Normal Lab Values

Week 15: Lower Urinary Tract & Male Reproductive System

Suggested readings from
Robbins 8th ed.
Male Urinary and Repro Systems: pp. 971-1004

Cases for Week 15

Review Items for Week 15: Lower Urinary Tract

Review Items for Week 15: Male Reproductive System

 

Pathology Case Descriptions

CASE NUMBER 18
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Clinical History: This 29-year-old male's illness began 10 weeks prior to death, with an episode of "flu" and pharyngitis. Two weeks later his urine became "smoky." He was found to have hematuria, albuminuria and elevated BUN (180 mg/dl). He died from a pulmonary embolus.

Image Gallery:

(Summary of Gross Findings - click here)
The kidneys were enlarged (230 gm each). The surface was granular and covered with pinpoint hemorrhages in the fresh state. The external surface with capsule removed is illustrated.
(Summary of Microscopic Findings - click here)
There is marked proliferation of epithelium of Bowman's capsule producing "crescents". In places fibrin strands are intermixed with the epithelial cells. Tubules are dilated and contain many red blood cells. There is marked interstitial edema and presence of numerous leukocytes. The presence of a large number of crescents is a bad prognostic sign.
(Review Normal Histology - click here)
Norm No. 2 Kidney
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The kidney excretes soluble waste from the body and controls electrolyte balance. It consists of the cortex and the medulla. Within the outer cortex, glomeruli with delicate capillary loops are seen.  The basement membrane is thin and without inflammation or thickening. Bowman’s capsule that surrounds the glomerulus is thin. The interstitium demonstrates no evidence of inflammation or fibrosis.  In the areas between the glomeruli, tubules and arterioles are seen. The tubules are intact.  The vessels exhibit no narrowing or wall thickening. The inner medulla of the kidney contains only tubules and blood vessels. Larger arteries and veins are located at the interface between cortex and medulla.

 

What is the MOST LIKELY diagnosis?

ANSWER

18-1. A distinctive feature in these images is the formation of crescents. These cellular crescents are in part due to:

  1. Proliferation of the mesangial cells
  2. Proliferation of the glomerular endothelial cells
  3. Proliferation of the Bowman’s capsule epithelial cells
  4. Proliferation of fibroblasts

ANSWER

18-2. The pathology shown may be seen in a condition characterized by pulmonary hemorrhage and renal failure due to cross-reacting antibodies against the lung and kidneys. What form of hypersensitivity reaction is demonstrated in such a disease?

  1. Type 1
  2. Type 2
  3. Type 3
  4. Type 4

ANSWER

 

 

 

CASE NUMBER 17
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Clinical History: Four years before death the patient was seen in the hospital because of nausea and vomiting. He had hematuria, proteinuria, urinary casts, and a BUN of 50 mg/dl. A diagnosis of "chronic glomerulonephritis" was made. He did well for over 3 1/2 years, with elevated BUN of 50-60 mg/dl. His blood pressure was 150/90. A month before death his BUN increased and he died of renal failure.

Image Gallery:

(Summary of Gross Findings - click here)
Both kidneys, distorted by multiple irregular broad scars, were small, each weighing about 60 grams (compared to a normal kidney, as shown in the center) and were pale and finely granular. The cortex in each was markedly thinned.
(Summary of Microscopic Findings - click here)
All of the 4 main constituents of the kidney (glomeruli, tubules, vessels, and interstitial tissue) are involved. Although all glomeruli are abnormal, they are not involved to the same degree; some are completely replaced by fibrous tissue, others are only partly scarred, and a few still contain patent capillary loops. The latter have increased mesangial and epithelial cells of Bowman's capsule. The tubules are dilated; some contain red blood cells, but most contain hyaline casts. The interstitial tissue is rather diffusely infiltrated with many lymphocytes and plasma cells. There is a moderate to marked degree of arteriosclerosis.
(Review Normal Histology - click here)
Norm No. 2 Kidney
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The kidney excretes soluble waste from the body and controls electrolyte balance. It consists of the cortex and the medulla. Within the outer cortex, glomeruli with delicate capillary loops are seen.  The basement membrane is thin and without inflammation or thickening. Bowman’s capsule that surrounds the glomerulus is thin. The interstitium demonstrates no evidence of inflammation or fibrosis.  In the areas between the glomeruli, tubules and arterioles are seen. The tubules are intact.  The vessels exhibit no narrowing or wall thickening. The inner medulla of the kidney contains only tubules and blood vessels. Larger arteries and veins are located at the interface between cortex and medulla.

