1 The Male Genital System

Male Genital System

THE PROSTATE GLAND

1. Acute Prostatitis:

Etiology:
- bacteria similar to that of a UTI (ie [Link])

Pathogenesis:
- Intraprostatic reflux of urine from posterior urethra/ urinary bladder
- Possible seeding by lymphohematogenous routes from distant infection

Clinical:
- Dysuria, frequency, urgency, Lower back/pelvic pain
- Fever chills, leukocytosis, loss of sex drive w painful erection/ejaculations
- DRE: enlarged tender prostate

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2. Chronic Prostatitis:

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Etiology:
- Recurrent UTIs (cystitis, urethritis) by same organism.

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- Most antibiotics penetrate the prostate poorly so bacteria find safe haven in parenchyma & constantly seed UT
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Clinical:
- Lower back pain, dysuria, perineal and suprapubic discomfort. Can be asymptomatic
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3. Benign Prostate Hyperplasia (BPH): NODULAR

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Etiology:
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- >40yo males
- Possible low Testosterone, ⇑ estrogen upregulating DHTR on prostate
5 alpha reductase as well
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Morphology:
- Gross: Defined nodules of central, transitional & periurethral zones
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- Histological: Proliferating glandular element & fibromuscular stroma

o Gland & stroma proliferating (unlike prostate CA)
o 2 layers of cells on glands (CA will only have 1)
- Copora Amylacea: Proteinaceous material in lumen of gland (normal)
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Pathogenesis:
- Testosterone ! DHT ! GFs !leads to hyperplasia
Clinical:
- Most asymptomatic
- Urethral compression: difficulty starting/stopping urination
o Dribbling, frequency, nocturia & dysuria
- Urinary retention: recurrent UTIs
- Complete urinary obstruction ! Obstructive uropathy
o Acute & chronic pyelonephritis with postrenal azotemia
o Bilateral hydronephrosis
o Bladder wall SM hypertrophy with ⇑ risk of diverticula
o Stone formation
- NO RISK OF CANCER
- DRE: nodular and rubbery prostate

[Link]
2 The Male Genital System

4. Prostate CA:
Etiology:
- 8-10X ⇑ in males >80 yo
- African/Caribbean at higher risk with low Asian risk
- HPC1: hereditary prostate cancer gene
o Linked to RNASEL gene

Morphology:
- Single layer of cuboidal cells with hyperchromatic nuclei
- Only gland proliferating NOT stroma (both in BPH) Peripheral zone
- Glands appear “back-to-back” with no basal cell layer (single layer)

Pathogenesis:
- precursor lesions: prostatic intraepithelial neoplasia levels (PIN)
o low grade ! high grade (carcinoma in situ)

Clinical:
- Hematuria, weight loss, dysuria & weakened flow

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- Later stage: bone (vertebral) pain from metastasis
o Osteoblastic metastasis: Hyperdensity on XR

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- DRE (smooth and firm nodular) & PSA screening (>10ng/ml) normal (4ng/ml)
- Transrectal ultrasound, Biopsy (6-12 in multiple locations)

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- Gleeson grading system
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o Prognosis: Gleason score 1-8 (architectural changes) & staging (TNM)
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TESTICULAR LESIONS
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1. Cryptorchidism:
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- Failure of testes to descend completely to scrotal position along gubernaculum

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o Upper scrotal/inguinal region (majority), higher up = worse prognosis

- More common on RIGHT side

- Etiology: Anatomical abnormalities, hormonal dysfunction

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- Complications: Germ cell tumor 3-5X risk commonly in contralateral testis

- Orchiopexy: surgery <5yo to prevent tumors & <2yo to prevent infertility

2. Testicular Atrophy:
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Top:Normal seminiferous tubules with many

germ cells (blue nuclei)
Etiology:
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Bottom: Testicular atrophy; No germ cells

- Testicular injury, atherosclerotic narrowing (old age), inflammatory orchitis (empty lumens) with hyperplasia of Leydig cells
- Cryptorchidism, hypopituitarism, Klinefelter Syndrome,
- Cirrhosis (⇑ estrogen)

Morph/path:
- Hyalinosis of BM & thickening of spermatic tubules
- NO spermatogesis
- Hyperplasia of Leydig cells
- Testosterone DOES NOT function: No binding protein (Sertoli cells)

Clinical:
- ⇓ libido, ⇓ muscle mass, depressed mood, ⇓ energy
- ⇓ spontaneous erections, gynaecomastia

[Link]
3 The Male Genital System

3. Male Infertility:
- Testicular failure > obstruction > genetic > endocrinopathy
- Pretesticular: hypopituitarism or estrogen excess
- Testicular: Agonadism, atrophy, germ cell aplasia or maturation arrest
- Post-testicular: bilateral obstruction, infections, immotile cilia syndrome

4. Testicular inflammation:
- Epididymitis or orchitis (Testicular inflammation)
- Children: gram negative bacteria
- <35yo: STD (ie. N. gonorrhea, C. trachomatis)
- >35yo: UTI (E. coli or Pseudomonas)

5. Testicular Torsion:
- Vascular lesions: twisting of spermatic cord, obstructed venous drainage or infarction

6. Testicular Tumors:

Etiology:

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- Isochrome i(12p)
- Cryptorchidism, testicular dysgenesis (Klinefelter’s Syndrome), radiation.

