Transcript MALE GENITAL SYSTEM - Virginia Commonwealth University

MALE GENITAL SYSTEM
• PENIS
• SCROTUM, TESTIS, & EPIDIDYMIS
• PROSTATE
KUMAR, COTRAN, AND ROBBINS
7th Edition
CH 18
PENIS
• MALFORMATIONS
• INFLAMMATORY LESIONS
• NEOPLASMS
MALFORMATIONS OF THE PENIS
ABNORMAL LOCATION OF
URETHRAL ORIFICE ALONG PENILE
SHAFT
– HYPOSPADIAS (VENTRAL ASPECT)
• MOST COMMON (1/300 LIVE MALE BIRTHS)
– EPISPADIAS (DORSAL ASPECT)
Hypospadias
Epispadias
HYPOSPADIAS AND EPISPADIAS
– MAY BE ASSOCIATED WITH OTHER
GENITAL ABNORMALITIES
• INGUINAL HERNIAS
• UNDESCENDED TESTES
– CLINICAL CONSEQUENCES
• CONSTRICTION OF ORIFICE
• URINARY TRACT OBSTRUCTION
• URINARY TRACT INFECTION
• IMPAIRED REPRODUCTIVE FUNCTION
INFLAMMATORY LESIONS
OF THE PENIS
• SEXUALLY TRANSMITTED DISEASES
• BALANITIS (BALANOPOSTHITIS)
– INFLAMMATION OF THE GLANS (PLUS
PREPUCE)
– ASSOCIATED WITH POOR LOCAL
HYGIENE IN UNCIRCUMCISED MEN
• SMEGMA
– DISTAL PENIS IS RED, SWOLLEN,
TENDER
• +/- PURULENT DISCHARGE
INFLAMMATORY LESIONS
OF THE PENIS
• PHIMOSIS
– PREPUCE CANNOT BE EASILY
RETRACTED OVER GLANS
– MAY BE CONGENITAL
– USUALLY ASSOCIATED WITH
BALANOPOSTHITIS AND SCARRING
– PARAPHIMOSIS (TRAPPED GLANS)
• URETHRAL CONSTRICTION
INFLAMMATORY LESIONS
OF THE PENIS
• FUNGAL INFECTIONS
– CANDIDIASIS
• ESPECIALLY IN DIABETICS
• EROSIVE, PAINFUL, PRURITIC
• CAN INVOLVE ENTIRE MALE
EXTERNAL GENITALIA
NEOPLASMS OF THE PENIS
• SQUAMOUS CELL CARCINOMA (SCC)
– EPIDEMIOLOGY
• UNCOMMON – LESS THAN 1 % OF CA IN US MEN
• UNCIRCUMCISED MEN BETWEEN 40 AND 70
– PATHOGENESIS
• POOR HYGIENE, SMEGMA
• HUMAN PAPILLOMA VIRUS (16 AND 18)
• CIS FIRST, THEN PROGRESSION TO INVASIVE
SQUAMOUS CELL CARCINOMA
Squamous Cell Carcinoma
SCC OF THE PENIS
• CLINICAL COURSE
– USUALLY INDOLENT
– LOCALLY INVASIVE
– HAS SPREAD TO INGUINAL LYMPH NODES
IN 25% OF CASES AT PRESENTATION
– DISTANT METS RARE
– 5 YR SURVIVAL
• 70% WITHOUT LN METS
• 27% WITH LN METS
LESIONS INVOLVING THE
SCROTUM
• INFLAMMATION
– TINEA CRURIS (JOCK ITCH)
• SUPERFICIAL DERMATOPHYTE INFECTION
• SCALY, RED, ANNULAR PLAQUES, PRURITIC
• INGUINAL CREASE TO UPPER THIGH
• SQUAMOUS CELL CARCINOMA
– HISTORICAL SIGNIFICANCE
– SIR PERCIVAL POTT, 18TH CENTURY
ENGLISH PHYSICIAN
– CHIMNEY SWEEPS
LESIONS INVOLVING THE
SCROTUM
