Ed Friedlander, M.D., Pathologist

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Welcome to Ed's Pathology Notes, placed here originally for the convenience of medical students at my school. You need to check the accuracy of any information, from any source, against other credible sources. I cannot diagnose or treat over the web, I cannot comment on the health care you have already received, and these notes cannot substitute for your own doctor's care. I am good at helping people find resources and answers. If you need me, send me an E-mail at Your confidentiality is completely respected. No texting or chat messages, please. Ordinary e-mails are welcome.

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Freely have you received, give freely With one of four large boxes of "Pathguy" replies.

I'm still doing my best to answer everybody. Sometimes I get backlogged, sometimes my E-mail crashes, and sometimes my literature search software crashes. If you've not heard from me in a week, post me again. I send my most challenging questions to the medical student pathology interest group, minus the name, but with your E-mail where you can receive a reply.

Numbers in {curly braces} are from the magnificent Slice of Life videodisk. No medical student should be without access to this wonderful resource.

I am presently adding clickable links to images in these notes. Let me know about good online sources in addition to these:

Freely have you received, freely give. -- Matthew 10:8. My site receives an enormous amount of traffic, and I'm still handling dozens of requests for information weekly, all as a public service.

Pathology's modern founder, Rudolf Virchow M.D., left a legacy of realism and social conscience for the discipline. I am a mainstream Christian, a man of science, and a proponent of common sense and common kindness. I am an outspoken enemy of all the make-believe and bunk that interfere with peoples' health, reasonable freedom, and happiness. I talk and write straight, and without apology.

Throughout these notes, I am speaking only for myself, and not for any employer, organization, or associate.

Special thanks to my friend and colleague, Charles Wheeler M.D., pathologist and former Kansas City mayor. Thanks also to the real Patch Adams M.D., who wrote me encouragement when we were both beginning our unusual medical careers.

If you're a private individual who's enjoyed this site, and want to say, "Thank you, Ed!", then what I'd like best is a contribution to the Episcopalian home for abandoned, neglected, and abused kids in Nevada:

I've spent time there and they are good. Write "Thanks Ed" on your check.

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Especially if you're looking for information on a disease with a name that you know, here are a couple of great places for you to go right now and use Medline, which will allow you to find every relevant current scientific publication. You owe it to yourself to learn to use this invaluable internet resource. Not only will you find some information immediately, but you'll have references to journal articles that you can obtain by interlibrary loan, plus the names of the world's foremost experts and their institutions.

Alternative (complementary) medicine has made real progress since my generally-unfavorable 1983 review. If you are interested in complementary medicine, then I would urge you to visit my new Alternative Medicine page. If you are looking for something on complementary medicine, please go first to the American Association of Naturopathic Physicians. And for your enjoyment... here are some of my old pathology exams for medical school undergraduates.

I cannot examine every claim that my correspondents share with me. Sometimes the independent thinkers prove to be correct, and paradigms shift as a result. You also know that extraordinary claims require extraordinary evidence. When a discovery proves to square with the observable world, scientists make reputations by confirming it, and corporations are soon making profits from it. When a decades-old claim by a "persecuted genius" finds no acceptance from mainstream science, it probably failed some basic experimental tests designed to eliminate self-deception. If you ask me about something like this, I will simply invite you to do some tests yourself, perhaps as a high-school science project. Who knows? Perhaps it'll be you who makes the next great discovery!

Our world is full of people who have found peace, fulfillment, and friendship by suspending their own reasoning and simply accepting a single authority that seems wise and good. I've learned that they leave the movements when, and only when, they discover they have been maliciously deceived. In the meantime, nothing that I can say or do will convince such people that I am a decent human being. I no longer answer my crank mail.

This site is my hobby, and I do not accept donations, though I appreciate those who have offered to help.

During the eighteen years my site has been online, it's proved to be one of the most popular of all internet sites for undergraduate physician and allied-health education. It is so well-known that I'm not worried about borrowers. I never refuse requests from colleagues for permission to adapt or duplicate it for their own courses... and many do. So, fellow-teachers, help yourselves. Don't sell it for a profit, don't use it for a bad purpose, and at some time in your course, mention me as author and William Carey as my institution. Drop me a note about your successes. And special thanks to everyone who's helped and encouraged me, and especially the people at William Carey for making it still possible, and my teaching assistants over the years.

Whatever you're looking for on the web, I hope you find it, here or elsewhere. Health and friendship!


More of Ed's Notes: Ed's Medical Terminology Page

Perspectives on Disease
Cell Injury and Death
Accumulations and Deposits
What is Cancer?
Cancer: Causes and Effects
Immune Injury
Other Immune
HIV infections
The Anti-Immunization Activists
Infancy and Childhood
Environmental Lung Disease
Violence, Accidents, Poisoning
Red Cells
White Cells
Oral Cavity
GI Tract
Pancreas (including Diabetes)
Adrenal and Thymus
Nervous System
Lab Profiling
Blood Component Therapy
Serum Proteins
Renal Function Tests
Adrenal Testing
Arthritis Labs
Glucose Testing
Liver Testing
Spinal Fluid
Lab Problem
Alternative Medicine (current)
Preventing "F"'s: For Teachers!
Medical Dictionary

Courtesy of CancerWEB


KCUMB Students
"Big Robbins" -- Lower Urinary / Male
Lectures follow Textbook


I used to pray, "Lord, give me chastity, but not yet!"

A man should definitely get married. If it's a good marriage, he will be happy. If it's a bad marriage, he will become philosophical.

