Male genital tract

Published on 19/03/2015 by admin

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The penis and scrotum231

22.2 The prostate232
22.3 The testis and epididymis233

Self-assessment: questions236
Self-assessment: answers237

Chapter overview
The male genital tract consists principally of the penis, foreskin, testes, epididymes and prostate gland. A large range of disease processes affect the male genital tract, but inflammation and tumours are probably the most important clinically. Malignancies of the testis and prostate are particularly common tumours and it is important that you have a working knowledge of these. Sexually transmitted diseases (STDs) are also seen and may affect a variety of organs in the male genital tract. Congenital diseases are also common and vary from the relatively insignificant (overly long foreskin) to the very significant (e.g. the maldescended testis with the associated increased risk of malignancy).

22.1. The penis and scrotum

Learning objectives
You should:

• know the basic anatomy of the penis
• have a working understanding of the common congenital and acquired disorders, in particular inflammatory and malignant diseases.
The penis is a skin-covered organ (as is the scrotum) and can therefore exhibit many of the common skin disorders (e.g. eczema/dermatitis). In addition, the penile urethra may be susceptible to tumours of the urothelium (proximally) and squamous epithelium (distally).

Congenital disorders

Abnormalities include an excessively small penis (micropenis) or a urethra that opens either on the ventral (under) surface (hypospadias) or dorsal surface (epispadias) of the penis rather than at the tip.

Acquired disorders

Inflammatory disorders

Many inflammatory skin conditions can occur in the penis, foreskin and scrotum, such as eczema, psoriasis and lichen planus. In addition, more specific inflammatory diseases may cause penile (skin) inflammation.

Granuloma inguinale

Granuloma inguinale is caused by the Gram-negative bacillus Calymmatobacterium granulomatis. This is an STD and causes an ulcer on the glans.

Lymphogranuloma venereum

Lymphogranuloma venereum is an STD caused by Chlamydia trachomatis (which also causes non-specific urethritis). Males may be asymptomatic carriers of the organism. The infection causes a spontaneously healing red papule on the penis. Enlarged lymph nodes in the groin then develop, which then become soft and attach to the overlying skin. Sinus formation occurs.
Syphilis (caused by the spirochaete, Treponema pallidum), herpes simplex and human papilloma virus (HPV) are all important causes of penile infection (see Table 41).
Table 41 Penile infections
Infection Organism Clinical features
Syphilis Treponema pallidum (bacterium, spirochaete) Rare
Penis usually involved in primary syphilis (‘chancre’ seen – nodule on penis).
Heals after about 1month
Penis can be involved in secondary syphilis (papular rash)
Herpes simplex Herpes simplex virus (herpes virus) Common
Painful recurrent blisters/ulcers on penile skin
May last 2–3weeks then resolve
Virus can remain latent in sacral sensory ganglia and reactivate/recur
Human papilloma virus Human papilloma virus (HPV; papillomavirus) Causes condylomata acuminata (‘venereal warts’)
Especially types 6 and 11
Types 16 and 18 can cause premalignant and malignant conditions
Chancroid Haemophilus ducreyi Rare
Penile ulceration and inguinal lymphadenopathy
Peyronie’s disease is a penile disease of unknown cause in which the penis becomes excessively curved or bowed due to accumulation of scar tissue (the curvature may make sexual intercourse impossible).


The penis can be affected by both in situ and invasive (squamous) malignancies. Benign tumours of the penis are rare.

Intra-epithelial neoplasia

Unfortunately, there are three very confusing historical names for intra-epithelial dysplasia in the region of the penis and scrotum (see Table 42).
Table 42 Carcinoma in situ of the penis
On glans On shaft Glans + shaft
Erythroplasia of Queyrat Bowen’s disease Bowenoid papulosis
Red patches Pale, thickened areas Velvety papules (younger men)
HPV-associated in most cases

Squamous cell carcinoma

This is a relatively rare tumour in Western countries (and very rare in circumcised males), but occur more frequently in parts of Asia and Africa. A poorly retracting infected foreskin and infected glans are probably risk factors. There is an association between HPV 16 and 18 infection and squamous cell carcinoma. The tumour may vary from a papillary and well-differentiated malignancy with abundant keratin formation to a solid, ulcerated, widely invasive, poorly differentiated lesion (which spreads via lymphatics to local lymph nodes).

