Bien Ag Nina Ian John “G” Rachel Mark Jocelle Edo Gienah Jho Kath Aynz Je Glad Nickie

Ricobear Teacher Dadang Niňa Arlene Vivs Paul F. Rico F. Ren Mai Revs Mavis Jepay Yana Mayi Serge Hung Tope

S3
S3 L5:
L5: Lower
Lower Urinary
Urinary Tract
Tract and
and Male
Male Genital System by
Genital System by Dr.
Dr. Arnel
Arnel Amata
Amata December 4, 2010

I. Lower Urinary Tract  Course:

a. Ureters 1. Pursue separate courses to the bladder
i. Congenital Anomalies 2. Commonly joined within the bladder wall and drain through a single
ii. Inflammations ureteral orifice
iii. Tumor and Tumor-like Conditions  Usually unilateral and of no clinical significance
iv. Ureteral Obstruction Ureteropelvic Junction Obstruction
b. Urinary Bladder  Congenital disorder
i. Congenital Anomalies o Usually presents in male infants or children
ii. Inflammations (Cystisis) o Bilateral in 20% of cases
iii. Metaplastic Lesions o May be part of other congenital anomalies
iv. Neoplasms o Result: Hydronephrosis (most common)
1. Urothelial (Transitional) Tumors  In adults
2. Mesenchymal tumors
o More common in women
v. Obstruction of the Bladder
o Usually bilateral
c. Urethra
i. Inflammations  Ascribed to:
ii. Tumor and Tumor-like Conditions o Abnormal organization of smooth muscle bundles at the UPJ
II. Male Genital System o Excess stromal deposition of collagen between smooth muscle
a. Penis bundles
i. Congenital Anomalies o Congenitally extrinsic compression by polar renal vessels
ii. Mechanical Trauma and  Possibly present with agenesis of the kidney on the opposit side
Hemodynamic Disorders Diverticula
iii. Inflammatory Lesions  Saccular outpouchings of the ureteral wall
iv. Non-infectious Inflammatory Lesions  Uncommon, usually asymptomatic, congenital/acquired
v. Tumors  Found on imaging studies
b. Testis  Significance: Pocket of stasis  secondary infection
i. Congenital Anomalies Hydroureter (Dilation)
ii. Regressive Changes Megaloureter
1. Atrophy
iii. Inflammations INFLAMMATION (URETERITIS)
1. Orchitis Morphology
2. Epididymoorchitis o Accumulation or aggregation of lymphocytes forming germinal centers in
3. Specific Inflammations the subepithelial region  Slight elevations of the mucosa  Fine
4. Granulomatous (Autoimmune) granular mucosal surface (ureteritis follicularis)
Orchitis o Fine cysts lined by flattened urothelium at the mucosa (Ureteritis cystica)
5. Non-specific Epididymitis
iv. Tumors
TUMOR AND TUMOR-LIKE LESIONS
c. Prostate
Benign tumors
i. Inflammations
 Generally of mesenchymal origin
ii. Hyperplasia
1. Fibroepithelial polyp
iii. Tumors o Tumor-like lesion that appear as a small mass projecting into the
lumen
o Often in children
LOWER URINARY TRACT
 Ureters o Composed of loose, vascularized CT mass lying beneath the
 Urinary bladder mucosa
 Urethra
URETERS Malignant tumors
 Resemble those arsing in the renal pelvis, calyces and bladder
CONGENITAL ANOMALIES  Majority: Urothelial carcinomas
Double and Bifid ureters  Most common during the 6th and 7th decades of life
 Forms:  Result: Obstruction of the ureteral lumen
1. Totally distinct double renal pelves
2. Large kidney having a partially bifid pelvis terminating in separate URETERAL OBSTRUCTION
ureters Causes of obstruction

