PATHOLOGY OF THE MALE REPRODUCTIVE SYSTEM

1. SYSTEMIC PATHOLOGY
MALE REPRODUCTIVE SYSTEM:
PENIS
SAMOEI – EGERTON UNIVERSITY, MBChB

2. MALE REPRODUCTIVE SYSTEM
1. TESTIS AND EPIDIDYMIS
2. TESTICULAR NEOPLASMS
3. PENIS
4. TUMORS OF PENIS
5. PROSTRATE
6. CARCINOMA OF PROSTRATE

3. CONTENTS
1. NORMAL STRUCTURE
2. DEVELOPMENTAL DISORDERS
3. INFLAMMATORY DISORDERS
4. PENILE NEOPLASMS

4. NORMAL STRUCTURE
The penis is covered by skin, foreskin (prepuce) and stratified squamous mucosa.
The structure of penis consists of 3 masses of erectile tissue: two corpora
cavernosa, one on each side dorsally, and the corpus spongiosum ventrally
through which the urethra passes.
The expanded free end of the corpus spongiosum forms the glans.
The lumen of the urethra in sectioned surface of the penis appears as an irregular
cleft in the middle of the corpus spongiosum.
In the prostatic part, it is lined by transitional epithelium, but elsewhere it is lined
by columnar epithelium except near its orifice where stratified squamous
epithelium lines it.
The urethra is divided into 4 parts: Pre-prostatic urethra, prostatic urethra,
membranous urethra & penile (spongy) urethra

5. DEVELOPMENTAL & INFLAMMATORY
DISORERS
 Glans and prepuce are frequently involved in inflammation in a number of specific
and non-specific conditions.
 The specific inflammations include various sexually-transmitted diseases such as
hard chancre in syphilis, chancroid caused by Hemophilus ducreyi, gonorrhoea
caused by gonococci, herpes progenitalis, granuloma inguinale (donovanosis),
and lymphopathia venereum caused by Chlamydia trachomatis.
CONGENITAL ANOMALIES OF PENIS
1. Hypospadias
2. Epispadias
3. Agenesis (absence of penis)
4. Micropenis (very small penis)
5. Bifid penis
6. Double penis
7. Phimosis

6. PHIMOSIS
Phimosis is a condition in which the prepuce is too small to permit its normal
retraction over the glans.
It may be congenital or acquired.
Congenital phimosis is a developmental anomaly whereas acquired phimosis may
result from inflammation, trauma or edema leading to narrowing of preputial
opening.
In either case, phimosis interferes with cleanliness and predisposes to the
development of secondary infection, preputial calculi and squamous cell
carcinoma.
Paraphimosis is a condition in which the phimotic prepuce is forcibly retracted
resulting in constriction over the glans penis and subsequent swelling.
Phimosis is often associated with pinhole meatus.

7. HYPOSPADIAS AND EPISPADIAS
Hypospadias is a developmental defect of the urethra in which the abnormal
urethral opening is found on the ventral aspect of the penis anywhere along the
shaft.
The hypospadias occur due to inadequate production of androgens by fetal
testes.
Epispadias is a developmental defect of the urethra in which the abnormal
urethral orifice is on the dorsal aspect of the penis.
2 major effects of hypospadias and epispadias:
1. May cause urethral constriction with consequent infection
2. May interfere with normal ejaculation and insemination.
Both these urethral anomalies are more frequently associated with
cryptorchidism.
Epispadias is less common

8. TYPES OF HYPOSPADIAS
TYPES OF HYPOSPADIAS
Depending upon the location of EUO, 5 types:
1. Glandular:
When the EUO is located on the ventral aspect of
the glans.
2. Coronal/balanic:
When urethra opens at the base of glans penis. In
this case the glans is often grooved on its ventral
aspect.
3. Penile:
When urethra opens anywhere between the base
of the glans and in front of the scrotum.
4. Penoscrotal:
When urethra opens at junction of the penis and
scrotum.
5. Perineal:
When a wide sagittal slit is found along entire
length of the penis and scrotum. The two scrotal
swellings closely resemble labia majora.

9. BALANOPOSTHITIS
Balanoposthitis refers to local inflammation of the inner surface of the prepuce
(balanitis) and adjacent surface of the glans (posthitis).
It is caused by a variety of microorganisms such as staphylococci, streptococci,
coliform bacilli, gonococci, candida albicans, anaerobic bacteria, Gardnerella, and
pyogenic bacteria.
Balanoposthitis usually results from poor hygiene resulting in accumulation of
desquamated epithelial cells, sweat, and debris, termed smegma, which act as a
local irritant.
It is a common accompaniment of phimosis.
The type of inflammation may be acute or chronic, sometimes with ulceration on
the mucosal surface of the glans.

10. BALANITIS XEROTICA OBLITERANS
Balanitis xerotica obliterans is a white atrophic lesion on the glans penis and the
prepuce and is a counterpart of the lichen sclerosus et atrophicus in the vulva.