Iron John. Iron John. What MY wife wants is iron-ING John!.
        -- Anonymous man

{47692} index identifies this as "human male"
{10268} prostate, normal gross section
{11762} prostate, normal histology
{11763} prostate, normal histology
{17008} prostate, normal histology
{15027} prostate, normal histology, with concretion
{00083} testis, normal histology
{20941} testis, normal histology, good Leydig cell
{15016} epididymis, normal histology, with sperms
{15026} seminal vesicles, normal histology
{25832} sperms, Pap stain; note two-headed sperm in center (not too unusual)

Testis, epididymis, penis
"Pathology Outlines"
Nat Pernick MD

Normal testis

WebPath Photo

Normal spermatogenesis

WebPath Photo

Male Histology
Ed's Histology Notes

Normal testis

WebPath Photo

Even where there is no mensch, strive to be a mensch.

While you are away, movie stars are taking your women. Robert Redford is dating your girlfriend. Tom Selleck is kissing your lady. Bart Simpson is making love to your wife.

        --"Baghdad Betty", Iraqi disk jockey, during the first Gulf War

Bart Simpson

Love, who is fairest among the immortal gods,
loosener of limbs, by whom all gods and all men
find their thoughts and wise counsels overcome in their hearts.

Lower Urinary / Male
Taiwanese pathology site
Good place to go to practice

Photo Library of Pathology
U. of Tokushima

Urologic Path
Surgical Pathology Atlas
Nice photos, hard-core

Surgical Pathology Atlas
Nice photos, hard-core

Penis Exhibit
Virtual Pathology Museum
University of Connecticut


Chaing Mi, Thailand

Photos, explanations, and quiz
Indiana U.

Male Images
University of Washington
Pictures and comments

Iowa Virtual Microscopy
Have fun

Utah cases for path students
Juliana Szakacs MD

HYPOSPADIAS (Urol. Clin. N.A. 37: 159 & 167, 2010): Abnormal opening of the urethra onto the ventral surface of the penis or scrotum.

EPISPADIAS: Abnormal opening of the urethra on the dorsal surface of the penis.

PHIMOSIS: Present when the prepuce cannot be retracted over the corona.

{24987} balanitis

PRIAPISM: A persistent, non-pleasurable erection (Mayo Clin. Proc. 72: 350, 1997; Urol. Clin. N.A. 28: 391, 2001).



Yutaka Tsutsumi MD

PEYRONIE'S DISEASE ("penile induration"): Proliferation of dense fibrous tissue involving a portion of the fascia. This leads to curvature of erection and some discomfort. Most cases are mild but some can be disabling. * Other names: "painful erection in the wrong direction", "squint of the cock" (Osler).

{25287} Peyronie's, histology

WARTS: There are two common "warts" involving the penis:

{24460} condyloma, gross
{25098} condyloma, histology; note HPV-effect (shrunken, wrinkled nuclei, perinuclear halo)

Male patient photos
Health Awareness Connection

GENITAL HERPES is familiar to you.

PEARLY PENILE PAPULES ("PPP on the pee-pee") aren't warts at all, but little bumps, sometimes hairy, which pop up in young adults, especially on the corona. Each is a single big dermal papilla. No need to treat. About one man in 100 has spectacular ones, and I get a very large number of questions from visitors to my site. I point out they can be considered a "plus". They may be removed using today's lasers (JAMA Derm 149: 748, 2013).

Pearly penile papules
Patient photo
From a correspondent -- thanks

Pearly penile papules
Patient photo
Brazilian site

Pearly penile papules
Patient photo

Pearly penile papules
And other adolescent skin stuff
USC Keck

Pearly penile papules
Classic look
Wikimedia Commons

CANCER OF THE PENIS: Almost all are variations on squamous cell carcinoma. Review Urol. Clin. N.A. 37: 343, 2010.

{46450} squamous cancer of the penis, metastatic to the head
{46451} squamous cancer of the penis, with inguinal node metastasis

Cancer of the Penis
Dino Laporte's PathosWeb

Cancer of the penis
WebPath Photo

Cancer of the penis
WebPath Photo


{25095} erythroplasia of Queyrat, gross
{25096} erythroplasia of Queyrat, histology

{25101} verrucous carcinoma, gross
{25102} verrucous carcinoma, histology

A standing army is like a standing member. It's an excellent assurance of domestic tranquility, but a dangerous temptation to foreign adventure.

Nice case photos
Charam M. Ramnani MD

Testis Exhibit
Virtual Pathology Museum
University of Connecticut

Testis I
From Chile
In Spanish

Testis II
From Chile
In Spanish


{00086} testicular atrophy, no sperms
{25154} testicular feminization (no sperms, hyperplasia of useless Leydig cells, why?)

Atrophic testis

WebPath Photo

Normal and atrophic testis

WebPath Photo

Testicular atrophy
Urbana Atlas of Pathology

CRYPTORCHIDISM (cryptorchism): Incomplete descent of the testis into the scrotal sac. Review Am. Fam. Phys. 62: 2037, 2000.


Epididymis Exhibit
Virtual Pathology Museum
University of Connecticut

{40116} abscess of the epididymis, gonococcal I'd bet; the tan structure with the white rim is a cross-section of testis

E. coli epididymitis

Yutaka Tsutsumi MD

Chlamydia of the epididymis

Yutaka Tsutsumi MD

Mumps orchitis
Great photo
KU Collection

{25221} tuberculosis of epididymis

TORSION OF SPERMATIC CORD ("torsion of the testis"): Am. Fam. Phys. 74: 1739, 2006

{10892} torsion, gross
{25208} torsion, gross
{10898} testes: normal vs. "atrophic" (could have been old torsion, old mumps, or whatever)


WebPath Photo

GERM CELL TUMORS (cancer of the testis): Cancer of the germinal epithelium. These tumors are the commonest solid cancers of men in their 20's and 30's. In 2006, there were around 8250 cses and 370 deaths in the US. Pathologists see Arch. Path. Lab. Med. 131: 1267, 2007; J. Clin. Path. 61: 20, 2008; Arch. Path. Lab. Med. 136: 435, 2012. Clinicians see Lancet 367: 754, 2006. Lance Armstrong

{25352} seminoma, gross
{25353} seminoma, histology
{08863} seminoma, histology
{40217} seminoma, histology (PAS stain for glycogen)
{08862} seminoma in situ in the tubular epithelium
{25355} spermatocytic seminoma, gross
{25173} spermatocytic seminoma, histology

Testicular Seminoma
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery


WebPath Photo


WebPath Photo


WebPath Photo


WebPath Photo

Lymphadenectomy incision
Supposedly belongs to
comedian Tom Green


WebPath Photo

    * If you don't let me play, I'm going to take my ball and go home.

