Lecturer: Ruth Birbe
Lecture: 21
1
Non-Neoplastic: Male Reproductive + Lower
Urinary Tract
A. RENAL PELVIS AND URETERS
I. Congenital disorders
1. Congenital obstruction of the ureteropelvic junction
* Most common cause of hydronephrosis in infants and children.
o Males, <6 months, left > right.
2. Others
o Agenesis, ectopic or duplicate ureters, obstructions and dilations.
II. Ureteritis
o Inflammation of the ureters d/t ascending or descending infection.
o Intrinsic causes: Ureteral obstruction (stones, clots, strictures, etc..)
o Extrinsic causes: tumors, pregnancy, endometriosis, etc…
III. Urolithiasis/Nephrolithiasis
1. General
o Urolithiasis: formation of stones w/in the collecting system of the urinary tract (ureter, bladder, etc…)
o Nephrolithiasis: formation of stones in the collecting system of the kidney (Tubules, calyxes, etc…)
o Usually unilateral, a/w obstruction or urinary stasis.
o All stones contain a matrix of mucoprotein plus some mineral(s).
o Symptoms: severe, abrupt flank pain, groin pain, fever, urinary frequency, urgency and pain. Hematuria.
o Treatment: Depends on location and severity but is often done with shockwave lithotripsy for small stones, and
percutaneous nephrolithotomy or open surgery for large stones.
2. Types of stones
 Calcium stones:
* Most common (75%), calcium oxalate is the most common subtype.
o A/w hypercalciuria, Hypercalcemia, hyperoxaluria, hyperuricosuria.
o Hard and dark. In an acidic urine.
o Enveloped shaped crystals. Highlighted by POLARIZED LIGHT.
o A/w ethylene glycol poisoning (antifreeze)
 Struvite:
o Triple phosphate stones: magnesium ammonium phosphate.
o A/w urea metabolizing bacteria: proteus, staphylococcus).
o Produces staghorn calculi that take the shape of the calcyx.
o Alkaline urine.
o Coffin shape.
 Uric Acid:
o A/w hyperuricemia from chemotherapy for leukemia, drugs, or dietary protein excess.
o Acidic urine.
o Crystals are rhomboid.
 Cysteine:
o Rare. D/t genetic cysteine transport defect.
o Acidic urine.
o Stop sign shaped crystals.
IV. Sclerosing retroperitoneal fibrosis
o Rare, causes ureteral obstruction.
o Dense fibrosis of the retroperitoneal soft tissue and chronic inflammation.
o Unknown causes. A/w other forms of fibrosis and inflammatory conditions.
B. URINARY BLADDER
I. Congenital Malformations
1. Bladder exstrophy
o Absence of anterior bladder wall, and part of anterior abdominal wall with much of the bladder exposed. Male >
female. A/w other urinary malformations.
2. Bladder Diverticula
Dave Reilly
Lecturer: Ruth Birbe
Lecture: 21
2
o Evaginations of the bladder wall that may become infected and require surgery.
o More often acquired (age > 50) than congenital.
3. Urachus
o Vestigial structure connecting the bladder to umbilicus that may fail to close completely during development.
4. Congenital incompetence of the Vesicoureteral valve
* Common cause of Vesicocureteral reflux (VUR) which is a common cause of UTI in children.
o Angle of entrance of ureters into bladder fail to prevent back flow. Girls > boys.
o May grow out of problems, or in symptomatic VUR, surgery is required.
II. Cystitis
o Inflammation of the bladder for any reason that causes dysuria, polyuria, urgency, nocturia, hematuria and
or lower abdominal pain.
o Bacteriuria: is the asymptomatic colonization of the bladder with bacteria that can be found in the urine.
