Pathology of Male Genital System Jan Laco, M.D., Ph.D.

Summary 1. Penis and scrotum 2. Testis and epididymis 3. Prostate

1. Penis and scrotum a. malformations b. inflammatory lesions c. neoplasms

1a. malformations Hypospadias + epispadias = abnormal location of distal urethral orifice + outer genital anomalies epispadias + urinary bladder exstrophy complications: obstruction infections infertility

1a. malformations Phimosis = stenosis of prepuce (+ acquired)  smegma  infection, urinary retention Paraphimosis = stenotic prepuce in coronal sulcus  penis congestion, infarction

1b. inflammatory lesions glans penis – balanitis prepuce – posthitis cavernitis  gangrene of penis STD – syphilis, gonorrhea, HSV, Candida purulent  ulcerations  scarring

1c. neoplasms benign x malignant epithelial x mesenchymal

Benign neoplasms Condyloma acuminatum (venereal wart) HPV 6, 11 - STD coronal sulcus G: multiple papillomas, mm – cm M: hyperplasia, akanthosis, parakeratosis koilocytes – perinuclear halo

Malignant neoplasms – carcinoma in situ Bowen disease > 35 years shaft of penis + scrotum: grey-white firm plaque + visceral neoplasms Erythroplasia de Queyrat glans penis + prepuce: soft, reddish patch Bowenoid papulosis young men, sex, brown papules, HPV 16

Malignant neoplasms - carcinoma penis > scrotum Africa, America, Asia > 40 years glans penis, prepuce exophytic x endophytic squamous cell Ca locally aggressive, LN metastases 5-year survival: 70%

Summary 1. Penis and scrotum 2. Testis and epididymis 3. Prostate

2. Testis and epididymis a. congenital anomalies b. regressive changes and scrotal enlargement c. inflammatory lesions d. neoplasms

2a. Congenital anomalies – failure of descent retroperitoneum  inguinal canal  scrotum spontanneous descent until 1st year adults = cryptorchidism prevalence: 0,3 - 0,8% idiopathic

2a. Congenital anomalies – failure of descent unilateral x bilateral (25%) M: tubular atrophy + hyperplasia of Leydig + changes in contralateral testis – blastoma in situ !!! infertility 30 - 50x  risk of germ cell tumor !!!  orchiopexy < 2 years

2b. Regressive changes torsion  infarction  necrosis acute urological emergency + shock atrophy senium vascular hormonal

2b. Scrotal enlargement hydrocele = serous fluid in t. vaginalis + inflammation, tumor hematocele = blood in t. vaginalis + torsion, injury varicocele = varices plexus pampiniformis

2c. Inflammatory lesions epididymis > testis + urinary tract and prostate infection children: Gramm- bacteria adults: N. gonorrhoe, Ch. trachomatis old: E. coli. Pseudomonas spp. epididymis = epididymitis testis = orchitis

2c. Inflammatory lesions suppurative e.: abscesses  scarring  chronic form  infertility non-suppurative o.: mumps adults (20%) infertility ? TBC e.: solitary hematogennous metastasis + prostate + seminal vesicles

2d. Testicular neoplasms 1. germ cell 2. stromal – Sertoli and Leydig cells 3. combination (1. + 2.) - gonadoblastoma 4. other – malignant lymphoma, … 5. secondary – ALL, Ca prostate, Ca GIT, lungs incidence 2-3 / 100 000 males !!! most common male tumors in 3rd and 4th decades !!!

1. Germ cell tumors seminoma x non-seminomas seminoma: atypic germ cell non-seminomas: totipotential cell  somatic and/or extraembryonic lines 90% testicular tumors malignant

Seminoma most common malignant 40 years G: solid, homogennous, grey-white intratesticular spread M: polygonal cells + clear cytoplasm fibrous septa + lymphocytes

Non-seminomas embryonal carcinoma (ECa) yolk sac tumor (YST) choriocarcinoma (ChCa) teratomas (T)

Embryonal carcinoma  malignant 20 – 30 years G: small, grey-white + hemorrhages, necrosis M: solid, trabecular, papillary, glandular irregular large cells  hCG

Yolk sac tumor malignant children G: large, solid, yellow-white M: polygonal cells + loose stroma Schiller – Duvall bodies  AFP

Choriocarcinoma malignant trophoblast G: irregular mass, hemorrhages, necrosis M: irregular cells  hCG

Teratomas somatic cell lines children, young differentiated mature – cystic  puberty – benign > puberty – uncertain differentiated immature – uncertain

Mixed germ cell tumors (ECa + YST + T + ChCa) + seminoma teratocarcinoma: T + ECa extensive sampling

Clinical features cryptorchidism:  risk unilateral metastases – LN – paraaortic - seminoma - blood – lungs, liver, brain, bones - non - seminomas

2. Stromal tumors Sertoli + Leydig cells androgens + estrogens uncommon adults 90% benign

Summary 1. Penis and scrotum 2. Testis and epididymis 3. Prostate

3. Prostate a. inflammatory lesions b. nodular hyperplasia c. neoplasms

3a. inflammations - prostatitis acute bacterial p. – E. coli, Gramm-, N. gonorrhoe from urethra, urinary bladder, cystoscopy G: enlargement, edema, abscesses, necrosis M: neutrophiles in glands chronic p. – bacterial x abacterial TBC p. – solitary hematogennous metastasis  spread to urinary tract

!!! NO relationship to carcinoma !!! 3b. Nodular hyperplasia    , > 50 years hormonal dysbalance periurethral zone – urethral compression G: nodules – various collor and consistency M: proliferation of glands + fibromuscular stroma cysts, bi-layered epithelium, c. amylacea  trabecular hypertrophy UB, urocystitis !!! NO relationship to carcinoma !!!

3c. Neoplasms - adenocarcinoma very common ethiology:  age, androgens late dg. – dysuria, hematuria, metastasis per rectum + biopsy + blood: PSA peripheral zone G: firm, yellowish M: various glandular structure !!! uni-layered epithelium !!!

3c. Neoplasms - adenocarcinoma local spread – prostate, urinary bladder, rectum, pelvis + perineural spread LN – pelvic LN blood – bones (osteoplastic) - lungs, liver grading – Gleason score: – glandular differentiation + growth structure 10-year survival: early dg. 90% x late dg. 10-40%