        -- Johnny Kruk, Philadelphia Phillies

          On being asked not to return to baseball until he was fully recovered from seminoma surgery
Johnny Kruk

{23954} embryonal cell carcinoma, lumen of some kind and some wilder stuff
{23956} embryonal cell carcinoma; cartilage and erectile tissue (subtle)

Tom Green

Embryonal cell carcinoma

WebPath Photo

Embryonal cell carcinoma

WebPath Photo

Embryonal cell carcinoma

WebPath Photo

{25401} teratocarcinoma
{25402} teratocarcinoma


WebPath Photo


WebPath Photo


WebPath Photo


WebPath Photo

{25175} yolk sac cancer, gross
{11551} yolk sac cancer, histology

Yolk sac carcinoma
Pittsburgh Pathology Cases

Yolk sac tumor

WebPath Photo


Leydig cell tumor
Pittsburgh Pathology Cases

HYDROCELE: Fluid in the tunica vaginalis. Usually idiopathic, a hydrocele may contain 100 cc or more of serous fluid.

{24589} hydrocele, gross


WebPath Photo

{25191} hematocele (guy got kicked probably)

Normal prostate
WebPath Photo

Pathology of the Prostate
WebPath Tutorial

Normal prostate

WebPath Photo

Normal prostate

WebPath Photo

Prostate gland
"Pathology Outlines"
Nat Pernick MD

Nice case photos
Charam M. Ramnani MD

Prostate Exhibit
Virtual Pathology Museum
University of Connecticut

Prostate I
From Chile
In Spanish

Prostate II
From Chile
In Spanish


{25212} acute prostatitis, gross
{25213} acute prostatitis, histology

{25214} chronic prostatitis, histology
{25215} chronic prostatitis, histology

{23968} granulomatous prostatitis

Cryptoccal prostatitis

Yutaka Tsutsumi MD

* A curious fact about prostate pathology is that benign cysts are common (and often seen on ultrasound), and may obstruct, but have never been seriously studied or subtyped by pathologists. See J. Urol. 181: 647, 2009.

PROSTATIC HYPERPLASIA ("benign prostatic hypertrophy or hyperplasia", "BPH"). Review: Disease-a-Month 41: 437, 1995; Urol. Clin. N.A. May 1995.

{10743} prostate hyperplasia, gross. Don't try this paper clip trick at home.
{17007} prostate hyperplasia, gross cut surface
{15382} prostate hyperplasia, gross; both gland and bladder have been opened anteriorly
{18766} prostate hyperplasia, gross
{24445} prostate hyperplasia, gross
{17458} prostate hyperplasia, good median bar
{08856} prostate hyperplasia, histology
{17457} prostate hyperplasia, histology
{17197} prostate hyperplasia, histology
{08857} prostate hyperplasia, histology

Benign Prostate Hyperplasia
Dino Laporte's PathosWeb

Prostatic Hyperplasia with Thick Bladder
Australian Pathology Museum
High-tech gross photos

Hyperplastic prostate

WebPath Photo

TURP chips

WebPath Photo

Median bar

WebPath Photo

Hypertrophic bladder
WebPath Photo

Hyperplastic prostate

WebPath Photo

Hyperplastic prostate

WebPath Photo

Prostate hyperplasia
Urbana Atlas of Pathology

Benign Prostatic Hyperplasia
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

PROSTATE CANCER: Adenocarcinoma of the subcapsular glands. All about the pathology: Cancer 70(S1): 235, 1992; Cancer 71(S3): 906, 1993 (deja vu); changes after therapy Arch. Path. Lab. Med. 131: 360, 2007; review of the disease Br. Med. J. 308: 780, 1994; Sci. Am. 279(6): 74, Dec. 1998. Frank Zappa
Frank Zappa

Gleason grading
Online quiz

{17012} prostate cancer in bone, x-ray

{21031} prostate cancer, gross
{18767} prostate cancer, gross; looks yellowish
{03236} hydroureter in prostate cancer
{08865} well-differentiated prostate cancer
{23979} well-differentiated prostate cancer, Gleason 2
{08866} prostate cancer, cribriform, Gleason 3
{08864} prostate cancer, Gleason 3
{23980} poorly-differentiated prostate cancer, Gleason 4-5
{23975} atrophy of the prostate, as, after removal of androgens
{23969} irradiated prostate; note radiation changes in vessel to right of center

Prostatic intraepithelial neoplasia

WebPath Photo

Prostate cancer

WebPath Photo

Prostate cancer

WebPath Photo

Prostate cancer

WebPath Photo

Prostate cancer

WebPath Photo

Prostate cancer

WebPath Photo

Prostate cancer

WebPath Photo

Prostate cancer
PSA stain
WebPath Photo

Prostate cancer
Tom Demark's Site

Metastatic prostate cancer
Pittsburgh Pathology Cases

Prostate Carcinoma
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

Gleason scale
Wikimedia Commons

Prostate cancer
Lots of photos
Wikimedia Commons



There is no difference between a wise man and a fool when they fall in love.

