Male genital tract 1
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This ppt part-1 of UG lectures on Male genital tract pathology for MBBS students.
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Male genital tract 1
- 1. Male Genital Tract Pathology- 1 Dr.CSBR.Prasad, M.D.
- 3. CONGENITAL ANOMALIES • Cryptorchidism (Undescended testes ) • Synorchism (Fused testes) CSBRP-Dec-2016
- 4. Cryptorchidism (Undescended testes) CSBRP-Dec-2016 • Frequency:1% (at the end of 1st year) • Bilateral in 25% • May be associated with: • GUT abnormalities – Hypospedias • Testicular descent: – Transabdominal phase • Müllerian-inhibiting substance – Inguinoscrotal phase • Androgen induced release of Calcitonin gene related peptide from genitofemoral nerve
- 5. Histology: • Arrest in maturation of germ cells • Hyalinization of basement membrane • Prominent Leydig cells • Paucity of germ cells is also seen in the contralateral descended testis CSBRP-Dec-2016 Cryptorchidism (Undescended testes)
- 7. The seminiferous tubules in this cryptorchid testis are completely atrophic. CSBRP-Dec-2016
- 8. Complications: – Sterility – Inguinal hernia – Testicular cancers – Prone for trauma (inguinal testis) Surgical correction: (Orchiopexy) – Before 2years of age – for fertility – Before 10yrs of age – for protection against cancer CSBRP-Dec-2016 Cryptorchidism (Undescended testis)
- 9. • When you are faced with intriguing intraabdominal / retroperitoneal tumor, always examine the scrotum / testis REMEMBER • Scrotum is 10th compartment of abdomen • Abdominal examination is never complete without scrotal examination CSBRP-Dec-2016 Pathology Pearls
- 10. Torsion - TestisTorsion - Testis Twisting of spermatic cord with occlusion of veins and patent arterial supply – results in vascular engorgement and hemorrhagic infarction Two types: neonatal, adult (seen in adolescents) Anatomic defect: testis exhibits increased mobility (bell- clapper abnormality) Should be untwisted within 6hrs to restore viability CSBRP-Dec-2016
- 11. Torsion - TestisTorsion - Testis CSBRP-Dec-2016
- 12. This testis has undergone infarction following testicular torsion. CSBRP-Dec-2016
- 14. Testicular torsion: In this case, the condition has proceeded to hemorrhagic infarction. Note the outlines of the tubules remaining, but there is loss of nuclear detail, and the interstitium is hemorrhagic. CSBRP-Dec-2016
- 15. Testicular atrophy Atherosclerosis Inflammatory lesions (Orchitis) Cryptorchidism Hypopituitarism Malnutrition Irradiation Excessive Estrogens: Antiandrogens in Tx of prostatic cancer Cirrhosis of liver CSBRP-Dec-2016
- 16. Note that the testis on the left is small and pale white while the opposite testis appears normal. The left testis did not descend into the scrotum during development, but remained in the abdomen, a condition called a cryptorchid testis. CSBRP-Dec-2016
- 17. On the left is a normal testis. On the right is a testis that has undergone atrophy. CSBRP-Dec-2016
- 18. Here is another example of focal atrophy of seminiferous tubules along with a few residual normal tubules in which there is active spermatogenesis. There is focal atrophy of the testicular tubules seen here. The most common infectious cause for this finding is mumps orchitis. CSBRP-Dec-2016
- 19. HydroceleHydrocele • Accumulation of serous fluid in tunica vaginalis • No apparent cause • Mistaken for tumors • Transillumination is positive CSBRP-Dec-2016
- 20. Upon physical examination, the scrotum appears enlarged. This enlargement is not painful, and there is no firm mass palpable. The enlargement is due to a fluid collection around the testis known as a hydrocele. CSBRP-Dec-2016
- 21. One diagnostic technique to detect a hydrocele is transillumination of the fluid-filled space with a light applied to the scrotum. The fluid will transmit the light, while a solid mass will not. CSBRP-Dec-2016
- 22. There is scrotal enlargment with fluid density from a hydrocele on the right. A hydrocele is a painless collection of clear fluid around the testis. Hydroceles generally develop over years. CSBRP-Dec-2016
