MALE GENITAL SYSTEM - Pathology

MALE GENITAL SYSTEM 

• PENIS 

• SCROTUM, TESTIS, & EPIDIDYMIS 

• PROSTATE 

KUMAR, COTRAN, AND ROBBINS 

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) 

– 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

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


OF THE PENIS 

• PHIMOSIS 

– PREPUCE CANNOT BE EASILY 

RETRACTED OVER GLANS 

– MAY BE CONGENITAL 

– USUALLY ASSOCIATED WITH 

BALANOPOSTHITIS AND 

SCARRING 

– PARAPHIMOSIS (TRAPPED GLANS) 

• URETHRAL CONSTRICTION


OF THE PENIS 

• FUNGAL INFECTIONS 

–CANDIDIASIS 

• ESPECIALLY IN DIABETICS 

• EROSIVE, PAINFUL, PRURITIC 

• CAN INVOLVE ENTIRE MALE 

EXTERNAL GENITALIA

NEOPLASMS OF THE PENIS 

• SQUAMOUS CELL CARCINOMA (SCC) 

– EPIDEMIOLOGY 

• UNCOMMON - ABOUT 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

SCC OF THE PENIS 

• 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

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

LESIONS INVOLVING THE 

SCROTUM 

• SCROTAL ENLARGEMENT 

– HYDROCELE - MOST COMMON CAUSE 

• ACCUMULATION OF SEROUS FLUID WITHIN 

TUNICA VAGINALIS 

• INFECTIONS, TUMOR, IDIOPATHIC 

– HEMATOCELE 

– CHYLOCELE 

• FILIARIASIS - ELEPHANTIASIS 

– TESTICULAR DISEASE

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

CRYPTORCHIDISM AND 



– WHEN UNILATERAL, MAY SEE ATROPHY IN 

CONTRALATERAL TESTIS 

– STERILITY 

– INCREASED RISK OF MALIGNANCY (10X) 

– ORCHIOPEXY 

• MAY HELP PREVENT ATROPHY 

• DOES NOT DECREASE RISK OF MALIGNANCY

OTHER CAUSES OF 


• CHRONIC ISCHEMIA 

• INFLAMMATION OR TRAUMA 

• HYPOPITUITARISM 

• EXCESS FEMALE SEX HORMONES 

– THERAPEUTIC ADMINISTRATION 

– CIRRHOSIS 

• MALNUTRITION 

• IRRADIATION 

• CHEMOTHERAPY


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

INFLAMMATORY LESIONS OF 

THE TESTIS 

• 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

TESTICULAR NEOPLASMS 


– MOST IMPORTANT CAUSE OF PAINLESS 

ENLARGEMENT OF TESTIS 

– 6/100,000 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)

TESTICULAR NEOPLASMS 


– 95% ARISE FROM GERM CELLS 

• ISOCHROMOSOME 12, i(12p), IS A COMMON 

FINDING 

– RARELY ARISE FROM SERTOLI CELLS 

OR LEYDIG CELLS 

• THESE ARE OFTEN BENIGN 

– Lymphoma 

• men > 60 yo

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 

GONADAL 

DIFFERENTIATION 

TOTIPOTENTIAL 


(NONSEMINOMA) 

SEMINOMA 

(40-50 Y) 

TROPHOBLASTIC 


EMBRYONAL CA 

(UNDIFFERENTIATED) 

(20-30 Y) 

YOLK SAC 

DIFF 

SOMATIC 


TERATOMA 

(20-30 Y) 

CHORIOCARCINOMA 

(20-30 Y) 

hCG + 

YOLK SAC TUMOR 

(< 3 Y) 

AFP + 

MATURE 

IMMATURE 

MALIGNANT TX

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

• ETIOLOGY 

ACUTE BACTERIAL 

PROSTATITIS 

– SAME ORGANISMS THAT CAUSE UTI 

• E coli, OTHER GNR 


– ORGANISMS ASCEND FROM URETHRA 

AND URINARY BLADDER 

– RARELY, HEMATOGENOUS SPREAD

ACUTE BACTERIAL 

PROSTATITIS 

• MORPHOLOGY 

– ACUTE INFLAMMATION, ESPECIALLY IN THE 

GLANDS, WITH MICROABSESSES 

– CONGESTION, EDEMA 


– DYSURIA, FREQUENCY, LOW BACK PAIN, 

PELVIC PAIN 

– ENLARGED, EXQUISITELY TENDER 

– +/- FEVER OR LEUKOCYTOSIS 

– USUALLY RESOLVES WITH WITH AB RX

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

CHRONIC PROSTATITIS 

• MORPHOLOGY 

– LYMPHOCYTIC INFILTRATE 

– NEUTROPHILS AND MACROPHAGES 

– SOME EVIDENCE OF TISSUE DESTRUCTION 


– SIMILAR TO AP 

• LESS ACUTE SYMPTOMS 

• MORE RESISTANT TO AB RX 

– CBP OFTEN ASSOCIATED WITH RECURRENT 

UTI

PROLIFERATIVE LESIONS OF THE PROSTATE 

PERIURETHRAL 

AND 

TRANSITIONAL 

ZONES 

NORMAL PROSTATE 

URETHRA 

PERIPHERAL 

ZONE 

NODULAR HYPERPLASIA 

CARCINOMA


• OTHER TERMS USED 

– GLANDULAR AND STROMAL 

HYPERPLASIA 

– BENIGN PROSTATIC HYPERTROPHY 

(HYPERPLASIA) 


– OCCURS IN 20% OF MEN OVER 40 

– OCCURS IN 90% OF MEN OVER 70

PATHOGENESIS OF 


• 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

CLINICAL COURSE OF 


• 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 


– 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


PROSTATE 


– 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 


– 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

• STAGING 

A 

B 

C 

D 


MICROSCOPIC ONLY 

MACROSCOPIC (PALPABLE) 

EXTRACAPSULAR 

METASTATIC 

PROSTATE 

• PROGNOSIS DEPENDENT ON STAGE AND 

HISTOLOGIC GRADE 

– 90% 10 YR SURVIVAL FOR A AND B 

– 10-40% 10 YR SURVIVAL FOR C AND D

MALE GENITAL SYSTEM - Pathology

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