The Lower Urinary System The Lower Urinary System and Male Genital Systemand Male Genital System

The Lower Urinary TractThe Lower Urinary Tract

Congenital anomaliesCongenital anomalies

Ureteropelvic junction obstruction – most Ureteropelvic junction obstruction – most common cause of hydronephrosis in common cause of hydronephrosis in infants and children, boys>girls, 20% infants and children, boys>girls, 20% bilateralbilateral

Ureteral Obstructive LesionsUreteral Obstructive Lesions

IntrinsicIntrinsic

CalculiCalculi

StricturesStrictures

TumorsTumors

Blood clotsBlood clots

NeurogenicNeurogenic

ExtrinsicExtrinsic

PregnancyPregnancy

Periureteral Periureteral inflammationinflammation

EndometriosisEndometriosis

TumorsTumors

Sclerosing Retroperitoneal FibrosisSclerosing Retroperitoneal Fibrosis

Fibrous proliferative inflammatory process Fibrous proliferative inflammatory process encasing the retroperitonal structures and encasing the retroperitonal structures and causing hydronephrosiscausing hydronephrosis

Similar to Riedel thyroiditisSimilar to Riedel thyroiditis70% no identifiable cause ( Ormond disease)70% no identifiable cause ( Ormond disease)Drugs ( ergot derivatives, Beta blockers)Drugs ( ergot derivatives, Beta blockers)Adjacent inflammatory conditionsAdjacent inflammatory conditions (Crohn disease)(Crohn disease)Malignant disease ( lymphoma, UT carcinoma)Malignant disease ( lymphoma, UT carcinoma)

Urinary BladderUrinary Bladder

Congenital anomaliesCongenital anomalies

DiverticulaDiverticula

ExstrophyExstrophy

VURVUR

Patent urachusPatent urachus

CystitisCystitisBacterialBacterial

E. Coli, Proteus, Klebsiella, EnterobacterE. Coli, Proteus, Klebsiella, EnterobacterTBTBCandida, CryptococcalCandida, CryptococcalChlamydia, MycoplasmaChlamydia, MycoplasmaSchistomiasisSchistomiasisAdenovirusAdenovirus

Predisposing factorsPredisposing factorsFemale, calculi, urinary obstruction, DM, instrumentation, immune deficiencyFemale, calculi, urinary obstruction, DM, instrumentation, immune deficiency

TriadTriadFrequency, Lower abdominal pain, DysuriaFrequency, Lower abdominal pain, Dysuria

Special formsSpecial formsInterstitial – chronic pelvic painInterstitial – chronic pelvic painMalacoplakia – soft yellow, raised mucosal plaquesMalacoplakia – soft yellow, raised mucosal plaquesPolypoid – irritation to the bladder mucosaPolypoid – irritation to the bladder mucosaHemorrhagic- adenovirus, cyclophosphamideHemorrhagic- adenovirus, cyclophosphamideFollicular- aggregates of lymphocytesFollicular- aggregates of lymphocytesEosinophilic- nonspecific subacute infectionEosinophilic- nonspecific subacute infection

Metaplastic lesionsMetaplastic lesions

Cystitis cystica et glandularis- nests of Cystitis cystica et glandularis- nests of urothelium grow downward into lamina urothelium grow downward into lamina propriapropria

Squamous metaplasiaSquamous metaplasia

Nephrogenic adenoma – shed renal tubular Nephrogenic adenoma – shed renal tubular cells that implant in the urothelium in cells that implant in the urothelium in response to injuryresponse to injury

NeoplasmsNeoplasms

Urothelial ( transitional) tumorsUrothelial ( transitional) tumors

90% of all bladder tumors90% of all bladder tumors

Exophytic papillomasExophytic papillomas

Inverted papillomasInverted papillomas

PUNLMPs- papillary urothelial neoplasms of low PUNLMPs- papillary urothelial neoplasms of low malignant potentialmalignant potential

Low grade and high grade papillary urothelial Low grade and high grade papillary urothelial cancerscancers

CISCIS

EpidemiologyEpidemiology

Males> FemalesMales> FemalesCigarette smokingCigarette smokingIndustrial exposures to arylaminesIndustrial exposures to arylaminesSchistosoma infectionsSchistosoma infectionsLong-term use of analgesicsLong-term use of analgesicsLong-term exposure to cyclophosphamideLong-term exposure to cyclophosphamidePrior exposure to irradiationPrior exposure to irradiationChromosome 9 deletionsChromosome 9 deletionsClinical – painless hematuriaClinical – painless hematuria

UrethraUrethra

UrethritisUrethritis

GCGC

Chlamydia, Mycoplasma, Chlamydia, Mycoplasma,

Enteric organismsEnteric organisms

Reiter’s syndromeReiter’s syndrome

Urethral carbuncleUrethral carbuncle

Peyronie disease – subcutaneous fibrosisPeyronie disease – subcutaneous fibrosis

CarcinomaCarcinoma

Male genital tractMale genital tract

PenisPenishypospadiashypospadiasEpispadiasEpispadiasPhimosisPhimosisBalanoposthitisBalanoposthitisCondyloma acuminatumCondyloma acuminatumCISCISBowen disease – single erythematous plaqueBowen disease – single erythematous plaqueBowenoid Papulosis – multiple warty lesions, HPV 16Bowenoid Papulosis – multiple warty lesions, HPV 16Invasive Squamous cell carcinomaInvasive Squamous cell carcinoma

