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Plan
• Disorders of penis
• Malformations
• Acquired disorders
• Semen analysis
• Male infertility - investigations
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Penis
Congenital
Acquired disorders
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Penis
Congenital
Acquired disorders
inflammatory
neoplasms
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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)
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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
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congenital disorder
Malformations
abnormality in the location of distal urethral orifice
Epispadias (opening of urethra along dorsal aspect of penis)
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Epispadias
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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
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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
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• Phimosis
Paraphimosis
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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
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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
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Tumours
• Benign
• Malignant
• Premalignant
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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
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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
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Histology
• Branching, villous, papillary connective tissue stroma
• Covered by epithelium which may have hyperkeratosis and thickening of epidermis (acanthosis)
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HistologyOrderly maturation of epithelial cellsClear vacuolization of prickle cellsBasement membrane intact, no evidence of infl
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Clinical course
• Tend to recur
• Do not evolve into cancers
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Tumours• Uncommon
• Most frequent is carcinoma and benign epithelial tumour - condyloma acuminatum
• Other forms - carcinoma in situ - Bowens disease
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Malignant tumors
• Carcinoma insitu
• Invasive carcinoma
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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Semen AnalysisMale infertility - investigations
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Semen analysis
Constituents
spermatozoa
secretions from
testes
epididymis
prostate
seminal vesicle
bulbourethral glands
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Semen analysis
evaluation of reproductive dysfunction
selection of donors for therapeutic insemination
to monitor the success of surgical procedures
varicocelectomy
vasectomy
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Semen analysis
Includes
Microscopic evaluation
Macroscopic evaluatin
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Semen analysisIncludes
Microscopic evaluation
Concentration
Motility
Morphology
agglutination
Macroscopic evaluation
physical
chemical properties
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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
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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
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Semen analysis
Classification of sperm morphology
Head defects
Neck and mid piece defects
Tail defects
Cytoplasmic droplets
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Semen analysis
Biochemical assays
prostate gland
Citric acid, Zinc, GGTP, Acid phosphatase
Seminal vesicle
Fructose and prostaglandins
Epididymis
Free L carnitine, glycerophosphocholine
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Male infertility
Semen analysis
FSH/Testosterone
Anti sperm antibodies
FNAC/biopsy of testes
Ctogenetics