Urology Quiz on Testicular Conditions

Penile Anatomy

• The penis has three cavernous bodies (corpora).
• The corpora cavernosa are two large spongy tissue beds.
• The corpus spongiosum is a smaller spongy tissue bed, surrounding the urethra.
• The tunica albuginea is a white connective tissue that surrounds the corpus cavernosa.
• Buck's fascia covers all three erectile structures.

Penis Physiology

• Key structures include arterioles and corpora.
• In a flaccid penis, cavernosal arterioles have high tone, leading to reduced blood flow.
• Erection (tumescence) involves smooth muscle relaxation, increasing blood flow into the corpora cavernosa, causing them to swell (sinusoids).
• Veins/venules are compressed, decreasing outflow.
• High inflow and low outflow result in increased intracorporeal pressure.
• Detumescence (loss of erection) is caused by smooth muscle contraction and increased venous outflow, making the corpora shrink.

Peyronie Disease

• Characterized by abnormal tunica albuginea, an acquired disorder.
• Likely results from trauma in a susceptible individual.
• Leads to localized fibrosis of the tunica albuginea.
• Symptoms include pain, nodule formation, and abnormal curvature during erection.
• Erectile dysfunction often accompanies the condition.
• Treatment includes Pentoxifylline, a phosphodiesterase inhibitor, which can reduce inflammation and prevent collagen deposition. Injection or oral administration is possible.

Penile Fracture

• Results from rupture of the tunica albuginea, often associated with urethral damage.
• Caused by blunt trauma.
• A clinical finding is an audible snap, followed by pain, swelling, and ecchymosis (bruising).

Priapism

• Characterized by a persistent erection lasting more than 2-4 hours, not associated with sexual activity.
• Ischemic priapism (95% of cases) is due to a lack of penile blood outflow, leading to tissue ischemia.
• Non-ischemic (high-flow) priapism involves a fistula between arteries and the corpus cavernosum, often following trauma.

Ischemic Priapism Etiology

• Failure of cavernosal outflow
• Two common causes: sickle cell disease and certain drugs.
• Veno-occlusion (blocked veins) is another underlying factor.
• Certain drugs (e.g., antipsychotics, antidepressants, alpha blockers, erectile dysfunction drugs) can contribute.

Ischemic Priapism Treatment

• Urologic emergency due to hypoxia and acidosis of penile blood.
• Can lead to permanent erectile dysfunction or penile necrosis.
• Treatment options include corporal aspiration, intracavernosal phenylephrine injection, and surgical intervention.

Condylomata Acuminata

• Anogenital warts caused by papillomavirus (types 6 and 11).
• Characterized by soft, tan, cauliflower-like lesions.
• Can appear on the penis, vulva, and perianal area.
• May cause rectal bleeding.
• Treatment involves chemical agents or surgical therapy, and the condition does not lead to cancer.

Histology of Condylomata Acuminata

• Microscopically, a characteristic feature is perinuclear clear vacuolization (koilocytosis).

Squamous Cell Carcinoma

• A rare penile malignancy arising from squamous skin cells in the glans or shaft.
• Primarily affects older men (mean age ~60).
• Uncommon in the US and Europe, but relatively prevalent in Africa, Asia, and South America.
• Risk factors include uncircumcision and HPV infection; smoking may also be a contributing factor.

Squamous Cell Carcinoma Risk Factors

• Uncircumcised penis.
• Reduced exposure to carcinogens with circumcision.
• High-risk HPV infections (types 16 and 18)
• Smoking.

Squamous Cell Carcinoma Pre-malignant Lesions

• In situ carcinoma: no basement membrane invasion, often presenting as whitish plaques (leukoplakia) on the shaft.
• Bowen disease: gray-white plaque, often on the shaft.
• Erythroplasia of Queyrat: dark red lesion, usually on the glans.
• Bowenoid papulosis: multiple red-brown papules.

