Lower Urinary Tract and Male Reproductive Disorders

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Ureteritis cystica:

• Due to inflammation.

Retroperitoneal fibrosis:

• Idiopathic.

• Due to: Ergot derivatives, sclerosing preconditions, lymphoma.

• Complications: hydronephrosis.

Congenital disorders: exstrophy of bladder:

• Developmental failure of anterior abdominal wall and bladder.

Complications:

• Glandular metaplasia, adenocarcinoma.

Cystitis:

• UTIs.

• Common in females due to: short urethra, ascending infection.

• Catherization.

• Diabetes mellitus, cyclophosphamide, Schistosoma hematobium.

• Acute cystitis: E. coli, adenovirus, S. saprophyticus, acute urethral syndrome in women due to C. Trachomatis.

Findings:

• Dysuria, urgency, suprapubic discomfort, hematuria.

Lab:

• Pyuria, bacteriuria, hematuria; + dipstick for leukocyte esterase and nitrite.

Asymptomatic bacteriuria in women:

• Pregnancy, elderly, diabetes mellitus.

Sterile pyuria:

• C. trachomatis, renal TB, acute tubulointerstitial nephritis.

Malacoplakia:

• E. coli.

Findings:

• Michaelis-Gutmann bodies (foamy macrophages), defective phagosomes.

Bladder tumors:

Bladder papilloma:

• Uncommon, benign.

Transitional cell carcinoma:

• Male dominant.

• Most common.

• Smoking, aniline dyes, cyclophosphamide, S. hematobium.

• Painless hematuria, dysuria.

Squamous cell carcinoma:

• S. hematobium.

• Common in Egypt.

• Type II hypersensitivity reaction related to S. hematobium eggs.

Embryonal rhabdomyosarcoma:

• AKA sarcoma botryoides.

• Common in children.

• Grape-like mass in urethra of boys.

Infections:

• Chlamydial and gonococcal infections.

Reiter's syndrome in men:

• Chlamydial urethritis, conjunctivitis, HLA-B27-associated arthritis.

Carcinoma in situ:

Bowen's disease:

• Penis shaft and scrotum.

Erythroplasia of Queyart:

• Erythroplakia on glans and prepuce; HPV type 16 association.

Bowenoid papulosis:

• Multiple pigmented reddish-brown papules on external genitalia; HPV type 16 association.

Squamous cell carcinoma:

• Most common penile cancer.

• HPV type 16, 18 association in most cases; smoking.

• Risk: lack of circumcision.

Epididymitis:

Causes:

• TB.

Infection in younger than 35 years old:

• N. gonorrhoeae, C. trachomatis.

Infection in older than 35 years old:

• E. coli, P. aeruginosa.

Findings:

• Scrotal pain, swelling, tenderness.

• Discharge, Prehn's sign.

Varicocele:

• Blocked right renal vein; blocked left spermatic vein.

Testicular tumors:

Risk factors:

• Cryptorchid testicle, testicular feminization, Klinefelter's symdrome (XXY).

Findings:

• Unilateral painless enlargement of testes.

• Increased: AFP, hCG, lactate dehydrogenase.

Prostatitis:

Acute:

• Urinary reflux from urethra to bladder.

• E. coli, K. pneumoniae.

Chronic:

• Abacterial.

Findings:

• Fever (acute), lower back pain, painful/swollen gland on rectal examination, dysuria, hematuira.

Diagnosis:

• More than 20 WBCs/HPF; increased bacterial count.

Benign prostatic hyperplasia:

• Digital rectal exam 50% sensitive.

• DHT is mediator.

• Estrogen is co-mediator.

Findings:

• Obstruction, hematuria, PSA.

Complications:

• Obstructive uropathy, bladder infections, prostatic infarcts.

Prostate cancer:

• Most common cancer in adult males.

• Risk: age, familial, black, smoking, high saturated fats in diet.

• DHT is mediator.

Findings:

• Obstructive uropathy, back pain, alkaline phosphatase is increased, spinal cord compression.

Diagnosis:

• Screening (DRE/PSA).

Confirmation:

• Needle biopsy.

Spreads to:

• Lungs, liver.

Normal physiology:

• FSH: stimulates spermatogenesis; inhibited by inhibin.

• LH: testosterone synthesis in Leydig cells.

• Prolactin: enhances testosterone function and spermatogenesis; increases GnRH; decreases LH and FSH.

• Testosterone: maintains male secondary characteristics, libido, enhances spermatogenesis.

• SHBG: synthesized in liver; decreased by androgens, obesity, hypothyroidism, insulin.

Male hypogonadism:

• Decreased testosterone; resistance to testosterone.

Findings:

• Impotency, loss of secondary male characteristics, osteoporosis, infertility.

Primary:

• Ledig cell dysfunction.

Causes:

• Liver disease, renal failure.

Findings:

• Decreased testosterone; increased LH, sperm count; normal FSH.

Secondary: hypothalamic/pituitary dysfunction:

Causes:

• Delayed puberty, Kallmann's syndrome, hypopituitarism.

Findings:

• Decreased testosterone; decreased LH, sperm count; decreased FSH.

Male infertility:

Decreased sperm count due to:

• Testicular dysfunction: Leydig cell and/or seminiferous tubule dysfunction.

• Secondary hypogonadism: pituitary and hypothalamic dysfunction.

• End-organ dysfunction.

Erectile dysfunction:

• Psychogenic, decreased testosterone, vascular insufficiency, neurologic disease (defect in parasympathetic S2-S4 (erection) or sympathetic T12-L1 (ejaculation)), drugs, endocrine disease, penis disorders.

Treatment:

• Sildenafil (Viagra); Yohimbe.

Additional Reading:

Basic Pathology

1. Cell Injury
2. Inflammation and Repair
3. Immunopathology
4. Water, Electrolyte, Acid-Base, Hemodynamic Disorders
5. Genetic and Developmental Disorders
6. Environmental Pathology
7. Nutritional Disorders
8. Neoplasia
9. Vascular Disorders
10. Heart Disorders
11. Red Blood Cell Disorders
12. White Blood Cell Disorders
13. Lymphoid Tissue Disorders
14. Hemostasis Disorders
15. Blood Banking and Transfusion Disorders
16. Upper and Lower Respiratory Disorders
17. Gastrointestinal Disorders
18. Hepatobiliary and Pancreatic Disorders
19. Kidney Disorders
20. Lower Urinary Tract and Male Reproductive Disorders
21. Female Reproductive and Breast Disorders
22. Endocrine Disorders
23. Musculoskeletal Disorders
24. Skin Disorders
25. Nervous System Disorders
26. Notes on Tissue Regeneration
27. A Table of Bleeding Disorders
28. FAQ on Structure and Function of Red Blood Cells
29. FAQ on Components of Blood
30. Notes on Hemostatic Mechanisms
31. What is Fever?
32. What is Edema?
33. FAQ on Blood Pressure
34. FAQ on principles of fluid and flow dynamics of Blood
35. Causes of Thrombocytopenia
36. Squamous cell carcinoma of head and neck mucosa
37. Four tumors which never metastasize to the brain
38. What is caustic injury?
39. What causes Peripheral Edema?

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