• SCROTAL ENLARGEMENT
– HYDROCELE - MOST COMMON CAUSE
• ACCUMULATION OF SEROUS FLUID
WITHIN TUNICA VAGINALIS
• INFECTIONS, TUMOR, IDIOPATHIC
– HEMATOCELE
– CHYLOCELE
• FILIARIASIS - ELEPHANTIASIS
– TESTICULAR DISEASE
Hydrocele
LESIONS OF THE TESTES
• CONGENITAL
• INFLAMMATORY
• NEOPLASTIC
CRYPTORCHIDISM AND
TESTICULAR ATROPHY
• FAILURE OF TESTICULAR
DESCENT
• EPIDEMIOLOGY
– ABOUT 1% OF MALES
– RIGHT > LEFT, 25% BILATERAL
• PATHOGENESIS
– HORMONAL ABNORMALITIES
– TESTICULAR ABNORMALITIES
– MECHANICAL PROBLEMS
Atrophic testes
secondary to
cryporchidism
CRYPTORCHIDISM AND
TESTICULAR ATROPHY
• CLINICAL COURSE
– WHEN UNILATERAL, MAY SEE ATROPHY IN
CONTRALATERAL TESTIS
– STERILITY
– INCREASED RISK OF MALIGNANCY (4-10X)
– ORCHIOPEXY
• MAY HELP PREVENT ATROPHY
• MAY NOT DECREASE RISK OF MALIGNANCY
OTHER CAUSES OF
TESTICULAR ATROPHY
•
•
•
•
CHRONIC ISCHEMIA
INFLAMMATION OR TRAUMA
HYPOPITUITARISM
EXCESS FEMALE SEX HORMONES
– THERAPEUTIC ADMINISTRATION
– CIRRHOSIS
• MALNUTRITION
• IRRADIATION
• CHEMOTHERAPY
INFLAMMATORY LESIONS
OF THE TESTIS
• USUALLY INVOLVE THE EPIDIDYMIS
FIRST
• SEXUALLY TRANSMITTED DISEASES
• NONSPECIFIC EPIDIDYMITIS AND
ORCHITIS
– SECONDARY TO UTI
• BACTERIAL AND NON-BACTERIAL
– SWELLING, TENDERNESS
– ACUTE INFLAMMATORY INFILTRATE
INFLAMMATORY LESIONS OF
THE TESTIS
• MUMPS
–
–
–
–
20% OF ADULT MALES WITH MUMPS
EDEMA AND CONGESTION
CHRONIC INFLAMMATORY INFILTRATE
MAY CAUSE ATROPHY AND STERILITY
• TUBERCULOSIS
– GRANULOMATOUS INFLAMMATION
– CASEOUS NECROSIS
• AUTOIMMUNE GRANULOMATOUS
ORCHITIS
– RARE FINDING IN MIDDLE AGED MEN
TESTICULAR NEOPLASMS
• EPIDEMIOLOGY
– MOST IMPORTANT CAUSE OF PAINLESS
ENLARGEMENT OF TESTIS
– 2/100,000 MALES, WHITES > BLACKS (US)
– INCREASED FREQUENCY IN SIBLINGS
– PEAK INCIDENCE 15-34 YRS
– MOST ARE MALIGNANT
– ASSOCIATED WITH GERM CELL
MALDEVELOPMENT
• CRYPTORCHIDISM
• TESTICULAR DYSGENESIS(XXY)
TESTICULAR NEOPLASMS
• PATHOGENESIS
– 95% ARISE FROM GERM CELLS
• ISOCHROMOSOME 12, i(12p), IS A COMMON
FINDING
• INTRATUBULAR GERM CELL NEOPLASMS
– RARELY ARISE FROM SERTOLI CELLS
OR LEYDIG CELLS
• THESE ARE OFTEN BENIGN
– Lymphoma
• men > 60 yo
WHO CLASSIFICATION OF
TESTICULAR TUMORS
• ONE HISTOLOGIC PATTERN (40%)
–
–
–
–
–
SEMINOMAS (30%)
EMBRYONAL CARCINOMA
