Male Genitals

Pathology (dr Cruz) Male Genital Tract December 07

TUMORS Benign Tumor Condyloma Acuminatum x Condyloma acuminatum is a benign tumor caused by human papillomavirus (HPV). x HPV type 6 and, less frequently, type 11 have been clearly associated with condylomata acuminata.

Malignant Tumors

Penis

Carcinoma in Situ (high-grade squamous intraepithelial neoplasia) / Bowen disease x Usually in the age of >35 years. x Involves the skin of the shaft of the penis and the scrotum. x Grossly, it appears as a solitary, thickened, gray-white, opaque plaque with shallow ulceration and crusting. x It can also manifest on the glans and prepuce as single or multiple shiny red, sometimes velvety, plaques where it is clinically referred to as Erythroplasia of Queyrat.

CONGENITAL ANOMALIES Hypospadias and Epispadias x Malformation of the urethral groove and urethral canal may create abnormal openings either on the ventral surface of the penis (hypospadias) or on the dorsal surface (epispadias). Phimosis x When the orifice of the prepuce is too small to permit its normal retraction INFLAMMATIONS x Balanoposthitis refers to infection of the glans and prepuce caused by a wide variety of organisms

Cuties ☺

Bowenoid papulosis x Occurs in younger, sexually active adults. x differs from Bowen disease by the presence of multiple (rather than solitary) pigmented (reddish brown) papular lesions.

1 of 6

Pathology – Male Genital Tract by Dr Cruz

x In some cases, the lesions may be verrucoid and readily mistaken for condyloma acuminatum. x Histologically, indistinguishable from Bowen disease x related to HPV 16. virtually never develops into an invasive carcinoma, and in many cases, it spontaneously regresses. Squamous cell carcinoma x usually found in patients between the ages of 40 and 70 x 10% to 20% of male malignancies in some parts of Asia, Africa, and South America. x uncommon malignancy in the United States x HPV type 16 is the most frequent culprit, but as with other genitourinary malignancies, HPV 18 is also implicated. x Carcinoma in situ (Bowen disease), the presumed precursor lesion

Page 2 of 6

INFLAMMATIONS Non-Specific Epididymitis and Orchitis x commonly related to infections in the urinary tract (cystitis, urethritis, genitoprostatitis), which presumably reach the epididymis and the testis through either the vas deferens or the lymphatics of the spermatic cord. x Uncommon in children, epididymitis in childhood is usually associated with a congenital genitourinary abnormality and infection with Gram-negative rods x In sexually active men younger than age 35 years, the sexually transmitted pathogens Chlamydia trachomatis and Neisseria gonorrhoeae are the most frequent culprits. x In men older than age 35, the common urinary tract pathogens, such as Escherichia coli and Pseudomonas, are responsible for most infections

Testis and Epididymis CONGENITAL ANOMALY Cryptorchidism x found in approximately 1% of 1-year-old boys x represents a complete or incomplete failure of the intraabdominal testes to descend into the scrotal sac. x unilateral in most cases, but it may be bilateral in 25% of patients. REGRESSIVE CHANGES Atrophy x Causes: 1. progressive atherosclerotic narrowing of the blood supply in old age; 2. the end stage of an inflammatory orchitis, whatever the etiologic agent; 3. cryptorchidism; 4. hypopituitarism; 5. generalized malnutrition or cachexia; 6. irradiation; 7. prolonged administration of female sex hormones, as in treatment of patients with carcinoma of the prostate; and 8. exhaustion atrophy, which may follow the persistent stimulation produced by high levels of folliclestimulating pituitary hormone.

Granulomatous (Autoimmune) Orchitis x Among middle-aged men, a rare cause of unilateral testicular enlargement is nontuberculous, granulomatous orchitis. x presents as a moderately tender testicular mass of sudden onset sometimes associated with fever. x may appear insidiously, however, as a painless testicular mass mimicking a testicular tumor x Histologically, the orchitis is distinguished by granulomas that are seen restricted within spermatic tubules. x Although an autoimmune basis is suspected, the cause of these lesions remains unknown. SPECIFIC INFLAMMATIONS Gonorrhea x Inflammatory changes similar to those described in the nonspecific infections occur, with the development of frank abscesses in the epididymis, resulting in extensive destruction of this organ. x In the more neglected cases, the infection can then spread to the testis and produce a suppurative orchitis. Mumps x a systemic viral disease that most commonly affects schoolage children. Testicular involvement is extremely uncommon in this age group. x In postpubertal males, however, orchitis may develop and has been reported in 20% to 30% of male patients. Tuberculosis x almost invariably begins in the epididymis and may spread to the testis. x In many of these cases, there is associated tuberculous prostatitis and seminal vesiculitis, and it is believed that epididymitis usually represents a secondary spread from these other involvements of the genital tract.

