The Lower Urinary Tract and Male Genital System- chapter 21

Gen. Pathology

An infant boy has had recurrent urinary tract infections since birth. Ultrasonography reveals dilated pelvis and calyces in the left kidney; the right kidney is absent. Surgical repair of an obstruction is performed. Which of the following pathologic findings is most likely present at the site of obstruction? \n

Smooth muscle discontinuity at the uteropelvic

junction

A 73-year-old man with urinary frequency and hesitancy has had three urinary tract infections within the past year. On physical examination, his prostate is diffusely enlarged. Which of the following pathologic findings is most likely to be present in his urinary bladder? \n

Interstitial cystitis \n

A 69-year-old man with history of recurrent pancreatitis treated with corticosteroids now has increasing fatigue for 2 years. He does not drink alcohol and has no evidence of gallbladder disease. On examination, there are no abnormalities. Laboratory studies show his serum creatinine is 5 mg/dL and urea nitrogen is 48 mg/dL. His serum IgG4 is elevated. Ultrasound imaging shows bilateral hydronephrosis. What is abdominal CT imaging most likely to show in this man? \n

Retroperitoneal fibrosis \n

The top of the diaper is often noted to be damp on a girl infant. Radiologic imaging with contrast enhancement shows that there is a connection from the bladder to umbilicus. What is the most likely diagnosis? \n

Persistent urachus \n

A 51-year-old woman with diabetic nephropathy receives a renal allograft. An episode of acute cellular rejection requires an increase in immunosuppressive therapy. She develops dysuria. On examination, she has suprapubic pain on palpation. A urinalysis shows hematuria. Cystoscopy is performed, and 3- to 4-cm soft, yellow, slightly raised mucosal plaques are seen. Biopsy specimens of these lesions microscopically show mucosal infiltration by foamy macrophages with abundant PAS-positive cytoplasmic granules and small, laminated mineralized concretions. Which of the following organisms is most likely to be found in her urine? \n

Escherichia coli \n

A study of patients with urothelial carcinoma of the urinary bladder is performed. Gross, microscopic, and molecular characteristics of these malignancies are analyzed. Survival is correlated with treatment. Which of the following findings in these malignancies is most likely to require radical cystectomy to improve survival? \n

Invasion of muscularis propria \n

A 58-year-old man from Shanghai has noted passing darker urine within the past 3 weeks. On physical examination, there are no abnormalities. Urinalysis shows blood is present. Cystoscopy is performed and there is a 0.5 × 1.7 cm reddish area on the dome of the bladder. Biopsies are obtained and have the microscopic appearance shown in the figure. What is the most likely risk factor for his disease? \n

Smoking \n

A 65-year-old man recently retired after many years

in a job that involved exposure to aniline dyes, including β-naphthylamine. One month ago, he had an episode of hematuria that was not accompanied by abdominal pain. On physical examination, there are no abnormal findings. Urinalysis shows 4+ hematuria, and no ketones, glucose, or protein. Microscopic examination of the urine shows RBCs that are too numerous to count, 5 to 10 WBCs per high-power field, and no crystals or casts. The result of a urine culture is negative. Cystoscopy is performed, and biopsy of a lesion reveals the microscopic appearance in the figure. Which of the following neoplasms is he most likely to have?

Urothelial carcinoma \n

\n A 78-year-old man has had increasing difficulties with urination for the past 6 years. He has difficulty starting and stopping the urine stream. On physical examination, his temperature is 37° C and blood pressure is 130/85 mm Hg. The figure shows the representative gross appearance of the bladder. Which of the following laboratory findings is most likely to be reported in this patient?

Prostate-specific antigen level of 5 ng/mL \n

A 57-year-old woman has had pain on urination for 5 months and yesterday noted blood on her underwear. On examination there is a tender red 1-cm nodule on the posterior lip of the external urethra. It is excised. What pathologic finding is most likely to be present on microscopic examination of her lesion?

Granulation tissue \n

A 74-year-old woman has noticed a slowly enlarging mass on her urethra for the past 6 months. The mass causes local pain and irritation and is now bleeding. Physical examination shows a 2.5-cm warty, ulcerated mass protruding from the external urethral meatus. There are no lesions on the labia or vagina. A biopsy specimen of the lesion is most likely to identify which of the following?

