisting of spermatocord) leading to blockage of venous drainage causing hemorrhagic infarction (arterial supply preserved)

Due to congenital failure of testes to attach to inner lining of scrotum.

Presents in adolescents w/ sudden testicular pain and absent cremasteric reflex (scraping inner thigh –> ascend into abdomen)

Question 21

Varicocele

Answer 21

Dilatation of spermatic vein due to impaired drainage

Presents as scrotal swelling w/ “bag of worms appearance)

Usually left-sided; associated w/ left sided renal cell carcinoma (anatomy of left renal vein w/ branching gonadal vein)

Seen in a large percentage of infertile males (warm blood theory)

Question 22

Hydrocele

Answer 22

Fluid collection within tunica vaginalis

Associated w/ incomplete closure of processus vaginalis (infants) or blockage of lymphatic drainage (adults)

Presents as scrotal swelling that can be transilluminated.

Question 23

Acute Prostatits

Answer 23

Acute inflammation of prostate, usually due to bacteria

Same bugs as orchitis

C trachomatis and N gonorrhoeae (young adults)

E coli and Pseudomonas (older adults –> UTI)

Presents w/ dysuria and fever and chills

Prostate is tender and boggy on DRE

Prostatic secretions shows WBCs and culture +.

Question 24

Chronic Prostaitis

Answer 24

Chronic inflammation of the prostate

Presents as dysuria with peliv or low back pain

Prostatic secretions show WBCs, but cultures are negative

Question 25

BPH

Answer 25

Hyperplasia of prostatic stroma and glands

Age related change; NO INCREASED RISK FOR CANCER

Related to DHT

Occurs in the periutrethral zone of prostate –> compression of urethra

Sx: Problems starting and stopping; impaired emptying; dribbling; hypertrophy of bladder wall smooth muscle (possible diverticulae in wall); microscopic hematuria

PSA is often slightly elevated (4-10)

Can cause hydronephrosis

Rx: alpha-1 antagonists (terazosin) to relax smooth muscle in hypertensive patietns;

Selective alpha-1a antagonists (tamulosin) in normotensive individuals;

5alpha-reductase inhibitors (reduce DHT levels; takes months before relief)

Question 26

Prostate Adenocarcinoma

Answer 26

Malignant proliferation of prostatic glands

MCC of Cancer in men; 2nd MCC of cancer death

Risk factrors: Age, race (black>white>asians), and a diet high in saturated fats

Occurs in posterior periphery (palpable on physical exam) and only urinary sx when very late

Screening:

• Begins at 50 with DRE and PSA
• Normal PSA increases w/ age (0-4 = normal; 4-10 = borderline)
• PSA > 10 is worrisome at any age
• Decreased % free-PSA is suggestive of cancer (makes bound PSA)

Prostatic biopsy required to confirm presence of cancer

Nuclei contain dark nucleoli on biopsy

Gleason grading system (based on architecture; not nuclear atypia).

Spread to lumbar spine is common –> osteoblastic metastasis that presents w/ low back pain, increased alk phos, PSA, and PAP

Rx: Prostatectomy (local disease); continuous GnRH analogs (leuprolide) and androgen receptor inhibitors (flutamide)