urology Flashcards
calcium stones
Majority of stones 75% • Calcium oxalate are the most common o due to hypercalciuria o hard and dark stones o acidic urine o Urinalysis: colorless tetrahedral (envelope shape), oval or dumbbell shape, polarizable o Seen in ethylene glycol poisoning • Calcium phosphate: less common, softer and paler stones in alkaline urine
struvite stones
- Struvite (triple phosphate): magnesium ammonium phosphate—15%
- Due to urea splitting bacteria (proteus, staph, providencia)
- Staghorn caliculi
- Urine is alkaline
- Urinalysis: colorless rectangles, coffin lid shaped crystals
uric acid stones
- Uric acid: 6%
- Due to hyperuricemia
- Radiolucent stones
- Acidic urine
- Urinalysis: rhomboid crystals
cysteine stones
- Cysteine: rare—1% of stones
- due to genetic defects in cystine transport
- Aut Rec
- Stones are yellow-brown and radioopaque
- Acidic urine
- Urinalysis: flat hexagonal crystals “stop sign”
etiologies of infectious cystitis
o Culture negative cystitis: ureaplasm urealyticum, Chlamydia, mycoplasma hominis
o Bacterial cystitis: E coli, Staph saprophyticus, klebsiella
• Tuberculous cystitis by mycobacterium tuberculosis
o Fungal cystitis: candida
o Parasite cystitis: schistosomiasis
o Viral cystitis: adenovirus (type 11), HSV2
• Hemorrhagic cystitis: Present as viral cystitis bone marrow transplant recipients (also caused by cyclophosphamide)
interstitial cystitis
“painful bladder syndrome”
o Persistent cystitis with pelvic pain and irritative voiding symptoms
o Females
o Multifactorial
o Cytoscopy: punctate hemorrhage of “hunner ulcer”
o Diagnosis of exclusion
o Vs overactive bladder—urgency of urination, pain is not the key feature but urine leakage is
malakoplakia
inflammatory d/o w/ accumulation of macrophages in GU tract (esp. bladder)
o Older females, immunosuppressed, chronic infection, cancer
o Assoc. w/ UTI caused by E. coli
o Soft yellow plaques on surface of bladder
o Michaelis-Gutman bodies (engorged lysosomes containing bacteria)
hypospadia
urethra opens on underside of penis; more common; easier to repair
epispadia
urethra opens on upper side of penis; less common; harder to repair
phimosis
narrowing of prepuce orifice; impairs retraction over glans; can strangulate glans and predisposes to infection/cancer
paraphimosis
strangulation of glans; usually due to recurrent infection/trauma; circumcision is cure
hydrocele
o Hydrocele: serous fluid in scrotal sac b/t 2 layers of tunica vaginalis;
• Comgenital: most common cause of scrotal swelling in infants; assoc. w/ inguinal hernia
• Acquired: occurs in adults 2/2 infection, tumor or trauma; if long standing can cause testicular atrophym compression epididymus, or fluid can become infected (periorchitis)
hematocele
blood b/t layers of tunica vaginalis; results from trauma, hemorrhage into hydrocele, tumors, infection
spermatocele
o Spermatocele: cyst from protrusion of widened efferent ducts of rete testis or epididymus
• Hilar paratesticular nodule or fluctuating mass filled with milky fluid
• Cyst lined by cuboidal epithelium containing spermatozoa
varicocele
o Varicocele: “bag of worms”
• Dilation of testicular veins and appears as nodularity on lateral side of scrotum
• Common cause of infertility; pts usually asymptomatic
genital herpes
o Genital herpes: painful, grouped vesicles that ulcerate and transform into crusts
• Cluster of vesicles on a red base
• Microscopically: viral nuclear inclusions, multinucleation, nuclear molding; skin separation with vesicle formation
syphilis
- Treponema pallidum
- Solitary, ulcer “chancre” with hard edges
- Painless
- Screen test VDRL, RPR
- Confirmatory test: FTA-ABS, treponema hemagglutination assay
chancroid
o Chancroid: haemophilus ducreyi (gram negatuve coccobacillus)
• Painful papule, pustule and shallow ulcers on glans or shaft
• Chancroid ulcer has pus and soft edges
• Painful suppurative inguinal lymphadenitis
granuloma inguinale
o Granuloma inguinale: Klebsiella granulomatis
• Donovan bodies (rod shaped bacteria within histiocytes)
• Tropical disease
• Raised painless red ulcer with copious chronic inflammatory exudate and granulation tissue
• Ulcers enlarge and heal very slowly
lymphogranuloma venereum
o Lymphogranuloma venereum: Chlamydia trachomatis
• Painless, small, innocuous vesicle that ulcerates
