Male Pathology

Question 1

Prostate anatomy

Answer 1

retroperitoneal - devoid of true capsule
4 Zones
1. Peripheral -> most carcinomas (detectable by DRE)
2. Central
3. Transitional -> most cases of BPH
4. Periurethral

Question 2

Acute bacterial prostatitis

Answer 2

mostly gram (-) rods —-> UTI organisms
- fever, chills, dysuria
- extremely tender and “boggy” -> don’t do DRE
Dx -> urine culture

Question 3

Chronic bacterial prostatitis

Answer 3

same organisms as acute

• nonspecific symptoms -> low back pain, dysuria, perineal pain
• longer course of antibiotics
• Dx = prostatic massage

Question 4

Chronic abacterial prostatitis

Answer 4

most common form of prostatitis

• similar to chronic bacterial but culture is negative
• usually sexually active men -> STD organisms

Question 5

Benign Prostatic Hypertrophy

Answer 5

it’s actually a hyperplasia -> high incidence
Primarily TZ & peri-urethral zones (nodular proliferation of glands and stroma)
Causes:
1. Androgens - DHT production increases in prostate stromal cells
2. Estrogens - estradiol levels increase with age -> induce an increase in androgen receptors in prostate

Question 6

Complications of BPH

Answer 6

1. obstruction -> push harder -> hypertrophy (trabeculated appearance)
2. Incomplete bladder emptying
3. Infection -> urine stasis “moat”
4. Infarction

Question 7

BPH Treatment

Answer 7

1. 5-alpha reductase inhibitor (Finasteride) -> blocks conversion of testosterone to DHT
   - need to multiply PSA by 2.3
2. Alpha-1 blocker (Tamsulosin) -> smooth muscle relaxant
   - careful of orthostatic hypotension

Question 8

Testicular drainage

Answer 8

L sided varicocele –> drains into L renal vein

Question 9

Lymphatic drainage

Answer 9

testicles -> para-aortic

penis -> superficial inguinal

Question 10

Testicular descent

Answer 10

Phase 1 - transabdominal -> controlled by mullerian inhibiting substance
Phase 2 - descends through inguinal canal -> androgen dependent

Question 11

Cryptorchid testis

Answer 11

25% of premature births, 5% of newborns have patent inguinal canal
- 75% unilateral –> decreased germ cells in contralateral testis –> don’t know why
- 70% located in upper scrotum
- cause is poorly understood
- sterility if bilateral, infertility if unilateral and uncorrected
Tx = orchiopexy -> freeing testis and tacking it down in scrotum (before 10), after 10 orchiectomy

Question 12

Testicular infertility

Answer 12

atherosclerosis, malnutrition, irradiation, female sex hormones

• reduced/absent sperm production (Sertoli only syndrome)
• chromosomal abnormalities

Question 13

Oligospermia

Answer 13

can have up to 20 million sperm/mL and still have oligospermia

• normal testicular biopsy –> most common cause is obstruction
• most is idiopathic

Question 14

Epididymo-orchitis

Answer 14

Bacterial - UTI bugs in patients older than 35
- STD bugs in patients younger than 35
* Syphilis (Treponema Pallidum goes to testis first)
Viral - Mumps (reason for mumps vaccine) –> goes to testis in adults and can cause infertility (infarction)

Question 15

Caseating granuloma

Answer 15

think TB or fungal infection!!!!!

Question 16

Testicular Torsion

Answer 16

typically prepubertal

- hemorrhagic infarction (need surgery within 4 hours)

Question 17

Varicocele

Answer 17

dilation of veins within pampiniform plexus -> more common on left side
- can cause infertility

Question 18

Clinical features of testicular cancer

Answer 18

progressive, painless testicular enlargement

• bilateral in 3%
• can have different phenotypic expression
• lymphoma is most likely cause in older males

Question 19

Seminoma

Answer 19

50% of all germ cell tumors -> fleshy homogenous mass that involves whole testicle
Peaks in 30s
Exact same cancer as dysgerminoma in ovary
Water clear cytoplasm with fibrous bands
If syncytiotrophoblasts present with hCG -> can use hCG as tumor marker

Question 20

Embryonal Carcinoma

Answer 20

2nd most common form of germ cell tumor -> doesn’t encompass entire testis
Peaks in 20s
- more aggressive than seminoma

Question 21

Yolk Sac tumor

Answer 21

most common testicular tumor in infants
Clear cell recapitulating endodermal sinus
- Schiller-Duval bodies
- marker = alpha-fetoprotein

Question 22

Choriocarcinoma

Answer 22

highly malignant - RARE

• small, trophoblastic elements
• beta-hCG marker
• distant metastasis almost universal at presentation

Question 23

Teratoma

Answer 23

recapitulates tissue from >1 germ cell layer

• infancy throughout adulthood
• never benign in adult males!!!!!!!
• lots of cysts

Question 24

Mixed tumors

Answer 24

60% of testicular tumors

- prognosis worsens with inclusion of more aggressive forms

Question 25

Patterns of metastases

Answer 25

Lymph spread - seminomas (para-aortic nodes)
Hematogenous - non-seminomas
Metastasis histology may be different than primary histology

Question 26

Stage I

Answer 26

local spread
1a - confined to testis
1b - spread to adnexa
1c - spread to scrotum

Question 27

Stage 2

Answer 27

involvement of retroperitoneal lymphatics
2a - microscopic only
2b - gross without capsule
2c - gross with capsule invasion
2d - massive retroperitoneal spread

Question 28

Stage 3

Answer 28

parenchymal metastases or nodes beyond retroperitoneal
3a - solitary
3b - multiple

Question 29

Alpha fetoprotein

Answer 29

major serum protein of early fetus - produced in yolk sac tumors
- also elevated in hepatocellular carcinoma

Question 30

HCG

Answer 30

choriocarcinoma or syncytiotrophoblasts

Question 31

Treatment of testicular cancer

Answer 31

Seminoma - orchiectomy +/- chemo

Non-seminoma - chemo

Question 32

Sertoli cell tumor

Answer 32

lots of variants

- associated with gynecomastia

Question 33

Leydig cell tumor

Answer 33

elaborate androgens and/or estrogens

- adults with gynecomastia

Question 34

Hernia/hydrocele

Answer 34

failure to obliterate inguinal canal

• inguinal canal - open communication to peritoneal cavity
• hydrocele - cystic space obliterated on each end
• spermatocele - cystic mass arising from efferent ducts