Lower Urinary Tract and Male Reproductive Disorders

Chapter 20 Lower Urinary Tract and Male Reproductive Disorders



I. Common Ureteral Disorders

A. Congenital megaloureter

• May be associated with Hirschsprung’s disease


Congenital megaloureter: association with Hirschsprung’s disease



B. Ureteritis cystica

1. Manifestation of chronic inflammation

2. Smooth cysts project from the mucosa into the lumen.

• Similar findings may be present in the bladder.


Ureteritis cystica: risk factor bladder adenocarcinoma


3. May undergo glandular metaplasia and predispose to adenocarcinoma

C. Ureteral stones

• Ureters are the most common site for stones to cause obstruction.

D. Retroperitoneal fibrosis

1. Causes

a. Majority are idiopathic.

b. Ergot derivatives used in the treatment of migraines

c. Association with other sclerosing conditions

(1) Primary sclerosing cholangitis

(2) Sclerosing mediastinitis, Reidel’s fibrosing thyroiditis

d. Retroperitoneal malignant lymphoma

2. Complications

a. Hydronephrosis is the most common complication.

b. May cause right scrotal varicocele (see section V)

• Blocks the drainage of the right spermatic vein into the vena cava


Hydronephrosis: most common complication of retroperitoneal fibrosis


E. Ureteral cancers

• Transitional cell carcinoma (TCC) is the most common cancer.


TCC: most common cancer of ureter


II. Urinary Bladder Disorders

A. Congenital disorders

1. Exstrophy of the bladder (Fig. 20-1)

a. Developmental failure of the anterior abdominal wall and bladder

(1) Bladder mucosa is exposed to the body surface.

(2) Often associated with epispadias (see section IV)

image

20-1: Exstrophy of the bladder. Red mucosa of the urinary bladder is seen protruding through the defect in the anterior abdominal wall.


(Courtesy of Dr. Roger D. Smith, Cincinnati, Ohio, and GRIPE.)



Exstrophy: developmental failure anterior abdominal wall and bladder


b. Complications

(1) Inflammation predisposes to glandular metaplasia.

(2) Predisposition for adenocarcinoma of the bladder


Exstrophy: risk factor for bladder adenocarcinoma


2. Urachal cyst remnants

a. Drainage of urine from umbilicus in a newborn; midline urachal cyst

b. Predispose to adenocarcinoma of the bladder


Urachal cyst remnants: most common cause of bladder adenocarcinoma; drainage of urine from umbilicus


• Most common cause of bladder adenocarcinoma

B. Acute and chronic cystitis

1. Risk factors for lower urinary tract (LUT) infection

a. Female sex

(1) Short urethra

(2) Ascending infection (refer to Chapter 19)

b. Indwelling urinary catheter


Indwelling catheters: most common cause sepsis/urinary tract infections in a hospital


(1) Most common cause of sepsis in hospitalized patients

(2) Account for 50% of nosocomial urinary tract infections

c. Sexual intercourse

(1) “Honeymoon cystitis” from trauma to the urethra

(2) Voiding after intercourse reduces the risk for infection

d. Diabetes mellitus, neurogenic bladder


Cyclophosphamide: hemorrhagic cystitis; prevented with mesna


e. Cyclophosphamide

(1) Produces hemorrhagic cystitis

(2) Prevented with mesna

f. Schistosoma hematobium

(1) Transmission

(a) Penetration of the skin by the fork-tailed cercariae

(b) Larvae enter veins in urinary bladder wall.

(c) Larvae develop into adult worms that deposit eggs.

(d) Host develops an intense inflammatory response.

(e) Produce squamous metaplasia of bladder epithelium


Schistosoma hematobium: egg with large terminal spine


(2) Eggs have a large terminal spine.

(3) Treatment is praziquantel.

2. Causes of acute cystitis

a. Escherichia coli

(1) Most common uropathogen (80–90%)

(2) Gram-negative rod (Fig. 20-2)

image

20-2: Gram stain of Escherichia coli: Note the gram-negative rods.


(From McPherson R, Pincus M: Henry’s Clinical Diagnosis and Management by Laboratory Methods, 21st ed. Philadelphia, Saunders, 2006, Fig. 56-14.)



