Problems in our Prison System or Penal Path (and the Scrotum)



March 6 (Tues)

Path 9am

Dr. Tran

David Ratcliff

P030609.doc

Scribe for hire: J. Morgan

Problems in our Prison System

(Penal Path and the Scrotum)

Side notes: Dr. Tran stated that the book is important and covers this subject very well. That is not to say that his notes are inadequate (far from, I’m sure), that is just what he said. Also, when slides are used, “SLIDES:” will be shown with the descriptions of the individual slides following.

To quote a lot of important people… “Gird up your loins…” this is a long scribe.

I. Congenital Anomalies of the Penis

A. Hypospadias (hypo, below + spadon, a split)

1. Opening (urinary meatus) on the ventral aspect of the penis.

a. due to a developmental defect of the urethral groove in which the ventral wall is incompletely formed.

2. Grossly, the meatus is usually found just proximal to normal (fairly minor defect)

NOTE: Both Hypospadias and Epispadias may be associated w/Cryptorchidism or other malformations of the urinary tract.

3. 1/500 births (more common than Epispadias)

4. Clinically (when untreated),

a. Associated with urinary retention and infection.

b. Can interfere with ejaculation - patient may be sterile (functional).

B. Epispadias (epi, above + spadon, a split)

1. Opening (urinary meatus) on the dorsal aspect of the penis.

a. due to a developmental defect of the urethral groove in which the dorsal wall is incompletely formed.

2. 1/50,000 births (fairly rare)

3. Clinically, will generally have the same problems as with untreated Hypospadias.

a. Additionally, there may be an association with 3 things:

1. extrophy of the bladder (open bladder is part of the abdominal wall)

2. incomplete sphincter formation

3. incontinence

C. Phimosis (Gr, muzzle)

1. Def. = Orifice of the prepuce is extremely stenotic and prevents normal retraction.

2. Caused primarily by a congenital anomaly or may be secondary scarring from an infection.

3. Complications of Phimosis include:

a. Urinary retention and urinary tract infection, possibly all the way to the kidney.

-Since the prepuce is so tight, this can lead some degree of stasis of the urine and therefore UTIs.

b. Can collect debris in the area and lead to secondary infection.

c. Other problems can arise due to trauma when the patient forcibly retracts the prepuce which causes swelling b/c it is constrictive, and then can’t get the foreskin to go back to where it was. This can lead to infection, ulceration and even necrosis (this process is called Paraphimosis).

4. Treatment is usually circumcision.

5. SLIDES:

a. Penis with prepuce over the glans.

b. Patient pushed the prepuce back, which then caused the prepuce to swell (Paraphimosis).

D. Absence or duplication of the penis is extremely rare, thankfully!

II. Penile Inflammation (Non-specific)

A. Balanitis (Gk, balanos, acorn + it is, swelling) got a good laugh out of that…

1. Inflammation of the glans secondary to non-sexually transmitted bacteria.

B. Balanoposthitis

1. Inflammation of the glans and prepuce secondary to non-sexually transmitted bacteria.

2. Caused by many organisms including: staph, strep, Gram (-) bacilli, etc.

III. Penile Inflammation due to STDs (5 kinds)

A. Syphilis

-this is caused by Treponema pallidum (a spirochete)

1. The 1st lesion (Primary Syphilis) is the chancre of the genitals that appears 3 weeks post infection.

a. This lesion is single, non-tender, firm (indurated border) and ulcerated, and generally is found on the coronal sulcus.

b. SLIDE: Primary syphilis with ulceration of the penis. (see also fig 9-30)

2. The 2nd lesion (Secondary Syphilis) is Condyloma latum which usually occurs 2-3 months post infection.

a. This is a non-ulcerated, papular lesion on or around the genitals.

b. SLIDE: Secondary syphilis with white papules on the scrotum.

3. Microscopically, both lesions show characteristic chronic inflammatory infiltrate ((( plasma cells) and reactive endothelial proliferation (Obliterative endarteritis)

a. SLIDE: ( amount of plasma cells.

b. The Obliterative endarteritis is very characteristic of syphilis and is a progressive narrowing of vessels due to the endothelial proliferation.

