The Lower Urinary System and Male Genital System

The Lower Urinary Tract Congenital anomalies Ureteropelvic junction obstruction – most common cause of hydronephrosis in infants and children, boys>girls, 20% bilateral

Ureteral Obstructive Lesions IntrinsicCalculiStricturesTumors Blood clots NeurogenicExtrinsicPregnancy Periureteral inflammation EndometriosisTumors

Sclerosing Retroperitoneal Fibrosis Fibrous proliferative inflammatory process encasing the retroperitonal structures and causing hydronephrosis Similar to Riedel thyroiditis 70% no identifiable cause ( Ormond disease) Drugs ( ergot derivatives, Beta blockers) Adjacent inflammatory conditions (Crohn disease) (Crohn disease) Malignant disease ( lymphoma, UT carcinoma)

Urinary Bladder Congenital anomalies DiverticulaExstrophyVUR Patent urachus

Cystitis Bacterial E. Coli, Proteus, Klebsiella, Enterobacter TB Candida, Cryptococcal Chlamydia, Mycoplasma SchistomiasisAdenovirus Predisposing factors Female, calculi, urinary obstruction, DM, instrumentation, immune deficiency Triad Frequency, Lower abdominal pain, Dysuria Special forms Interstitial – chronic pelvic pain Malacoplakia – soft yellow, raised mucosal plaques Polypoid – irritation to the bladder mucosa Hemorrhagic- adenovirus, cyclophosphamide Follicular- aggregates of lymphocytes Eosinophilic- nonspecific subacute infection

Metaplastic lesions Cystitis cystica et glandularis- nests of urothelium grow downward into lamina propria Squamous metaplasia Nephrogenic adenoma – shed renal tubular cells that implant in the urothelium in response to injury

Neoplasms Urothelial ( transitional) tumors 90% of all bladder tumors Exophytic papillomas Inverted papillomas PUNLMPs- papillary urothelial neoplasms of low malignant potential Low grade and high grade papillary urothelial cancers CIS

Epidemiology Males> Females Cigarette smoking Industrial exposures to arylamines Schistosoma infections Long-term use of analgesics Long-term exposure to cyclophosphamide Prior exposure to irradiation Chromosome 9 deletions Clinical – painless hematuria

Urethra UrethritisGC Chlamydia, Mycoplasma, Enteric organisms Reiter’s syndrome Urethral carbuncle Peyronie disease – subcutaneous fibrosis Carcinoma

Male genital tract PenishypospadiasEpispadiasPhimosisBalanoposthitis Condyloma acuminatum CIS Bowen disease – single erythematous plaque Bowenoid Papulosis – multiple warty lesions, HPV 16 Invasive Squamous cell carcinoma

Testes and Epididymis Cryptorchidism- increased incidence of germ cell tumors Atrophy and decreased fertility Nonspecific epididymitis and orchitis Granulomatous ( auto-immune) orchitis GCMumpsTBSyphilis Torsion – bell clapper deformity Tunica Vaginalis Hydrocele, Hematocele, Chylocele, Spermatocele, Varicocele

Testicular Tumors Germ Cell tumors Seminomas – very radiosensitive, most frequent, analogous to dysgerminoma in females Spermatocytic Seminoma Embryonal carcinoma – second most common, painful, worse prognosis Yolk Sac tumor Choriocarcinoma Teratoma – almost always malignant Mixed tumors Clinical features Painless enlargement of the testis Spread via para-aortic nodes to medistinal and supraclavicular NSGCTs more aggressive, poorer prognosis HCG, AFP, LDH Sex Cord-Gonadal Stroma Leydig Cell – precocious puberty Sertoli Cell – no endocrine Gonadoblastoma Testicular Lymphoma

Prostate 4 biologically and anatomically distinct zones: Peripheral – most carcinomas Central Transitional – most hyperplasia Anterior fibromuscular stroma

Acute bacterial Same organisms as UTIs Fever, chillls, dysuria, tender,boggy prostate Chronic bacterial Recurrent UTIs Low back pain, abd discomfort, dysuria Chronic abacterial Most common form Negative culture Leukocytes in fluid Granulomatous BCG treatment for bladder cancer Reaction to secretions from ruptured ducts Prostatitis

Benign Prostatic Hyperplasia Nodular hyperplasia Very common in men>50 years of age Partial or complete obstruction of urethra Overall reduction in the rate of cell death DHT from stromal cells induces growth factors Bladder hypertrophy and distension Urine retention Frequency, nocturia, difficultystarting and stopping stream, overflow dribbling, dysuria Increased risk of infection Sudden acute urine retention –emergency catherization

Prostate Tumors Adenocarcinoma Most common cancer in men Androgens play an important role FH important BRCA2 Inflammation may set the stage TMPRSS2 promoter, ETS gene Hypermethylation of GSTRP1 EZH-2AMACRPCA3 PSA – organ specific, velocity of change

Prostate Tumors PIN – high grade prostatic intraepithelial neoplasia Gleason score – 2 numeric grades added together Gritty and firm Outer layer of basal cell layer is absent in carcinoma Grade and stage are best prognostic factors Boney metastases in vertebrae – universally fatal