E. coli: most common uropathogen; sepsis in hospital


(3) Most common cause of sepsis in a hospitalized patient

(4) Treatment is trimethoprim-sulfamethoxazole

b. Adenovirus

• Causes hemorrhagic cystitis

c. Staphylococcus saprophyticus

(1) Causes acute cystitis in young sexually active women

• Accounts for ∼︀10% to 20% of LUT infections


S. saprophyticus: LUT infection in young, sexually active female; coagulase negative


(2) Coagulase negative

(3) Treatment is trimethoprim-sulfamethoxazole

d. Acute urethral syndrome in women

• Female counterpart to nonspecific urethritis (NSU) in men

e. Chlamydia trachomatis

C. trachomatis: most common cause of acute urethral syndrome in women and NSU in men


(1) Most common cause of acute urethral syndrome

(2) Identification of Chlamydia

• Polymerase chain reaction (PCR) testing of voided urine

(3) Treatment is azithromycin 1 g orally

f. Other pathogens

• Mycoplasma hominis, Ureaplasma urealyticum, Neisseria gonorrhoeae

3. Clinical findings in LUT infections


LUT signs: dysuria, ↑ frequency, urgency


a. Dysuria (painful urination)

b. Increased frequency, urgency, nocturia

c. Suprapubic discomfort

d. Gross hematuria

4. Laboratory findings in LUT infections

a. Pyuria at or above 10 WBCs per high-power field (HPF) in a centrifuged specimen

• More than 2 WBCs/HPF in an uncentrifuged specimen

b. Bacteriuria, hematuria

c. Positive dipstick for leukocyte esterase and nitrite (refer to Chapter 19)

d. At or above 105 colony-forming units (CFUs)/mL


≥105 CFUs/mL: gold standard for LUT infection


• Gold standard criterion of infection

5. Asymptomatic bacteriuria in women

a. Two successive cultures with 105 or more CFUs/mL in an asymptomatic patient

b. Causes

(1) Pregnancy

• Acute pyelonephritis may occur in 1% to 2% of cases.

(2) Elderly women in nursing homes


Asymptomatic bacteriuria: treat pregnant woman with amoxicillin; no treatment for healthy elderly women


c. Treatment

(1) Pregnant women

• Amoxicillin

(2) Asymptomatic, healthy elderly women

• No treatment necessary

6. Sterile pyuria

a. Neutrophils in the urine and negative standard culture after 24 hours


Sterile pyuria: neutrophils in the urine, negative standard culture


• Positive leukocyte esterase, negative nitrite

b. Causes

(1) Chlamydia trachomatis

(2) Renal tuberculosis

(3) Acute tubulointerstitial nephritis (refer to Chapter 19)

7. Malacoplakia

a. Associated with a chronic E. coli infection of the bladder

b. Microscopic findings

(1) Yellow, raised mucosal plaques

(2) Foamy macrophages filled with laminated mineralized concretions


Malacoplakia: Michaelis-Gutmann bodies


(a) Called Michaelis-Gutmann bodies

(b) Defective phagosomes that cannot degrade bacterial products

C. Miscellaneous disorders

1. Acquired diverticula


Acquired bladder diverticula: most common cause is BPH; chronic E. coli infection


a. Most are due to benign prostatic hyperplasia (BPH)