- 23. A large hydrocele of the testis.A large hydrocele of the testis. CSBRP-Dec-2016
- 24. CSBRP-Dec-2016
- 25. A cross section through a frozen hydrocele demonstrates the relationship of the fluid to the testis. The fluid in a hydrocele accumulates slowly but can produce a mass effect and discomfort. CSBRP-Dec-2016
- 27. VaricoceleVaricocele • Prominent dilation of the pampiniform plexus of veins posterior to the testis • The increased blood flow increases the temperature of testicular tubules, thus inhibiting spermatogenesis • One possible cause for infertility is a varicocele CSBRP-Dec-2016
- 28. Varicocele, a lesion that consists of a prominent dilation of the pampiniform plexus of veins posterior to the testis. CSBRP-Dec-2016
- 29. Acute LEFT varicocele RCC growing into renal vein causes obstruction to left testicular vein which drains into it, there by causing engorgement of left pampiniform plexus. CSBRP-Dec-2016 Pathology Pearls
- 30. Name some tumors that enter the major vessels and even reach right side of the heart? Renal cell carcinoma Hepatocellular carcinoma CSBRP-Dec-2016 Pathology Pearls
- 32. CSBRP-Dec-2016
- 33. CSBRP-Dec-2016
- 34. Granulomatous orchitis • Seen in middle aged men • Unilateral testicular enlargement • Usually tender • Granulomas confined to seminiferous tubules (cf: TB orchitis) – Probably autoimmune CSBRP-Dec-2016
- 35. CSBRP-Dec-2016
- 36. CSBRP-Dec-2016
- 38. Tuberculosis almost invariably begins in the epididymis and may spread to the testis Syphilis, primarily involves the testis Pathology Pearls CSBRP-Dec-2016
- 39. CSBRP-Dec-2016
- 41. Contact: Dr.CSBR.Prasad, M.D., Professor of Pathology, Sri Devaraj Urs Medical College, Kolar-563101, Karnataka, INDIA. CSBRPRASAD@REDIFFMAIL.COM CSBRP-Dec-2016
Editor's Notes
- Atrophic testis is demonstrated here. Note the marked loss of germ cells with remaining tall pink Sertoli cells, peritubular fibrosis, and interstitial fibrosis. If generalized, this is a cause for infertility. About half the time when infertility occurs in couples wanting children, the cause is a problem in the male genital system.
- The seminiferous tubules in this cryptorchid testis are completely atrophic. If the testis does not assume its extra-abdominal position, then it will not function properly. Spermatogenesis must occur at a temperature a couple of degrees cooler than the rest of the body. A cryptorchid testis will not function to produce sperm. Unilateral cryptoorchidism leads to a decreased sperm count, but infertility is unlikely, because the other testis is functional. There is a long term risk in a cryptorchid testis for malignancy--usually a seminoma. In childhood, an orchiopexy procedure can be done (recommended before the age of 2) and the testis placed in the proper position, and most of the time the testis will function. Following puberty, it is unlikely that a cryptorchid testis will have spermatogenesis function.
- Testicular salvage is most likely if the duration of torsion is less than 6-8 hours. If 24 hours or more elapse, testicular necrosis develops in most patients. Manual detorsion is contraindicated if the duration of torsion is more than 6 hours.
- Failure of normal posterior anchoring of the gubernaculum, epididymis and testis is called a bell clapper deformity because it leaves the testis free to swing and rotate within the tunica vaginalis of the scrotum much like the gong (clapper) inside of a bell. Twisting of the testis on the axis of the spermatic cord is called spermatic cord torsion. The twisting causes edema of the spermatic cord resulting in obstruction of the lymphatic, then venous and finally arterial vessels to the testis. When the arterial supply is impaired, testicular ischemia results. If a boy has had pain and swelling for 8 hours due to spermatic cord torsion, there is a 50% chance that the testis will be lost. Therefore, prompt diagnosis and treatment are very important.