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 Type of Obstruction Cause 4. Carcinomas
Intrinsic
Calculi Of renal origin, rarely >5mm in diameter Exstrophy
Larger renal stones cannot enter ureters  Developmental failure in the anterior wall of the abdomen and the
Impact at loci of ureteral narrowing – bladder  Bladder either communicates directly through a large defect
ureteropelvic junction, where ureters cross iliac
vessels and where they enter the bladder— with the surface of the body or lies as an opened sac
causing excruciating “renal colic”  Complications:
Strictures Congenital or acquired (inflammation) 1. Colonic glandular metaplasia
Tumors Transitional cell carcinomas arising in ureters 2. Infection
Rarely, benign tumor of fibroep. polyps 3. Increased risk of adenocarcinoma
Blood clots Massive hematuria from renal calculi, tumors or  Treatment: Surgical correction
papillary necrosis Miscellaneous Anomalies
Neurogenic Interruption of neural pathways to bladder
1. Vesicoureteral reflux
Extrinsic
Pregnancy Physiologic relaxation of smooth muscle or  Most common ad serious anomaly
pressure on ureters at pelvic brim from  Cause renal infection and scarring
enlarging fundus 2. Congenital vesicouterine fistulas
Periureteral Salpingitis, diverticulitis, peritonitis, sclerosing  Abnormal connections between the bladder and the vagina, rectum or
inflammation retroperitoneal fibrosis uterus
Endometriosis With pelvic lesions, followed by scarring
3. Patent urachus
Tumors Cancers of the rectum, bladder, prostate,
ovaries, uterus, cervix; lymphomas, sarcomas  Urachus: Canal that connects the fetal bladder with the allantois
o Note: Unilateral obstruction results from proximal causes; bilateral  Patency  Fistulous urinary tract that connects the bladder with the
obstruction results from distal causes umbilicus
o Sclerosing retroperitoneal fibrosis 4. Urachal cyst
 An uncommon cause of ureteral narrowing or obstruction  Lined by either urothelium or metaplastic gladular epithelium
 Characterized by a fibrosing proliferative inflammatory process  Cause: persistence of only the central region of urachus
encasing the retroperitoneal structures and causing hydronephrosis 5. Carcinomas
 Occurs in middle to late age  Mostly glandular tumors
 Causes:  Account for 0.1-0.3% of all bladder cancers, and 20-40% of bladder
a. Drugs (ergot derivatives, β adrenergic blockers) adenocarcinomas
b. Adjacent inflammatory conditions (vasculitis, diverticulitis, Crohn
disease) INFLAMMATIONS (Cystitis)
c. Malignant disease (lymphoma, UT carcinoma) Acute and Chronic Cystitis
d. Idiopathic (also Ormond disease)  Etiologic agents:
 Microscopic examination: Inflammatory fibrosis marked by 1. E. Coli (most common) 6. Cryptococcal agents
lymphocytic infiltration, with germinal centers, plasma cells and 2. Proteus 7. Schistosoma haematobium
eosinophils 3. Klebsiella 8. Viruses (eg. Adenovirus)
 Treatment: surgical extrication 4. Enterobacter 9. Chlamydia and Mycoplasma
5. Candida albicants
URINARY BLADDER  Predisposing factors
1. Bladder canaliculi
CONGENITAL ANOMALIES 2. Urinary obstruction
Diverticula 3. Diabetes Mellitus
 Consists of a pouchlike evagination of the bladder wall 4. Instrumentation
 Diameter: 1cm to 5-10 cm 5. Immune deficicency
 May arise as: 6. Radiation (Result to radiation cystitis)
1. congenital defects  Triad of symptoms
o Cause: Focal failure of development of the normal musculature or 1. Frequency (may be as much as once every 15 to 20 mins)
to some urinary tract obstruction during fetal development 2. Lower abdominal pain localized over the suprapubic region
2. Acquired lesions 3. Dysuria= pain or burning on urination
o Pathogenesis: Prostatic enlargement (hyperplasia or neoplasia)  Morphology:
Urine flow obstruction  Bladder wall thickening  ↑ 1. Acute cystitis
intravesical pressure  Bladder wall outpouching  Diverticula o Comprise most cases of cystitis
formation o Gross: Hyperemia of the mucosa; sometimes with exudate
o Frequently mutliple and located between the interweaving o Hemorrhagic cystitis
hypertrophied muscle bundles  Cause: cytotoxic antitumor drugs (ie. Cyclophosphamide),
 Complications: adenovirus
1. Infection  Stasis 2. Chronic cystitis
2. Formation of bladder calculi  Stasis o Due to the persistence of the infection
3. Vesicoureteral reflux  Impingement on the ureter o Differs from the acute form in the character of inflamm infiltrate