 

What is the MOST LIKELY diagnosis?

ANSWER

 

17-1. What may have caused this end-stage glomerular disease?

  1. Previous post streptococcal glomerulonephritis
  2. Rapidly Progressive glomerulonephritis (RPGN)
  3. Membranous glomerulonephritis
  4. Membranoproliferative glomerulonephritis
  5. IgA nephropathy
  6. Focal Segmental Glomerulonepritis (FSGN)
  7. No antecedent history of acute glomerulonephritis
  8. ALL of the above

ANSWER

 

 

CASE NUMBER 30
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Clinical History: This 80-year-old woman had been known to be hypertensive for many years. She died of congestive heart failure, following a period of hospitalization for pneumonia.

Image Gallery:

(Summary of Gross Findings - click here)
The heart was enlarged. Both kidneys were somewhat smaller than normal (100 grams each) and were finely and diffusely granular.
(Summary of Microscopic Findings - click here)
The arterioles are prominent with hyalinized walls. Note the thickened arterioles at the vascular poles of the glomeruli, and observe the extension of the hyaline material into the glomerulus. Some glomeruli are more scarred than others. This "sclerosis" is secondary to the ischemia caused by the narrowed lumens of the arterioles. There are also scattered patches of interstitial fibrosis and chronic inflammation.
(Review Normal Histology - click here)
Norm No. 2 Kidney
[ImageScope] [WebScope]

The kidney excretes soluble waste from the body and controls electrolyte balance. It consists of the cortex and the medulla. Within the outer cortex, glomeruli with delicate capillary loops are seen.  The basement membrane is thin and without inflammation or thickening. Bowman’s capsule that surrounds the glomerulus is thin. The interstitium demonstrates no evidence of inflammation or fibrosis.  In the areas between the glomeruli, tubules and arterioles are seen. The tubules are intact.  The vessels exhibit no narrowing or wall thickening. The inner medulla of the kidney contains only tubules and blood vessels. Larger arteries and veins are located at the interface between cortex and medulla.

 

What is the MOST LIKELY diagnosis?

ANSWER

 

30-1. Which of the following BEST describes the pathological changes seen in the blood vessels?

  1. Arteriolosclerosis
  2. Amyloidosis
  3. Polyarteritis nodosa
  4. Monckeberg medial calcific sclerosis
  5. Cystic medial necrosis

ANSWER

 

 

 

CASE NUMBER 2
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Clinical History: This 45-year-man noticed blood in his urine. His physician ordered a CT of the lower abdomen and pelvis. A mass in the superior pole of the kidney was discovered. A biopsy was performed and then the kidney was removed.

Image Gallery:

(Summary of Gross Findings - click here)
There is a large yellow tan tumor with areas of hemorrhage in the superior pole of the kidney. The tumor invades the renal vein and the perinephric adipose tissue.
(Summary of Microscopic Findings - click here)
The capsule is revealed to be actually a pseudo capsule formed by compression of surrounding renal parenchyma. The tumor is made up mainly of large irregular cells, some with granular cytoplasm, and others with large vacuoles. The nuclei vary in size and shape. Some are pyknotic and some are displaced to the periphery of the large vacuolated cells characteristic of this disease.
(Review Normal Histology - click here)
Norm No. 2 Kidney
[ImageScope] [WebScope]

The kidney excretes soluble waste from the body and controls electrolyte balance. It consists of the cortex and the medulla. Within the outer cortex, glomeruli with delicate capillary loops are seen.  The basement membrane is thin and without inflammation or thickening. Bowman’s capsule that surrounds the glomerulus is thin. The interstitium demonstrates no evidence of inflammation or fibrosis.  In the areas between the glomeruli, tubules and arterioles are seen. The tubules are intact.  The vessels exhibit no narrowing or wall thickening. The inner medulla of the kidney contains only tubules and blood vessels. Larger arteries and veins are located at the interface between cortex and medulla.

