Plan

• Disorders of penis

• Malformations

• Acquired disorders

• Semen analysis

• Male infertility - investigations

Penis

Congenital

Acquired disorders

Penis

Congenital

Acquired disorders

inflammatory

neoplasms

congenital disorder

Malformations

abnormality in the location of distal urethral orifice

Hypospadias (opening of urethra along ventral aspect)

epispadias (opening of urethra along dorsal aspect)

congenital disorderMalformations

abnormality in the location of distal urethral orifice

Hypospadias (opening of urethra along ventral aspect of penis)

more common (1 in 300 live male births)

urinary obstruction common

associated with other genital anomalies

inguinal hernia

undescended testis

congenital disorder

Malformations

abnormality in the location of distal urethral orifice

Epispadias (opening of urethra along dorsal aspect of penis)

Epispadias

PhimosisOrifice of prepuce is too small to permit normal retraction over the glans penis

Maybe due to

Anomalous development

Scarring of preputial ring following infections

Importance

Interferes with cleanliness

Accumulation of secretions and detritus under prepuce

Favours development of infection and carcinoma

Paraphimosis

• When a phimotic prepuce is forcibly retracted over the glans penis, marked constriction and subsequent swelling of glans may prevent replacement of prepuce creating paraphimosis

• Condition extremely painful

• Potential cause of acute urinary retention due to urethral obstruction

• Phimosis

Paraphimosis

Inflammations• Invariably involve the glans and prepuce

• Specific infections

• Syphilis, chancroid, granuloma inguinale

• Genital herpes

• Non specific infections

• Balanoposthitis: caused by

• Candida albicans

• Anerobic bacteria

• Gardnerella

• Pyogenic bacteria

Inflammations

• Pathogenesis

• Consequence of poor local hygiene in uncircumcised males

• accumulation of desquamated squamous cells, sweat and debris - SMEGMA - acts as local irritant

• Persistence of infection leads to scarring - phimosis

Tumours

• Benign

• Malignant

• Premalignant

Condyloma Acuminatum

• Benign tumour

• Caused by Human papilloma Virus - HPV

• Related to common wart (verruca vulgaris)

• Occurs on moist mucocutaneous junctions

• HPV and associated diseases are sexually transmitted

• Type 6 and type 11 associated with Condylomata Acuminata

Morphology• May occur on genital or perineal

areas

• On penis occurs commonly about the coronal sulcus and inner aspect of prepuce

• Single or multiple

• Sessile or pedunculated

• Red papillary excrescences

• Vary from 1 mm to several mms

Histology

• Branching, villous, papillary connective tissue stroma

• Covered by epithelium which may have hyperkeratosis and thickening of epidermis (acanthosis)

HistologyOrderly maturation of epithelial cellsClear vacuolization of prickle cellsBasement membrane intact, no evidence of infl

Clinical course

• Tend to recur

• Do not evolve into cancers

Tumours• Uncommon

• Most frequent is carcinoma and benign epithelial tumour - condyloma acuminatum

• Other forms - carcinoma in situ - Bowens disease

Malignant tumors

• Carcinoma insitu

• Invasive carcinoma

Carcinoma in situ

• Histologic term

• Epithelial lesion

• Cytologic changes of malignancy are limited to the epithelium

• No evidence of local invasion or distant metastasis

• Considered precancerous condition

• Potential to evolve into invasive cancer

Carcinoma in situ

• In the male external genitalia there are two distinct lesions that show carcinoma in situ

• BOWEN Disease

• BOWENOID papulosis

• Lesions strongly associated with HPV type 16

Carcinoma in situ• Bowen Disease

• Genital region of both men and women

• Usually over the age of 35 years

• In men it involves: skin of shaft of penis, scrotum

• Grossly: appears solitary thickened gray white opaque plaque with shallow ulcerations and crusting

• When it occurs on glans or prepuce - single or multiple shiny red velvety plaques - clinically referred to as Erythroplasia of Querat

Carcinoma in situ

• Bowen Disease

• Histology

• Proliferation of epidermis

• Numerous mitosis, some atpical

• Cells markedly dysplastic

• Large hyperchromatic nuclei

• Over years 10% may transform in carcinoma

Carcinoma in situ• Bowenoid papulosis

• Occurs in sexually active adults

• Younger age of patients

• Presence of multiple pigmented (reddish brown) papular lesions, some cases maybe verrucoid mistaken for Candyloma acuminatum

• Histologically indistinguishable from Bowen disease, related to HPV 16

• Never develops into invasive carcinoma

• Many cases spontaneously regress

Invasive Carcinoma

• Common in Asia 10% to 20%

• Uncommon in United states. Less than 1%

• Striking correlation between Circumcision and occurrence of carcinoma

• Circumcision confers protection

• Extremely uncommon in Jews and Moslems

Invasive Carcinoma

• Circumcision associated with better genital hygiene

• Reduces exposure to carcinogens that are concentrated in Smegma

• Decreases likelihood of infection with potentially oncogenic HPV

• HPV type 16 is the most common, also HPV 18

Invasive Carcinoma

• Carcinoma in situ - 80% associated with HPV

• Invasive carcinoma - 50 % association-HPV

• Indicates that HPV alone may not be sufficient to convert Ca in situ to invasive malignancy. Requires other carcinogenic influences like

• Cigarette smoking

Verrucous carcinoma

• Uncommon

• Well differentiated variant of squamous carcinoma

• Has low malignant potential

• Locally invasive, can invade the underlying tissue

• Rarely metastasize

• Has a papillary appearance similar to condyloma but larger in size

Invasive Carcinoma

• Morphology

• Usually begins on glans or inner surface of prepuce near the coronal sulcus

• Two macroscopic patterns

• Papillary : simulate condylomata, produces cauliflower like fungating masses

• Flat : appear as epithelial thickening accompanied by graying and fissuring.

Invasive Carcinoma• Clinical course

• Slow growing

• Locally invasive

• Lesion not painful unless ulcerated/infected

• Bleed frequently

• Early metastases to inguinal and iliac nodes

• Prognosis related to stage of tumor

• Prognosis poor if regional lymphnodes are involved

Semen AnalysisMale infertility - investigations

Semen analysis

Constituents

spermatozoa

secretions from

testes

epididymis

prostate

seminal vesicle

bulbourethral glands

Semen analysis

evaluation of reproductive dysfunction

selection of donors for therapeutic insemination

to monitor the success of surgical procedures

varicocelectomy

vasectomy

Semen analysis

Includes

Microscopic evaluation

Macroscopic evaluatin

Semen analysisIncludes

Microscopic evaluation

Concentration

Motility

Morphology

agglutination

Macroscopic evaluation

physical

chemical properties

Semen analysis

Macroscopic evaluation

Liquefaction - normal : within 60 minutes

Appearance - After liquefaction - homogenous grey opalescent

Volume - 2 to 5 ml

Viscosity

pH : 6.4 to 8.0

Semen analysisIncludes

Microscopic evaluation

Concentration

Less than 20 mill/ml - Oligospermia

Motility

less than 50% motile sperms - Asthenospermia

Morphology

Less than 50% normal morphology - Teratozoospermia

agglutination

Semen analysis

Classification of sperm morphology

Head defects

Neck and mid piece defects

Tail defects

Cytoplasmic droplets

Semen analysis

Biochemical assays

prostate gland

Citric acid, Zinc, GGTP, Acid phosphatase

Seminal vesicle

Fructose and prostaglandins

Epididymis

Free L carnitine, glycerophosphocholine

Male infertility

Semen analysis

FSH/Testosterone

Anti sperm antibodies

FNAC/biopsy of testes

Ctogenetics