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The Male Genital System pathology

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Presentation on theme: "The Male Genital System pathology"— Presentation transcript:

1 The Male Genital System pathology

2 The Male Genital System
Penis scrotum and testes prostate

3 Disease Categories Malformations Inflammatory conditions & STDs

4 Penis Malformations Hypospadias epispadias

5 Hypospadias more common (1 in 250 live male births)
urethral opening along ventral aspect urinary tract obstruction risk of infections other anomalies: Inguinal hernias UDTs


7 Epispadias Orifice on dorsal aspect of penis
Lower urinary tract obstruction Urinary incontinence Commonly associated with bladder extrophy.


9 Penis Inflammatory Lesions
balanitis : glans penis balanoposthitis : glans penis & prepuce by smegma Phimosis paraphimosis congestion, swelling & pain Urinary retention Candidiasis


11 Neoplasms of the Penis >95% originate from squamous epithelium
Higher rates in developing countries Most cases are uncircumcised & older than 40 Pathogenesis: Poor hygiene (smegma) Smoking HPV 16 and 18

12 Intraepithelial neoplasia (carcinoma in situ)
Three clinical variants : 1-Bowen disease Older uncircumcised males Solitary, plaquelike lesion on shaft Malignant cells throughout epidermis No invasion of stroma Invasive SCC in 33% .

13 Bowen disease (carcinoma in situ)
Hyperchromatic Dysplastic Dyskeratotic epithelial cells scattered mitoses

14 Intraepithelial neoplasia (carcinoma in situ)
2-Erythroplasia of Queyrat Erythematous patch on glans

15 Intraepithelial neoplasia (carcinoma in situ)
3-Bowenoid papulosis young, sexually active males multiple reddish brown papules on glans most often transient rare progression to carcinoma in immunocompetent patients

16 Squamous cell carcinoma of penis
gray, crusted, papular lesion on glans penis or prepuce infiltrates underlying tissue indurated, ulcerated lesion irregular margins keratinizing SCC with infiltrating margins

17 Glans penis deformed by a firm, ulcerated, infiltrative mass

18 Gray, crusted, papule on glans or prepuce that infiltrates underlying tissue

19 Most case are indolent locally infiltrative Regional metastases in inguinal lymph nodes (25% ) Distant metastases relatively uncommon Overall 5-year survival rate averages 70%

20 Verrucous carcinoma a variant of SCC papillary architecture
less striking cytologic atypia rounded, pushing deep margins

21 SCROTUM SCC: Sir Percival Pott observed a high incidence in chimney sweeps

22 SCROTUM Hydrocele: most common cause of scrotal enlargement
serous fluid within tunica vaginalis causes: infections tumors idiopathic

23 SCROTUM blood : Hematoceles Lymphatic fluid :chyloceles

24 SCROTUM Elephantiasis lymphatic obstruction (filariasis)
Scrotum & lower extremities

25 The Testes Cryptorchidism & Testicular Atrophy Inflammatory Lesions
Testicular Neoplasms

26 Cryptorchidism failure of testicular descent into scrotum
Descent from coelomic cavity into pelvis by the third month of gestation Through inguinal canals into scrotum during the last 2 months of intrauterine life Diagnosis difficult to establish before 1 yr


28 Cryptorchidism By 1 yr seen in 1% of the male population
10% are bilateral Causes: hormonal intrinsic testicular abnormalities mechanical (inguinal canal obstruction) congenital syndromes (Prader-Willi) unknown

29 Cryptorchidism Sterility Risk of testicular malignancy x3-5 times
unilateral cryptorchidism : 1- cancer risk in contralateral, descended testis 2- atrophy of contralateral gonad and sterility

30 Orchiopexy Surgical placement of UDT into scrotum before puberty decreases likelihood of atrophy,cancer and infertility

31 Cryptorchidism Right >left 10% bilateral normal size early in life
at 5 to 6 yrs: tubular atrophy at puberty: hyalinization hyperplasia of Leydig cells intratubular neoplasia

32 Atrophic changes Cryptorchidism chronic ischemia Trauma Radiation
antineoplastic chemotherapy chronic elevation in estrogen levels (cirrhosis)