• Swollen groin (inguinal) LN
• Sinuses draining ous from nodes into skin
condyloma acuminatum
o Condyloma acuminata: HPV 6 and 11
• Flat topped warts on shaft, small polyps on glans and urethral meatus, or large cauliflower-like tumors
balanitis
inflammation of glans, due to poor hygiene
• Balanoposthitis: glans and foreskin caused by bacteria, fungi, or virus
• Complications: meatal stricture, phimosis, paraphimosis
balanitis xerotica obliterans
- Balanitis xerotica obliterans: chronic inflammatory condition
- Fibrosis and sclerosis or subepithelial connective tissue
- Affected glans becomes white and indurated
- Fibrosis can cause phimosis
circinate balanitis
- Circinate balanitis: circular, linear or confluent plaque-like discoloration of glans
- Assoc. w/ superficial ulcerations
- Seen in reiter syndrome: HLA-B27 autoimmune condition with arthritis, inflammation of eye, urethritis
plasma cell balanitis
- Plasma cell balanitis: aka Zoon balanitis
- Macular discoloration or painless papules of the glans
- Connective tissue shows infiltrates of plasma cells and lymphocytes; overlying epithelium is thickened
peyronie disease
- Peyronie disease: fibrous induration of penis
- Focal, asymmetric fibrosis of penile shaft with ill-defined induration and normal overlying skin
- “penile strabismus”: loss of penile curvature and painful erections
- young and middle aged men
- dense fibrosis with sparse chronic inflammation
sexually transmitted urethritis
o Sexually transmitted urethritis: most common manifestation of STDs in men
• Purulent and greenish yellow urethral or vaginal discharge
• Pain or tingling at meatus, pain on urination
• Gonorrhea
• Chlamydia trachomatis, ureaplasma urealyticum
non-specific infectious urethritis
o Non-specific infectious urethritis: E coli and pseudomonas; assoc. w/ cystitis
• Urgency and burning on urination
• Usually no discharge
• Men can express milky fluid by milking the urethra
urethral caruncles
o Urethral caruncles: polypoid inflammatory lesions near female urethral meatus that produce pain and bleeding
• Post-menopausal women with exophytic, ulcerated, polypoid mass at or near urethral meatus
• M: inflammation, blood vessel granulation tissue, ulceration, urothelial or squamous epithelium hyperplasia
• Does not lead to cancer
tx is surgical excision
reiter syndrome
o Reiter syndrome: urethritis, conjunctivitis, and arthritis of weight bearing joints
• Circinate balanitis, cervicitis, skin eruptions
• Young adults, HLA-B27
• Sx appear after urethritis or enteric infection
• Sx resolve in 3-6months
cryptorchidism
• Cyptorchidism: congenital undescended testis
o Bilateral in 30%; Prevalence of 1%
o Most common urologic condition requiring surgery in infants
o Location: abdominal, inguinal, upper scrotal
o Increases infertility and germ cell neoplasia
o Orchiopexy: 6months-1year to prevent infertility; but does not reduce cancer risk
infertility–possible findings on testicular biopsy
- Immature seminiferous tubules (hyogonadotrophic hypogonadism 2/2 hypothalamic-pituitary disease)
- M: seminiferous tubules w/o spermatic differentiation resembling prepubertal testes
- Decreased spermatogenesis (cryptorchid testes, malnutrition, AIDS)
- Germ cell maturation arrest (idiopathic)
- Germ cell aplasia (sertoli cell only syndrome)
- Orchitis
- Peritubular and tubular fibrosis (cryptorchdism, infection, ischemia, radiation)
bacterial epididymitis
young men with gonorrhea of chlamdyia; older men and children with E. coli
• Intrascrotal pain w/ or w/o fever and infertility
tuberculous epididymitis
assoc. w/ tuberculosis and caseating granulomas
spermatic granuloma
from sperm extravasation due to traumatic rupture
• M: mixed inflammatory cell infiltrate with numerous extravasated sperm fragments and phagocytosis by macrophages; later=fibrosis and ductal obstruction
spermatic cord torsion
o Twisting of the spermatic cord with compromise of testicular blood supply
o Results from abnormal fixation of testis and spermatic cord
o Seen in children and young adults during vigorous activity
o Presents as abrupt onset of pain and swelling
o Can cause testicular infarct
orchitis
inflammation of the testis
o Gram-neg bacterial orchitis is the most common form; 2/2 UTI
o Syphilitic orchitis
o Mumps orchitis: unilateral!