Despite "conventional wisdom", impotence is often organic, even in younger men without obvious disease. Ask the guy if he gets erections out of bed, or try the famous low-tech "postage-stamp coil" test. In Portugal, not known for being wild, the doctors have developed a "visual erotic stimulation test" that they concluded will give an erection to any guy not organically impotent (J. Urol. 157: 134, 1997). Even tiny prolactinomas are notorious anti-aphrodisiacs. See JAMA 249: 1736, 1983. Did you check for hemochromatosis? Injection therapy (phentolamine, prostaglandin E1, papaverine) for the guy to use when he wants an erection: Arch. Phys. Med. Rehab. 75: 276, 1994. Viagra: Too many articles to count, all in 1998. Watch for cabergoline therapy (anti-prolactin) to increase male libido. Blunt trauma to the shaft during masturbation or intercourse can crack the side of the dorsal vein, allowing blood to drain in easily and causing impotence. How to fix it: J. Urol. 148: 1171, 1992. Update on injuries during romance: J. Trauma 62: 1522, 2007.

For premature ejaculation, if the guy doesn't get good results from the squeeze technique (which is fun), try a selective serotonin reuptake inhibitor (Am. J. Psych. 151: 1377, 1994; dudes: these'll improve an anal-retentive outlook on life, too). Some men cannot ejaculate; for the electronic gadget that helps, see J. Urol. 152: 1034, 1994. Retrograde ejaculation results from failure of one of those little bands of muscle to relax; ask about whether he's taking thioridazine, or an anatomic cause (J. Urol. 151: 1017, 1994).

Viscerosomatic reflex: Very rapid overfilling of the prostate and seminal vesicles (i.e., prolonged arousal without ejaculation in a young male) results in pain referred to the testes that can be severe ("blue balls", "lovers' nuts", etc.) The cure is ejaculation by any means. Your instructor suspects the mechanism is pressure of the overfilled seminal vesicles on the genitofemoral nerves and maybe veins.

Junk science! Hey dudes, are we being un-masculinized by rampant estrogen pollution (diethylstilbestrol cattle-fattener, women's oral contraceptive pill components excreted unchanged, other substances)? In a widely-publicized paper, researchers presented evidence that the average sperm count has declined by half over the 1900's (Lancet 341: 1392, 1993, totally unconvincing graph Science 265: 308, 1994). This was based on a handful of determinations of "average sperm counts" from before 1970 compared to today. There has been no drop since 1970. There is exactly no evidence that male infertility is increasing: NEJM 332: 327, 1995. So far there's a single claim, from Finland (Br. Med. J. 314: 13, 1997) that testicular histology has changed. (Anybody noticed a decrease in testicular size? I don't think so....) The most recent studies have failed to show an effect, or shown the counts to be increasing with time, or shown how inaccurate sperm-counting must be (i.e., New Yorkers counted in the New York lab averaged exactly twice the counts for Angelinos counted in the L.A. lab; Br. Med. J. 312: 1183, 1996). And if un-masculinization were really at work, your lecturer believes we modern men would have less body hair, less baldness, less B.O., and less belligerence. Nuh-uh! Your lecturer thinks that modern-day dudes simply ejaculate more often (you can figure out why yourself, and this has been confirmed in interviews) and resorb less fluid between ejaculations, concentrating the sperms less. Alternatively, today's man stays excited longer beforehand, producing more fluid. Every teenaged guy knows about this stuff, but the authors of the original paper apparently didn't think of this; I called them on it immediately, and the NEJM article above thought that "duration of abstinence" was probably the explanation too. After this paper, there was a silly media hype, and an inflammatory best-seller ("Our Stolen Future"). A Greenpeace poster of a man with a tiny penis proclaiming "You're not half the man your father was" (the campaign is over and the claim has disappeared from the Greenpeace website by 2008, no "sorry about the mistake / sorry we lied" though). There was an even sillier discussion on the floor of the U.S. senate. The most obvious source of substantial xeno-estrogen exposure is soybeans. Have you heard of any "socially-conscious environmentalists" calling for a ban on tofu? Of course not.