34 Inflammatory Lesions epididymis > testis
Acute gonococcal epididymitis (abscess)

35 Inflammatory Lesions Nonspecific epididymorchitis :
begins as a primary UTI secondary ascending infection of testis testis is swollen and tender with PMNs

36 Inflammatory Lesions mumps orchitis 20% of infected adults
rarely in children testis is edematous and congested lymphoplasmacytic infiltrate tubular atrophy, fibrosis & sterility

37 Inflammatory Lesions Testicular TB:
most common cause of testicular granulomas epididymitis testis granulomas & caseous necrosis

38 Testicular Neoplasms Firm, painless enlargement 5 /100,000 males
peak yrs

39 Testicular Neoplasms cause unknown
Cryptorchidism (10%): X3-5 in both sides syndromes: androgen insensitivity gonadal dysgenesis isochromosome 12p risk in siblings of patients risk in contralateral testis whites >blacks Caucasians

40 Heterogeneous group: 1-germ cell tumors (95%,all are malignant) 2-sex cord/stromal tumors (uncommon,usually benign)

41 Classification of Germ Cell Tumors
One Histologic Pattern (60%) Seminoma nonseminoma Embryonal carcinoma Yolk sac tumor Choriocarcinoma Teratomas Mature Immature malignant transformation More Than One Histologic Pattern

42 Intratubular germ cell neoplasia
most tumors arise from in situ lesions in situ foci are adjacent to germ cell tumors in almost all cases

43 Seminoma 1-classic: 50% of germ cell neoplasms
identical to dysgerminomas & CNS germinomas

44 Large Soft well-demarcated Homogeneous gray-white bulge from cut surface confined to testis intact tunica albuginea foci of coagulation necrosis usually without hemorrhage

45 Large,uniform cells distinct cell borders Clear,glycogen-rich cytoplasm round nuclei conspicuous nucleoli small lobules intervening fibrous septa lymphocytic infiltrate granulomatous reaction

46 cells staining positively for hCG in 25 %
similar to syncytiotrophoblasts elevated serum hCG concentrations

47 Seminoma 2-spermatocytic occur in older patients medium-sized cells
large uninucleate or multinucleate cells small cells with round nuclei no association with intratubular germ cell neoplasia metastases are exceedingly rare

48 Embryonal carcinomas Ill-defined,invasive masses Hemorrhage & necrosis
primary lesions may be small,even in cases with metastases may invade epididymis & spermatic cord

49 Embryonal carcinomas Large,primitive cells basophilic cytoplasm
indistinct cell borders large nuclei prominent nucleoli

50 Embryonal carcinomas undifferentiated, solid sheets
glandular structures & irregular papillae other patterns are admixed with embryonal areas

51 Embryonal carcinomas Pure forms 2% to 3% of all testicular germ cell tumors foci of intratubular germ cell neoplasia frequently present in adjacent tubules

52 Yolk sac tumors (endodermal sinus tumors)
the most common primary testicular tumor in children <3 In adults,often admixed with embryonal carcinoma

53 Yolk sac tumors often large and well demarcated
low cuboidal to columnar epithelial cells microcysts, sheets, glands, and papillae

54 structures resembling primitive glomeruli, Schiller-Duvall bodies
Eosinophilic hyaline globules (AFP)

55 Choriocarcinomas Trophoblastic differentiation
primary tumors often small & nonpalpable May have extensive systemic metastases small cuboidal cytotrophoblastic cells large, eosinophilic syncytiotrophoblastic cells (multiple dark & pleomorphic nuclei) hCG within cytoplasm of syncytiotrophoblasts Well-formed placental villi not seen

56 Choriocarcinomas Hemorrhage necrosis c s

57 Teratomas Differentiation along somatic cell lines
in prepubertal boys : usually benign Pure forms In adults: metastases in 37% of cases often contain other malignant elements

58 Teratoma: variegated cut surface with cysts

59 1-Mature teratomas one or more germ cell layers
neural, cartilage, adipose, bone & epithelial haphazard array

60 neural glandular cartilaginous squamous

61 2- Immature teratomas immature somatic elements reminiscent of those in developing fetal tissue