 

2-1. What is the BEST diagnosis?

  1. Collecting (Bellini) duct carcinoma
  2. Papillary carcinoma
  3. Clear cell carcinoma
  4. Chromophobe renal carcinoma
  5. Wilm's tumor

ANSWER

 

2-2. What is the MOST COMMON location of metastases from this neoplasm?

  1. Liver
  2. Bone
  3. Brain
  4. Lung
  5. Lymph nodes

ANSWER

 

2-3. Which genetic alteration is associated with this tumor?

  1. Trisomy 17
  2. Gains of MET
  3. Loss of VHL
  4. t (X; 1)
  5. Loss of multiple chromosomes

ANSWER

 

 

CASE NUMBER 33
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Clinical History: This 57-year-old female complained of hematuria. She was cystoscoped and found to have a papillary mass near the dome of the bladder.

Image Gallery:

(Summary of Gross Findings - click here)
A normal transitional epithelium lines the central portion of the surface of the opened bladder. The tumor appears as mass protruding into the lumen.
(Summary of Microscopic Findings - click here)
Histologic section shows that the tumor is composed of many fingerlike fronds (papillae). Note the adjacent normal urothelium. The connective tissue and vascular core of the tumor fronds is lined by thickened, atypical transitional epithelium. There is a suggestion of very early invasion into the mucosa at the base of the tumor but the muscularis is uninvolved.
(Review Normal Histology - click here)
Norm No. 31 Urinary bladder
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The urinary bladder is composed of thick smooth muscle and lined by transitional epithelium.

 

33-1. What is the MOST LIKELY diagnosis?

  1. Inverted papilloma
  2. Papilloma
  3. Papillary urothelial carcinoma
  4. Squamous carcinoma

ANSWER

 

33-2. What neoplasm is associated with Schistosomiasis?

  1. Adenocarcinoma
  2. Papilloma
  3. Papillary urothelial carcinoma
  4. Squamous carcinoma

ANSWER

 

33-3. What neoplasm is associated with urachal remnants?

  1. Adenocarcinoma
  2. Papilloma
  3. Papillary urothelial carcinoma
  4. Squamous carcinoma

ANSWER

 

33-4. The MOST IMPORTANT risk factor for bladder cancer, associated with >50% of all bladder cancers in men is:

  1. Exposure to arylamines
  2. Schistosoma haematobium infections
  3. Cigarette smoking
  4. Bladder stones

ANSWER

 

 

 

CASE NUMBER 202
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Clinical History: A 74-year-old white man had hesitancy, intermittency, nocturia, and increasing difficulty in urination for one year. Rectal examination revealed an enlarged, nodular firm prostate.

Image Gallery:

(Summary of Gross Findings - click here)
The prostate was large, nodular, and 120 grams in weight. The capsule was tense, and many gray-white firm nodules bulged out of the cut surface. These nodules varied from 3 mm to 1 cm. The larger ones were present in the lateral lobes and compressed the urethra.
(Summary of Microscopic Findings - click here)
Two types of nodules can be distinguished. One is composed essentially of fibro-muscular elements - stromal hyperplasia. The other is composed predominantly of epithelial glands. The size of the glands varies remarkably, and cystic dilatation of some is present. There are two types of cells forming the glands. The luminal cells are tall columnar cells with basal nuclei and apocrine secretory activity in the cytoplasm. The basal cell layer is composed of cuboidal or flattened epithelium. These glandular nodules are well demarcated by the encircling fibro-muscular stroma.
(Review Normal Histology - click here)
Norm No. 1 Prostate
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The prostate gland is composed of multiple glandular spaces lines by a basal layer of cuboidal epithelium covered by columnar secretory cells with frequent papillary projections into the gland lumen. The cells are uniform in size and shape. The nuclei are not crowded. They do not have nucleoli that are visible. Glands are separated by fibrovascular stroma.

 

What is the MOST LIKELY diagnosis?

ANSWER

 

202-1. The MOST COMMON symptom of this disease is:

  1. Bone pain
  2. Urinary hesitancy
  3. Hematuria
  4. Flank pain

ANSWER

 

202-2. This disease predisposes patients to all of the following conditions EXCEPT:

  1. Pyelonephritis
  2. Incomplete bladder emptying
  3. Adenocarcinoma of prostate
  4. Nocturia

ANSWER

 

 

CASE NUMBER 5
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Clinical History: This 77-year-old male had an enlarged hard prostate gland on digital rectal exam. Blood test for prostate specific antigen was elevated. The prostate gland was surgically removed.