YOLK SAC TUMOR
CHORIOCARCINOMA
TERATOMA
• MULTIPLE HISTOLOGIC PATTERNS (60%)
– EMBRYONAL CA + TERATOMA
– CHORIOCARCINOMA + OTHER
– OTHER COMBINATIONS
HISTOGENESIS OF TESTICULAR
NEOPLASMS (PEAK INCIDENCE)
GERM CELL PRECURSOR
GONADAL
DIFFERENTIATION
TOTIPOTENTIAL
DIFFERENTIATION
(NONSEMINOMA)
SEMINOMA
(40-50 Y)
TROPHOBLASTIC
DIFFERENTIATION
CHORIOCARCINOMA
(20-30 Y)
hCG +
EMBRYONAL CA
(UNDIFFERENTIATED)
(20-30 Y)
YOLK SAC
DIFF
YOLK SAC TUMOR
(< 3 Y)
AFP +
SOMATIC
DIFFERENTIATION
TERATOMA
(ALL AGES)
MATURE
IMMATURE
MALIGNANT TX
Seminoma, with focal hemorrhage and necrosis
Normal testicular tissue
Seminoma
Seminoma
Syncytiotrophoblast
Dermoid Cyst
Immature Teratoma
With Embryonal Carcinoma
CLINICAL COURSE OF
TESTICULAR TUMORS
• USUALLY PRESENT WITH PAINLESS
ENLARGEMENT OF TESTIS
• MAY PRESENT WITH METASTASES
– NONSEMINOMAS (MORE COMMON)
• LYMPH NODES, LIVER AND LUNGS
– SEMINOMAS
• USUALLY JUST REGIONAL LYMPH NODES
• TUMOR MARKERS (hCG AND AFP)
• TREATMENT SUCCESS DEPENDS ON
HISTOLOGY AND STAGE
– SEMINOMAS VERY SENSITIVE TO BOTH RADIOAND CHEMOTHERAPY
DISEASES OF THE PROSTATE
• PROSTATITIS
• NODULAR HYPERPLASIA
• CANCER
PROSTATITIS
• ACUTE BACTERIAL PROSTATITIS
• CHRONIC BACTERIAL PROSTATITIS
• CHRONIC ABACTERIAL PROSTATITIS
ACUTE BACTERIAL
PROSTATITIS
• ETIOLOGY
– SAME ORGANISMS THAT CAUSE UTI
• E coli, OTHER GNR
• PATHOGENESIS
– ORGANISMS ASCEND FROM URETHRA
AND URINARY BLADDER
– RARELY, HEMATOGENOUS SPREAD
ACUTE BACTERIAL
PROSTATITIS
• MORPHOLOGY
– ACUTE INFLAMMATION, ESPECIALLY IN
THE GLANDS, WITH MICROABSESSES
– CONGESTION, EDEMA
• CLINICAL COURSE
– DYSURIA, FREQUENCY, LOW BACK
PAIN, PELVIC PAIN
– ENLARGED, EXQUISITELY TENDER
– +/- FEVER OR LEUKOCYTOSIS
– USUALLY RESOLVES WITH WITH AB RX
CHRONIC PROSTATITIS
• ETIOLOGY
– MAY FOLLOW ACUTE PROSTATITIS
– MAY DEVELOP INSIDIOUSLY
– CULTURE POSITIVE (BACTERIAL)
• SAME ORGANISMS THAT CAUSE AP
– CULTURE NEGATIVE (ABACTERIAL)
• MAY BE RELATED TO
– CHLAMYDIA TRACHOMATIS
– UREAPLASMA UREALYTICUM
• MOST COMMON FORM OF CP
CHRONIC PROSTATITIS
• MORPHOLOGY
– LYMPHOCYTIC INFILTRATE
– NEUTROPHILS AND MACROPHAGES
– SOME EVIDENCE OF TISSUE
DESTRUCTION
• CLINICAL COURSE
– SIMILAR TO AP
• LESS ACUTE SYMPTOMS
• MORE RESISTANT TO AB RX
– CBP OFTEN ASSOCIATED WITH