* Some men have had accidents. See J. Emerg. Med. 8: 305, 1990 (caught in the zipper), Acta. Urol. Jap. 34: 514, 1988 abstract 88267069 (caught in a milk bottle for seventeen hours), J. Urol. 170: 2385, 2003 (hard-to-cut plastic bottle finally yields to a stryker cast saw); J. Urol. 147: 1265, 1992 (all about bites, come in early if it happens to you, dude, 'cause infections can be really bad), J. Urol. 133: 1046, 1985 (etiology of "sclerosing lipogranuloma", you would enjoy reading this one), guy electrocutes himself while attaching the second electrode to his penis (the first was in back -- AJFMP 19: 198, 1998); Plast. Rec. Surg. 91: 352, 1993 (review of sclerosing granuloma, with a case study of a guy who injected himself with transmission oil in the hopes of having a permanent erection; bad idea, fellow); J. Urol. 134: 274, 1985 & Br. J. Surg. 89: 555, 2002 (fractures of the erect penis), J. Trauma 56: 1138, 2004 (by far the most common cause of fracture is striking the female pubic bone too forcefully); Urology 24: 18, 1984 (rings), Plast. Rec. Surg. 87: 771, 1991 (electrical injury), J. Emerg. Med. 8: 419, 1990 (young skateboarder impales scrotum on a metal rod), Br. Med. J. 281: 26, 1980; Br. Med. J. 281: 591, 1980; JAMA 224: 630, 1973; Urology 25: 41, 1985 & Indiana Med. 81: 252, 1988 (vacuum cleaners; there are several other articles on the same subject), Urology 26: 12, 1985 (foreign bodies), Urology 26: 50, 1985 (pet rattlesnake), J. Urol. 153: 1929, 1995 (alligator, reconstructed after 20 years and it worked), Br. J. Urology 74: 121, 1994 (pig), Plast. Recon. Surg. 108: 805, 2001 (another pig), Urology 26: 81, 1985 (necklace), Am. J. For. Med. Path. 7: 254, 1986 ("Eddie Spaghetti"), Genit. Med. 68: 334, 1992 (penicillin bottle under an enormous foreskin), electric cable, paper clip, tweezers, etc., (Br. J. Urol. 68: 510, 1991), J. Roy. Soc. Med. 98: 122, 2005 (magnet and metal); Arch. Sex. Behav. 34: 469, 2005 (bottles); Int. Ur. Neph. 25: 77, 1993 (uses high-tech term "SFB" for self-inserted foreign body), guy self-injecting olive oil into his scrotum to make it bigger gets fat embolus (Chest 107: 875, 1995), romantic love between a man and his hydraulic tractor ends in death (J. For. Sci. 38: 359, 1993), Med. Asp. Hum. Sex. July 1991 (guy in love with a sander belt loses a testis and repairs himself on-the-job with his handy staple gun; much-photocopied). Two guys mutilate their genitals elaborately while high on amphetamines (Addiction 97: 1215, 2002); both said it was extremely pleasurable at the time and both continued the drug use and the self-mutilation. There's no figuring drug-users out. A man gets it caught in a bottle and eventually dies of gangrene because he is too embarrassed or whatever to tell anyone (Am. J. For. Med. Path. 32: 344, 2011). Huge review of gunshot wounds: J. Trauma 64: 1038, 2008. "Alcock syndrome" is insensitivity of the penis (lasting up to several weeks) resulting from pressure on the pudendal nerve (which runs through "Alcock's canal") during bicycling. Mishap with the laser: Urology 48: 155, 1996. Caught in the zipper? See Injury 25: 59, 1994 -- easy to manage. Complications of penis-piercing, now become popular in the US: Cutis 60: 237, 1997. A "cultural practice" in some Asian communities is attempting suicide by cutting off the penis and bleeding to death (Am. J. Psych. 150: 350, 1993). Even less amusing: In past wars, when a captured man was being tortured either for information or fun, mutilating the genitals was commonplace. This was fairly common as recently as the Vietnam era (both sides), and surfaced again in Bosnia. Sexual torture: Lancet 345: 1307, 1995. Injury to the vas deferens from torture: Br. J. Urol. 72: 515, 1993. In "the new South Africa", the phenomenon of "Muti killing" has emerged in which body parts are excised from victims while they are still alive in the belief that these can be used to cure diseases such as AIDS (Med. Sci. Law 46: 255, 2006); boys are likely to have the genitals cut off. Sexual abuse of a child in any form is one of the vilest and most disgusting things a person can do. We hear mostly about fondling (which does no physical damage but is supposed to lead to terrible lifelong emotional scarring). The GAO's 1996 review of whether children who get molested go on to become child molesters themselves and documented the difficulty of studying this scientifically -- the prospective studies would lead most readers to conclude that it really very seldom happens. However, boys who are abused sexually often have severe physical damage in addition / instead (burns, cuts, crush injuries; Arch. Dis. Child. 92: 328, 2007 acknowledges that nobody's paid attention -- the politics is so bizarre). Reconstructing a youngster's penis using microsurgery, so that it works: J. Urol. 149: 1521, 1993. A grown-up's amputated penis is re-attached and still works: J. Urol. 147: 1628, 1992. Another Arch. Sex. Behav. 19: 343, 1990. We await publication of the full details of John Wayne B....

A penis that, when stretched to its maximum flaccid length (which is pretty much the same as its fully-erect length), is shorter than 2 SD below the mean for the guy's age is an official "micropenis". For a grown man:

More stuff on measurements: J. Urol. 156: 995, 1996 found that the average erect length was 12.9 cm, lower than Kinsey's 15.5 cm. Lower than 7.5 cm: consider surgical enhancement. The vacuum pump enlargers haven't been given a controlled study, but there's one report that they help after Peyronie's disease surgery. Among a group of men 4-10 cm, the consensus was, indeed, that "it's not what you've got, it's what you do with it." (Not stated in exactly these terms, of course, and partners were not surveyed by the tactful researchers; see J. Urol. 142: 569, 1989). The cause is probably androgenic deprivation for some reason during embryogenesis (Arch. Dis. Child. 66: 1033, 1991).

Lots of guys have some curvature, most often upwards, often downwards, sometimes a little to one side or the other (J. Sex. Marit. Ther. 23: 195, 1997).

*  Agenesis of the penis: J. Urol. 143: 338, 1990. Two of them (diphallus): J. Urol. 142: 356, 1989.