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- Infant & Children: Teratoma/yolk sack (non-hemorrhagic)
- 15-30yo: Mixed germ cell tumor (hemorrhagic)

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- 30-50yo: Seminoma
- >60yo: Lymphoma
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- NEVER biopsy, risk of spread

Clinical:
- Unilateral mass, heaviness in scrotum, dull ache in abdomen or groin
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- Hydrocele, testicular pain, breast enlargement, metastasis to LN

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Germ cell Tumors:

a. Seminoma:
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Etiology:
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o Commonest Germ cell tumor with cryptochidism strongest factor (malignant)

o Ovary identical tumor: dysgerminoma (30-50 yrs )

Morph/Path:
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o Fried Egg appearance: Sheets of cells + lymphocytic infiltrate

o Cells are large, round & have distinct cell membrane
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o Clear or watery-appearing cytoplasm

o Large central nucleus with one or two prominent nucleoli
o NO necrosis & NO visible hemorrhage
o isochromosome12p; expression of OCT3/4 & NANOG
o 25% have c-KIT activating mutations.
o lymphatic metastasis: Paraaortic lymph nodes

Clinical:
o DO NOT BIOPSY
o Bulky masses on testes, heaviness in the testes, pain due to this
o Slight ⇑ βHCG
o Radiosensitive (only one that is)

[Link]
4 The Male Genital System

b. Yolk Sac Tumor:

Etiology:
o Most common for Infants & children <3 yo

Morph/Path:
o Gross: Nonencapsulated, & on cross-section it presents a homogeneous, yellow-white, mucinous
appearance
o Schiller-Duval bodies: Structures resembling glomeruli. They consist of a mesodermal core with a central
capillary & a visceral & parietal layer of cells.
o Immunohistochemical staining: Eosinophilic, hyaline-like globules of AFP & α1-antitrypsin present
within & outside the cytoplasm
Clinical:
o ⇑ AFP

c. Embryonal Carcinoma:
Etiology:
o 2-30yo; more aggressive then seminomas

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Morph/Path:

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o More undifferentiated than seminoma lesions may display sheets of cells
o Primitive glandular differentiation. The nuclei are large & hyperchromatic

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Clinical:
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o Elevated AFP
o Positive for cytokeratin & CD30, & negative for c-KIT
o Hematogenous spread: Liver & lungs
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d. Choriocarcinoma:
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Etiology:
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o Rare germ cell tumor however highly malignant

Morph/Path:
o Small tumors; no testicular enlargement & detected only as a small palpable nodule.
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o HCG in cytoplasm.
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Clinical:
o Early metastasis to lungs

e. Teratoma:
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Etiology:
o Infants & children (benign), adults (malignant)
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Morph/Path:
o tumors with various normal derivatives from more than one germ layer

Non Germ Cell Tumors:

f. Leydig cell tumor:

o Androgen producing tumor: Gynacomastia in men, Early puberty in boys
o Large polygonal eosinophilic cells
o Cytoplasm: lipid granules, vacuoles, or lipofuscin pigmen
" Reinke crystals: rod-shaped crystalloids inside Leydig cells

g. Sertoli cell tumor:

[Link]
 5 The Male Genital System

o Big and clear with some Ca++ in lumen

h. Testicular lymphoma:
o >60yo
o Diffuse large Bcell tumor
o Immunologically privileged area so WBC will not get in

PENILE & SCROTAL DISORDERS

1. Penile congenital abnormalities:

- Hypospadias: Malformation of urethral groove & urethral canal creating an opening at the ventral surface of penis

- Epispadias: Malformation of urethral groove & urethral canal creating an opening at the dorsal surface of penis
o Associated with: cryptorchidism, inguinal hernia, UT obstruction, recurrent UTI & infertility

- Phimosis: Orifice of prepuce too small to permit normal retraction

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o developmental issue or infection with scarring of pretutial ring
o Balanitis: inflammation of penis

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- Paraphimosis: When a phimotic prepuce is forcibly retracted of glans penis ! swelling & constriction

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o Balantitis & UTI
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2. Penile Neoplasms:

Etiology:
- HPV 16/18; smoking, smegma, in elderly (>60 yrs)
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- Bowen Disease: (older men) solitary, scaly plaque like lesion on penis shaft.
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o Associated w visceral malignancies (skin/mucosal surfaces) & can progress to invasive squamous cell
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carcinoma (10%)

- Eyrthroplasia of Queyrat: Solitary or multiple red/shiny patches on glans/preupuce penis ! progresses to invasive
CA
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- Bowenoid Papulosis: (younger males) Multiple reddish, brown papules on shaft; Non malignant

Clinical:
- Itching or burning under foreskin
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- Ulceration common
- Less in Jews and Muslims because of circumcision
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3. Scrotal disorders:

- Hematocele: blood in Tunica Vaginalis from trauma

- Hydrocele: Accumulation of fluid in Tunica Vaginalis
- Varicocele: Dilation of congested blood vessels (veins) in spermatic cord
- Chylocele: Accumulation of lymphatic fluid in Tunica Vaginalis
- Spermatocele: Dilation of epididymis with semen
- Scrotal CA: Chimney sweepers, coal, tar, skin cancer

[Link]

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