Squamous cell carcinoma \n

A 5-year-old boy has a history of recurrent urinary tract

infections. Urine cultures have grown Escherichia coli, Proteus mirabilis, and Enterococcus. Physical examination now shows an abnormal constricted opening of the urethra on the ventral aspect of the penis, 1.5 cm from the tip of the glans penis. There also is a cryptorchid testis on the right and an inguinal hernia on the left. What term best describes the child’s penile abnormality?

Hypospadias \n

A 19-year-old man has worsening local pain and

irritation with difficult urination over the past 3 years. He has become more sexually active during the past year and describes his erections as painful. Physical examination shows that he is not circumcised. The prepuce (foreskin) cannot be easily retracted over the glans penis. What is the most likely diagnosis?

\n

Phimosis \n

A 46-year-old man with a history of poorly controlled diabetes mellitus has had painful, erosive, markedly pruritic lesions on the glans penis, scrotum, and inguinal regions of the skin for the past 2 months. Physical examination shows irregular, shallow, 1- to 4-cm erythematous ulcerations. Scrapings of the lesions are examined under the microscope. Which of the following microscopic findings in the scrapings is most likely to be reported?

Budding cells with pseudohyphae \n

A 23-year-old, sexually active man has been treated for Neisseria gonorrhoeae infection 6 times during the past 5 years. He now comes to the physician because of the increasing number and size of warty lesions slowly enlarging on his external genitalia during the past year. On physical examination, there are multiple 1- to 3-mm sessile, nonulcerated, papillary excrescences over the inner surface of the penile prepuce. These lesions are excised, but 2 years later, similar lesions appear. Which of the following conditions most likely predisposed him to development of these recurrent lesions?

Human papillomavirus infection \n

A 56-year-old man from Fortaleza, Brazil, has noted

increasing size of a penile lesion for the past 18 months. Physical examination reveals the appearance shown in the figure, following resection. What is most likely to be seen on microscopic examination?

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Infiltrating, pleomorphic, poorly differentiated squamous cells \n

A 48-year-old man has noticed a reddish area on the penis for the past 3 months. On physical examination, there is a solitary 0.8-cm, plaquelike, erythematous area on the distal shaft of the penis. A routine microbiologic culture with a Gram-stained smear of the lesion shows normal skin flora. Microscopic examination of a biopsy specimen of the lesion shows dysplasia involving the full thickness of the epithelium. What is the most likely diagnosis?

Bowen disease \n

An 18-year-old man comes to his physician for a routine health maintenance examination. On physical examination, there is no left testis palpable in the scrotum. The patient is healthy, has had no major illnesses, and has normal sexual function. Which of the following complications will you tell this man is most likely to occur?

Carcinoma \n

A 64-year-old man noted pain with burning on urination a week ago. He has had discomfort in his scrotum for the past 2 days. On examination, the right testis is swollen and tender. Which of the following organisms is most likely to cause this man’s illness?

Escherichia coli \n

A 36-year-old man and his 33-year-old wife have tried to

conceive a child for 12 years, and now they are undergoing an infertility work-up. On physical examination, neither spouse has any remarkable findings. Laboratory studies show that the man has a sperm count in the low-normal range. On microscopic examination of the seminal fluid, the sperm have a normal morphologic appearance. A testicular biopsy is done. The biopsy specimen shows patchy atrophy of seminiferous tubules, but the remaining tubules show active spermatogenesis. Which of the following disorders is the most likely cause of his findings?

Past mumps virus infection \n

A 23-year-old, previously healthy man suddenly develops severe pain in the scrotum. The pain continues unabated for 6 hours, and he goes to the emergency department. On physical examination, he is afebrile. There is exquisite tenderness of a slightly enlarged right testis, but there are no other remarkable findings. The gross appearance of the right testis is shown in the figure. Which of the following conditions is most likely to cause these findings?

Obstruction of blood flow \n

A 33-year-old man has noted asymmetric enlargement of the scrotum over the past 4 months. On physical examination, the right testis is twice its normal size and has increased tenderness to palpation. The right testis is biopsied. The epididymis and the upper aspect of the right testis have extensive granulomatous inflammation with epithelioid cells, Langhans giant cells, and caseous necrosis. Which of the following infections is the most likely cause of these findings?

Tuberculosis \n

A study of testicular carcinomas in adults is performed. These neoplasms have a high frequency of karyotypic abnormalities, particularly i(12p). Pathologic findings include focal intratubular germ cell neoplasia adjacent to the malignancies. Which of the following is the most likely risk factor for these carcinomas?