Testes and EpididymisTestes and Epididymis

Cryptorchidism- increased incidence of germ cell tumorsCryptorchidism- increased incidence of germ cell tumorsAtrophy and decreased fertilityAtrophy and decreased fertilityNonspecific epididymitis and orchitisNonspecific epididymitis and orchitisGranulomatous ( auto-immune) orchitisGranulomatous ( auto-immune) orchitisGCGCMumpsMumpsTBTBSyphilisSyphilisTorsion – bell clapper deformityTorsion – bell clapper deformityTunica VaginalisTunica Vaginalis

Hydrocele, Hematocele, Chylocele, Spermatocele, VaricoceleHydrocele, Hematocele, Chylocele, Spermatocele, Varicocele

Testicular TumorsTesticular TumorsGerm Cell tumorsGerm Cell tumors

Seminomas – very radiosensitive, most frequent, analogous to dysgerminoma in femalesSeminomas – very radiosensitive, most frequent, analogous to dysgerminoma in femalesSpermatocytic SeminomaSpermatocytic SeminomaEmbryonal carcinoma – second most common, painful, worse prognosisEmbryonal carcinoma – second most common, painful, worse prognosisYolk Sac tumorYolk Sac tumorChoriocarcinomaChoriocarcinomaTeratoma – almost always malignantTeratoma – almost always malignantMixed tumorsMixed tumors

Clinical featuresClinical featuresPainless enlargement of the testisPainless enlargement of the testisSpread via para-aortic nodes to medistinal and supraclavicularSpread via para-aortic nodes to medistinal and supraclavicularNSGCTs more aggressive , poorer prognosisNSGCTs more aggressive , poorer prognosisHCG, AFP, LDHHCG, AFP, LDH

Sex Cord-Gonadal StromaSex Cord-Gonadal StromaLeydig Cell – precocious pubertyLeydig Cell – precocious pubertySertoli Cell – no endocrineSertoli Cell – no endocrine

GonadoblastomaGonadoblastomaTesticular LymphomaTesticular Lymphoma

ProstateProstate

4 biologically and anatomically distinct 4 biologically and anatomically distinct zones:zones:

Peripheral – most carcinomasPeripheral – most carcinomas

CentralCentral

Transitional – most hyperplasiaTransitional – most hyperplasia

Anterior fibromuscular stromaAnterior fibromuscular stroma

Acute bacterialAcute bacterial Same organisms as UTIsSame organisms as UTIs

Fever, chillls, dysuria, Fever, chillls, dysuria, tender,boggy prostatetender,boggy prostate

Chronic bacterialChronic bacterial Recurrent UTIsRecurrent UTIs

Low back pain, abd Low back pain, abd discomfort, dysuriadiscomfort, dysuria

Chronic Chronic abacterialabacterial

Most common formMost common form

Negative cultureNegative culture

Leukocytes in fluidLeukocytes in fluid

GranulomatousGranulomatous BCG treatment for bladder BCG treatment for bladder cancercancer

Reaction to secretions from Reaction to secretions from ruptured ductsruptured ducts

ProstatitisProstatitis

Benign Prostatic HyperplasiaBenign Prostatic Hyperplasia

Nodular hyperplasiaNodular hyperplasiaVery common in men>50 Very common in men>50

years of ageyears of agePartial or complete Partial or complete

obstruction of urethraobstruction of urethraOverall reduction in the rate Overall reduction in the rate

of cell deathof cell deathDHT from stromal cellsDHT from stromal cells

induces growth factorsinduces growth factors

Bladder hypertrophy and Bladder hypertrophy and distensiondistension

Urine retentionUrine retentionFrequency, nocturia, Frequency, nocturia,

difficultystarting and difficultystarting and stopping stream, overflow stopping stream, overflow dribbling, dysuriadribbling, dysuria

Increased risk of infectionIncreased risk of infectionSudden acute urine Sudden acute urine

retention –emergency retention –emergency catherizationcatherization

Prostate TumorsProstate Tumors

AdenocarcinomaAdenocarcinomaMost common cancer in Most common cancer in

menmenAndrogens play an Androgens play an

important roleimportant roleFH importantFH important

BRCA2BRCA2Inflammation may set the Inflammation may set the

stagestage

TMPRSS2 promoter, ETS TMPRSS2 promoter, ETS genegene

Hypermethylation of Hypermethylation of GSTRP1GSTRP1

EZH-2EZH-2AMACRAMACRPCA3PCA3PSA – organ specific, PSA – organ specific,

velocity of changevelocity of change

Prostate TumorsProstate Tumors

PIN – high grade prostatic intraepithelial neoplasiaPIN – high grade prostatic intraepithelial neoplasia

Gleason score – 2 numeric grades added togetherGleason score – 2 numeric grades added together

Gritty and firmGritty and firm

Outer layer of basal cell layer is absent in Outer layer of basal cell layer is absent in carcinomacarcinoma

Grade and stage are best prognostic factorsGrade and stage are best prognostic factors

Boney metastases in vertebrae – universally fatalBoney metastases in vertebrae – universally fatal