Male Pathology Flashcards
How big is the prostate in a normal adult weight?
20 grams
Is the prostate retro or intraperitoneal?
retroperitoneal
What are the four anatomic zones?
peripheral
central
transitional
periurethral
Which zone has most of the caricnomas?
peripheral zone
Which zone has most of the BPH?
transitional
What ar ehte three general types of prostatitis?
acute bacterial
chronic bacterial
abacterial
Acute bacterial is usually from what kind of bugs?
gram negative rods - same as in UTIs
What is the exam like in acute bacterial prostatits?
fever, chills, dysuria, extremely tender/boggy prostate on exam
How do you make the diagnosis of acute bacterial rpsotatitis
urinalysis
How will a chronic bacterial prostatitis present?
not as severe - non-specific symptoms like low bak pain, dysuria, or perineal pain
may see recurrent UTIs
How do you make the diagnosis of chronic bacterial prostatitis?
do a prostatic massage and then take fluid to examine microscopically - you’d see increased leukocytes
What is the most common cause of prostatitis today?
chronic abacterial
Who usually gets the chronic abacterial prostatitis?
sexually active men
What are the typical bugs in chronic abaterial (it just means you can’t isolate is on culture)?
chlamydia
mycoplasma
ureaplasma
Prostatitis can increase the PSA. Should you care?
no - just treat with antibiotics and then recheck
What is the incidence of BPH?
20% of 40 yr olds
70% of 60 yr olds
90% of 70 yr olds
What percentage of those with BPH become symptomatic?
50%
What are the hormonal causes of BPH?
dihydrotestosterone production increases in prostate stromal cells with aging - stimulate growth
Estrogen levels increase in aging - induce an increase in androgen receptors in the prostate
Is it a hyperplasia or hypertrophy?
actually more of a hyperplasia - the name is wrong
you get nodular proliferation of both glands and stroma, but it’s not pre-malignant
What are the lcinical features of BPH?
hesitancy urgency frequency decreased stream size nocturia terminal dribbling
What’s the ONE question to ask males?
how many times a night do you get up to go to the bathroom?
What are the complications of BPH?
obstruction
incomplete bladder emptying
infection
infarction if it outgrows its blood supply (pain)
What happens to the bladder wall? What is a possible proximal sequelae of this?
trabeculated muscular hypertropy
might hypertrophy so much that the ureteral valves might close leading to reflux of urine back up into the kidneys! this is renal nephropathy.
What are the mediation treatments for BPH?
- 5-alpha reductase inhibitors like Finasteride (proscar) which inhibits conversion of testosterone to DHT
- Alpha-1 blocker Tamsulosin (Flomax) which is a smooth muscle relaxant
What is the consideration for PSA screening with finasteride?
finasteride inhbitis PSA production, so if they’re on it, you need to multiply the PSA by 2.3 to give you the equivalent.
What is the side effect issue with tamsulosin in the elderly?
orthostatic hypotension - increases fall risk
What are the surgical options for BPH?
TURP cryotherapy microwave laser US
What are the two testicular descent phases?
phase 1: transabdominal where it desscends to lower abdomen/pelvic brim
phase 2: inguinoscrotal - descends through the inguinal canal into scrotum
What hormone controls phase i?
mullerian-inhibiting substance
What hormone controls phase 2?
androgens
What percentage of preemies will have a cryptorchid testis?
25%
4-6% of newborns have patent inuginal canals, which usually closes by when?
3 months of age
Where is the most common location for cryptorchid testis?
70% are high in the scrotum
20% are in the inguinal canal
10% inraabdominal
What causes cryptochidism?
we don’t know - rarely seen in hormonal disorders
What is the concern with cryptorchidism?
the testicle can’t mature appropriately, so you get infertility (sterility if bileratl), and increased cancer risk
also typical to have a hernia, higher risk for crush injuries
What percent of cyrptorchid testis are unilateral?
75%
What are the histologic changes seen as early as 2 years in cryptocrhid testis?
germ cell arrest
basement membrane thickening.hyalinization
What do you also seein the contralateral testis/
often see decreased germ cells there too!
What class of testicular tumors are more common in cryptorchid testis?
germ cell tumors
What is the treatment fr cryptorchid testis?
orchiopexy - free it up and bring it down to the sctorum and tack it to the scrotal wall (otherwise it will ascend back up)
WHen do you want to do the orchiepexy?
before 2 to save fertility
before 10 to avoid cancer
True or false: orchiepexy before age 10 completely resolves their cancer risk
false - still have increased risk, even in the contralateral testis
What are the three general classifications of male infertility?
hypothalamic-pituitary
testicular
posttesticular
What are 4 general things that can cause testicular atrophy and testicular infertility?
atherosclerosis
malnutrition
irradiation
female sex hormones
What is Sertoli only syndrome?
germ cell aplasia - seen in 10-20% of biopsies in infertile males
What levels of sperm in a ml are considered oligospermia?
2-20,000,000
What are some causes of post-testicular infertility?
usually obstruction
- usually due to infection in the epididymi
- absence of the vas (especially in cystic fibrosis)
obstruction of the vas or ejaculatory ducts
What percent of the time is male infertility considered idiopathic after workup?
40%
Bacterial epididymo-orchitis is usuallyd ue to what bugs?
UTI bugs in older men and STDs in younger men - Neisseria, chlamydia, mycoplasma, trponema
What makes treponema different than the others? -
trponema will go right to the testis, while the others do epididymis first
What kind of orchitis will TB cause?
granulomatous
rare now
What virus can cause orchitis in particular?
mumps
WHy does orchitis lead to infertility?
because of that tight tunic, it’s quick to become ischemic in infection - especially with abscess formation
In torsion, is the issue with arterial supply or venous drainage?
venous drainage - blood can’t get back out. tunica inhibits swelling, so you get infarction
What is the indidence of varicocele?
up to 25% of adults!