Gonadal dysgenesis \n

A 29-year-old man complains of a vague feeling of painless heaviness in the scrotum for the past 5 months. He is otherwise healthy. Physical examination shows that the right testis is slightly larger than the left testis. An ultrasound scan shows a solid, circumscribed, 1.5-cm mass in the body of the right testis. The representative gross appearance of the mass is shown in the figure. A biopsy is done, and microscopic examination of the mass shows uniform nests of cells with distinct cell borders, glycogen-rich cytoplasm, and round nuclei with prominent nucleoli. There are aggregates of lymphocytes between these nests of cells. Which of the following features is most characteristic of this lesion?

Response to radiation therapy \n

A 37-year-old man has noticed bilateral breast enlargement over the past 6 months. On physical examination, both breasts are enlarged without masses. His right testis is firm and 1.5 times larger than his left testis. His serum estrogen is increased. An ultrasound scan shows a circumscribed 2-cm mass in the body of the right testis. A right orchiectomy is performed, and grossly the mass has a uniform, brown cut surface. The microscopic appearance is shown in the figure. With electron microscopy the cells have rod-shaped crystalloids of Reinke. What is the most likely diagnosis?

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Leydig cell tumor \n

A 28-year-old man has noticed increasing enlargement

and a feeling of heaviness in his scrotum for the past year. On physical examination, the right testis is twice its normal size, and it is firm and slightly tender. An ultrasound examination shows a 3.5-cm solid right testicular mass. Abdominal CT scan shows enlargement of the para-aortic lymph nodes. Multiple lung nodules are seen on a chest radiograph. Laboratory findings include markedly increased serum levels of chorionic gonadotropin and α-fetoprotein. Which of the following neoplasms is the most likely diagnosis?

Mixed germ cell tumor \n

A 32-year-old man has noticed an increased feeling of heaviness in his scrotum for the past 10 months. On physical examination, the left testis is three times the size of the right testis and is firm on palpation. An ultrasound scan shows a 6-cm solid mass within the body of the left testis. Laboratory studies include an elevated serum α-fetoprotein level. Which of the following cellular components is most likely to be present in this mass?

Yolk sac cells \n

A 26-year-old man has occasionally felt pain in the scrotum for the past 3 months. On physical examination, the right testis is more tender than the left, but does not appear to be enlarged. An ultrasound scan shows a 1.5-cm mass within the right testis. A right orchiectomy is performed, and gross examination shows the mass to be hemorrhagic and soft. A retroperitoneal lymph node dissection is done. In sections of the lymph nodes, a neoplasm is found with extensive necrosis and hemorrhage. Microscopic examination shows that areas of viable tumor are composed of cuboidal cells intermingled with large eosinophilic syncytial cells containing multiple dark, pleomorphic nuclei. Immunohistochemical staining of syncytial cells is most likely to be positive for which of the following?

Human chorionic gonadotropin \n

The mother of a 2-year-old boy notices that he has had increasing asymmetric enlargement of the scrotum over the past 6 months. On physical examination, there is a well circumscribed, 2.5-cm mass in the left testis. A left orchiectomy is performed, and histologic examination of this mass shows sheets of cells and ill-defined glands composed of cuboidal cells, some of which contain eosinophilic hyaline globules. Microcysts and primitive glomeruloid structures also are seen. Immunohistochemical staining shows α-fetoprotein (AFP) in the cytoplasm of the neoplastic cells. What is the most likely diagnosis?

Yolk sac tumor \n

A 32-year-old man has noticed increased heaviness with enlargement of the scrotum over the past 9 months. On physical examination, there is an enlarged, firm left testis, but no other remarkable findings. An ultrasound scan shows a 5-cm solid mass within the body of the left testis. An orchiectomy of the left testis is performed. Microscopic examination of the mass shows areas of mature cartilage, keratinizing squamous epithelium, and colonic glandular epithelium. Laboratory findings include elevated levels of serum human chorionic gonadotropin (hCG) and α-fetoprotein (AFP). Despite the appearance of the cells in the tumor, the surgeon tells the patient that he probably has a malignant testicular tumor. The surgeon’s conclusion is most likely based on which of the following factors?

Elevation of hCG and AFP levels \n

A 59-year-old man notices gradual enlargement of the scrotum over the course of 1 year. The growth is not painful, but produces a sensation of heaviness. He has no problems with sexual function. Physical examination shows no lesions of the overlying scrotal skin and no obvious masses, but the scrotum is enlarged, boggy, and soft bilaterally. The transillumination test result is positive. What is the most likely diagnosis?

