Systemic Pathology

SBD2214

PATHO OF MALE REPRO. SYS.

& STD
AZRINA ZAINAL ABIDIN
 Learning Outcome
1. Explain individually the pathogenesis of the
diseases related to male reproductive system .
2.Clarify individually the pathological findings
based on the symptoms and lab finding of
patient.
3.Determine specifically the methods of
diagnosing and treatment of the diseases.
4.Differentiate individually the diseases in
reproductive system based on the pathological
findings and history of patient.
5.Identify microscopically the abnormal slide of
reproductive.
MALE Reproductive System Overview

Purpose
To produce, maintain, and transport
sperm (the male reproductive cells)
and protective fluid (semen)
To discharge sperm within the female
reproductive tract during sex
To produce and secrete male sex
hormones responsible for maintaining
the male reproductive system
 CRYPTORCHIDISM
TESTICULAR TORSION
BENIGN PROSTATIC HYPERPLASIA
CRYPTORCHIDISM
 CRYPTORCHIDISM :Intro
One or both testicles fail to move into the scrotum
before birth.

Increased likelihood of developing cancer,

regardless of whether or not they are brought down
into the scrotum.

Bringing the testicle into the scrotum maximizes

sperm production and increases the odds of good
fertility.
CRYPTORCHIDISM :Symptoms

There are usually no

symptoms, except that
the testicle cannot be
found in the scrotum.
Adult males with an
undescended testicle may
have problems with
infertility.
CRYPTORCHIDISM : Predisposing factors
Prematurity,
Low birth weight,
Small size for gestational age,
Twinning,
Maternal exposure to
estrogen during the first
trimester.
CRYPTORCHIDISM : Etiology
1. Differential body growth relative to spermatic
cord/gubernaculum.

2. Increased abdominal pressure.

3. Hormonal factors, including testosterone and extrinsic

estrogen.

4. Development/maturation of the epididymis.

5. Gubernacular attachment.

6. Genitofemoral nerve/calcitonin generelated peptide

(CGRP).
 CRYPTORCHIDISM : Diagnosis
Physical exam:
feel the undescended testicle in the abdominal wall
above the scrotum.
Lab test
LH testing & FSH testing

Testosterone level testing before and after

stimulation with hCG: If both elevated basal
gonadotropin levels and a negative testosterone
response to hCG stimulation are observed, then
congenital bilateral anorchism is suggested.
CRYPTORCHIDISM : Treatment
Usually the testicle will descend into the scrotum
without any intervention during the first year of life.
If this does not occur, the child may receive
hormone injections (B-HCG or testosterone) to try to
bring the testicle into the scrotum.
Surgery (orchiopexy) is the main treatment.
Earlier surgery may prevent irreversible damage to
the testicles. This damage can cause infertility.
 HCG
The action of hCG = pituitary LH.
(stimulates production of gonadal steroid hormones
by stimulating the Leydig cells to produce
androgens).
Distally located testes in older boys are more likely to
descend in response to hormonal treatment than
abdominal testes.
Adverse effects : increased scrotal rugae,
pigmentation, pubic hair, and penile growth, which
regress after treatment cessation.
 CRYPTORCHIDISM : Complication
If one or both testicles do not descend, a man
may be infertile later in life.

Men who have an undescended testicle at birth

are at higher risk of developing testicular cancer
in both testes.

Surgery to correct the problem may result in

damage to the testicle.
 MEDICAL
EMERGENCY!!
Case Study
10 yr old male
CC: acute sudden onset of Left
testicular pain waking him from
sleep
Pain:
constant
no change with position
No Hx of trauma
Other Sx:
No dysuria
No fever/No chills
No nausea/vomiting
Clinical Examination
A febrile
moderate distress 2ndary to L
scrotal pain
L hemiscrotum edematous &
erythematous
L testicle = transverse lie + marked
tenderness to palpation
Absent cremasteric reflex on L
R hemiscrotum & testicle normal on
exam
circumcised penis = N + no urethral
discharge
Investigations
CBC & urinalysis = N (this results in an unnecessary delay of one
hour)
Color Doppler ultrasound of scrotum =
absence of blood flow to L testicle and epididymis
N blood flow to R testicle
No testicular masses
Treatment/Recovery
An emergent urological consult is obtained
IMMEDIATE SURGERY Scrotal exploration
reveals a 720 degree torsion of the left spermatic cord,
an ischemic testicle
a "bell-clapper" deformity
DETORTION:
L testicle's normal color returns
L testicle : "fixed" to scrotal wall
(prevents retorsion)
R testicle : also fixed to scrotal wall
Postoperatively,
pain markedly relieved with detorsion
of L testicle
remainder of recovery unremarkable
Bell Clapper Deformity
Risk Factors