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 o Follicular cystitis  Adenocarcinoma
 Characterized by the aggregation of lymphocytes into lymphoid  Small cell carcinoma
follicles within the bladder mucosa and underlying wall  Sarcomas
 Not necessarily associated with infection
Urothelial (Transitional) Tumors
o Eosinophilic cystitis
WHO/ISUP Grades (2004) WHO Grades (1974)
 Characterized by infiltration with submucosal eosinophils ▫ Urothelial ▫ Urothelial
 Typically represents nonspecific subacute inflammation papilloma papilloma
Rarely a manifestation of systemic allergic disorder ▫ Urothelial ▫ Urothelial
neoplasm of low malignant neoplasm of low malignant
Special Forms of Cystitis potential potential
 Interstitial Cystitis (Hunner Ulcer) ▫ Papillary ▫ Papillary
o Persistent, painful (dysuria), chronic urothelial carcinoma, low grade urothelial carcinoma
o Women ▫ Papillary ▫ Grade 1,
o Early (Nonclassic): submucosal hemorrhages are urothelial carcinoma, high grade 2, 3
present
o Late (Classic): localized ulceration (Hunter ulcer), with  Papillary to nodular or flat
inflammation and fibrosis of all layers  Red elevated excrescences 1-5 cm
o Mast cells are present  lateral or posterior wall at bladder base
o Biopsy to rule out carcinoma  Men>women
 50-80
 Malacoplakia  Factors: smoking, arylamines, schistosoma
o Chronic bacterial cystitis hematobium, analgesics, cytophosphamide, radiation
o Soft, yellow, slightly raised mucosal plaques  Chromosome 9 monosomy, deletions 9p, 9q, 17p,13q,
o Large foamy macrophages/ histiocytes (with PAS- 11p, 14q
positive granules), multinucleated giant cells, lymphocytes
o Michaelis-Gutman bodies – mineralized concretions; Mesenchymal tumors
targetoid intracellular structures; represent incompletely digested  Leiomyoma
bacteria  Sarcomas
o Also occur in lungs, bones, colon, kidney, prostate and o embryonal rhabdomyosarcoma – infancy and childhood
epididymis; associated with immunosuppression o Leiomyosarcoma – adults
o E. coli – most common causative agent  Secondary tumors
o Cervix, uterus, prostate, rectum
 Polypoid Cystitis
o Indwelling catheters OBSTRUCTION OF THE BLADDER
o Broad, bulbous projections  Males – nodular hyperplasia or carcinoma
 Females – cystocele
METAPLASTIC LESIONS  Less common:
 Cystitis Glandularis (metaplasitc cuboidal or o Congenital urethral narrowing or strictures
columnar epithelium) & Cystitis Cystica (cystic spaces) o Inflammatory strictures, fibrosis, contraction
- resembles intestinal mucosa, with goblet cells (intestinal o Growths in perivesical structures
metaplasia) o Foreign body, calculi
- incidental findings in normal bladders, but are prominent in o Injury to innervation
inflamed and chronically irritated bladders
- not associated with increased risk for adenocarcinoma
 Squamous Metaplasia URETHRA
 Nephrogenic Metaplasia (Nephrogenic
Adenoma) INFLAMMATIONS
o Broad, bulbous projections
 Gonococcal
o Response to injury
 Nongonococcal urethritis – E. coli, Chlamydia
o Transitional-like – cuboidal epithelim, papillary growth
pattern Tumor and tumor-like conditions
o Tubular proliferation in the lamina propria and superficial  Urethral caruncle
detrusor muscle = mimic carcinoma!  Squamous, transitional papillomas, condylomas
 Intestinal Metaplasia  Carcinoma – transitional or squamous
NEOPLASMS
 Urothelial (transitional cell) tumors – 90% of
MALE GENITAL SYSTEM
all bladder tumors (remainder: mesenchymal)
 Penis
- many are multifocal at presentation
 Testis, Epididymis and Vas Deferens
o Inverted papilloma
 Prostate
o Papilloma (exophytic) PENIS
o Urothelial tumors of low malignant potential
o Papillary urothelial carcinoma
CONGENITAL ANOMALIES
o Carcinoma in situ
 Congenital absence (aphalia)
 Squamous cell carcinoma  Hypoplasia (micropenis) to hyperplasia
 Mixed carcinoma

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 Duplication
 Aberrations in size and form (curved) TESTIS