Which side more commonly gets a vericocele/
left side, but 10-15% are bilateral
this is due to the left testicle drainage into the left renal instead of the IVC
Why is varicocele a cause of infertility?
because blood is warm
What are the general categories of testicular neoplasia?
germ cell tumors
sex cord stromal tumors
What tumors are included in the germ cell tumor group?
seminoma emryonial carcinoma yolk sac tumor teratoma choriocarcinoma
What are the 4 sex cord stromal tumors?
sertoli cell tumor
leydig cell tumor
granulosa cell tumor
mixed
Which is more common - germ cell or sex cord?
germ cell by a long shot
Testicular cancer makes up _% of malignancies in men age 20-34.
30%
rest are leuikemias and lymphomas
What ethnic gruop is at higheer risk for testicular cancer?
us - white:black ratio is 5:1
True or false: most cases are familial
false - most non-familial and no major gene linkage are apparent
there are some familial clusters, but only in a few african tribes
True or false: testicular cancer has a very good survival rate
true
What is the precursor lesion to germ cell tumor?
intratubular germ cell neoplasia (CIS) - seen in almost 1% of all males biopsied in denmark
What percent has intratubular germ cell neoplasia in cryptorchidism?
10%
How about in androgen insensitivity syndrome?
over 25% - related to the cryptorchidism
90% of testicular cancers will have what chromosomal thing?
isochromosome 12p
What is the typical presentation for testicular cancer?
progressive, painless testicular enlargement
What percentage of testicular cancer will be bilateral?
1-3% (higher in cryptorchidism - and can have different phenotypic expression!)
Wat is the most common of the germ cell tumors?
seminona - 50% of all germ cell tumors!
good news because they’re the most curable
The seminomas peak at what age group?
30s
What is the version of seminoma in the ovary?
dysgerminoma
What does a seminoma look like grossly?
Seminomas are fleshy masses that usually encompass the entire testicle. Very homogeneous – almost like a filleted fish.
What do they look like microscopically?
Microscopically they have water-clear cytoplasm with central round nuclei and bands of fibrous tissue that criss-cross through the tumor, infiltrated by T lymphocytes.
also frequently see noncaseating granulomas
and multinucleated syncitiotrophoblasts that secrete beta hCG (makes the urologists happy because you can use it as a marker)
What is the second most frequent form or pure germ cell tumor?
embryonal carcinoma
What age group do you get embryonal carcinoma?
20-30
Which is more aggressive - seminoma or embryonal carcinoma?
embryonal
What do the embryonal look like grossly?
They typically don’t encompass the whole testis. It’s really hemorrhagic and necrotic because they’re fast-growing. Multicolored.
Microscopically?
More pleomorphic – less clear cytoplasm. Tend to be more eosinophilic. Form glands often. Nuclei vary more in size and shape.
What’s the most common testicular cancer in infants?
yolk sac tumors - by far
THe yok sac recapitulates what structure?
endodermal sinus
What is the classic pathology sign for yolk sac tumor?
schiller-duval bodies
What do the yolk sac tumors look like grossly?
yellow
What are the schiller duval bodies?
structure that looks like a glomrulus, but isn’t
Yolk sacs also have eosinophilic inclusions of what?
alphafetoprotein (the marker!)
What germ cells tumor do you NOT want?
choriocarcinoma - they’re highly malignant
What’s the marker for choriocarcinoma?
beta hCG again
WHy is the prognosis so bad?
usually metastasized at diagnosis - usually the presenting symptom
Which do choriocarcinoma have - cytotrophoblasts or syncitriotrophoglasts?
trick questions - need both for this diagnosis
When are teratomas benign and when are they malignant?
benign in a child, always malignant in the adult male
Which is more common - a pure germ cell tumor or a mixed germ cell tumor?
60% will be mixed
Seminomas really like to go to lymph nodes. Which nodes would they go to?
para-aortic usually, but also can get up to the mediastinal/supraclavicular nodes
The non-seminomas tend to be hematogneous. Where will they go?
lung, brain, liver
True or false: in testicular germ cell tumors, the mets can have a different histology from the primary
true - very weird
Staging of testicular cancer….What is Stage 1?
still in the testicle
1a - confined to testis
1b - spread to adnexa
1c - spread to scrotum
WHat is stage II?
involvement of retroperitoenal lymphatics
WHat is stage III?
parenchymal metastases or nodes beyond retroperitoneal
Seminomas usually present in what stage?
70% in stage I
Non-seminomatous germ cell tumors uuslaly present in what wtage/
60% will be in stage II or III
How do you treat seminomas?
they’re super radiosensitive
stage I you can do orchiectomy alone
Stage II orchiectomy with radiation or chemo (usually cisplatin)
How do you treat non-seminoma germ cell tumors?
chemotherapy and possibly radiation
Are non-germ cell testicular tumors benign or malignant
basically always benigh
What two types of non-germ cell tumors that can present with gynecopastia?
sertoli cell tumors
leydig cell tumors
If a man comes in with testicular cancer in his 60s, what is the likely diagnosis?
lymphoma or metastatic tumors (maybe seminoma)
If it’s met, where is it probably from?
lung or prostate
WHat will cause a hernia in the scrotm?
failure to obliterate the inguinal canal
If there is a cystic space in the testicle obliterated on each end, what is the diagnosis?
hydrocele
If the fluid has sperm in it, what is it?
spermatocele - a cystic mass arising from the efferent ducts
