Male Reproductive System Notes Hypospadias - abnormal opening of the urethra onto the ventral surface of the penis or scrotum - this results from failure of fusion of the urethral folds - a fibrous band (chordee) distal to it will cause ventral curvature of the erect penis - there is often associated cryptochidism, ureterovesical reflux, inguinal hernia, and/or other developmental problems Epispadias - abnormal opening of the urethra on the dorsal surface of the penis - actually a form of exstrophy of the urinary bladder; there is often associated separation of the pubic bones and inadequacy of the urinary sphincters; incontinence and bladder infections are usual - less common than epispadias and more difficult to correct sugically Phimosis - present when the prepuce cannot be retracted over the corona - may be congenital if the opening is too small - more often due to poor hygeine, resulting in chronic infection - such an infections is called balanoposthitis - paraphimosis results when a tight foreskin is forcibly retracted, and edema of the glans prevents its replacement; this can quickly lead to acute urinary retention and even gangrene of the glans Priapism - a persistent, non-pleasurable erection - most are due to obstruction of the deep dorsal veins of the penis - causes include sickle-cell disease, leukemia, metastatic cancer, and trauma Urethritis - gonorrhea and NGU are important STDs - Reiter's syndrome - the enigmatic triad of arthritis, conjunctivitis, and urethritis - most pts are positive for HLA-B27 Peyronie's Disease - proliferation of the dense fibrous tissue involving a portion of the fascia; this leads to curvature of an erection - many pts require a penis prosthesis Warts - condyloma acuminata - a papillary, keratinizing lesion caused by the sexually transmitted HPV (6); commonly occurs in the urethral meatus in men - to spot HPV, wet the man's external genitalia with acetic acid and involved areas show white; it's now called androscopy - condyloma latum - groups of flat-topped lesions which may ooze serous fluid; caused by secondary syphilis; typically occur in skin folds Cancer of the Penis - almost all are variations of squamous cell carcinoma - originates on glans and prepuce - risk factors include phimosis, smegma, and balanoposthitis - the strongest risk is infection with HPV-16 - males circumcised as infants almost never get cancer of the penis - spreads to inguinal lymph nodes; five year survival is around 50% overall Premalignant lesions of the Penis - erythroplasia of Queyrat - a raised, velvety plaque on the uncircumcised glans or prepuce - histologic study shows dysplasia of the squamous epithelium - a minority of cases develop into squamous cell carcimona if not removed - Bowen's disease - carcinoma in situ of the skin, most often on the penis or scrotum in men - some cases develop into invasive squamous cell carcinoma - Bowenoid papulosis - multifocal carcinoma in situ, caused by HPV-16 - giant condyloma of Buscke-Lowenstein, or verrucous carcinoma - another HPV related, very ugly cauliflower like lesion; invasive cancer can breed here Male Infertility - spermatogenesis can be temporarily diminished or even stopped by a host of factors ranging from heavy drinking to anabolic steroids to alcoholism to bicycling - obstruction of the sperm passages may be more amenable than the above to surgical help Cryptochidism - incomplete descent of the testis into the scrotal sac - cryptorchid testes may be found anywhere along the normal route of descent - the epididymis is likely to be malformed or at least elongated - ectopic testes is less common; it may stray into the superficial inguinal region, penis, or femoral sheath - failure of the testes to descend causes problems: - the tubules will undergo atrophy and fibrosis, beginning in infancy - there is an increased risk of torsion of the spermatic cord and gangrene of the testis - the risk of germ cell cancer in undescended testes is 30X greater than normal - most is idiopathic - may be associated with diethyl-stilbesterol exposure Epididymitis and Orchitis - nonspecific infections of the contents of the scrotum are usually complications of the urinary tract infection, instrumentation, or prostate surgery - gonorrhea - the infection often spreads to the epididymis, less often the testis - mumps - orchitis is common in adolescents and adults - may cause atrophy of the germinal epithelium and infertility; the Leydig cells are spared - TB can cause granulomas involving the epididymis - syphilis can have gummas involving the testis; may spread to the epididymis Torsion of the Spermatic Cord - twisting of the spermatic cord is likely to result in venous infarction and gangrene in a few hours; quite common in children and adolescents - the involved testis is painful and elevated, ususallt twisted 540 - the underlying problem may be abnormal fixation of the testis or cryptochidism - unilateral spermatic cord torsion can somehow damage the opposite testis - a person can also suffer los of one testis by catching it in a hernia Germ Cell Tumors - cancer of the germinal epithelium - among the commonest solid tumors of young men - over 95% of these tumors are malignant germ cell tumors - current thinking is that these cancers emphasize their common origin from germ cells: - seminoma (40%) - embryonal cell carcinoma (25%) - choriocarcinoma (2%) - yolk sac carcinoma - teratocarcinoma (25%) - all present as painless, non-tender masses of the testis - risk factors are poorly understood, they include cryptochidism and intersex malformations - seminoma - cancer that closely resembles young spermatocytes - tumor cells have fried egg appearance; arranged