Image Gallery:

(Summary of Gross Findings - click here)
The prostate was quite large and firm with multiple rubbery nodules measuring 2 mm to 6 mm in diameter. Some of the nodules contain yellowish flecks. The seminal vesicles were firm bilaterally.
(Summary of Microscopic Findings - click here)
There are a number of glands shown in varied patterns. In some cases the epithelial cells are found in non-glandular masses. The epithelial cells are cuboidal or polygonal with central, round, deeply pigmented nuclei. Few, if any, mitotic figures can be seen. The presence of perineural and perivascular invasion is clearly in evidence. This is a useful diagnostic characteristic of adenocarcinoma of the prostate.
(Review Normal Histology - click here)
Norm No. 1 Prostate
[ImageScope] [WebScope]

The prostate gland is composed of multiple glandular spaces lines by a basal layer of cuboidal epithelium covered by columnar secretory cells with frequent papillary projections into the gland lumen. The cells are uniform in size and shape. The nuclei are not crowded. They do not have nucleoli that are visible. Glands are separated by fibrovascular stroma.

 

5-1. The BEST histological diagnosis is:

  1. prostatic hypertrophy.
  2. prostatic intraepithelial neoplasia (PIN).
  3. prostatic adenocarcinoma.
  4. leiomyoma.
  5. small cell neuroendocrine carcinoma.

ANSWER


5-2. Which of the following features are seen in this tumor?

  1. Islands of squamous cells
  2. Perineural spread of the tumor
  3. Highly pleomorphic nuclei
  4. Production of mucus
  5. Signet ring cells

ANSWER


5-3. Which group has the HIGHEST incidence of this disease?

  1. Caucasians living in USA
  2. Chinese living in Southeast Asia
  3. African-Americans living in USA
  4. Japanese living in USA

ANSWER

 

5-4. Which of the following bones is MOST LIKELY to receive metastases from this neoplasm?

  1. Femur
  2. Skull
  3. Pelvis
  4. Spine

ANSWER

 

5-5. What histological feature MOST RELIABLY identifies this neoplasm on biopsy?

  1. Large glands
  2. Small glands
  3. Perineural invasion
  4. Nuclear anaplasia

ANSWER

 

5-6. What combined Gleason score would you assign to this case?

  1. 2
  2. 5
  3. 7
  4. 9

ANSWER

 

5-7. Which combined Gleason score is associated with the WORST prognosis?

  1. 2
  2. 5
  3. 7
  4. 10

ANSWER

 

5-8. Which prostate cancer patient will benefit the MOST from radical prostatectomy?

  1. >65 years, neoplasm confined to prostate
  2. <65 years, neoplasm confined to prostate
  3. >65 years, distant metastases present
  4. >65 years, distant metastases present

ANSWER

 

 

CASE NUMBER 34
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Clinical History: This 48-year-old white male had a history of embryonal carcinoma and seminoma of the left testis when he was 37. A mass was noted on the remaining right testis. An orchiectomy was done.

Image Gallery:

(Summary of Gross Findings - click here)
The orchiectomy specimen has been opened to demonstate the soft fleshy tumor which has replaced the normal testis. The spermatic cord is attached.
(Summary of Microscopic Findings - click here)
Note the characteristic arrangement of cells in small groups outlined by delicate fibrous stroma. The cells are relatively uniform with distinct borders. The cytoplasm is clear and sometimes almost foamy. The cells are polygonal with large, round, central nuclei and prominent nucleoli. In many sections a fragment of atrophic and fibrotic testis may be seen adjacent to the tumor.
(Review Normal Histology - click here)
Norm No. 22 Testis
[ImageScope] [WebScope]

The testis is the male gland responsible for sperm production. There is a fibrous capsule and multiple glands separated by a loose stoma. Within the glands there are mature and immature sperm. Within the stroma there are a few large Leydig cells which are responsible for testosterone production.

 

34-1. What is the MOST LIKELY diagnosis?

