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The Lower Urinary System and Male Genital System

The Lower Urinary System and Male Genital System. The Lower Urinary Tract. Congenital anomalies Ureteropelvic junction obstruction – most common cause of hydronephrosis in infants and children, boys>girls, 20% bilateral. Intrinsic Calculi Strictures Tumors Blood clots Neurogenic.

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The Lower Urinary System and Male Genital System

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  1. The Lower Urinary System and Male Genital System

  2. The Lower Urinary Tract Congenital anomalies Ureteropelvic junction obstruction – most common cause of hydronephrosis in infants and children, boys>girls, 20% bilateral

  3. Intrinsic Calculi Strictures Tumors Blood clots Neurogenic Extrinsic Pregnancy Periureteral inflammation Endometriosis Tumors Ureteral Obstructive Lesions

  4. Sclerosing Retroperitoneal Fibrosis Fibrous proliferative inflammatory process encasing the retroperitonal structures and causing hydronephrosis Similar to Riedel thyroiditis 70% no identifiable cause ( Ormond disease) Drugs ( ergot derivatives, Beta blockers) Adjacent inflammatory conditions (Crohn disease) Malignant disease ( lymphoma, UT carcinoma)

  5. Urinary Bladder Congenital anomalies Diverticula Exstrophy VUR Patent urachus

  6. Cystitis Bacterial E. Coli, Proteus, Klebsiella, Enterobacter TB Candida, Cryptococcal Chlamydia, Mycoplasma Schistomiasis Adenovirus Predisposing factors Female, calculi, urinary obstruction, DM, instrumentation, immune deficiency Triad Frequency, Lower abdominal pain, Dysuria Special forms Interstitial – chronic pelvic pain Malacoplakia – soft yellow, raised mucosal plaques Polypoid – irritation to the bladder mucosa Hemorrhagic- adenovirus, cyclophosphamide Follicular- aggregates of lymphocytes Eosinophilic- nonspecific subacute infection

  7. Metaplastic lesions Cystitis cystica et glandularis- nests of urothelium grow downward into lamina propria Squamous metaplasia Nephrogenic adenoma – shed renal tubular cells that implant in the urothelium in response to injury

  8. Neoplasms Urothelial ( transitional) tumors 90% of all bladder tumors Exophytic papillomas Inverted papillomas PUNLMPs- papillary urothelial neoplasms of low malignant potential Low grade and high grade papillary urothelial cancers CIS

  9. Epidemiology Males> Females Cigarette smoking Industrial exposures to arylamines Schistosoma infections Long-term use of analgesics Long-term exposure to cyclophosphamide Prior exposure to irradiation Chromosome 9 deletions Clinical – painless hematuria

  10. Urethra Urethritis GC Chlamydia, Mycoplasma, Enteric organisms Reiter’s syndrome Urethral carbuncle Peyronie disease – subcutaneous fibrosis Carcinoma

  11. Male genital tract Penis hypospadias Epispadias Phimosis Balanoposthitis Condyloma acuminatum CIS Bowen disease – single erythematous plaque Bowenoid Papulosis – multiple warty lesions, HPV 16 Invasive Squamous cell carcinoma

  12. Testes and Epididymis Cryptorchidism- increased incidence of germ cell tumors Atrophy and decreased fertility Nonspecific epididymitis and orchitis Granulomatous ( auto-immune) orchitis GC Mumps TB Syphilis Torsion – bell clapper deformity Tunica Vaginalis Hydrocele, Hematocele, Chylocele, Spermatocele, Varicocele

  13. Testicular Tumors Germ Cell tumors Seminomas – very radiosensitive, most frequent, analogous to dysgerminoma in females Spermatocytic Seminoma Embryonal carcinoma – second most common, painful, worse prognosis Yolk Sac tumor Choriocarcinoma Teratoma – almost always malignant Mixed tumors Clinical features Painless enlargement of the testis Spread via para-aortic nodes to medistinal and supraclavicular NSGCTs more aggressive , poorer prognosis HCG, AFP, LDH Sex Cord-Gonadal Stroma Leydig Cell – precocious puberty Sertoli Cell – no endocrine Gonadoblastoma Testicular Lymphoma

  14. Prostate 4 biologically and anatomically distinct zones: Peripheral – most carcinomas Central Transitional – most hyperplasia Anterior fibromuscular stroma

  15. Prostatitis

  16. Nodular hyperplasia Very common in men>50 years of age Partial or complete obstruction of urethra Overall reduction in the rate of cell death DHT from stromal cells induces growth factors Bladder hypertrophy and distension Urine retention Frequency, nocturia, difficultystarting and stopping stream, overflow dribbling, dysuria Increased risk of infection Sudden acute urine retention –emergency catherization Benign Prostatic Hyperplasia

  17. Adenocarcinoma Most common cancer in men Androgens play an important role FH important BRCA2 Inflammation may set the stage TMPRSS2 promoter, ETS gene Hypermethylation of GSTRP1 EZH-2 AMACR PCA3 PSA – organ specific, velocity of change Prostate Tumors

  18. Prostate Tumors PIN – high grade prostatic intraepithelial neoplasia Gleason score – 2 numeric grades added together Gritty and firm Outer layer of basal cell layer is absent in carcinoma Grade and stage are best prognostic factors Boney metastases in vertebrae – universally fatal

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