Findings Associated with Decreased Fertility x These include hypospermatogenesis, maturation arrest, and findings associated with vas deferens obstruction

Pathology – Male Genital Tract by Dr Cruz

Page 3 of 6

Syphilis x The testis and epididymis are affected in both acquired and congenital syphilis, but almost invariably, the testis is involved first by the infection. x In many cases, the orchitis is not accompanied by epididymitis. x The morphologic pattern of the reaction takes two forms: the production of gummas or a diffuse interstitial inflammation characterized by edema and lymphocytic and plasma cell infiltration with the characteristic hallmark of all syphilitic infections (i.e., obliterative endarteritis with perivascular cuffing of lymphocytes and plasma cells). VASCULAR DISTURBANCES Torsion x Twisting of the spermatic cord may cut off the venous drainage and the arterial supply to the testis. x There are two types of testicular torsion. 1. Neonatal torsion 2. Adult torsion

SPERMATIC CORD AND PARATESTICULAR TUMORS Lipomas x common lesions involving the proximal spermatic cord x often identified at the time of inguinal hernia repair. Adenomatoid tumor x most common benign paratesticular tumor x usually small nodules that typically occur near the upper pole of the epididymis. @@ The most common malignant paratesticular tumors located at the distal end of the spermatic cord are rhabdomyosarcomas in children and liposarcomas in adults. TESTICULAR TUMORS Germ Cell Tumors Seminoma x most common type of germinal tumor (50%) and the type most likely to produce a uniform population of cells. x almost never occur in infants; they peak in the thirties x produce bulky masses, sometimes 10 times the size of the normal testis x has a homogeneous, gray-white, lobulated cut surface, usually devoid of hemorrhage or necrosis x Microscopically, the typical seminoma presents sheets of uniform cells divided into poorly demarcated lobules by delicate septa of fibrous tissue

Spermatocytic Seminoma x an uncommon tumor, representing 1% to 2% of all testicular germ cell neoplasms. x Affected individuals are generally over the age of 65 years x slow-growing tumor that rarely if ever produces metastases; hence, the prognosis is excellent x Grossly, spermatocytic seminoma tends to be larger than classic seminoma and presents with a pale gray, soft, cut surface sometimes with mucoid cysts x three cell populations, all intermixed: 1. medium-sized cells (15 to 18 µm), which are the most numerous, containing a round nucleus and eosinophilic cytoplasm; 2. smaller cells (6 to 8 µm), with a narrow rim of eosinophilic cytoplasm resembling secondary spermatocytes; and 3. scattered giant cells (50 to 100 µm), either uninucleate or multinucleate. In some intermediatesized cells, chromatin is similar to that seen in the meiotic phase of non-neoplastic spermatocytes Embryonal Carcinoma x occur mostly in the 20- to 30-year age group . x more aggressive than seminomas. x Grossly, the tumor is smaller than seminoma and usually does not replace the entire testis. On cut surfaces, the mass is often variegated, poorly demarcated at the margins, and punctuated by foci of hemorrhage or necrosis x Histologically, the cells grow in alveolar or tubular patterns, sometimes with papillary convolutions More undifferentiated lesions may present sheets of cells. The neoplastic cells have an epithelial appearance and are large and anaplastic. Mitotic figures and tumor giant cells are frequent.

Pathology – Male Genital Tract by Dr Cruz

Yolk Sac Tumor x Also known as infantile embryonal carcinoma or endodermal sinus tumor x most common testicular tumor in infants and children up to 3 years of age x In adults, the pure form of this tumor is rare; instead, yolk sac elements frequently occur in combination with embryonal carcinoma x Grossly, the tumor is nonencapsulated, and on crosssection, it presents a homogeneous, yellow-white, mucinous appearance. x Characteristic on microscopic examination is a lacelike (reticular) network of medium-sized cuboidal or elongated cells. x In approximately 50% of tumors, structures resembling endodermal sinuses (Schiller-Duval bodies) x Present within and outside the cytoplasm are eosinophilic, hyalin-like globules in which AFP and α1-antitrypsin can be demonstrated by immunocytochemical staining. Choriocarcinoma x highly malignant that is composed of both cytotrophoblastic and syncytiotrophoblastic cells. x In its "pure" form, choriocarcinoma is rare, constituting fewer than 1% of all germ cell tumors. As will be emphasized later, foci of choriocarcinoma are much more common in mixed patterns. x Typically, these tumors are small, rarely larger than 5 cm in diameter. x Hemorrhage and necrosis are extremely common

Teratoma x refers to a group of complex tumors having various cellular or organoid components reminiscent of normal derivatives from more than one germ layer. x may occur at any age x Pure forms of teratoma are fairly common in infants and children, second only in frequency to yolk sac tumors. x In adults, pure teratomas are rare, constituting 2% to 3% of germ cell tumors. As with embryonal carcinomas, their frequency in combination with other histologic types is about 45%. x Grossly, teratomas are usually large, ranging from 5 to 10 cm in diameter. x gross appearance is heterogeneous, with solid, sometimes cartilaginous and cystic areas x Hemorrhage and necrosis usually indicate admixture with embryonal carcinoma, choriocarcinoma, or both x composed of a heterogeneous, helter-skelter collection of differentiated cells or organoid structures, such as neural tissue, muscle bundles, islands of cartilage, clusters of squamous epithelium, structures reminiscent of thyroid gland, bronchial or bronchiolar epithelium, and bits of intestinal wall or brain substance, all embedded in a fibrous or myxoid stroma x Elements may be mature (resembling various tissues within the adult) or immature (sharing histologic features with fetal or embryonal tissue).