b. Causes obstruction of urine outflow and increased intravesical pressure

c. Diverticulitis and stone formation are common complications

2. Cystocele

a. Common in middle-aged to elderly women

b. Mechanism

(1) Relaxation of pelvic support causes descent of the uterus


Cystocele: bladder wall protrudes into vagina


(2) Bladder wall protrudes into the vagina

• Creates a pouch that collects residual urine

3. Cystitis cystica and glandularis


Cystitis cystica/glandularis: risk of bladder adenocarcinoma


a. Bladder rendition of ureteritis cystica

b. Increased risk for developing bladder adenocarcinoma


Urinary bladder control and incontinence disorders: Relaxation of the detrusor muscle is involved in the storage of urine, while contraction of the muscle is important in emptying the bladder. The sympathetic nervous system relaxes the detrusor muscle and contracts the internal sphincter; hence, it is important in the retention of urine in the bladder. In contradistinction, the parasympathetic nervous system is involved in emptying the bladder. It accomplishes this function by contracting the detrusor muscle and relaxing the internal sphincter muscle. There are four types of urinary incontinence: urge incontinence (40–70% of cases), overflow incontinence, stress incontinence, and functional incontinence. Urge incontinence is caused by overactivity of the detrusor muscle resulting in the production of low volumes of urine. Symptoms include increased urinary frequency, urgency, small volume voids, and nocturia. The most common causes are bladder irritation due to BPH, atrophic urethritis, and infection. Treatment is with anticholinergics, which inhibit parasympathetic stimulation of detrusor contraction. The mechanisms for outflow incontinence are outflow obstruction (e.g., BPH) or detrusor underactivity related to autonomic neuropathy (e.g., diabetes mellitus). Symptoms include dribbling and low urine flow. Treatment involves the use of cholinergic drugs to enhance muscle tone (i.e., increase detrusor contraction) or, if obstruction is the cause (e.g., BPH), α-adrenergic blockers to relax smooth muscles in the bladder neck. The mechanism for stress incontinence is laxity of pelvic floor muscles with a concomitant lack of bladder support. This may be the result of not maintaining the posterior urethrovesical angle of 90–100 degrees or a lack of estrogen; hence, this type of incontinence primarily occurs in women. Symptoms relate to the loss of urine when there is an increase in intra-abdominal pressure (e.g., laughing, cough, sneezing). Treatment is to increase internal sphincter tone with α-adrenergic agonists (contract smooth muscle cells at the bladder neck); using topical estrogen therapy; and encouraging the patient to do Kegel pelvic floor muscle exercises. If these treatments do not control the incontinence, then surgery is the final option. The mechanism for functional incontinence is inability to reach toilet facilities in time. Patients are normally continent; however, if they are taking diuretics or drinking too many caffeinated beverages incontinence may occur



Void urine: ↑ parasympathetic activity—contract detrusor muscle, relax internal sphincter muscle



Retain urine: ↑ sympathetic activity—relax detrusor muscle, contract internal sphincter muscle


D. Bladder tumors

1. Bladder papilloma

• Very uncommon benign tumor

2. Transitional cell carcinoma (TCC)

a. Epidemiology

(1) Most common bladder cancer (>95% of cases)


TCC: most common bladder cancer


(2) More common in men than women

(3) Incidence increases with age.

(4) Causes

(a) Smoking cigarettes (most common cause)

• Less risk for other tobacco products


TCC: most common cause is smoking cigarettes


(b) Workers in dye, rubber, or leather industries

(c) Cyclophosphamide

(d) Arsenic exposure

(e) Beer consumption

• Due to nitrosamines in beer

(f) Schistosoma hematobium

Squamous cell carcinoma of bladder: S. hematobium infection


• 70% produce squamous cell carcinoma, 30% TCC

b. Pathogenesis

(1) Genetic factors

(a) Numerous chromosomes implicated

(b) Genes implicated: TP53 and RB suppressor genes; HRAS protooncogene

(c) Alteration in epidermal derived growth factor receptor

(2) Environmental factors (see earlier discussion)


TCC: multifocal tumor; recurrences are the rule


(3) Multifocality (“field effect”) and recurrence are the rule.

(a) Common malignant stem cell abnormality

(b) Reimplantation of the tumor from another site

c. Gross and microscopic findings

(1) Low-grade cancers

• Usually papillary and are not usually invasive (Fig. 20-3)

(2) High-grade cancers

• Papillary or flat and are usually invasive

(3) Most common sites

• Lateral or posterior walls at the base of the bladder

(4) Significance of blood group antigens (A, B, or H)

• Better prognosis if the tumor has the antigens

d. Clinical findings

(1) Painless gross/microscopic hematuria

image

20-3: Transitional cell carcinoma of urinary bladder. The arrow shows a papillary exophytic mass arising from the mucosal surface of the bladder. The red lesion in the prostate gland is an infarction.


(From Rosai J, Ackerman LV: Surgical Pathology, 9th ed. St. Louis, Mosby, 2004, p 1328, Fig. 17-175.)



TCC: painless hematuria most common sign


• Most common sign (70–90%)

(2) Dysuria, increased frequency of urination

e. Treatment

(1) Surgical resection

(2) Intravesical chemotherapy

(3) Radiotherapy

f. Prognosis

• Five-year survival rate for all stages combined is 80%.

3. Squamous cell carcinoma of the bladder

a. Epidemiology

(1) Association with Schistosoma hematobium

• Eggs are located in the urinary bladder venous plexus.


Bladder squamous cancer: S. hematobium


(2) Common cancer in Egypt

(3) 70% of cancers are squamous cell carcinoma, 30% are TCC

b. Pathogenesis of squamous cell carcinoma

(1) Eggs are surrounded by eosinophils.