in masses separated by fibrous septa with a lymphocytic infiltrate, may have syncytiotrophoblast and/or granuloma formation - chorionic gonadotrophin is a tumor marker for the 50% or so of seminomas that contain syncytiotrophoblast - typically metastasize to the retroperitoneal lymph nodes and then to the lungs - good response to radiation; five-year survival rate of 95% or better - embryonal cell carcinoma - a very primitive cancer that arises in the testis - grossly grayish-white masses with hemorrhage and necrosis - teratoma + embryonal cell carcinoma = teratocarcinoma - hCG and alpha-ferroprotein are tumor markers - tumors with an embryonal cell carcinoma component metastasize to the retroperitoneum and everywhere else - the response to newer chemotherapy protocols is very good, with around 85% apparent cures even when metastatic disease is widespread - choriocarcinoma - the bloodiest tumor; solid areas may be hard to find - the malignant cells resemble placenta, and the pathologist must identify cytotrophoblast and syncytiotrophoblast - HCG levels are very elevated - until recently, choriocarcinoma arising in the testis was always lethal - teratomas - cystic teratoma of testis is rare and is mostly composed of skin, hair, sebaceous glands, teeth - solid teratomas are of two types: - mature solid teratoma is benign, usually occurs in children - immature solid teratoma is malignant, usually contains embryonal cell carcinoma or sometimes squamous cell carcinoma - a tumor of germ cell origin may be mixed with any other tumor of germ cell origin - any tumor of germ cell origin may metastasize as another histologic type of germ cell tumor - lymphoma arises in the testes of older men with some frequency - adenomatoid tumor is a benign nubbin derived from mesothelium - germ cell tumors can and do arise in the retroperitoneum, mediastinum, and pineal "because they are midline structures" Stromal Tumors - Leydig cell tumors - occur at any age, are usually benign, can produce precocious puberty or gynecomastia - the gross and microscopic appearances aretypical for endocrine tumors Hydrocele - fluid in the tunica vaginalis; usually idiopathic, a hydrocele may contain 100cc or more of serous fluid - you can distinguish a hydrocele from a tumor mass by transilluminating it with a bright light in a dark room - hematocele - blood in the tunica vaginalis Varicocele - variscosities of the pampiniform plexus, usually on the left side - common in young men, may cause fertility problems by warming the testes - spermatocele - a cystic lesion up to 1 cm or so in the area of the rete testis, filled with fluid and dead sperms Prostatitis - acute and chronic prostatitis are uncomfortable problems, and are common in men who catch sexually-transmitted urethritis or lower urinary tract infections - e. coli is the most common agent - in acute prostatitis the gland is exquisitely tender; gonorrhea is an important cause - in chronic prostatitis the gland is somewhat tender and the prostatic fluid you express contain WBC's and grows bacteria - prostatodynia is a stress-related pain syndrome in which there are no WBC's in the prostatic fluid - granulomatous prostatitis may be due to TB or idiopathic Prostatic Hyperplasia - something that happens to most intact men over about age 50; 10% men will need surgery - the increased tissue is nodular overgrowth of periurethral glands and stroma - the hyperplasia most often involves the lateral and median lobes - the posterior lobe is the most common site for the development of prostatic adenocarcinoma - median lobe hyperplasia by itself produces a median bar, obstruction without an enlarged gland - prostatic hyperplasia casuses many problems, though most pts are are asymptomatic - frequency, difficulty starting and stopping urination, incontinence, dysuria, hernias, acute urinary retention - hematuria, bladder hypertrophy and trabeculation, bladder diverticula, bladder stones, hydronephrosis, renal failure - residual urine accumulates in an enlarged bladder behind the prostate gland Prostate Cancer - adenocarcinoma of the subcapsular glands - the second most common cancer in men, and the third leading cancer killer of men - a disease of men over 50 - majority arise in the posterior lobes - the etiology is essentially unknown - early castration prevents the development of adenocarcinoma - probably no link to infection or prostatic hyperplasia, or lack of sexual activity - industrial exposure to cadmium - cancer of the prostate preents as a painless lump in the gland - almost all are prostate type adenocarcinomas: to diagnose you need one of the following - prominent nucleoli in large nuclei with marginated chromatin - invasion - obvious distortion of architecture - most prostate cancers, even the ones that have metastasized, are fairly well-differentiated adenocarcinomas - cancer of the prostate seldom causes problems unless it spreads: - rectal exam is the most effective method of diagnosis - prostate cancer is often indolent even when it has metastasized, but some prostate cancers are very aggressive - prostate cancer typically metastasizes to the axial skeleton, eventually causing miserable bone pain - serum acid phosphatase is a classic tumor marker for prostate cancer - surgery and/or radiation are useful for localized disease; conventional chemotherapy is of limited usefulness in prostate cancer, but protocols do exist - usually quite responsive to endocrine manipulations - one new important agent is leuprolide, a GnRH agonist - another is anti-androgen flutamide, which shrinks prostate cancer supposedly without causing impotence - ketoconazole is also an anti-prostatic drug