11. PENILE NEOPLASMS
The following lesions may occur on the penis:
1) Benign neoplasms
2) Premalignant neoplasms
3) Malignant neoplasms

12. BENIGN NEOPLASMS
CONDYLOMA ACUMINATUM (ANOGENITAL WART)
Is a benign tumor caused by HPV types 6 and 11.
The tumor may occur singly, or there may be
conglomerated papillomas.
A more extensive, solitary, exophytic and
cauliflower-like warty mass is termed giant
condyloma or Buschke-Löwenstein tumour or
verrucous carcinoma.
MORPHOLOGIC FEATURES
The condyloma is commonly located on the coronal
sulcus on the penis or the perineal area.
Grossly,
 The tumour consists of solitary or multiple, warty,
cauliflower-shaped lesions of variable size with
exophytic growth pattern.
Histologically,
The lesions are essentially like common warts (verruca
vulgaris).
The features include formation of papillary villi
composed of connective tissue stroma and covered by
squamous epithelium which shows hyperkeratosis,
parakeratosis, and hyperplasia of prickle cell layer.
Many of the prickle cells show clear vacuolization of
the cytoplasm (koilocytosis) indicative of HPV
infection.
Giant condyloma shows upward as well as downward
growth of the tumor but is otherwise histologically
identical to condyloma acuminatum.
Though histologically benign, clinically the giant
condyloma is associated with recurrences and behaves
as intermediate between truly benign condyloma
acuminatum and squamous cell carcinoma.

13. PREMALIGNANT LESIONS (CARCINOMA IN SITU)
(BOWEN’S DISEASE, ERYTHROPLASIA OF QUEYRAT & BOWENOID PAPULOSIS)
In the region of external male genitalia, three lesions display cytological changes of
malignancy confined to epithelial layers only without evidence of invasion.
These conditions are: Bowen’s disease, erythroplasia of Queyrat and bowenoid
papulosis.
BOWEN’S DISEASE
 Bowen’s disease is located on the shaft of the penis and the scrotum besides the sun-
exposed areas of the skin.
Grossly,
It appears as a solitary, circumscribed plaque lesion with ulceration.
Histologically,
The changes are superficial to the dermoepidermal border.
The epithelial cells of the epidermis show hyperplasia, hyperkeratosis, parakeratosis and
scattered bizarre dyskeratotic cells.
A fair proportion of cases of Bowen’s disease are associated with internal visceral cancers.

14. CONT…
ERYTHROPLASIA OF QUEYRAT
 The lesions of erythroplasia of Queyrat
appear on the penile mucosa.
Grossly,
The lesions are pink, shiny and velvety soft.
Histologically,
The thickened and acanthotic epidermis
shows variable degree of dysplasia.
Unlike Bowen’s disease, there is no relationship
between erythroplasia of Queyrat and internal
malignancy.
BOWENOID PAPULOSIS
 The lesions of bowenoid papulosis appear on
the penile shaft and adjacent genital skin.
Grossly,
They are solitary or multiple, shiny, red-brown
popular lesions.
Histologically,
There is orderly maturation of epithelial cells
in hyperplastic epidermis with scattered
hyperchromatic nuclei and dysplastic cells.

15. MALIGNANTTUMOURS
SQUAMOUS CELL CARCINOMA
The incidence of penile carcinoma shows wide variation in different populations.
In the United States, the overall incidence of penile cancer is less than 1% of all cancers in males but it
is 3-4 times more common in blacks than in whites.
In some Asian,African and Latin American countries, its incidence is about 10% of all cancers.
Relationship of penile cancer with HPV has been well supported; high-risk HPV types 16 and 18 are
strongly implicated and their DNA has been documented in the nuclei of malignant cells.
Carcinoma of the penis is quite rare in Jews and Muslims who undergo a ritual of circumcision early in
life.
In India, cancer of the penis is rare in Muslims who practice circumcision as a religious rite in infancy,
whereas Hindus who are normally not circumcised have a higher incidence.
Circumcision provides protection against penile cancer due to prevention of accumulation of smegma
which is believed to be carcinogenic.
The greatest incidence of penile cancer is between 45 and 60 years.

16. CONT…
MORPHOLOGIC FEATURES
Grossly,
The tumor is located, in decreasing frequency, on frenum, prepuce, glans and
coronal sulcus.
The tumor may be cauliflower-like and papillary, or flat and ulcerating.
Histologically,
Squamous cell carcinoma of both fungating and ulcerating type is generally well
differentiated to moderately-differentiated type which resembles in morphology
to similar cancer elsewhere in the body.
The tumor metastasises via lymphatics to regional lymph nodes.
Visceral metastases by hematogenous route are uncommon and occur in
advanced cases only.

17. Carcinoma in situ (Bowen disease) of the penis.The epithelium
above the intact basement membrane shows delayed maturation
and disorganization (left). Higher magnification (right) shows
several mitotic figures, some above the basal layer, and nuclear
pleomorphism.
Carcinoma of the penis.The glans penis is
deformed by an ulcerated, infiltrative mass.

18. Carcinoma of the penis.
Diagrammatic representation of flat-ulcerating (A) and cauliflower papillary (B) patterns of growth at common locations.
C, Amputated specimen of the penis shows a cauliflower growth on the coronal sulcus (arrow).
The surface of the growth is ulcerated and is chalky-white in appearance.

19. Squamous cell carcinoma penis. Microscopy shows whorls of malignant squamous cells with central keratin pearls.