- This testis has undergone infarction following testicular torsion. Torsion is an uncommon condition, but is a medical emergency. It occurs when twisting of the spermatic cord cuts off the venous drainage, leading to hemorrhagic infarction. Greater mobility from incomplete descent or lack of a scrotal ligament predisposes to this condition. Immediate treatment by surgically untwisting and suturing the cord in place to prevent future torsion will prevent infarction. Sometimes, just the little appendix testis undergoes torsion. ----------------------- Prevalence: 1/125 males. Torsion occurs most commonly in boys age 13 to 17 years. There is also an increased incidence in neonates. However, it can occur at any age and it is the most common cause of acute scrotal pain and swelling in boys from birth through age 18. It is not clear why spermatic cord torsion, caused by the congenital bell clapper deformity, often occurs years after development is complete. Diagnosis: Torsion should be suspected in any boy with acute scrotal/testicular pain. The testis and scrotum are swollen, tender and erythematous. Normal landmarks (epididymis) may not be palpable because of the swelling. These same symptoms and signs, however, can be found in males with epididymitis, orchitis or torsion of a testicular appendage. Non-invasive tests (radioisotope testis scan, color doppler ultrasound) have shown a high sensitivity in detecting perfusion to the testis. However, obtaining these tests takes precious time during which the testis may be lost. Therefore, non-invasive tests should be performed in boys with an acute scrotum in whom torsion is not deemed likely. Treatment: urgent scrotal exploration. If the testis, when untwisted, shows signs of perfusion, scrotal orchiopexy is performed by placing three permanent sutures to anchor the testis to the deep scrotal layers, preventing further twisting. If the testis shows no perfusion, orchiectomy should be performed. Because the defect can be present bilaterally, the contralateral testis must also be anchored.
- Testicular torsion. In this case, the condition has proceeded to hemorrhagic infarction with no viable seminiferous tubules remaining. Note the outlines of the tubules remaining, but there is loss of nuclear detail, and the interstitium is hemorrhagic.
- Here is another reason for testicular atrophy. Note that the testis on the left is small and pale white while the opposite testis appears normal. The left testis did not descend into the scrotum during development, but remained in the abdomen, a condition called a cryptorchid testis. Such a testis not only fails to have spermatogenesis, but carries an increased risk for neoplasia--a seminoma.
- On the left is a normal testis. On the right is a testis that has undergone atrophy. Bilateral atrophy may occur with a variety of conditions including chronic alcoholism, hypopituitarism, atherosclerosis, chemotherapy or radiation, and severe prolonged illness. A cryptorchid testis will also be atrophic. Inflammation may lead to atrophy. Mumps, the most common cause for orchitis, usually has a patchy pattern of involvement that does not lead to sterility.
- Here is another example of focal atrophy of seminiferous tubules along with a few residual normal tubules in which there is active spermatogenesis. There is focal atrophy of the testicular tubules seen here. The most common infectious cause for this finding is mumps orchitis. Mumps infection may be complicated by orchitis in a fourth to a third of cases. In general, the orchitis is unilateral and patchy so that sterility following infection is uncommon.
- Here is a large hydrocele of the testis. Such hydroceles are fairly common. Clear fluid accumulates in a sac of tunica vaginalis lined by a serosa with a variety of inflammatory and neoplastic conditions. A hydrocele must be distinguished from a true testicular mass, and transillumination may help, because the hydrocele will transilluminate but a testicular mass will be opaque.
- Fig. 18.143 Outer appearance of hydrocele. The wall is translucent and the content had a serous quality.
- One possible cause for infertility is a varicocele, a lesion that consists of a prominent dilation of the pampiniform plexus of veins posterior to the testis. The increased blood flow increases the temperature of testicular tubules, thus inhibiting spermatogenesis.
- Fig. 18.144 Idiopathic calcinosis of scrotum. (Courtesy of Dr. Juan J. Segura, San Jose, Costa Rica) <https://www.google.co.in/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwimscqi1NzQAhVGPY8KHelHDagQjxwIAw&url=https%3A%2F%2Ftwitter.com%2Fwtfgifspics%2Fstatus%2F630865669207126016&psig=AFQjCNG5qvxbvKqKFSJ4i9N_brKqN_CU0Q&ust=1481013707703377>
- Fig. 18.145 Idiopathic calcinosis of scrotum, with accompanying foreign body-type giant cell reaction.
- Fig. 18.48 Gross appearance of granulomatous orchitis. The testis is increased in consistency, enlarged, and vaguely nodular.
- Fig. 18.49 Microscopic appearance of granulomatous orchitis. The inflammatory infiltrate is centered in the seminiferous tubules.
- Orchitis with epididymitis = TB Orchitis without epididymitis = Syphilis