Hydrocele \n

A 54-year-old man has had dysuria with increased frequency and urgency of urination for the past 6 months. He has sometimes experienced mild lower back pain. On physical examination, he is afebrile. There is no costovertebral angle tenderness. The prostate gland feels normal in size; no nodules are palpable. Laboratory studies show that expressed prostatic secretions contain 30 leukocytes per high-power field. What is the most likely diagnosis?

Chronic abacterial prostatitis \n

A 65-year-old man has had multiple, recurrent urinary tract infections for the past year. Escherichia coli and streptococcal organisms have been cultured from his urine during these episodes, with bacterial counts of more than 105/mL. He has difficulty with urination, including starting and stopping the urinary stream. Over the past week, he has again developed burning pain with urination. Urinalysis now shows a pH of 6.5, and specific gravity of 1.020. No blood or protein is present in the urine. Tests for leukocyte esterase and nitrite are positive. Microscopic examination of the urine shows numerous WBCs and a few WBC casts. Which of the following is the most likely condition predisposing him to recurrent infections?

Nodular prostatic hyperplasia \n

A clinical trial of two pharmacologic agents compares one agent that inhibits 5α-reductase and diminishes dihydrotestosterone (DHT) synthesis in the prostate with another agent that acts as an α1-adrenergic receptor blocker. The subjects are 40 to 80 years old. The study will determine whether symptoms of prostate disease are ameliorated in the individuals who take these drugs. Which of the following diseases of the prostate is most likely to benefit from one or both of these drugs?

Nodular hyperplasia \n

A 72-year-old man has had increasing difficulty with urination for the past 10 years. He now has to get up several times each night because of a feeling of urgency, but each time the urine volume is not great. He has difficulty starting and stopping urination. On physical examination, the prostate is enlarged to twice its normal size, but is not tender to palpation. One year ago, his serum prostate-specific antigen (PSA) level was 6 ng/mL, and it is still at that level when retested. Which of the following drugs is most likely to be effective in treatment of this man?

Finasteride (5α-reductase inhibitor) \n

A 71-year-old, previously healthy man comes to his physician for a routine health examination. On palpation, there is a nodule in his normal-sized prostate. Laboratory studies show a serum prostate-specific antigen (PSA) level of 17 ng/mL. A routine urinalysis shows no abnormalities. Which of the following histologic findings is most likely to be found in a subsequent biopsy specimen of his prostate?

Adenocarcinoma \n

An 85-year-old man has experienced urinary hesitancy and nocturia for the past year. He has had increasing back pain for the past 6 months. On digital rectal examination, there is a hard, irregular prostate gland. A bone scan shows increased areas of uptake in the thoracic and lumbar vertebrae. Laboratory studies show a serum alkaline phosphatase level of 300 U/L, and serum prostate-specific antigen (PSA) level of 72 ng/mL. The blood urea nitrogen concentration is 44 mg/dL, and the serum creatinine level is 3.8 mg/dL. Transrectal biopsy specimens of all lobes of the prostate are obtained. Microscopic examination shows that more than 90% of the tissue has a pattern of cords and sheets of cells with hyperchromatic pleomorphic nuclei, prominent nuclei, and scant cytoplasm. Which of the following is the best classification for this patient’s disease?



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D 5, 5

\n

A 71-year-old African American man visits his physician

for a checkup because he is worried about his family history of prostate cancer. Physical examination does not indicate any abnormalities. Because of the patient’s age and family history, his prostate-specific antigen (PSA) level is measured and is 8 ng/mL. Six months later, the PSA level is 10 ng/mL. A urologist obtains transrectal biopsy specimens, and microscopic examination shows multifocal areas of glandular hyperplasia and the appearance shown in the figure. Which of the following statements applies best to this clinical and pathologic scenario?

Associated with increased risk for invasive cancer \n

A 45-year-old man comes to the physician for a routine health maintenance examination. On physical examination, there are no remarkable findings. Laboratory findings include serum creatinine, 1.1 mg/dL; urea nitrogen, 17 mg/ dL; glucose, 76 mg/dL; alkaline phosphatase, 89 U/L; and prostate-specific antigen (PSA), 16 ng/mL. Prostate biopsies are performed and the high power microscopic appearance of a biopsy specimen is shown in the figure. Which of the following is the most likely risk factor for his disease?

Epigenetic hypermethylation of GSTP1 gene \n