Increase in testicular volume (puberty)

testicular tumor
testicles with horizontal lie
spermatic cord with long intrascrotal portion
Cryptorchidism (one or both testes)
Strenuous exercise
Diagnosis is
CRITICAL!!
 Testicular Torsion
Initially obstructs
venous return

Equalization of venous and

arterial pressures
As soon as
4 hours!!
Compromised arterial flow

TESTICULAR ISCHEMIA
Testicular PAIN!
16-42% acute scrotal pain

TESTICULAR TORSION

NOT something you want to miss!!!

 Epididymitis/ Incarcerated
Orchitis Hernia

Differential
Diagnosis
Torsion of
Varicocele Idiopathic
Appendix Testis Scrotal Edema
Clinical Examination
Epididymitis: edematous , orange
peel (late), possible pyuria

Appendix Testis: hard, tender nodule

(2-3mm) on upper pole of testicle,
BLUE DOT sign, edema, epididymis
remains posterior

Scrotal Edema: develops rapidly

obscuring physical exam findings
Clinical Examination (cont)
Testicular Torsion:
PAIN in scrotum: often described as sharp and
debilitating
No necessary precipitant event
Scrotal erythema and edema
Associated irritative voiding Sx, burning on
urination, urethral discharge of note: urinalysis
and culture = Normal with early course of
testicular torsion
Possible Nausea/Vomiting
Lightheadedness
Clinical Examination (cont)
Testicular Torsion:
Epididymis: medially, laterally or anteriorly
(depends on degree of torsion) one side

Spermatic cord shortens as it twists

higher appearing testis

STRONG EVIDENCE
OF TORSION
 Clinical Examination (cont)
Testicular Torsion: NO Cremasteric Reflex (most
sensitive finding; 99%) if testicle moves 0.5 cm = +ve
Testicle:
Hard
Fixed to dartos & scrotal wall
Larger than unaffected side
(due to congestion of blood)
Prehns sign negative
Diagnostic Modalities

Imaging:
ONLY IF
SUSPICION FOR
TORSION =LOW

Doppler Ultrasound
Faster Radionuclide Testing
More available More sensitive

Surgical Exploration
Evaluation of Acute Scrotal Pain
 Treatment
Rapid restoration of blood flow: CRITICAL
Manual detorsion = quick, noninvasive treatment rotate
testicle away from midline 180 degrees (done with IV
sedation) document return of blood flow relieves problem
acutely, however elective orchipexy still recommended

open book

DONT DELAY SURGICAL CONSULT!!! only definitive

resolution of torsion

DONT MISS THE DIAGNOSIS

Most Significant Complication
Loss of testis may lead to infertility
Common Causes of loss of testis:
58%: DELAY in seeking medical attention
29%: INCORRECT initial DIAGNOSIS
13%: DELAY in TREATMENT at hospital!
BENIGN PROSTATE
HYPERPLASIA ( BPH )
 BPH : INTRO
Hyperlasia-abnormal in cell
BPH- noncancerous cell growth of the prostate
gland
Known also as benign prostatic hypertrophy
As man matures, prostate undergoes 2 main
periods of growth.
1st phase- early in puberty, when the prostate
doubles in size.
2nd phase- at around age 25, the gland begins to grow
again. This often results, years later, in BPH.
 BPH : RISK FACTOR
Age
Family History- >3
Ethnic Groups-African American men
are at higher risk and Asian men at
lower risk for BPH than Caucasians
Medical Conditions-obesity, heart and
circulatory diseases, and type 2 diabetes
Married man more common than
unmarried
 BPH : ETIOLOGY
Exact cause is not known
Androgens
Testosterone, dihydrotestosterone(DHT) play
permissive role-stimulate cell growth
Estrogens
Estrogen level (free testosterone ).
Stromal-epithelial interactions
Paracrine growth factor signaling
Cell proliferation
Apoptosis
Inflammatory cells in the prostate
Smooth muscle controlled by adrenergic nerves
Nervous supply has a permissive role and allows for
maximal growth
 BPH : CLINICAL FEATURES