Erectile Dysfunction

• Inability to achieve or maintain an erection.
• Often associated with psychological factors, as well as conditions like heart disease, hypertension (HTN), diabetes, obesity, certain medications, smoking, alcoholism, and sleep apnea.

Phosphodiesterase 5 Inhibitors

• Medications (e.g., sildenafil, vardenafil, tadalafil) inhibiting PDE5.
• Increasing levels of cyclic GMP (cGMP) results in smooth muscle relaxation, improving blood flow.
• Uses include erectile dysfunction, pulmonary hypertension, and benign prostatic hyperplasia (BPH).
• Side effects include vision problems (temporary blue vision), headache, flushing, and priapism.
• Contraindicated in patients taking nitrates (like nitroglycerin) as this can cause life threatening hypotension.

Scrotal Disorders

• This section focuses on various conditions involving the scrotum. Individual disorders like testicular torsion, varicocele, hydrocele, spermatocele, and cryptorchidism are discussed below.

Testicular Torsion

• The testicle rotates within the scrotum, twisting the spermatic cord, which contains blood vessels (arteries and veins).
• The torsion compresses the veins, causing impaired venous outflow; artery flow continues, this leads to engorgement and infarction (tissue death) of the testicle.
• Clinical presentation can include a painful, swollen testicle and the absence of the cremaster reflex.
• Treatment necessitates urgent surgical intervention (detorsion or orchiopexy).

Testicular Torsion Neonatal Form & Adult Form

• Neonatal torsion occurs in the first 30 days after birth, often when the testes are not fully secured to the scrotum.
• Adult torsion is seen in boys aged 12 to 18. Anatomic defects like the bell clapper deformity may cause increased mobility and twisting of the testicle.

Varicocele

• Dilated veins of the pampiniform plexus in the spermatic cord, typically seen on the left side.
• It's often caused by obstruction of venous blood flow. Left spermatic vein is longer with the risk of compression between the aorta and the superior mesenteric artery ("nutcracker effect").
• Clinical presentation may include scrotal pain and swelling.
• Diagnosis is made by ultrasound.
• Potentially associated with infertility.

Hydrocele

• Accumulation of fluid in the tunica vaginalis, a sac surrounding the testicle.
• Newborns sometimes experience a communicating form, where peritoneal fluid enters the tunica vaginalis; this often resolves on its own by the first year.
• Adults may have a noncommunicating hydrocele that is often idiopathic.
• Symptoms include scrotal swelling. The fluid can be visualized (transilluminated) by light.

Spermatocele

• A cystic mass typically located at the head of the epididymis.
• Typically not associated with pain and is usually diagnosed through physical exam.
• Easily differentiated from an underlying testis mass by ultrasound.

Cryptorchidism

• Undescended testes; can be unilateral or bilateral.
• Can be located in the abdominal cavity or inguinal canal.
• Potential complications include reduced sperm count, increased risk of germ cell tumors, and increased risk of testicular torsion.
• Treatment includes watchful waiting, with orchiopexy to relocate the undescended testes if necessary.

Testicular Tumors

• A general category encompassing various tumor types.
• Testicular malignancy often mirrors ovarian cancers in pattern but lacks common epithelial cancers.
• Germ cell tumors and sex cord-stromal tumors are the primary classifications. Germ cell tumors are further subdivided.

Germ Cell Tumors

• Highly malignant tumors derived from cells of the germ line, always capable of metastasis.
• Usually a mixture of several subtypes.
• Seminomas, embryonal carcinomas, yolk sac tumors, and chorocarcinomas among other types.
• 5-year survival rate is generally high (~95%).

Seminoma

• The most common germ cell tumor, usually having a uniform appearance (homogeneous mass).
• Generally appears grey-white, without hemorrhage or necrosis.
• May secrete beta-hCG.
• Diagnosis may use tumor markers, like placental alkaline phosphatase.
• Treatment is focused on surgery +/− chemotherapy or radiation.