(2) IgE antibodies are attached to the eggs.

(3) Eosinophils have Fc receptors for IgE.


Killing helminth eggs: type II hypersensitivity reaction involving eosinophils


(4) Eosinophils attach to receptors and release major basic protein, which destroys the egg.

• Type II hypersensitivity reaction

(5) Chronic bladder irritation/infection produces squamous metaplasia.

• Metaplasia can progress to dysplasia and squamous cell carcinoma.

4. Causes of adenocarcinoma of the bladder

a. Urachal remnants (most common cause)

b. Cystitis glandularis

c. Exstrophy of the bladder

5. Embryonal rhabdomyosarcoma (sarcoma botryoides)

a. Most common sarcoma in children

• Accounts for ∼︀3% of childhood cancer


Embryonal rhabdomyosarcoma: most common sarcoma in children; in boys, protrudes from urethra


b. Most common site for boys is urinary system.

• Presents as grape-like masses protruding from the urethral orifice

c. Most common site in girls is the vagina.

6. Cancers invading the bladder

a. Invasive cervical cancer and prostate cancer


Cancers invading bladder: cervical and prostate cancer


b. Produce obstruction of the urethra and the ureters

c. Produce hydronephrosis, postrenal azotemia, and death by renal failure

III. Urethral Disorders

A. Infections

1. Chlamydial and gonococcal infections in men and women

• Urethra is the most common site for these sexually transmitted diseases.


STD urethritis: Chlamydia trachomatis and Neisseria gonorrhoeae


2. Nonvenereal diseases causing urethritis

a. Most commonly due to E. coli

b. Complications

(1) Cystitis in women

(2) Prostatitis in men

3. Chlamydial urethritis is a common component of Reiter’s syndrome in men.


Reiter’s syndrome: Chlamydial urethritis, conjunctivitis, HLA-B27 arthritis


a. Urethritis

b. Sterile conjunctivitis

c. HLA-B27–associated arthritis (refer to Chapter 23)

B. Urethral caruncle

1. Female dominant disease

2. Friable, red painful mass is present at the urethral orifice.

3. Chronically inflamed granulation tissue causes bleeding.

C. Squamous cell carcinoma

Urethra cancer: squamous cell carcinoma most common cause


• Most common cancer of the urethra

IV. Penis Disorders

A. Malformations of the urethral groove

1. Hypospadias

a. Abnormal opening on the ventral surface of the penis (Fig. 20-4)

image

20-4: Hypospadias. The arrow shows the urethral opening on the ventral surface of the penis.


(From Damjanov I, Linder J: Pathology: A Color Atlas. St. Louis, Mosby, 2000, p 211, Fig. 11-6.)



Hypospadias: abnormal opening on ventral surface of penis


b. Most common malformation of urethral groove

c. Risk factors


Hypospadias: most common malformation of urethral grove


(1) Father or previous male sibling had defect

(2) Monozygotic twins

• ? Insufficient production of human chorionic gonadotropin by single placenta

d. Frequently associated with ventral curvature of penis

• Called chordee

e. Pathogenesis

(1) Due to faulty closure of the urethral folds


Hypospadias: faulty closure urethral folds; androgen dysfunction


(2) Possibly related to abnormal androgen production

2. Epispadias


Epispadias: abnormal opening on dorsal surface of penis; defect of genital tubercle


a. Abnormal opening on the dorsal surface of the penis

b. Due to a defect in the genital tubercle

B. Phimosis

1. Orifice of the prepuce is too small to retract over the head of the penis


Phimosis: orifice of prepuce cannot retract over head of penis


2. Commonly associated with infections

C. Balanoposthitis

1. Infection of the glans and prepuce

a. Usually occurs in uncircumcised males with poor hygiene


Balanoposthitis: infection of glans and prepuce


b. Accumulation of smegma leads to infection.

• Candida, pyogenic bacteria, and anaerobes

2. Inflammatory scarring may produce an acquired phimosis.

D. Miscellaneous disorders

1. Peyronie’s disease

a. Type of fibromatosis (refer to Chapter 23)

b. Painful contractures of the penis

Related posts:

  1. White Blood Cell Disorders
  2. Vascular Disorders
  3. Genetic and Developmental Disorders
  4. Red Blood Cell Disorders

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Jun 25, 2017 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on Lower Urinary Tract and Male Reproductive Disorders

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