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

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.
Penis

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
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.

Cuties ☺ 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
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 intra-
abdominal 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 follicle-
stimulating pituitary hormone.
Findings Associated with Decreased Fertility
x These include hypospermatogenesis, maturation arrest,
and findings associated with vas deferens obstruction
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
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 school-
age 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.
 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 intermediate-
sized 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 cross-
section, 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 gray-
white 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 Page 5 of 6

x The histologic type in almost all cases is the diffuse large
cell lymphoma
x The prognosis is extremely poor
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.
Spermatocele
x refer to a small cystic accumulation of semen in dilated
efferent ducts or ducts of the rete testis
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.
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.

Varicocele
x dilated vein in the spermatic cord

TUMORS

Prostate Adenocarcinoma
x extremely common disorder in men over age 50.
INFLAMMATIONS x "prostate cancer" and "prostate adenocarcinoma," when
used without qualifications, refer to the common or
Acute bacterial prostatitis acinar variant of prostate cancer.
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
 Pathology – Male Genital Tract by Dr Cruz Page 6 of 6

High-grade prostatic intraepithelial neoplasia (PIN).

x consist of benign glands with intra-acinar proliferations of
cells that demonstrate nuclear anaplasia