Embryonal Carcinoma

• A component of mixed germ cell tumors.
• Can be distinguished from seminoma by the presence of necrosis and hemorrhage.
• Usually includes syncytiotrophoblast tissue and produces beta-hCG. (Tumor marker)

Yolk Sac Tumor

• Most frequent germ cell tumor in children under age 3.
• Originates from extraembryonic yolk sac cells.
• Characterized by Schiller-Duval bodies microscopically, along with glomerular-like structures.

Choriocarcinoma

• A rare but potentially aggressive germ cell tumor, often following a normal or molar pregnancy.
• It's characterized by the presence of syncytiotrophoblast and cytotrophoblast cells.
• Secretion of hCG (human chorionic gonadotropin) is a diagnostic indicator; it may also produce gynecomastia.
• May cause aggressive hematogenous spread throughout lungs, liver, and bone, often compared to its placental counterpart.

Teratoma

• Includes cells from all three germ layers (ectoderm, endoderm, and mesoderm).
• Commonly presents as a large mass composed of neural tissue, muscle, cartilage, or other elements.
• Found often in young children and adults.

Mixed Germ Cell Tumors

• Usually a combination of two or more germ cell tumor types; for example, seminomas plus embryonal carcinomas.
• Often show a poorer prognosis compared to those with single-subtype tumors.

Leydig Cell Tumor

• A non-germ cell tumor originating from interstitial cells of Leydig.
• Presents as a golden brown mass with Reinke crystals.
• These tumors produce androgens and estrogens and may result in sexual precocity or gynecomastia (breast development in boys).

Sertoli Cell Tumor

• Often a benign tumor of Sertoli cells.
• Usually do not produce hormones.

Testicular Lymphoma

• Relatively uncommon testicular tumor; often presents as a mass.
• Can involve the testes as part of diffuse large B-cell lymphoma.

Extragonadal GCTs

• Occur in various sites outside the gonads, most commonly the anterior mediastinum in adults.
• Can develop in children in the sacrococcygeal and intracranial regions.
• Often arise from germ cell migration failures

Prostate

• A gland located anterior to the rectum, surrounding the urethra.

Acute Prostatitis

• Acute inflammation often bacterial, usually in older men.
• Typically involves common urinary pathogens like E. coli.
• Characterized by fever, chills, malaise, dysuria, frequency, and cloudy urine.
• On digital rectal exam, the prostate is often swollen, tender and boggy.

Chronic Prostatitis

• Chronic symptoms (pain, difficulty voiding) of prostatic inflammation, often with no identified bacteria.

BPH (Benign Prostatic Hyperplasia)

• Age-related condition causing enlargement (hyperplasia) of prostate stromal and epithelial tissue.
• Leads to urinary obstruction (partial or complete), with symptoms like hesitancy, frequency, and dribbling.

Prostate Adenocarcinoma

• Most frequent prostate cancer type.
• Occurs in older men (>50), and is more common in African Americans. It's often found in the peripheral zone. A nodule on physical exam may occur.
• Diagnosed through prostate biopsies guided by imaging, including transrectal ultrasound (TRUS).
• Screening with prostate-specific antigen (PSA) levels might identify the condition.

Prostate Cancer Metastasis

• Prostate cancer can spread hematogenously to the spine and other regions, often leading to bone pain and elevated levels of serum alkaline phosphatase. Deposition of new bone (osteoblastic) may occur, as opposed to bone breakdown (osteolytic).

Prostate Cancer Treatment

• Treatment strategies include surgery, competitive androgen receptor inhibitors, including Flutamide, and GnRH agonists such as Leuprolide. These medications suppress hormone production or block receptor function.

PSA (Prostate-Specific Antigen)

• An androgen-regulated protein commonly found in semen, elevated levels are associated with BPH and prostate cancer, thus, used in screening (controversial).