22.2. The prostate

Learning objectives
You should:

• understand the basic anatomical relations and zones of the prostate
• understand benign prostatic hyperplasia and carcinoma of the prostate.
The prostate is a 20g, walnut-shaped gland located in the male perineum. The exact function of the gland is still unclear. The gland lies subjacent to the bladder and is traversed by the urethra. Any enlargement of the prostate gland, particularly that part surrounding the urethra (see Figure 60 for zones of the prostate), can lead to reduction/obstruction of flow of urine –dribbling, hesitancy, poor stream or complete blockage (retention). The prostate is composed of glandular and fibromuscular components, and it is hyperplasia/hypertrophy of both of these elements and malignancy of the glandular elements that commonly lead to urinary symptoms.

Hyperplasia of the prostate

This is such a common finding in adult men that it is often considered to be a normal part of ageing (probably about 80% of 80-year-olds will have evidence of prostatic hyperplasia). The prostate has a nodular, whorled appearance to the naked eye (nodular hyperplasia). It is mainly the periurethral and transition zones that are affected. Down the microscope, the glandular and/or stromal components may be affected. The glands may become papillary in form, or cystically dilated. However, hyperplastic glands have two cell layers – an inner clear cell layer and an outer, more darkly staining, basal cell layer. Hyperplasia of the prostate is often accompanied by areas of infarction, chronic inflammation and glandular atrophy.
Acute and chronic prostatitis can also occur in the setting of urinary tract infection (UTI) with organisms such as Escherichia coli, Pseudomonas and Klebsiella.

Carcinoma of the prostate

Carcinoma of the prostate is a very common malignancy. The biological behaviour of this tumour is poorly understood – a significant number of latent and incidental cancers are found at autopsy or in tissue removed at operation on an apparently benign prostate (e.g. transurethral resection of the prostate, TURP). Thus, it is likely that some prostatic cancers either never progress or only do so very slowly. The disease is more common in older men (particularly those aged over 60) and is seen more often in black men than in white men or Asian men. A small number of prostatic cancers appear familial. Most cases (about 70%) arise in the peripheral zone of the prostate.
Macroscopically, it is usually difficult to see prostatic cancer (it may or may not cause gland enlargement). On microscopy, prostatic cancer is usually an adenocarcinoma (although leiomyosarcoma and lymphoma occur, and rhabdomyosarcoma may be seen in children; Table 43). The Gleason grading system is now widely used for prostatic adenocarcinoma. This system depends on the glandular differentiation and pattern of infiltration of the tumour (see Table 44).
Table 43 Cancer checklist: Prostatic adenocarcinoma
Incidence Age >50years (very common in >80-year-olds)
Risk factors Black men > white men > Asians + family history
?fats in diet
Associated lesions High-grade PIN (particularly multifocal)
Clinical presentation Incidental finding
Urinary symptoms
Diagnosis Per rectal examination, ultrasound scan and biopsy
Blood levels of prostatic-specific antigen (PSA)
Macroscopic Usually invisible to the naked eye
Microscopic Gleason scoring system (see Table 44)
Pattern of spread Local versus lymphatic versus blood
Treatment Carefully supervised ‘watch and wait’ (small intraprostatic lesions)
Table 44 The Gleason grading system
Gleason grade (or pattern) Characteristics
1 Uncommon Very round, regular, monotonous, closely packed glands
Well circumscribed
2 Similar to 1, but less circumscribed, some variation in gland size and shape
3 Commonest grade
May be small or large glands or cribriform (sieve-like) pattern
May be marked variation in size/shape of glands
Ragged edges and infiltrates widely
4 Glands now fused together
Nests and streams of cells seen
5 Large sheets of malignant cells
Necrosis may be seen
May be very undifferentiated
The higher the Gleason score (achieved by adding together the commonest two patterns or doubling a single pattern tumour) the more poorly differentiated the tumour. There is a correlation between the score of the tumour and its biological behaviour (the higher the score, the higher the cancer mortality rate). The tumour may be associated with high-grade prostatic intra-epithelial neoplasia (PIN; thought to be a likely precursor lesion). Adenocarcinoma of the prostate typically invades locally through the gland and into surrounding pelvic tissues and then by lymphatics to local/regional lymph nodes. Prostatic cancer has a propensity to metastasise via the bloodstream to bones (particularly the spine).

22.3. The testis and epididymis

Learning objectives
You should:

• have a working knowledge of the histology of the testis
• be familiar with the basic classification of testicular tumours.

The testis

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