About 1 in 3 men aged over 50 enlargement

of prostate
Narrowing of first part of urethra
Obstructive symptoms
Poor stream
Hesistancy
Dribbling
Incomplete voiding
Frequency
Urgency
 PATHOLOGY /
HISTOLOGICAL FINDING
NORMAL PROSTATE GLAND
BPH : Pathological Finding
Pathological changes
Nodular
Smooth
2 4 weight from normal
weight
Fibromuscular tissue/
gandular

Histological changes
Double-layered
epithelium
Papillary infoldings
Corpora amylacea
 BPH : Diagnosis

Digital rectal exam

Urine analysis
Prostate-specific Antigen (PSA) blood
test
Urinary flow test
Post-void residual volume test
Ultrasound
Urodynamic studies
Cytoscopy
Intravenous pyelogram or CT urogram
Retrograde pyelography
 BPH : Treatment

Watchful waiting
Medical treatment
Surgery
STDs
 INTRODUCTION
A. Bacterial, viral (considered incurable), parasitic,
fungal
B. Incidence: WHO estimates 250 million cases/year
C. On the rise because
1. Increased premarital sex with multiple partners
2. Increased divorce rate
3. Non-monogamy among married persons
4. Bisexuality
 All causes = behaviors
1. Prevention = behavioral modification
2. Behavioral modifications suggested by above
a. Abstinence until monogamous
relationship
b. Maintain monogamy
c. Barrier protection is next best choice
 Gonorrhea
1. Patho
a. 15-29 y/o women at greatest risk
b. Transmission by epithelial contact
c. Perinatal transmission during monitoring,
birth, or post birth
2. Manifestations:
May be asymptomatic; S/s include: inflammation of
urethra, cervix, throat, & eyes; anorectal infection,
mucopurulent discharge
3. Complications:
epididymitis, lymphangitis, salpingitis or PID
(most common local complication in
women), infertility, bacteremia, neonatal
blindness

4. Rx:
Resistant strains & accompanying chlamydial
infections impact rx
 Chlamydia trachomatis

1. At risk = young heterosexuals with multiple partners

who have a gonococcal infection and are lower socio-
economic status; also at risk are black females who
are pregnant or using oral contraceptives
2. Patho can create permanent scarring with resulting
infertility in women
a. Chlamydia enters and reproduces within epithelial cells
b. With cell rupture, new organisms released to invade other
cells
3. Manifestations: purulent discharge, inflammation of
genitalia, urethra, rectum; newborn conjunctivitis and
pneumonia, tender lymph nodes
 Syphilis
1. Incidence
a. Epidemic since the mid-80s
b. Greatest increase in black heterosexuals
c. Associated with crack-cocaine use
2. Pathology
a. Transmitted via sexual intercourse during
early disease stage
b. 50% of exposure to someone with early
disease will contract it
c. Maternal-fetal transmission
3. Manifestations
a. Primary = local non-painful chancre at site
b. Secondary = systemic involvement with rash
and lymphadenopathy; macular to pustular
skin lesions that are highly infective
c. Latent syphilis = no clinical symptoms
d. Tertiary = destructive lesions of skin, bone,
and soft tissue (called gummas) caused by
hypersensitivity
e. Congenital: dental deformities, destructive
bone lesions; late stage is rare and appears as
tertiary syphilis in puberty
4. Complications: CV and
neuro destructive lesions
5. Rx = penicillin; syphilis has
not developed resistance
 AIDS (HIV)

1. Incidence
a. Highest risk = homosexual and bisexual
men
b. Heterosexual transmission: 25% of cases
in women are via heterosexual contact; by
2000, 90% of AIDS transmission will be
heterosexual
2. Pathology
a. Blood & body fluid transmission (incl. prenatal,
perinatal, & breast-feeding)
b. Virus attaches to CD4 antigen on T-helper cell
surface & inserts RNA
c. RNA converted to DNA and incorporated in cell
DNA where may remain latent for years
d. HIV makes copies of itself within the cell which
are then released from cell
e. Average time of infection to AIDS = 10 years
f. Infected person may be seronegative because of
depressed immune system
2. Manifestations : depressed immune
system, opportunistic infections,
malignancies
3. Rx : focuses on 2 aspects: Restoring
immune function & Preventing viral
replication