RECURRENT UTI
PROLIFERATIVE LESIONS OF THE PROSTATE
PERIURETHRAL
AND
TRANSITIONAL
ZONES
URETHRA
PERIPHERAL
ZONE
NORMAL PROSTATE
NODULAR HYPERPLASIA
CARCINOMA
NODULAR HYPERPLASIA
• OTHER TERMS USED
– GLANDULAR AND STROMAL
HYPERPLASIA
– BENIGN PROSTATIC HYPERTROPHY
(HYPERPLASIA)
• EPIDEMIOLOGY
– OCCURS IN 20% OF MEN OVER 40
– OCCURS IN 90% OF MEN OVER 70
PATHOGENESIS OF
NODULAR HYPERPLASIA
• PROLIFERATION OF BOTH EPITHELIAL
AND STROMAL ELEMENTS
• BOTH ANDROGENS AND ESTROGENS MAY
PLAY A ROLE
– NOT SEEN IN MALES CASTRATED BEFORE
PUBERTY
– INHIBITORS OF TESTOSTERONE METABOLISM
USEFUL IN TREATMENT
– RELATIVE INCREASE IN ESTROGENS IN OLDER
MEN MAY INCREASE DHT RECEPTORS IN
PROSTATE
CLINICAL COURSE OF
NODULAR HYPERPLASIA
• SYMPTOMS OCCUR IN ONLY 10% OF MEN
WITH NODULAR HYPERPLASIA
• HESITANCY
• URINARY RETENTION
– URGENCY, FREQUENCY, NOCTURIA, UTI
• TREATMENT
– MEDICAL
– SURGICAL
• COMMON CAUSE FOR ELEVATED
PROSTATE SPECIFIC ANTIGEN (PSA)
CARCINOMA OF THE
PROSTATE
• EPIDEMIOLOGY
– MOST COMMON VISCERAL CANCER
• ABOUT 70/100,000 MEN IN US
• 200,000 NEW CASES/YR IN US
• 20% ARE LETHAL
– SECOND MOST COMMON CAUSE OF
CANCER DEATH IN MEN
– PEAK INCIDENCE OF CLINICAL CANCER
IS 65-75 YO
– LATENT CA IS EVEN MORE PREVALENT
• >50% IN MEN > 80 YO
CARCINOMA OF THE PROSTATE
• PATHOGENESIS
– HORMONAL FACTORS
• DOES NOT OCCUR IN EUNUCHS
• ORCHIECTOMY AND/OR ESTROGEN
TREATMENT INHIBITS GROWTH
– GENETIC FACTORS
• INCREASED RISK IN FIRST ORDER
RELATIVES
• BLACKS > WHITES (SYMPTOMATIC CA)
– ENVIRONMENTAL FACTORS
• GEOGRAPHIC DIFFERENCES IN INCIDENCE
OF CLINICAL CANCER (NOT OF LATENT CA)
• CHANGE IN INCIDENCE WITH MIGRATION
CARCINOMA OF THE PROSTATE
• CLINICAL COURSE
– OFTEN CLINICALLY SILENT
– DIGITAL RECTAL EXAM (DRE)
– PROSTATE SPECIFIC ANTIGEN (PSA)
• > 4 ng/ml IN PERIPHERAL BLOOD
• FREE PSA < 25%
–
–
–
–
TRANSRECTAL ULTRASOUND
NEEDLE BIOPSY
PROSTATISM (LIKE BPH)
METASTASES
• OSTEOBLASTIC
– TREATMENT- SURGERY, RADIATION,
HORMONES, CHEMO
Needle bx of prostate
CARCINOMA OF THE PROSTATE
• STAGING
A (T1)
B(T2)
C(T3 &T4)
D(N1-3,M1)
MICROSCOPIC ONLY
MACROSCOPIC (PALPABLE)
EXTRACAPSULAR
METASTATIC
• PROGNOSIS DEPENDENT ON STAGE AND
HISTOLOGIC GRADE
– 90% 10 YR SURVIVAL FOR A AND B
– 10-40% 10 YR SURVIVAL FOR C AND D
Hydronephrosis