4. Diagnosis of Syphilis

a. Warthin-Starry Stain will show the organisms under the light microscope

b. Dark-field microscopy of a sample scraping of the lesion will show the “corkscrew” appearance of Treponema pallidum.

B. Chancroid

-this is caused by Hemophilus ducreyi (Gram -)

1. The lesion begins as a single pustule that ulcerates. It is located on the glans or the prepuce.

a. The ulcer is soft which is important in differentiating it from the above, indurated, ulceration of primary syphilis.

b. Frequently, there are multiple lesions (unlike syphilis)

2. Diagnosis is important not only for the obvious reasons (b/c you are a Dr. and that is your job), but you want to rule out Syphilis.

a. So, 1st feel the lesion. Is it hard (think Syphilis - but can be other things too), or soft (think Chancroid)?

b. then scrape it and send to the lab to test it. They will use W-Giemsa to show a Gram (-) rod if it is H. ducreyi.

3. SLIDE: Another penis with an ulcer except this one has a soft border.

C. Granuloma inguinale

Granuloma inguinale and Lympho-granuloma venereum are both common in tropical areas of the world.

-this is caused by Calymmatobacterium granulomatis (Gram -, encapsulated bacillus)

1. The lesion is a subQ nodule around the genitalia and in later stages, the lesion moves into the regional lymph nodes.

2. Histologically,

a. Will see C. granulomatis in macrophages which are called Donavan Bodies.

b. Will also see granulation tissue with chronic inflammatory infiltrate in response to the bacteria.

D. Lymphogranuloma venereum

-this is caused by Chlamydia trachomatis (types L1, L2, L3)

1. The primary lesion is a vesicle that ulcerates and is located in the genital, anal, and oral areas.

2. The secondary lesions occur when certain lymph nodes become swollen (lymphadenitis) with suppurative, granulomatous material and are called buboes. These occur in distinct areas depending on the sex of the pt:

a. In males, the buboes are in the inguinal nodes (Inguinal buboes?) – sounds like a good ska band

-also, lymphedema can cause scrotal elephantiasis

b. In females, the buboes occur in the pelvic and perirectal nodes.

E. Herpes simplex

-genital herpes is caused by HSV-2

1. The lesion is a painful vesicle that occurs 3-14 days after sexual contact.

a. The vesicle is located on the glans, prepuce, or shaft of the penis and will rupture to form soft ulcers which heal in about 2 weeks.

2. Microscopically, you (or the pathologist at least) will see Cowdry type A eosinophilic intranuclear inclusions. (fig 9-28)

IV. Non-inflammatory STD

A. Condyloma Acuminatum (Gk, kondyloma, a knob) (fig 23-1, 23-2, 23-3)

-caused by HPV - usually #’s 6 and 11 (#16,18 and 31 are associated with dysplasia)

1. This is classified as a viral induced hyperplasia (as opposed to the classification of benign tumor by Robbins)

2. The lesion is soft, verrucoid, papillary and microscopically has epidermal hyperplasia and koilocytosis.

3. SLIDES:

a. Penis with raised, warty lesions all over it – they are white.

b. See a condyloma “hiding” in the urethral meatus. This shows the importance of a thorough physical exam.

c. Micro: Shows koilocytic atypia (halos around nucleus) with hyperplastic squamous epithelium.

B. Giant Condyloma (a.k.a. Buschke-Lowenstein tumor, verrucous carcinoma)

-this looks just like a large condyloma acuminatum (so it is also caused by HPV 6 and 11)

-actually this is a well-differentiated variant of SCC with low malignant potential (see below)

1. This lesion is larger and more aggressive than condyloma acuminatum, and has local invasion, but not metastasis.

a. Giant Condylomas are on the glans and have a large mushroom appearance.

b. Microscopically these remain very well-differentiated, but can penetrate basement membrane.

2. Treatment is excision, but they tend to recur.

3. For the most part these have a good prognosis, but giant condylomas do make up 5% of all penile cancers.

4. SLIDES:

a. Very “cauliflower” looking or to be medically correct, it looks verrucous.

b. Micro: May have invasion through the basement membrane and reach the underlying connective tissue.