Hypospadias
 Malformation of urethral groove and urethral canal creating an abnormal CONGENITAL ANOMALIES
opening on the ventral surface  Cryptorchidism – 1% 1 year old boys
 Anorchism
Epispadias  Monorchism
 Malformation of urethral groove and urethral canal creating an abnormal  Polyorchism
opening on the dorsal surface
Cryptorchidism
Phimosis  Complete or incompletely undescended testis
 Orifice of the prepuce is too small to permit its normal retraction  Cause is poorly understood
 Hormonal?
Paraphimosis
 Part of trisomy 13
 When the phimotic prepuce is forcibly retracted over the glans penis,
 Asymptomatic
marked constriction and subsequent swelling may block the replacement
 > risk testicular CA
of the prepuce
REGRESSIVE CHANGES
MECHANICAL TRAUMA AND HEMODYNAMIC DISORDERS
Atrophy
 Direct force
 Causes:
 Blunt trauma
o Progressive atherosclerotic narrowing of the blood supply in old age
o End stage of inflammatory orchitis
Priapism – persistent erection, congestion and pain
o Cryptorchidism
INFLAMMATORY LESIONS o Hypopituirism
o Generalized malnutrition or cachexia
Balanoposthitis o Obstruction of the semen
 Non-specific infection of the glans and prepuce caused by a wide variety o Irradiation
of organisms: o Prolonged administration of female hormones
o Candida o Exhaustion – high FSH
o Anaerobic bacteria
o Gardnerella INFLAMMATIONS
o Pyogenic bacteria Orchitis
 Poor hygiene  Duration: Acute or chronic
 Smegma – desquamated cells, debris, sweat  Etiology: Bacterial, Viral, Fungal, Protozoal or Parasitic
 Route: Ascending, Hematogenous, Lymphatic, Transcutaneous
NON-INFECTIOUS INFLAMMATORY LESIONS  Morphology: Suppurative, Interstitial, granulomatous or fibrotic
 Sclerosing lipogranuloma (Paraffinoma)
o Subcutaneous nodules on the shaft of the scrotum Epididymoorchitis
 Plastic induration of the Penis (Peyronie’s disease)  Causes:
o Fibromatosis of unknown origin o Sexually Transmitted
 Balanitis xerotica obliterans  N. gonorrhoea
o Atrophy of the epidermis of the glans and prepuce and a band  T. pallidum
lymphatic infiltrates in the underlying connective tissue o Uropathogens
 E. coli
TUMORS  Mixed flora
o Mycobacteria
Benign  M. tuberculosis
 Condyloma accuminatum – HPV 6, 11  M. leprae
Malignant o Rare blood borne pathogens
 Carcinoma in situ  H. influenza
o Bowen disease  Salmonella spp.
- >35 yo  Brucella spp.
- Solitary plaque shaft or glans velvety plaques (Erythroplasia of o Fungi
Queyrat)  Histoplasma capsulatum
- 10% malignancy  Blastomyces dermatitis
o Bowenoid papulosis  Coccidioidesimmitis
- Sexually active young adults o Parasites
- Multiple reddish brown  Wuchereria bancrofti
- Never develop into CA  Schistosoma hematobium
 Squamous cell carcinoma  Echinococcus granulosus
o <1% male cancers in US vs 10-20% in Asia, Africa, South America o Viruses
o Circumcision protects  Mumps virus
 Adenovirus
o HPV 16 and 18
 Coxsackie virus B
o Cigarette smoking  Cytomegalovirus
o 40-70 yo o Idiopathic or immune

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  Sarcoidosis  Smaller
 Malakoplakia (granulomatous orchitis)  Variegated poorly demarcated, hemorrhagic, necrotic
 Alveolar or tubular
Specific Inflammations  Patterns, papillary convolutions
 Gonorrhea – extension of infection from posterior urethra to the prostate,  (+) HCG, AFP
seminal vesicles and epididymis
 Mumps – systemic viral infection that affects school age children Yolk Sac Tumor
o 20-30% develops orchitis  Infantile embryonal carcinoma, endodermal sinus tumor
o One week following onset of parotitis  Infants- 3yo- most common testicular tumor
o Unilateral in 70% of cases  Very good prognosis
 Tuberculosis > epididymis  Non encapsulated, homogenous yellow white mucinous
 Syphilis > testis  Lace-like network of cuboidal or elongated cells
o 2 morphological patterns  Schiller-Duval bodies
o Production of gummas  (+) AFP, α1-antitrypsin globules
o Diffuse interstitial inflammation characterized by edema and lymphocytic
& plasma cell infiltrates Mixed Tumor
 60%
Granulomatous (Autoimmune) Orchitis  Teratoma + embryonal ca + yolk sac
 Unilateral testicular enlargement  Seminoma + embryonal
 Sudden onset with fever  Embryonal + teratoma
 Painless  Clinical Features:
o Nonseminomatous germ cell tumors (NSGCT) 60% present with
Non specific Epididymitis advance stage
 Uncommon in children: Gram negative rods o Hematogenous metastasis more frequent
 Sexually active men < 35 years old: C. trachomatis and N. gonorrhoea o Radioresistant
 Sexually active men > 35 years old: E. coli and Pseudomonas o Poorer prognosis