1. Infectious Cystitis
* Very common. Increased risks include catheters, immunosuppression, being female, etc.
o Acute cystitis: increased neutrophils
o Chronic cystitis: lymphocytes and plasma cells
o Follicular cystitis: lymphocytic follicles
o Eosinophilic cystitis: eosinophils (schistosomiasis)
o Granulomatous cystitis: Granulomas – Tuberculosis and schistosomiasis.
 Culture negative cystitis
o Ureaplasma urealyticum, Chlamydia, mycoplasm hominis.
 Bacterial culture positive cystitis
* E. coli
o Staph, Klebsiella
 Fungal cystitis
o Candida
 Schistosomiasis
o North Africa, middle east  Schistosoma haematobium  infect the bladder wall and lay eggs in wall 
released into urine.
o Long term complication = squamous cell carcinoma of the bladder.
 Viral cystitis
o Adenovirus, Herpes simplex virus 2
o Present as Hemorrhagic cystitis (also caused by cyclophosphamide chemotherapy)
 Tuberculous cystitis
o Mycobacterium tuberculosis. Presents with granulomas.
2. Other forms of Chronic Cystitis
 Interstitial cystitis, “Painful bladder syndrome”
o Pelvic pain, dysuria. Cause is not completely known but may involve autoimmunity, neurogenic up regulation,
mast cell activation, etc…
o Females.
o Hunner Ulcers: mucosal ulceration of the bladder wall with inflammation, increased mast cells and transmural
fibrosis.
* Diagnosis of exclusion since there is no definitive test.
* Distinguish from overactive bladder syndrome based on PAIN.
 Malakoplakia
o Uncommon, unknown cause. Inflammatory disorder.
o Female. 50-70. a/w UTIs, immunosuppression, chronic infections and cancer history.
o Soft yellow plaques on the mucosal surface of the bladder.
o ***Von Hansemann Histiocytes: Large macrophages with abundant eosinophilic cytoplasm with PAS
positive granules
 Michaelis-Gutmann bodies: some von hansemann histiocytes may have these basophilic
calcification.
 Radiation Cystitis
o 4-6 weeks post radiation therapy  edema, chronic cystitis, ulcers and fibrosis.
III. Benign Proliferative and Metaplastic Urothelial Lesions
o Characterized by hyperplasia or metaplasia and are a/w chronic inflammation and calculi.
o Brunn Buds: normal invaginations of the surface urothelium into the lamina propria.
o Brunn nests: similar to above, except the buds have detached from the surface and formed nests.
o Cystitis cystica: Looks like above, except the nests now have a lumen
Dave Reilly
Lecturer: Ruth Birbe
Lecture: 21
o Cystitis grandularis: looks like above, except the cells lining the lumen of the nest are now a single layer of
mucin seceting glandular cells (metaplasia)
o Squamous metaplasia: Reaction of chronic injury  urothelium changes to become squamous mucosa
(keratinizing or non-keratinizing). Very common.
o Nephrogenic metaplasia: same as above, except the urothelium changes to resemble renal tubule like
structures. Cause may be renal tubular cells carried downstream, implanting and proliferating.
C. PENIS AND SCROTUM
I. Congenital disorders of the penis
o Hypospadia: Urethra opens on the underside. Surgical repair is uncomplicated. Common.
o Epispadia: Rare. Urethra opens on the upper side. May be small openings or along the entire shaft.
 Surgical repair is often complicated.
* Both are a/w other malformations of the urogenital system.
o Phimosis: narrowing of the foreskin impairing retraction. Increased risk of infections and malignancy.
o Paraphimosis: when phimosis foreskin is retracted causing strangulation of the glans. Can cause necrosis of
the penis… Medical emergency!!
II. Scrotal Masses
 Hydrocele
o Collection of serous fluid between the parietal and visceral layers of the tunica vaginalis.
o Most common cause of scrotal swelling in new borns a/w inguinal hernia.
o Acquired in adults, a/w trauma, hernia, infection, tumor.
o Will transilluminate.
o Complications include: testicular compression and atrophy, infection, infertility.