* Your lecturer predicts male circumcision will remain popular for newborns, as well as a popular choice for older males. It has long been politically incorrect for pediatricians to recommend routine circumcision of newborns, despite the obvious health benefits for some groups. In 1999, the American Academy of Pediatrics issued a new statement affirming that there are real health benefits, but not enough to make the right choice obvious, and of course asking that an anesthetic be used (Pediatrics 103: 686, 1999). Circumcision in infancy prevents cancer of the penis very effectively, and it greatly (10 x, from 1 in 100 to 1 in 1000; not "slightly", as the AAP states) reduces urinary tract infections in little boys (Pediatrics 83: 1011, 1989; good review, everything I've seen since this confirms this; most recent Lancet 352: 1813, 1998). Hygiene is much easier, the risk of catching AIDS from a woman during normal lovemaking is much less (NEJM 319: 274, 1988, Nat. Rev. Micro. 3: 914, 2005; Urol. Clin. N.A. 22: 57, 1995, Sci. Am. 1996; Lancet 369: 643, 2007; Lancet 363: 1039, 2004 shows the risk is cut by 5/6, though there's no comparable benefit for syphilis or gonorrhea), the other common sexually transmitted diseases are harder for him to catch (NEJM 322: 1308 & 1312, 1996; STD's in general Pediatrics 118: 1917, 2006 -- curiously, no "political incorrectness" disclaimer; HPV Lancet 369: 657, 2007; Br. Med. J. 334: 712, 2007; prevents herpes 2, HPV and HIV but not syphilis NEJM 360: 1298, 2009; dissenting prospective study J. Ped. 152: 383, 2008; today nobody seriously doubts it protects from HIV transmission in the poor nations J. Urol. 183: 21, 2010), and what's more, many people like it ("Mine looks streamlined, it's my pocket-rocket, yours looks dirty;" most women prefer for that special man to be circumcised: Pediatrics 105: 620, 2000). An uncircumcised man's glans is a bit more sensitive (i.e., more intense sensations, both pleasant and unpleasant? less total time before ejaculation?; men who've been circumcised as adults have told me about both). In order to appease anti-circumcision militants, the AAP included the unsubstantiated claim that circumcision reduces the man's pleasure in its "Information for Parents." Of course the media spun the whole position statement as "Circumcision is no longer recommended." Opposition to circumcision deals with other issues than physical health. Opponents cite "unnatural", "a male's right to make the decisions affecting his own body", "religious freedom", "problems of the uncircumcised are treatable" (except HIV and gangrene, of course; the latter can happen to an unwashed little boy). Sexuality is powerful, individual, and incomprehensible. The truth is that any boy has a fair chance of growing up to be a man who really likes having a foreskin and/or bitterly resents not having one. And the latter's a real problem, much worse than having a few kidney scars from an infection. In the 1990's there was considerable anti-circumcision activism among men across the Kinsey scale ("I will NEVER forgive my parents for..."), though this is based on personal-freedom issues rather than health issues. Since we're comparing physical health and emotional satisfaction, the right choice will never be "clear-cut" (ha ha). Around the turn of the century, as it became more acceptable to criticize "indiginous practices", the medical literature began to discuss a terrible problem in the poor nations -- "traditional healers" who perform circumcisions as a result of which "not uncommonly, amputation occurs" (Ann. Plast. Surg. 44: 311, 2000). South Africa prosecutes one of these quacks for murder (Br. Med. J. 313: 647, 1996 -- "the [tribal] king complained that gross damage was being done [by the prosecution] to a culture that was the pride of the nation. His complaint was not upheld."). Things do not seem to be improving in "The New South Africa": Curationis 27: 57, 2004; the "traditional society" is obviously subjecting the boys to willful, cruel abuse -- continuing problem Soc. Sci. Med. 70: 729, 2010 (even this far-left ultra-multiculturalist journal knows it's wrong). The mohel may kiss the circumcision site (metzitzah b'peh) and transmit herpes (series of eight cases from Israel; Pediatrics 114: e259, 2004; update MMWR 61: 405, 2012 -- two boys die in NYC alone and there's a huge "religious freedom" hoopla; your lecturer believes that surgery is surgery and the field needs to remain sterile). By contrast, in the United States, the circumcision rate for newborns has actually been increasing in all ethic groups except Native Americans since 1988; it's around 70% in the Midwest and Northeast, but less than 30% out West, and the more affluent and educated the family, the more likely they are to have the son circumcised (J. Urol. 173: 978, 2005), even though third-parties are refusing to pay for it (Urol. Clin. N.A. 31: 461, 2004; J. Urol. 170: 1533, 2003). The fact that postnatal circumcision will be required for health reasons in almost 10% of boys, and is much more expensive, is now persuading third-party payers to change their minds about neonatal circumcision (J. Urol. 175: 1111, 2006). The obvious protection that circumcision provides against acquiring and transmitting sexually-transmitted diseases as an adult is leading to calls for the pediatrics organizations to reverse their politically-correct decision not to recommend routine neonatal circumcision (Arch. Ped. Adol. Med. 164: 78, 2010). Update on just how difficult it is to advise parents: Ped. Clin. M.A. 59: 977, 2012.

* Men with endometriosis (I always believed in the coelomic metaplasia theory rather than the reverse menstruation theory, anyway): Eur. J. Surg. 158: 7, 1992; Am. J. Ob. Gyn. 165: 214, 1991, others.

* When men of my generation get old, we men might get hormone replacement, just as many women do. This is probably a good idea (NEJM 334: 707, 1996; Br. Med. J. 312: 859, 1996; Ann. NY Acad. Sci. 774: 128, 1995; update NEJM 350: 482, 2004; J. Clin. Endo. Metab. 96: 38, 2011.) DHEA (the miracle-claims "nutritional supplement" of 1997) flunks tests of its ability to produce psychological benefits: J. Clin. End. Metab. 82: 2363, 1997. No one knows how many men get hypogonadism as they get older, or what is physiological; many, probably most, men do not undergo "andropause" (BMJ 337: b352, 2009). Stay tuned on this. A study of the effects of testosterone supplementation on a selected group of low-testosterone men who were also loaded with coronary risk factors had to be stopped in 2010 because the test group had many more "coronary events" (NEJM 363: 109, 2010).

The British found no link between vasectomy and testicular cancer, prostate cancer, or any other of the common diseases for which they sought a connection: Br. Med. J. 304: 743, 1992. Surprised? Of course not. Full of disclaimers about insufficient duration, insufficient patient numbers, etc.