  1. Seminoma
  2. Choriocarcinoma
  3. Yolk sac tumor
  4. Embryonal carcinoma

ANSWER


34-2. Which of the following tumors is MOST radiosensitive?

  1. Seminoma
  2. Choriocarcinoma
  3. Yolk sac tumor
  4. Embryonal carcinoma

ANSWER


34-3. Which is LEAST LIKELY to metastasize via a hematogenous route?

  1. Seminoma
  2. Choriocarcinoma
  3. Yolk sac tumor
  4. Embryonal carcinoma

ANSWER

 

LOWER URINARY TRACT PATHOLOGY Review Items

Key Vocabulary Terms (click here to search any additional terms on Stedman's Online Medical Dictionary)

bacteriuria hematuria
cystitis hypospadias

cystitis cystica

neurogenic (cord) bladder

cystitis glandularis

pyuria
dysuria

urethral caruncle

epispadias urolithiasis
exstrophy  

LEARNING OBJECTIVES

Absolutely critical information you must know to practice medicine is in bold font.
Important information that will be needed for routine patient care is in regular font.
Information about less common diseases that you may encounter in clinical practice and that will probably appear on examinations is in italics

  1. Describe the normal anatomy (gross and microscopic) of each of the following:
    • ureter
    • urinary bladder
    • urethra

  2. Discuss the proper use of urinalysis in the evaluation of lower urinary tract disease, and interpret abnormalities of this test in clinical context

  3. Discuss obstruction at various levels of the urinary tract in terms of:
    • site and nature of lesion
    • etiology and pathogenesis
    • alteration in renal function
    • morphologic effect on kidney

  4. Discuss diverticula of the urinary bladder, in terms of:
    • etiology
    • pathogenesis
    • morphology
    • complications

  5. Discuss urolithiasis in terms of:
    • relative incidence of various types of stones
    • pathophysiologic abnormalities associated with the common types of stones
    • etiology and pathogenesis of stone formation
    • effect of location of stones on clinical and anatomic findings
    • clinical course and complications

  6. Discuss the clinical and pathologic features of the following congenital anomalies:
    • patent urachus
    • hypospadias
    • eductivepispadias
    • exstrophy of the bladder
    • duplications of the collecting system
    • urethral valves

  7. Compare and contrast clinical and pathologic features of inflammatory conditions:
    • infectious cystitis
    • interstitial cystitis
    • malacoplakia

  8. Compare and contrast the clinical and pathologic features of lower urinary tract neoplasms
    • urothelial (transitional cell) carcinoma
    • squamous cell carcinoma
    • adenocarcinoma

 

MALE GENITAL SYSTEM Review Items

Key Vocabulary Terms (click here to search any additional terms on Stedman's Online Medical Dictionary)

balanitis phimosis
balanoposthitis  prepuce
choriocarcinoma prostatic intraepithelial hyperplasia (PIN)
condyloma acuminatum prostatitis
cryptorchidism seminoma
embryonal carcinoma Schiller-Duval body
epispadias  Sertoli-Leydig cell tumor
gonadoblastoma smegma
hematocele spermatocytic seminoma
hydrocele teratoma
hypospadias yolk sac tumor
orchitis  

LEARNING OBJECTIVES

Absolutely critical information you must know to practice medicine is in bold font.
Important information that will be needed for routine patient care is in regular font.
Information about less common diseases that you may encounter in clinical practice and that will probably appear on examinations is in italics

  1. Compare and contrast the following congenital anomalies:
    • hypospadias
    • epispadias

  2. Discuss the clinical and pathologic features of the following neoplasms:
    • squamous cell carcinoma of penis and scrotum
    • adenocarcinoma of prostate
    • germ cell tumors of testis
    • sex cord-stromal tumors of testis
    • malignant lymphoma of testis

  3. Compare and contrast the clinical and pathologic features of the following inflammatory conditions:
    • prostatitis (acute, chronic granulomatous)
    • orchitis (nonspecific, mumps, granulomatous)
    • torsion of spermatic cord

  4. Discuss the clinical and pathologic features of the following disorders:
    • nodular hyperplasia of the prostate
    • cryptorchidism

  5. Classify anatomically the causes of male infertility.

 

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