V. Penile Tumors

A. Carcinoma-in-situ

-all of the following are full thickness dysplasias and therefore look very similar microscopically.

1. Erythroplasia of Queyrat

a. This is a single well-circumscribed patch of red on the glans or corona.

b. It generally occurs on uncircumcised men and is NOT associated with any visceral cancer, but is potentially invasive.

2. Bowen’s Disease (fig 23-4)

a. This is a single scaly plaque on the shaft or the scrotum.

b. It occurs on mostly middle aged – older men and has been refuted as to its association with visceral cancer, but is potentially invasive.

3. Bowenoid Papulosis

a. This papular lesion is similar to Bowen’s but is multiple, and HPV 16 has been cited as a possible cause.

b. It occurs in young males, but almost never becomes invasive carcinoma.

4. SLIDE:

a. Bowenoid Papulosis with many lesion on the shaft of the penis.

B. Squamous Cell Carcinoma (SCC)

-this is probably caused by HPV 16 and 18

1. Epidemiology: SCC causes ~1% male cancer (in the U.S.), is more common in blacks (2:1 Caucasian), more often in Africa, Asia, and Latin America. Also, it is more common in uncircumcised men.

a. In addition, 5% become verrucous carcinoma (discussed above)

2. The lesion usually involves the prepuce and glans (possible reason for (’r incidence in uncircumcised men?) and will likely have distant metastasis if the corpus cavernosa (blood supply) or urethra (urinary tract) are involved.

3. Histologically, they look like the typical malignant squamous cells.

4. Treatment for late stage carcinoma is unfortunately a penectomy.

5. SLIDES:

a. Cut penis with SCC.

b. Untreated SCC lesion on the penis that became ulcerated (similar to fig 23-5)

c. Advanced SCC with the penis missing due to advanced disease, the scrotum is also involved.

d. Advanced SCC with entire area covered and destroyed by cancer.

Peyronie’s Disease

-a.k.a. Plastic Induration of the penis

6. Abnormal fibrous proliferation in the penis (fibromatosis) causes it to be curved drastically enough to interrupt normal functioning.

a. Patients will have difficulty urinating and painful erections.

7. This generally occurs in men over 50.

VI. Balanitis Xerotica Obliterans

A. This is lichen sclerosis of the glans and prepuce with epidermal atrophy, thinning of the rete ridges, and replacement of the superficial dermis by band-like collagenization and edema

1. or…chronic skin disease characterized by a white indurated area surrounding the meatus.

B. This is not malignant.

C. SLIDES:

1. Example of Balanitis Xerotica Obliterans (a white band around the shaft).

2. The glans and the prepuce are whitish.

VII. Priapism

A. Defined as a prolonged painful erection that is not due to sexual stimulation.

B. Cause of Priapism are as follows:

a. Idiopathic

b. Secondary to hematologic disease because damaged RBCs can cause hypercoagulation and/or accumulate in small vessels in the penis (corpus cavernosum).

-example = Sickle Cell Disease

c. Certain drugs cause Priapism such as Trazodone (antidepressant).

C. SLIDE: Priapism (amazingly looks like an erection!)

…and now, back by popular demand, the one, the only…

The Scrotum

I. Idiopathic Scrotal Calcinosis

A. This is an accumulation of rock hard calcifications of the scrotal skin. They actually are fairly common and start in childhood or early adulthood and slowly increase in number and size over time.

1. The cause of this is unknown and they are asymptomatic (benign).

B. The importance of Calcinosis is to differentiate between it and Epidermal Inclusion Cysts of the scrotum which will be much fewer in number and softer, and microscopically will be lined by squamous epithelium.

C. SLIDES:

1. Grossly, this looks very strange, almost like someone put 50 or 60 marbles in a scrotum. It is distended and has lots of calcified nodules all over.

2. Microscopically, there is focal calcification (they are seen as a foreign body) that causes an inflammatory reaction with numerous multinucleated giant cells.