Page 4 of 6

Mixed Tumors x About 60% of testicular tumors are composed of more than one of the "pure" patterns x Common mixtures include teratoma, embryonal carcinoma, and yolk sac tumor; seminoma with embryonal carcinoma; and embryonal carcinoma with teratoma (teratocarcinoma) Tumors of Sex Cord-Gonadal Stroma Leydig (Interstitial) Cell Tumors x They arise at any age, although most of the reported cases have been noted between 20 and 60 years of age. x most common presenting feature is testicular swelling, but in some patients, gynecomastia may be the first symptom. x In children, hormonal effects, manifested primarily as sexual precocity, are the dominating features x they may elaborate androgens or combinations of androgens and estrogens, and some have also elaborated corticosteroids x circumscribed nodules, usually less than 5 cm in diameter. They have a distinctive golden brown, homogeneous cut surface. x Histologically, tumorous Leydig cells usually are remarkably similar to their normal forebears in that they are large and round or polygonal, and they have an abundant granular eosinophilic cytoplasm with a round central nucleus. Cell boundaries are often indistinct. x rod-shaped crystalloids of Reinke occur in about 25% of the tumors Sertoli Cell Tumors (Androblastoma) x may be composed entirely of Sertoli cells or may have a component of granulosa cells. x Some induce endocrinologic changes. Either estrogens or androgens may be elaborated but only infrequently in sufficient quantity to cause precocious masculinization or feminization. x appear as firm, small nodules with a homogeneous graywhite to yellow cut surface. x Histologically, the tumor cells are arranged in distinctive trabeculae with a tendency to form cordlike structures resembling immature seminiferous tubules. Gonadoblastoma x rare neoplasms containing a mixture of germ cells and gonadal stromal elements Testicular Lymphoma x Although not primarily a tumor of the testis, testicular lymphoma is included here because affected patients present with only a testicular mass x Lymphomas account for 5% of testicular neoplasms and constitute the most common form of testicular neoplasm in men over the age of 60.

Pathology – Male Genital Tract by Dr Cruz

x The histologic type in almost all cases is the diffuse large cell lymphoma x The prognosis is extremely poor

Page 5 of 6

Chronic bacterial prostatitis x difficult to diagnose and treat x common clinical setting is recurrent urinary tract infections (cystitis, urethritis) caused by the same organism.

Miscellaneous Lesions of the Tunica Vaginalis Hydrocele x Clear serous fluid may accumulate from neighboring infections or tumors, often spontaneously and without apparent cause Hematocele x presence of blood in the tunica vaginalis. x It is an uncommon condition that is usually encountered only when there has been either direct trauma to the testis or torsion of the testis with hemorrhagic suffusion into the surrounding tunica vaginalis or in hemorrhagic diseases associated with widespread bleeding diatheses. Chylocele x refers to the accumulation of lymph in the tunica and is almost always found in patients with elephantiasis who have widespread, severe lymphatic obstruction.

Chronic abacterial prostatitis x Clinically, it is indistinguishable from chronic bacterial prostatitis. x no history, however, of recurrent urinary tract infection x Expressed prostatic secretions contain more than 10 leukocytes per high-power field, but bacterial cultures are uniformly negative. Granulomatous prostatitis Nodular Hyperplasia (Benign Prostatic Hyperplasia) x extremely common disorder in men over age 50. x characterized by hyperplasia of prostatic stromal and epithelial cells, resulting in the formation of large, fairly discrete nodules in the periurethral region of the prostate. x Histologic evidence of nodular hyperplasia can be seen in approximately 20% of men 40 years of age, a figure that increases to 70% by age 60 and to 90% by age 70.

Spermatocele x refer to a small cystic accumulation of semen in dilated efferent ducts or ducts of the rete testis Varicocele x dilated vein in the spermatic cord

TUMORS Prostate INFLAMMATIONS Acute bacterial prostatitis x typically results from bacteria that cause urinary tract infections. x most cases are caused by various strains of E. coli, other Gram-negative rods, enterococci, and staphylococci. x The organisms become implanted in the prostate, usually by intraprostatic reflux of urine from the posterior urethra or from the urinary bladder, but occasionally, they seed the prostate by the lymphohematogenous routes from distant foci of infection. x The diagnosis can be established by urine culture and clinical features

Adenocarcinoma x extremely common disorder in men over age 50. x "prostate cancer" and "prostate adenocarcinoma," when used without qualifications, refer to the common or acinar variant of prostate cancer.

Pathology – Male Genital Tract by Dr Cruz

High-grade prostatic intraepithelial neoplasia (PIN). x consist of benign glands with intra-acinar proliferations of cells that demonstrate nuclear anaplasia

Page 6 of 6