A Streetcar Named Desire

* Among adults, only ideologues won't recognize that sexual behavior (broadly defined) has many purposes (good, bad, indifferent) in addition to fertilization. As far as I know, all durable societies have decided that a stable, lifelong, committed, faithful relationship is by far the best setting for sex. (Margaret Mead was, of course, the victim of a hoax by some teenagers.) It is one thing to be compassionate and not get preachy with everybody who comes into your office. It is quite another to advocate attitudes and behaviors that will predictably lead people to harm themselves and others. (I see this as a problem today in the U.S.; you might disagree.) People think about sex a lot, and we know that making it a taboo subject or a big dreadful mystery is asking for trouble, just as having casual sex is always asking for trouble. The wise adult learns that setting limits is the key, and decides what limits to set. Not everyone does this. Further, it is easier (and better power-politics) to get up on a soap-box about sex than to try to understand it. As a physician you must at least do the latter. Male sexuality becomes a major concern for the pathologist when it leads to death (i.e., homicide, in which sex is usually a factor, suicide, in which sex is often a factor, and autoerotic asphyxia, which is not rare) or when it involves someone who does not, or cannot, consent. Almost every man realizes that to force himself on another person (employee, family member, date, stranger, child) is shameful, wrong, disgusting, and un-masculine. Most men also feel entitled to "get their loving", and for many men, self-esteem gets tied up with "getting it". Most bright men figure out early that self-control, though difficult, is muy macho. For some men, controlling the urge to act-out sexually (which can take various forms, some of them harmful for other people) is as hard as sticking to a weight-reduction diet (see especially Psych. Clin. N.A. 15: 675, 1992). Probably these men have a wiring problem, whatever else may have gone wrong, and a psychiatrist can help (swallow your pride, dude; major review Psych. Clin. N.A. 15: 703, 1992; clomipramine fixes up a compulsive flasher Am. J. Psych. 149: 843, 1992; fluoxetine cures a Peeping Tom: Am. J. Psych. 148: 950, 1991; naltrexone (the opioid antagonist popular for alcoholics, drug abusers, compulsive eaters, obsessive-compulsives, and impulse-control problems) now finds its use for sexual acting-out as well (J. Clin. Psych. 65: 982, 2004). there's behavioral ("beak the compulsion loop"), insight, and pharmacological ways of helping most problem guys, if they want to be helped, and for criminal-justice cases, there's now leuprolide, which works better than saltpeter). Perhaps the most interesting article on male sexuality that your lecturer has ever seen was a prison survey in which 23% of prisoners admitted to having been forcibly raped by a male bully, and those who could tell the interviewer about this without becoming visibly and acutely upset were almost all sex offenders. The conclusion is that at least a good number of sex offenders come to terms with what's happened to them by acting out "in a strange and cruel way" (Med. and Law 12: 181, 1993). There's gotta be a better way of making sense of what's happened to you; perhaps a family physician, talking sense and explaining "you're still a man", etc., etc. could have made all the difference. Since dominance relationships among humans are so complex, subtle, and important, all men and many women fantasize some about this being tied up with sexuality; this is part of the human condition, as much as we'd like all loving to be a full coming-together of equals. It is also very hard for a man to defend against a false accusation of rape (in spite of what you've been told by "women's advocates", this is all-too-common; remember the Bible tale of Potiphar's wife, Athens's Phaedra, Gail Crystal Mangum (Duke lacrosse case) or ask a cop, and the forensic pathologist / DNA work can make all the difference here. How the British police decide: Medicine Science & the Law 36: 135, 1996. Good police work and a sympathetic physician who remains kindly, helpful, and also totally objective can be a huge help in preventing situations in which everyone is a loser. A study at Purdue showed to my satisfaction that at least 40% of initial campus and community accusations are false (at least in their jurisdiction, Arch. Sex. Behav. 23: 81, 1994) -- women who are confused, being coerced by the real abuser ("To Kill a Mockingbird"), seeking revenge, or desperately in need of help with some other (often terrible) life situation. With over 300 convicted men (about 2/3 of them black) now exonerated by DNA evidence, this should prompt serious thinking before anyone is convicted solely on someone's word. The US Air Force, which is reality-based, gives a figure of 60% -- in this series, it was common for a woman who was upset to initially overstate things and admit it as things settled down. (Forensic Science Digest 11(4): 64, December 1985). That these women are often deeply troubled excites any decent person's pity without diminishing the injustice. Today, even the conservative Victoria Forensic Science Center considers "false sexual assault" to be a common diagnosis that the physician in the emergency room can often make just by examining the clothing (J. For. Sci. 45: 568, 2000). The "2% statistic" from the old politically-correct FBI Uniform crme report program, while dogma in many (most?) women's-protection circles, is clearly not true and even informed women's advocates say it needs to be abandoned (Violence Against Women 16: 1356, 2010). Neither gender has a monopoly on good and evil, but currently the law places men at certain disadvantages that puzzle me. For example, a woman's previous false accusations of rape, even if numerous, generally cannot be mentioned by a man in his own defense. During the early 1990's, coinciding with the "false memories" / "people forget things" fiasco, if a man passed a polygraph exam, and there was no physical evidence against him, and he appeared utterly sincere, and it was simply her word against his, the man got told that he was inded a rapist and "had forgotten" or was "in denial". If the physical evidence contradicted the accuser's story, the "child protection advocates" egregiously misused the scientific literature (notably Pediatrics 94: 310, 1996). I still see this. You can cite additional examples. However, guys -- you do NOT want to end up a defendant. It helps to obtain specific and verbal permission prior to each step of the lovemaking process (that's gentlemanly and fun). Dude: You text her ("I want you"), she texts back ("I want you") and you're safe. But the moment she seems even slightly uncomfortable, end the whole thing. Speaking of "links", in the one massive study comparing normal men, rapists, and child molesters, "frequency of adult use of sexually explicit material does not differ significantly among groups". This surprised me. Nor did the frequency of sex crimes increase in Sweden when they made the even the most dopiest-nastiest stuff as available as alcohol and tobacco. See J. Sex. Marit. Ther. 19: 77, 1993. Update: Scientific American July 22, 2011 ("no negative effects, and it may even deter sexual violence"). I'd like an easy scapegoat, too, Mr. Bundy and the rest of you, but the roots of your evil went much, much deeper. The pop claim is that x-rated stuff is naturally addictive (like tobacco or heroin) and leads to escalating tensions that must eventually be acted out. This may be true for individuals like the young Mr. Bundy, and probably specialist treatment would be wise for these men sooner rather than later. It's clearly not true for the vast majority of men, or the world would be a far different place. But we're into politics rather than science. And as politicians and "progressive thinkers" tell us over and over about the dangers of erotica, we still hear almost no complaints about the vile school of rap music with lyrics that degrade women and glorify sexual violence. The evidence that this causes to violence against young women in the underclass communities is overwhelming (Pediatrics 118: e430, 2006). Porn addiction melts away with a little naltrexone: Mayo Clin. Proc. 83: 226, 2008. Meds for Parkinson's trigger porn addiction: Parkinsonism 12: 392, 2006. The paraphilias: Psych. Clin. N.A. 15: 675, 1992. "A review of sexual behavior in the United States": Am. J. Psych. 151: 330, 1994. Natural selection obviously is much harsher on men than on women, and this is the case throughout nature. Is this why there's sex? Nature 411: 689 & 692, 2001.