II. Scrotal Carcinoma

A. Squamous Cell Carcinoma of the scrotum is extremely rare (< 10 new case per year in the U.S.)

B. Historically, Sir Percivall Pott, noted that chimney sweeps had an (’d incidence of scrotal cancer (this was in 1755)

1. This was compared to coal miners who have no (’d incidence and so now it is thought that combustion of coal forms a carcinogen that seems to go for the scrotum.

C. Actual importance of this lies in the fact that Dr. Pott is the “Father of Pathology.”

D. SLIDE: SCC of the scrotum.

Testis

I. General Disease

A. Cryptorchidism

-associated with 10% of testicular cancer.

-this is bilateral in 25% of cases

1. Defined as a failure of testicular descent due to: Idiopathic reasons; Trisomy 13; or Deficiency of Lutein Releasing Hormone (a normal HPA-axis is needed for normal development and descent of the testicles).

2. Normally, the testes start in the abdomen move through inguinal canal and then into the scrotum.

a. Cryptorchidism can occur anywhere along the descent

b. So can have ectopic descent where the testicle ends up in the superficial inguinal area, the inguinal area, or the femoral area.

3. Microscopically

a. Can see changes to the testicle as early as 2 years old including: spermatic tubule basement membranes that are thickened and hyalinized; germs cells that are developmentally arrested; increased interstitial stroma. So, for testicle to be functional, surgery must be performed before the age of 2.

b. Also will see that the contralateral testicle shows paucity of the germ cells.

c. Interestingly, the Leydig cells are not affected.

4. Complications of Cryptorchidism

a. Will have a 7-11 x’s increase in risk of developing testicular tumors even when corrected by surgery. Will also have in increased risk in the contralateral testicle.

b. If the patient does not get surgery, though, they will more than likely be sterile because of the increased temperature of the abdomen (that will not allow spermatogenesis). (

c. But even if the testicle is non-functional, the patient will be sexually functional. (

B. Testicular Atrophy (compare normal, fig 23-6a, to atrophic, 23-6b)

1. Etiology (this is a big list)

a. Atherosclerosis (causes a decrease in the blood supply to the testes)

b. Orchitis

c. Cryptorchidism (this causes atrophy of germ cells)

d. Hypopituitarism

e. Malnutrition

f. Obstruction to outflow of semen

g. Irradiation

h. Use of female sex hormones (i.e. For the treatment of prostate cancer)

i. Persistent stimulation of FSH

j. Genetic defects (i.e. Klinefelter’s Syndrome

k.

Non-Specific Orchitis and Epididymitis

4 This is usually secondary to a UTI (the causes depend on the age of the patient).

2. For children, it is usually due to a Gram (-) rod

3. For young, sexually active, men, it is due to: Chlamydia trachomatis and Neisseria Gonorrheacae

4. For older men, it is due to E. coli and pseudomonas.

5 Pathologically, early on (the acute phase) there is an inflammatory process in the interstitial tissue that extends to the tubules and may form an abscess.

5. The inflammation travels via the lymphatics and the vas deferens to the testis.

6. Eventually, the inflammation can cause fibrous scarring and lead to sterility, but sexual activity is spared.

6 SLIDES:

7. Histo: The presence of PMNs, lymphocytes, and edema can be seen

8. Cut testicle with a large cavity being the abscess

Specific types of Orchitis

9 Granulomatous Orchitis

9. Usually presents in mid-aged men as a painless, yet tender testicular mass with or without fever.

10. This is a granulomatous reaction that likely an autoimmune origin.

11. Microscopically, there is a granuloma with multinucleated giant cells with inflammatory infiltrate.

a. looks similar to TB, but will find no organisms

10 Gonorrhea associated Orchitis

12. This is due to extension of infection to the prostate, seminal vesicles and epididymis from the posterior urethra.

13. If left untreated, it can from an abscess in the testis and epididymis. (fig 23-7)

14. SLIDE: Abscess in the epididymis.

11 Mumps and Orchitis

15. Though mumps is very common in children, the orchitis is not.

a. In postpubertal males with mumps, 20-30% will get orchitis one week after the involvement of the parotid gland.