o Granulomatous orchitis: type IV cell-mediated hypersensitivity reaction and tuberculosis
• Non-caseating granulomas
o Malakoplakia
BPH
o Enlargement of prostate and urinary tract outflow obstruction
• Decreased vigor or urinary stream
• Increasing frequency
• Post-urinary dripping
• Hydroureter, hydronephrosis, and renal failure
o Blacks>whites>Asians
o Older men
o DRE: firm, enlarged nodular prostate
o Tx: transurethral resection prostate (TURP), suprapubic enucleation
urothelial papilloma
- Benign
- Exophytic or inverted
- M: papillary fronds lined by normal urothelium
- Single lesion, 2-5cm in diameter
bladder inverted papilloma
rare, nodular mucosal lesions, trigone area
• M: cords of urothelium descend into lamina propria covered by normal urothelium
urothelial carcinoma
- Present with Hematuria
- 15% have mets at presentation
- Tx: transurethral resection for T0, T1 and non-muscle invading tumors; radical cystectomy for others
non-urothelial bladder cancer
rare!
• Squamous cell carcinoma: schistosomiasis
• Adenocarcinoma: urachal remnants in bladder dome
• Neuroendocrine: like small cell lung cancer
• Rhabdomyosarcoma: children, sarcoma botryoides
urethral carcinoma
o Elderly women
o Distal urethral squamous cell carcinoma
o Proximal urethra: urothelial carcinoma
o Most tumors have spread at presentation
penis carcinoma
uncircumcised men, 60yo, uncommon
o HPV 16, 18
o Phimosis and smegma
o SCC
bowen disease of the penis
shaft; solitary, sharply demarcated, red or white plaque
penile intraepithelial neoplasia
eryhroplasia of queyrat
glans and foreskin; solitary of multiple shiny, soft red plaques
o Both of these are carcinoma w/o invasion of the dermis; 10% progress to invasive carcinoma
penile intraepithelial neoplasia
bowenoid papulosis of the penis
not a carcinoma!
o young sexually active men, HPV type 17; multiple brownish or violet papules
o lesions regress spontaneously and do not progress to invasive carcinoma
invasive SCC of penis
o Ulcer, crater, friable hemorrhagic mass
o Exophytic, fungating
o Glans or prepuce and less commonly shaft
o M: well differentiated, focally keratinizing, SCC;
• Invasive tumors have dense chronic inflammation of dermis
verrucous carcinoma of the penis
low grade SCC
o slow growing, exophytic, locally aggressive but rarely mets
o not related to HPV
o surgical removal is cure
Must differentiate from giant condyloma acuminata of Buschke and Lowenstein
• Benign condyloma in anogenital area assoc. w/ HPV 6 and 11 and overexpression p53
• Locally destructive but doesn’t met
• Men <50
• Most common on glans
• Recurs
scrotal cancer
: SCC affecting older men; pts show invasion of scrotal contents and mets to regional LN; tx is surgical excision
prostatic intraepithelial neoplasia
o Noninvasive neoplastic transformation of lining of prostatic epithelium
o Low grade and high grade
o Precedes invasive cancer by 20years
o M: dilated branching glands with intraluminal papillary projections; lined by crowded enlarged cells with prominent nucleoli
prostate adenocarcinoma
malignant glands
o Multicentric on the peripheral zone
o Irregulary, yellow-white indurated nodules
o M: glands with conspicuous “nucleoli” that infiltrate stroma; lacks architectural organization
o Gleason grading pattern: based on tumor architecture
• Score of 2-10
• Lower score=better prognosis
o Blastic bony mets (vertebrae, ribs, pelvis); painful (positive PSAP on IHC confirms prostate origin)
o Usually detected by PSA and DRE
o Pts do not usually present with bladder probs (vs BPH)
nephroblastoma/Wilm’s tumor
o Most common pediatric renal tumor!
