MALE GENITAL SYSTEM

PENIS
SCROTUM, TESTIS, & EPIDIDYMIS
PROSTATE

KUMAR, COTRAN, AND ROBBINS
7
th
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
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

HYPOSPADIAS AND EPISPADIAS
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
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
INFLAMMATORY LESIONS
OF THE PENIS
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
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
SCC OF THE PENIS
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

SCROTAL ENLARGEMENT
HYDROCELE - MOST COMMON CAUSE
ACCUMULATION OF SEROUS FLUID
WITHIN TUNICA VAGINALIS
INFECTIONS, TUMOR, IDIOPATHIC
HEMATOCELE
CHYLOCELE
FILIARIASIS - ELEPHANTIASIS
TESTICULAR DISEASE
LESIONS INVOLVING THE
SCROTUM
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

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
CRYPTORCHIDISM AND
TESTICULAR ATROPHY
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
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
INFLAMMATORY LESIONS OF
THE TESTIS
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)
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

TESTICULAR NEOPLASMS
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
SEMINOMA
(40-50 Y)
GONADAL
DIFFERENTIATION
EMBRYONAL CA
(UNDIFFERENTIATED)
(20-30 Y)
TOTIPOTENTIAL
DIFFERENTIATION
(NONSEMINOMA)
CHORIOCARCINOMA
(20-30 Y)
hCG +
TROPHOBLASTIC
DIFFERENTIATION
YOLK SAC TUMOR
(< 3 Y)
AFP +
YOLK SAC
DIFF
TERATOMA
(ALL AGES)
MATURE
IMMATURE
MALIGNANT TX
SOMATIC
DIFFERENTIATION
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
RADIO- AND 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
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
ACUTE BACTERIAL
PROSTATITIS
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
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
CHRONIC PROSTATITIS
PROLIFERATIVE LESIONS OF THE PROSTATE
URETHRA
PERIURETHRAL
AND
TRANSITIONAL
ZONES
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
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
PATHOGENESIS OF
NODULAR HYPERPLASIA
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
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
CARCINOMA OF THE PROSTATE
Needle bx of prostate
STAGING
A (T1) MICROSCOPIC ONLY
B(T2) MACROSCOPIC (PALPABLE)
C(T3 &T4) EXTRACAPSULAR
D(N1-3,M1) 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
CARCINOMA OF THE PROSTATE
Hydronephrosis