Male Reproductive I) Penis A) Congenital Ref: Robbins; Pathologic Basis of Dis - hypospadias = opening on the ventral surface - epispadias = opening on dorsal surface - both associated with failure of testes to descend and other urinary malformat’s B) Prepuce Circumcision or not? - phimosis = orifice of prepuce is too small to retract; swelling; constriction of glans = paraphimosis, leading to urinary retention C) Inflammation - balanoposthitis = inflammation of glans and prepuce, many bugs, fungi etc. - may lead to scaring and restriction of urinary flow. D) Tumors: remember HPV Ref: Robbins; Pathologic Basis of Dis 1 - condyloma acuminatum = papilloma; HPV types 6 and 11 - carcinoma in situ: - Bowen’s disease; shaft (men and women; other malignancies) - Erythroplasia of Queyart; glans - Bowenoid papulosis: pigmented-brown; in situ; both men and women; HPV 16 - invasive carcinoma - squamous cell ca - infections, irritation, HPV 16 and 18 - not too common, goes to local nodes - white to grey and gritty II) Testis and epididymis A) congenital - cryptorchid: undescended; position; unilateral; cancer; infertility; buserlin 2 - synorchism: fusion B) atrophic changes; atherosclerosis; age; inflammation; crypt; hypopit; obstruction; radiation and chemothrx; exhaustion atrophy C) inflammation; bug, less often autoimmune - rarely separate, ie epidid and testis; bug frequently from urinary tract; age - GC; younger men; ascending infection - mumps; rare in prepuberty; about 30% in post puberty; edema and mononuclear infiltrate - TB; starts in epidid and spreads to testis; blood 3 - syphilis; testis first, then epidi; secondary phases of disease; end arteritis D) Vascular and “mechanical”; torsion and infarction; HURTS E) Scrotal masses - Testicular Tumors, i.e. neoplasia (Solid) - Epididymal Inflammatory (rubor, dolor, calor, TUMOR) - Peritesticular Hernia, hydrocele (transilluminates) vascular F) tumors of testis; (1) germ cell = reproductive element; (2) non-germinal = supportive - Tumor markers (measured in blood) - Embryonic tissue signals - Beta HCG - Alpha-feto protein 4 - When to draw blood sample? - germinal line; highly aggressive; wide spread; trx progress; histology classes; many are “mixed pattern”; mediastinum and supraclavicular nodes - development; crypt; genetic, isochromosome I(12p), testicular dysgenesis - seminoma; most common; three common patterns; no AFP or HCG - watery clear cells with fibro ct stromal bands; lobules - Embryonal carcinoma; aggressive; 20-30 yrs group - fleshy with areas of hemorrhage and necrosis 5 - glandular and “alveolar” arrangements; embryonic - often part of something else, rare as a single tumor - +/- markers - yolk sac; embryonic yolk sac looking; rare; AFP+ - choriocarcinoma; HCG+ Ref: Robbins; Pathologic Basis of Dis - syncytium of pink staining cells like syncytial trophoblasts - small primary with wide spread mets -teratoma; three categories, most are malignant in males - embryonic tissues types, look for cartilage, skin and bone - markers +/- - “mixed pattern”; most frequent; grade by most aggressive element - general features of all forms of testicular malignancies - painless enlargement - distant spread - mediastinum and supraclavicular nodes - mediastinal primary (?) - clinical stage is very important - Stage I; testis - Stage II: retroperitoneal mets bellow diaphragm - Stage III: above diaphragm 7 - Markers always !! - nongerm line: sex cord and gonadal stroma - Leydig cell: stroma: androgens, estrogens and even corticosteroids - testicular enlargement; maybe gynecomastia - Sertoli cell tumor: sex cord; “androblastoma”; rarely hormonally active - primary testicular lymphoma; rare - non-neoplastic “tumors” - hydrocele - hematocele 8 - spermatocele - varicocele - chylocele (lymph obstruction, not really chyle as in GI) III) Prostate: (1) inflammation; (2) hyperplastic enlargement and (3) cancer Ref: Robbins; Pathologic Basis of Dis A) inflammation; (1) acute and chronic bacterial and (2) “chronic prostatitis” - acute bacterial: ascending; E. Coli; gram neg rods; enterococci - catheter, surgical manipulation, TUR, “experimentation” - dysuria, fever, chills 9 - chronic bacterial: low back pain, dysuria, suprapubic pain, common bugs - chronic abacterial prostatitis: very much like chronic bacterial, but sterile cultures, Chlamydia, Ureaplasma (?) B) BPH, very common - androgens; dihydrotestosterone (DHT), transitional zone of prostate, periutheral - nodular enlargement with glandular hyperplasia; both glands and stroma - urethral compression with secondary problems - cancer risk (?) not much if any Ref: Robbins; Pathologic Basis of Dis. Ref: Robbins; Pathologic Basis of Dis C) Cancer, frequency increases with age; very common tumor, but not common cause of death - not common in Asia - risk factors; age; race; family hx; hormone levels; environmental - adeno with various patterns; Gleason’s grading system - sclerosis in many cases - perineural involvement - PIN - Gleason is cyto grade: ‘Score’ and ‘Grade’ Score = 1 – 5, Grades is sum of best and worst - stages = spread - I (A1 and A2) microscopic, focal or diffuse, no spread out of cap - II (B1 and B2) confined to prostate; +/- 1.5 cm - III (C1 and C2) extracapsular spread, but confined to pelvis - IV (D1) retroperitoneal nodes 3 or fewer (D2) distant spread - bone mets may be OSTEOBLASTIC OR LYTIC, but prostate is one of the few that will produce blastic mets - PSA; made by both benign and malignant growths of prostate. Must know size of gland to accurately interpret. - serine protease, liquefies seamen - greater diffusion of PSA out of malignant cells, not more production - Surgery , hormone manipulation and chemo - synthetic analogs of LHRH - Androgen refractory prostate cancer IV Sexually transmitted diseases - HPV - Hepatitis B - GC - Syphilis Primary Secondary Tertiary Congenital Testing; false positive VDRL - HIV - Chlamydia