* Heard that FSH is necessary for Sertoli cell development, spermatogenesis and fertility? Surprise -- it's not (though it helps; in mice or men, Nature Genetics 15: 201 & 205, 1997).

{09753} scabies
{11550} syphilis
{25537} chancre and gonorrhea both
{12598} lichen planus
{12600} lichen planus
{24988} lichen planus
{14133} herpes simplex
{14238} candida
{23958} epidermoid cyst of the testis
{24988} lichen sclerosus
{12188} lichen sclerosus
{12189} balanitis xerotica
{25049} balanitis xerotica, histology
{25116} Fabry's angiokeratomas
{25196} sperm granuloma after a vasectomy
Potiphar's Wife

Potiphar's Wife, by Rembrandt

Primary syphilis

Yutaka Tsutsumi MD


{00083} testes, normal
{10268} prostate, normal
{10898} atrophy, testes with normal comparison
{11762} prostate, normal
{11763} prostate, normal
{15000} testis (tunica albuginea), normal
{15001} testis, normal
{15002} seminiferous tubule, normal
{15003} seminiferous tubule, normal
{15004} seminiferous tubule, normal
{15005} seminiferous tubule, normal
{15006} seminiferous tubule, normal
{15007} sertoli cell, normal
{15008} sertoli cell, normal
{15009} interstitial cells leydig, normal
{15010} interstitial cells leydig, normal
{15011} rete testis, normal
{15012} rete testis, normal
{15013} rete testis, normal
{15014} ductuli efferentes, normal
{15015} epididymis, normal
{15016} epididymis with spermatozoa, normal
{15017} epididymis with * spermatozoa, normal
{15018} epididymis with stereocilia, normal
{15019} epididymis with stereocilia, normal
{15020} ductus deferens, normal
{15021} ductus deferens, normal
{15022} ductus deferens, normal
{15023} ductus deferens, normal
{15024} seminal vesicle, normal
{15025} seminal vesicle, normal
{15026} seminal vesicle (secretory epithelium)
{15027} prostate with concretion, normal
{15028} prostate with concretion, normal
{15029} prostate epithelium, normal
{15030} prostate epithelium, normal
{15031} prostate epithelium and concretions, nor
{15032} urethra, normal
{15033} urethra, normal
{15125} prostate
{15127} prostate
{15128} prostate
{15129} prostate
{15304} prostate
{15330} seminal vesicle, normal
{15331} seminal vesicle, normal
{15332} testes, tunica albuginea
{15333} testes, tunica albuginea
{15577} testes, normal unfixed
{15578} testes, normal unfixed
{15579} testes, normal
{15580} testes, normal unfixed
{15587} bladder and prostate, normal unfixed
{15589} prostate, normal
{17008} prostate, normal
{20213} prostate, normal
{20652} leydig cell, testes
{20653} rete testis, normal
{20653} rete testis, normal
{20654} rete testis, normal
{20654} rete testis, normal
{20655} testis, normal
{20656} sertoli cell nucleus, testis
{20657} spermatogonia, testis
{20658} testis, normal
{20659} epididymis, normal
{20660} ductus deferens, normal

* When I was one-and-twenty
I heard a wise man say,
"Give crowns and pounds and guineas
But not your heart away;
Give pearls away and rubies
But keep your fancy free."
But I was one-and-twenty,
No use to talk to me.

When I was one-and-twenty
I heard him say again,
"The heart out of the bosom
Was never given in vain;
'Tis paid with sighs a-plenty,
And sold for endless rue."
And I am two-and-twenty,
And oh, 'tis true, 'tis true.

      -- A.E. Housman, "A Shropshire Lad"

* When I was one-and-twenty,
My ills were in their prime,
With aches and pains aplenty,
And gout before my time;
I had the pyorrhea,
And fever turned me blue--
They said that I would be a
Dead man at twenty-two.

Now I am two-and-twenty,
The aches and pains I thought
Were miseries a-plenty,
Compared to these, are naught;
And even these are bubbles,
That scarce can worry me,
When I regard the troubles
I'll have at twenty-three.

      Samuel Hoffenstein,
      -- "The Shropshire Lad's Cousin"


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Teaching Pathology

Pathological Chess

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