 Hematocele
o Collection of blood between layers of tunica vaginalis. Trauma, hemorrhage, tumors, infections.
 Spermatocele
o Cyst formed from dilation of the rete testis or epididymis. Mass filled with milky fluid.
Dave Reilly
3
Lecturer: Ruth Birbe
Lecture: 21
4
o **cyst is a true cyst lined by cuboidal epithelium containing spermatozoa undergoing degeneration.
 Varicocele
o “Bag of worms” dilation of the testicular veins.
o Most common on left side d/t venous return.
o Common cause of infertility.
 Scrotal inguinal hernia
o Protrusion of intestine through the inguinal canal into the scrotum.
III. Circulatory Disorders of the Male genitals
1. Scrotal Edema
o Lymphatic or serious fluids accumulate in the scrotum tissue and tunica cavity d/t changes in starlings forces.
o Tumors, scars, filariasis infections, heart failure, cirrhosis, nephrotic syndrome.
2. Erectile Dysfunction
o Inability to achieve an erection. Increases with age. Causes include drugs, idiopathic, neuropsychiatric,
endocrine and vascular disorders.
3. Priapism
o Painful erection not related to sexual arousal. d/t failure of blood to exit penis. A/w hematologic disorders
including sickle cell, PV, leukemia, etc…
IV. Penile Inflammatory Disorders
1. Source is sexually transmitted disease
o Genital herpes: HSV-2, most common STD effecting the glans. PAINFUL grouped vesicles that ulcerate.
 Histologically: 3 M’s (Multinucleation, Molding of nuclei, Margination of chromatin)
o Syphilis: (Treponema pallidum) solitary, PAINLESS, soft ulcer.
o Chancroid: (Haemophilus ducreyi) PAINFUL ulcer of the penis. Often a/w unilateral inguinal lymphadenitis.
o Granuloma inguinale: (Intracellular Calymmatobacterium granulomatis) A tropic infection. PAINLESS raised
ulcer with copius chronic inflammatory exudate. Ulcers enlarge and heal very slowly.
o Lymphogranuloma venereum: (Chlamydia trachomatis) small benign looking PAINLESS ulcer. Spreads to
inguinal LN where it forms large draining sinus tracks that drain pus!!!
o Condylomata acuminate: (HPV) flat topped or cauliflower like warts. Hyperkeratosis. Koilocytes.
o Balantis: inflammation of the glans d/t poor hygiene. Extends to the foreskin and becomes balanoposthitis.
May cause phimosis or paraphimosis.
2. Penile inflammatory disorders of unknown origin
o Balantis Xerotica Obliterans: **Essentially the male equivalent of Lichen Sclerosus et atrophicus of the vulva.
 Chronic inflammatory conditions resulting in fibrosis and sclerosis of the subepithelial connective
tissue leaving the epithelium in tact.
 Effect portion is white and indurated.
 Histologically: subepithelium is acellular and fibrosed.
o Circinate Balantis: fine, circular, linear plaque-like discolorations of the glans. May have ulcerations.
 A/w Reiter syndrome (see later)
o Plasma Cell Balantis: Benign. Discoloration of the glans. Shows large quantities of plasma cells in the
connective tissue with thickened epithelium.
D. URETHRITIS
o Inflammation of the urethra. Acute or chronic.
I. Sexually transmitted urethritis
o Acute (quick) onset after sexual intercourse  purulent discharge from penis.
o Pain, tingling, and dysuria.
o Acute Neisseria Gonococcal infection is most common  may become chronic
o Chlamydia, Ureaplasma, etc…
II. Non-specific infectious urethritis
o Most commonly a/w indwelling cathethers  E. coli or pseudomonas.
o Rarely have discharge.
o Urgency and burning.
III. Reiter Syndrome
* Triad of Urethritis, conjunctivitis and arthritis (of weight baring joints)
o Also a/w circinate balanitis,
o Effects young adults with HLA-B27 haplotype
o Caused by an inappropriate immune reaction to unknown microbial infection
o Will resolve over 3-6 months but arthritis may recur.