TUMORS Sex Cord-Stromal Tumors

 Leydig cell tumor: androgen and estrogen
Spermatic cord and Paratesticular Tumors o Gynecomastia
 Lipomas – retroperitoneal adipose tissues o Testicular swelling
 Adenomatoid tumor – small nodules, upper pole epididymis, may be
 Sertoli cell tumor
minimally invasive
o Sertoli cells or granulose cells
 Rhabdomyosarcomas – children
o Precocious masculinization, feminization
 Liposarcoma – adults
o Occasional gynecomastia
Testicular Tumors  Gonadoblastoma
 Germ cell tumors – 95%  Testicular lymphoma: commong age 60
 Nongerminal Tumors – sex cord or stroma
Miscellaneous Lesions of the Tunica Vaginals
 Germ cell tumors – single 40% or mixed 60%
 Tunica Vaginalis: serosa lined sac immediately proximal to the
o Originate from intratubular germ cell neoplasia (ITGCN)
testis and epididymis
o Cryptorchidism, prior germ cell tumors, strong family history, androgen
 Hydrocoele: serous fluid may accumulate from neighboring
insensitivity syndrome, gonadal dysgenesis
infection and tumors often spontaneously and without apparent
cause
Germ Cell Tumors
 Hematocoele
 Seminoma
o presence of the blood in tunica vaginalis
 Spermatocytic seminoma
o direct trauma to the testis
 Embryonal Carcinoma
o torsion
 Yolk sac (endodermal) sinus tumor
 Chylocele: accumulation of lymph in the tunica vaginalis
 Choriocarcinoma
 Teratoma PROSTATE
Seminoma
 Most common 50% INFLAMMATIONS
 30’s  Acute bacterial prostatitis
 Ovary = dysgerminoma  Chronic bacterial prostatitis
 Classic type or spermatocytic  Chronic abacterial prostatitis
Prostatitis
 Bulky masses
 15 leukocytes/ HPF in prostatic secretions obtained by transrectal
 Homogeneous gray whit alcohol
prostatic massage
 Sheets of uniform cells divided into poorly demarcated lobules by
 Bacterial
delicate septa
o Bacterial growth is > t log higher than urethral & bladder urine
 (-)AFP, HCG, (+) PLAP
culture
Embryonal Carcinoma  Abacterial
o Culture is negative despite unambiguous evidence of prostate
 20-30 yo
inflammation
 More aggressive
Acute Bacterial Prostatitis

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 Acute focal or diffuse suppurative inflammation in prostate substance
 E. coli, Enterococci and Staphylococcus
Chronic Bacterial Prostatitis
 Low back pain, dysuria, perineal & suprapubic discomfort
 Asymptomatic
 Recurrent UTI (cystitis, urethritis)

HYPERPLASIA
Nodular Hyperplasia (Benign Prostatic Hypertrophy)
 Common in men >50 yo
 Formation of large discrete nodules in the periurethral region in prostate
 20% in men > 40 yo
 70% > 60 yo
 90% > 80 yo
 Etiology
o Unknown
o DHT
o Derived from testosterone by the action of 5a reductase
o With aging DHT accumulates in the prostate
 60- 100 grams up to 200 grams
 McNeal “preprostatic region”
o Proximal to the veromontanum
o Corresponds to the periurethral portion of the classical middle and
lateral lobes
TUMORS
 Mostly adenocarcinoma- acinar
 Less common
 Ductal adenocarcinoma
 Colloid carcinoma
 Urothelial cancer from the bladder
 Mesenchymal- lymphomas
Adenocarcinoma
 Most common form of cancer in men
 2nd leading cause of cancer death
 > age 50
 Initial screening- 40 yo
 Age, race, family history, hormonal levels, environmental influences
 Minority with Androgen receptor mutation
 Hypermethylation of gluthatione-S- transferase (GSTP1) gene promoter
– 90%
Grading and staging
Gleason system
 5 grades: Grades 1-5 MERRY CHRISTMAS and HAPPY NEW YEAR from the Patho-Team! 
 Glandular pattern and degree of differentiation Have a maeningful holiday!
 Combined Gleason grade or score of 2 numeric grades; well
differentiated
o 2 = well differentiated
o 10 = least differentiated
 Grade + stage = best marker predicting prognosis

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