o Chr11, WT1/2 genes are overexpressed
o Mean age is 3-4years
o Present w/ abdominal mass (rarely with hematuria, pain, HTN)
o Assoc. w/:
• Wilms-Aniridia-genital anomaly-retardation syndrome
• Beckwith-Weideman syndrome: abdominal wall defect, macroglossia, macrosomia
o M: blasema (small blue cells in solid nests), hypocellular stroma with myxoid spindle cells, epithelial arranged in tubules
o Excellent prognosis!
congential mesoblastic nephroma
hamartoma
o Translocation 12;15, ETV6-NTRK3 fusion gene
o Most are benign
o 5-10% recurrences and mets
o solitarym tranb, bulgy soft mass (like leiomyoma)
o M: spindle cells with mitosis on cellular pattern
clear cell sarcoma of the kidney
: “bone metastatizing tumor” aggressive malignant sarcoma; late recurrence and bad prognosis
o Located in medulla
o M: epitheloid with clear cytoplasm and nucleus arranged in sheets with arbozing blood vessels in myxoid stroma
rhabdoid tumor
highly malignant seen in first 2 years of life
o Deletion/mutation of IN11 gene on chr 22q
o Does not have muscle differentiation
o Assoc. w/ brain tumor (atypical rhabdoid teratoid tumor)
oncocytoma
benign adult renal tumor
• Central scar
• Mahogany brown mass with a central scar
• M: eosinophilic cells w/ abundant cytoplasm, round nucleus with prominent nucleoli arranged in nests, cords, tubules or cysts
metanephric adenoma
benign renal tumor
• Epithelial nephroblastic cells
• Women, 40s, polycythemia
• Presents with hematuria and flank pain
• Gray-tan tumor, unencapsulated 5cm
• Metanephric adenofibroma: younger age, equally common in males, 80% have polycythemia
• Trisomy 7 and 17 with loss of Y or X (sim to papillary)
papillary adenoma
benign renal tumor \: most common renal neoplasm!! • Asymptomatic or hematuria • Gray-tan <0.5cm • Psammoma bodies • Genetics: +7, +17, -Y
angiomyolipoma
benign renal cell tumor
• Derived from perivascular epithelioid cells
• Females
• Tuberous sclerosis (mutation in TSC1 and TSC2)
• Co-express melanocytic and muscle markers
• Presents with flank pain
• HMB45+ on IHC
clinical presentation of malignant renal cancer
• Hematuria • Triad: hematuria, flank pain, palpable mass • Metastasis • Paraneoplastic syndrome: • Hypercalcemia: PTHrP; sx of lethargy, nausea, fatigue, weakness, decreased DTR • Hypertension • Polycythemia (inc. EPO) • Incidental finding o Risk factor=tobacco!
renal clear cell carcinoma
- Elderly, male predominant
- Sporadic
- VHL: multifocal, bilateral RCC, inactivation tumor suppressor on chr3
- Well-circumscribed, golden yellow, cystic solid, hemhorrhagic, necrosis
- Fuhrman grades 1-4
- Sarcomatoid RCC=worse prognosis
papillary renal cell carcinoma
2nd most common RCC
• Multifocal, tan-white nodules >0.5cm
• Genetics: +7, +17, -Y
• Type 1: small cells, pale cytoplasm; foamy macrophages
• Type 2: large cells, eosinophilic cytoplasm; younger pts, and pts with end-stage renal disease
chromophobe renal cell carcinoma
- From intercalating cell of collecting duct
- Multiple chromosomal losses (1, Y, 6, 10, 13, 17) and hypodiploidy
- DDX is oncocytoma (can also have central scar)
- Hale’s colloidal iron stain + (vs oncocytoma is negative)
renal collecting duct carcinoma
collecting ducts of bellini
• Adenocarcinoma with high grade cytology
• Poor prognosis
• Ulex europaeus lectin reactivity (differentiates from papillary RCC)
medullary renal cell carcinoma
- Sickle cell trait, sickle cell disease, SC disease
- Aggressive (most pts have mets at diagnosis)
- Young black males
- Poor prognosis
renal carcinoma assoc w/ Xp11.2/TFE gene fusion
- Children and young adults
- Presents at advanced stage but has an indolent clinical course
- Papillary architecture and psamomma bodies
multilocular cystic renal cell carcinoma
- Multi-cystic with small clusters of clear cells
* Excellent prognosis
Germ cell tumors of the testicles epidemiology