E. TESTIS, EPIDIDYMIS AND VAS DEFERENS
Dave Reilly
Lecturer: Ruth Birbe
I. Cryptorchidism
Lecture: 21
5
o “undescended testis” – testis fails to make its way to its proper location in the scrotal sack. May be left behind
anywhere along its descention.
o Most common urological condition requiring treatment in infants.
* Increases risk of infertility and germ cell-neoplasia.
II. Infertility
o Definition: inability to conceive after 1 year of sex with the same partner without contraception.
o Male Causes (20% of total):
 Testicular infertility: testicles are not producing sperm d/t intrinsic issue (Kleinfelters, cryptorchidism)
 Post-testicular: blockage of excretory duct
 Supra-testicular: hormonal or metabolic causes (injury to the Hypothalamic/pituitary axis,
prolactinoma, etc..
III. Epididymitis
o Acute or chronic inflammation of the epididymis
 Bacterial
o Progressive gonorrhea or chlamydia in younger men
o E.Coli in older men and children
o Symptoms: intra-scrotal pain and tenderness with/ without fever and infertility.
o Micro: Acute or chronic inflammation
 Tuberculous epididymitis
o Rare. Look for caseating granulomas.
IV. Spermatic Cord Torsion
* Twisting of the spermatic cord with restriction of blood inflow and outflow. Medical emergency!!
o D/t abnormal anchoring of the testicle.
o Most common in young men following vigorous activity.
o Abrupt onset of pain and swelling  if lasts >24 hours can cause infarction of testis.
V. Orchitis
o Inflammation of the testis d/t infection, immune mediated disease or hematogenous spread of pathogens.
o Gram-Negative Bacterial Orchitis: common. Secondary to UTI.
o Syphilitic orchitits: chronic perivascular inflammation OR granulomatous inflammation.
o Mumps orchitis: UNILATERAL, gonadal swelling a/w mumps infection. Interstitial inflammation w/ loss of
seminiferous epithelium.
o Granulomatous orchitits of unknown cause: rare. Considered an Type IV hypersensitivity reaction.
o Malakoplakia of the testis: same features and causes as malakoplakia of other locations.
F. PROSTATE
I. Prostatitis
* Often caused by coliform uropathogens but often unknown.
* Causes elevated serum PSA prompting the need for biopsy to r/o cancer.
1. Acute prostatitis
o Caused by complicated UTI. Acute inflammation with neutrophils.
2. Chronic prostatitis
o Longer duration. Symptoms of dysuria, burning, pain, and nocturia. Infiltrates of lymphocytes and plasma
cells.
3. Non-bacterial prostatitis
o Common. Diagnosis of exclusion.
o Likely d/t Chlamydia, trachomatis, mycoplasma, urea-plasma.
o Infiltration of acute and chronic inflammatory cells.
4. Granulomatous prostatitis
o Caused by TB
o Caseating or non-caseating granulomas + destruction of prostate glands.
II. Benign Prostatic Hyperplasia (BPH)
o Aka. “Nodular Hyperplasia of the prostate”
o Common. Blacks > whites > Asians. Onset is very high by age 70.
o Hyperplasia (increased proliferation of cells) begins in the inner region surrounding the urethra causing
compression of the urethra.
o Basically just remember that the hyperplasia is nodular and starting from the inside moving out (as
opposed to cancer which starts on the outside).
* Post urinary dripping is the most identifiable test taking clue!!
Dave Reilly
Lecturer: Ruth Birbe
Lecture: 21
o Also: decreased urinary pressure, increased frequency, hydroureter, hydronephrosis, and ultimately
renal failure.
o Firm, enlarged, nodular prostate.
o Treatment: transurethral resection of the prostate (TURP), or suprapublic enucleation.
Dave Reilly
6