16. Pathologically, there is patchy interstitial inflammation including edema, lymphocytes and plasma cells (the usual suspects), and is unilateral in most cases (70%)

a. Sometimes (usually not though) there are PMNs (b/c this is viral), and possible acute inflammatory exudate in the tubular lumens.

17. One possible complication is testicular atrophy.

12 Tuberculosis Orchitis

18. TB orchitis is usually secondary to infection from prostate and seminal vesicles.

19. Like Granulomatous orchitis, this is a granulomatous infection but this time you can find the offending bug.

13 Syphilis and Orchitis

20. Usually syphilis goes to the testicle first and then the epididymis

21. Pathologically, you will see: Gumma, or diffuse interstitial inflammation (edema, lymphocytic and plasma cell infiltration) with the syphilitic hallmark, Obliterative endarteritis with perivascular cuffing of lymphocytes and plasma cells.

14 Lepromatous Orchitis

22. Since the testicles are the at the lowest temperature of the body and Leprosy like low temperature, think of these two together (as seen by the fact that 50% of lepromatous infections involve the testicles).

II. Tunica Vaginalis

15 Hydrocele

1. Defined as an accumulation of serous fluid within the tunica vaginalis

2. To differentiate from a tumor, you transilluminate to see the shadow of the testicle.

3. The causes of hydrocele can be any inflammatory disease of the testes, epididymis or CHF

-In the case of CHF, the ascites can move through the abdomen into the tunica vaginalis

4. SLIDE: Cut specimen show a large space (once fluid filled) between the tunica vaginalis and the testicle.

16 Hematocele

5. Defined as an accumulation of blood within the tunica vaginalis.

6. Usually due to trauma or torsion of the testicle.

17 Chylocele

7. Defined as an accumulation of lymph within the tunica vaginalis.

8. This is what is seen in patients with elephantiasis.

18 Spermatocele

9. Defined as an accumulation of sperm in the spermatic cord.

10. SLIDE: Large spermatic cord.

19 Varicocele

11. Defined as a dilation of veins in the pampiniform plexus.

12. SLIDE: You can see a vein in the scrotum (I guess representative of the dilated pampiniform plexus).

III. Torsion of the Testis (fig 23-8)

20 This is caused by any of the following:

21 violent movement

22 trauma

23 incomplete descent

24 absence of scrotal ligaments or gubernacular testis

25 atrophic testis

26 abnormal attachment of testis to epididymis.

27 Pathologically, there is congestion and extravasation of blood into interstitial tissue of the testis and epididymis or an infarct due to twisting of the arterial lumen with the cord.

28 If untreated, an quickly become necrotic and then it must be removed.

29 Microscopically, you will see a lot of interstitial RBCs.

30 To treat, must surgically untwist the testicle.

31 Side note on Acute Testicular Pain (that happens to be excruciating)

-this is due to only two things:

1. Torsion of the testicle.

2. Torsion of an epididymal head appendix (just like what it sounds – the head of the epididymis has a little 1-2mm projection like an appendix sometimes and if it gets twisted, you will squeal like a pig – or like a man with torsion of an epididymal appendix).

“Like a dog that returns to its vomit is a fool who repeats his folly.”

“In fact, if you want to find out how proud you are the easiest way is to ask yourself, “How much do I dislike it when other people snub me, or refuse to take any notice of me, or shove their oar in , or patronise me, or show off?” The point is that each person’s pride is in competition with everyone else’s pride. It is because I wanted to be the big noise at the party that I am so annoyed at someone else being the big noise. Two of a trade never agree. Now what you want to get clear is that Pride is essentially competitive ~ is competitive by its very nature ~ while the other vices are competitive only, so to speak, by accident. Pride gets no pleasure out of having something, only out of having more of it than the next man. We say that people are proud of being rich, or clever, or good-looking, but they are not. They are proud of being richer, or cleverer, or better-looking than others. If every one else became equally rich, or clever, or good-looking there would be nothing to be proud about. It is the comparison that makes you proud: the pleasure of being above the rest. Once the element of competition has gone, pride has gone. That is why I say that Pride is essentially competitive in a way the other vices are not. – C.S. Lewis, Mere Christianity.

I want to honestly thank those who have provided feedback on the scribes and good luck on exams –james

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download