62 Teratoma disorganized collection of glands, cartilage, smooth muscle & immature stroma

63 3-Teratomas with somatic-type malignancies
frank malignancy in preexisting teratomatous elements usually scc or adenocarcinoma

64 Mixed germ cell tumors 40% of all testicular germ cell neoplasms
Combinations of any of described patterns teratoma, embryonal carcinoma & yolk sac tumors

65 Clinical Features Seminomas often remain confined to testis
may reach considerable size Metastases to iliac and para-aortic nodes Hematogenous metastases occur later

66 Clinical Features non-seminomatous widespread metastases at diagnosis
with no palpable testicular lesion metastasize earlier lymphatic & hematogenous (liver & lungs)

67 Testicular germ cell neoplasms staging
Stage I: confined to testis Stage II: Regional LN only Stage III: Nonregional and/or distant metastases

68 Assay of tumor markers role in primary diagnosis & staging
Serially measured to monitor patients

69 hCG syncytiotrophoblastic cells always elevated in choriocarcinoma
Seminoma: 10-25%

70 AFP Glycoprotein fetal yolk sac & other fetal tissues
reliable indicator of a nonseminomatous component (yolk sac) most nonseminomatous tumors have elevations of both hCG and AFP also elevated in hepatocellular carcinoma.

71 treatment Seminomas Radiosensitive respond well to chemotherapy
nonseminomatous germ cell tumors platinum-based chemotherapy

72 PROSTATE Prostatitis nodular hyperplasia carcinoma

73 Acute bacterial prostatitis
E.coli & other gram-negative rods Most patients have acute urethrocystitis direct extension from urethra or bladder vascular channels from more distant sites

74 Chronic prostatitis bacterial episodes of acute prostatitis
may also develop insidiously abacterial account for most cases nonbacterial agents: Chlamydia trachomatis Ureaplasma urealyticum,

75 Granulomatous prostatitis
not a single disease a reaction to a variety of different insults disseminated TB Sarcoidosis fungal infections Wegener granulomatosis reaction to inspissated prostatic secretions Following TURP

76 Morphology Acute prostatitis: neutrophilic inflammatory infiltrate
Congestion stromal edema glandular epithelium may be destroyed Microabscesses Gross abscesses uncommon (in diabetics).

77 Morphology chronic prostatitis nonspecific in most cases
lymphoid infiltrate glandular injury concomitant acute inflammation tissue destruction fibroblastic proliferation

78 Morphology granulomatous prostatitis multinucleate giant cells
foamy histiocytes sometimes eosinophils Caseous necrosis only in TB prostatitis

79 Clinical Features of Prostatitis
acute: Dysuria urinary frequency lower back pain suprapubic or pelvic pain fever and leukocytosis chronic: recurrent UTI in men silent

80 normal prostate: glandular stromal parenchyma: 1-Peripheral 2-Central 3-Transitional 4-periurethral

81 most hyperplastic lesions arise in inner transitional & central zones
most carcinomas (70-80%) arise in peripheral zones

82 Nodular Hyperplasia of the Prostate
glandular & stromal hyperplasia extremely common abnormality a significant number of men by age 40 its frequency rises progressively with age (90% by the 8th decade)

83 "Benign prostatic hypertrophy" (BPH)
a synonym for nodular hyperplasia redundant and a misnomer the lesion is a hyperplasia rather than a hypertrophy

84 Cause remains incompletely understood androgens have a central role
not seen in males castrated before puberty Not in men with genetic diseases (blocked androgen activity)

85 pathogenesis of nodular hyperplasia
local, intraprostatic concentrations of androgens and their receptors increases in estrogens may increase expression of DHT receptors on prostatic parenchymal cells ( age-related )


87 currently 5α-reductase inhibitors are used to treat symptomatic nodular hyperplasia

88 Morphology periurethral glands of prostate
prostate is enlarged even >300 gm cut surface well-circumscribed nodules solid or with cystic spaces urethra is usually compressed (slit-like orifice) may project into bladder lumen

89 Well-defined nodules compress urethra into a slitlike lumen

90 Microscopical appearance
Glands tall columnar epithelial cells flattened basal cells crowding of epithelium (papillary projections) corpora amylacea Infarction (advanced cases) squamous metaplasia in adjacent glands