• Germ cell tumors: 95% of testicular tumors
o Most common in men between 15-34; Whites>Blacks
o Risk factors: cyrptorchidism, gonadal dysgenesis, family hixostyr, isochromosome 12
testicular seminomas
radiosensitive and present at an early age
• Homogenous mass with no hemorrhage and necrosis
• Most common adult testicular tumor
• Painless mass in 4th decade
• Non-hemorrhagic tumor
• IHC: PLAP+, CD117+, OCT ¾+
• Can be bHCG positive
Spermatic seminoma
- Pts >55
- 3 sizes of cells in sheets w/o fibrovascular septa
- excellent prognosis
embryonal testicular carcinoma
o Non-seminomas: relatively radiosensitive, more aggressive, usually mixed
-hemorrhagic mass with necrosis (vs seminoma)
• Embryonal carcinoma:
• Aggressive, arises from primitive cells
• 30s-40s
• usually mixed
• pts present with mets
• pain is common sign
• poorly demarcated, variegated with foci of hemorrhage and necrosis
• IHC: CD30, cytokeratins, PLAP, OCT3/4, CD117
testicular teratoma
non-seminoma–relatively radiosensitive, more aggressive, usually mixed
contains all 3 germ layers (endoderm, mesoderm ectoderm)
• kids < 2
• in adults, teratomas are malignant
yolk sac tumors
•non-seminoma
Pure form in kids < 4
• Mixed GCT in adults as rapidly growing painless mass
• Schiller duval bodies
• AFP is marker (found in tissue in hyaline globules)
choriocarcinoma
non-seminoma
rare malignant tumor
• Marked increase in bHCG
• Aggressive with hematogenous spread to lungs, liver, GI, brain
• can present as gynecomastia and hyperthryoidism
• can be hemorrhagic or burn out scar
• syncytiotrophoblasts and cytotrophoblasts
mixed germ cell tumor of testicles
• Mixed germ cell tumors: 2 or more germ cell tumor types
o Elevated AFP (yolk sac) and HCG (choriocarcinoma) are common
o Presents as painless mass
o Tumor is variegated soft, firm, cystic with hemorrhage and necrosis
o Metastasis is via lymphatics to retroperitoneal lymph nodes
o Teratocarcinoma= teratoma + embyronal carcinoma
• Intratubular Germ cell neoplasia, Unclassified:
o Malignant transformation of primordial germ cell
o Precursor of all invasive germ cell tumors except spermatocytic seminoma
o Higher incidence in cryptorchid testes and prior GCT
o Prophylactic orchiectomy recommended
o IHC: PLAP+
leydig cell tumors
- hormonally active and secrete androgens, estrogens, and corticosteroids
- can have precocious puberty, gynecomastia etc
- Present with testicular swelling
- Bimodal age peaks
- Reinke crystals
- IHC: inhibin+
sertoli cell tumor
- No hormonal sx!
- Testicular mass < age of 40
- Small nodules
- Large cell calcifying sertoli cell tumor is subtype assoc. w/ Peutz-Jeghers syndrome and carney’s complex
metastasis to testicles
o Testicular lymphoma is most common testicular neoplasm in men >60
• Diffuse large B cell lymphoma
o Mets from prostate, large intestine, bladder
most significant cause of bladder cancer
cigarette smoking
major risk factors assoc. w/ bladder cancer
- carcinogens–aryl amines, benzidine, naphthylamines, phenacetin,
- cyclophosphadmide
- infection (schistosomiasis)
- chronic inflammation
treatment of early stage bladder cancer
BCG
Von Hippel-Lindau syndrome
-30% pts get kidney cancer
kidney cancer
chemoresistant
never perform a percutaneous biopsy (risk spread)
testicular cancer (clinical)_
- most common malignancy men 15-35
- never perform a transcrotal biopsy in testicular mass (risk spread)
- metastatic testicular cancer is curable with chemotherapy +/- radiation in 90% pts
PSA and DRE
screening for prostate cancer in men >50 (but not proven to reduce mortality)
-PSA is helpful in assessing follow-up of pts with PSA secreting tumors that were treated
recurrent prostate cancer
progress and become hormone refractory
-hormone refractory prostate cancer should be treated with systemic chemo (improves overall survival)