91 Microscopical appearance
fibromuscular stroma surround glands Spindle cells & connective tissue nodules

92 basal cell and secretory cell layers


94 Clinical Features in only about 10% of patients
lower urinary tract obstruction & infections Hesitancy intermittent interruption of urinary stream painful distention of bladder hydronephrosis bladder irritation ( frequency, nocturia & urgency)

95 Carcinoma of the Prostate
the most common visceral cancer in males 2nd cancer-related death cause in men >50 peak incidence between 65 and 75 years overall frequency >50% in men above 80

96 Pathogenesis Hormones: not seen in males castrated before puberty
androgens probably contribute growth inhibited by orchiectomy or DES Genes: Higher risk among 1st-degree relatives Environment: American blacks >whites, Asians or Hispanics A high animal fat diet is suggested as a risk factor

97 prostatic intraepithelial neoplasia (PIN)
frequent coexistence with infiltrating carcinoma probable precursor to carcinoma high-grade and low-grade patterns degrees of atypia vary an intermediate between normal & malignant tissue

98 Gross pathology 70-80 % in periphery irregular hard nodules
less likely to cause urethral obstruction ill-defined masses firm, gray-white to yellow Infiltrative margins

99 Microscopy adenocarcinoma small glands lie "back to back"
single layer of cuboidal cells basal cell layer absent conspicuous nucleoli

100 perineural invasion by malignant glands

101 Low-grade (Gleason score 2)
back to back uniformly sized glands

102 Anaplasia irregular, ragged glands papillary or cribriform structures
sheets of poorly differentiated cells

103 Moderately differentiated
(Gleason score 6) variably sized widely dispersed Moderately differentiated (Gleason score 10) Poorly differentiated sheets of malignant cells

104 Clinical Features often clinically silent during early stages
may be discovered by routine rectal exam 10% found in histologic examination of tissue removed for nodular hyperplasia autopsy studies,30% in men 30 to 40 years Prostatism when more extensive : local discomfort lower urinary tract obstruction

105 Clinical Features More aggressive cases come to attention because of metastases regional pelvic LN seminal vesicles periurethral zones bladder wall Invasion of rectum less common

106 Clinical Features Bone metastases axial skeleton common:
osteolytic (destructive) osteoblastic (bone-producing) osteoblastic metastases in an older male strongly suggests advanced carcinoma

107 Metastatic osteoblastic prostatic carcinoma within vertebral bodies

108 prostate-specific antigen (PSA)
proteolytic enzyme secreted into prostatic acini and seminal fluid increases sperm motility serum level 4.0 ng/L is the upper limit of normal Cancer cells produce more PSA also elevated in : nodular hyperplasia prostatitis

109 prostate-specific antigen
limited value when used as an isolated screening test for cancer diagnostic value enhanced when used with digital rectal examination transrectal sonography needle biopsy

110 prostate-specific antigen
great value in monitoring patients after treatment for cancer rising levels indicate recurrence and/or metastases

111 prostate-specific antigen
useful refinements PSA (4 to 10) gray zone: PSA velocity PSA density free vs bound forms of PSA Free PSA level >25% indicate a lower risk level <10% are worrisome

112 staging

113 Treatment combinations:
Surgery Radiation Hormonal ( advanced carcinomas)

114 Quiz

115 1-In Bowen disease which statement is true
A)it is seen in young uncircumcised males B)it is a solitary, plaquelike lesion. C)it has invasion of stroma D)invasive SCC never develops in such patients

116 2-in Epispadias which sentence is false?
A) The orifice is on ventral aspect of penis. B) Lower urinary tract obstruction is seen C) Urinary incontinence may occur D) Bladder extrophy is commonly noted

117 3-AFP is A)A Glycoprotein B)Produced by fetal yolk sac & other tissues
C)A reliable indicator of yolk sac tumor D)All of the above.

118 4-in acute prostatitis which change is not present?
A) neutrophilic inflammatory infiltrate B) Congestion & stromal edema C) glandular epithelium destruction D) granulomas.

119 5-prostate cancer is associated with :
A)irregular soft nodules B)well-defined masses C)High serum PSA level. D)All of the above

120 The End

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