Prostate gland

Ahmed Sakr,Urology MD

By

Zagazig Urology Department

Anatomy of the prostate• The prostate surrounds the bladder outlet & the beginning of male urethra.• Its shape is like a chestnut or inverted cone.• It measures 3 × 4 × 2 cm & weighs about 18 gm.• Relations:

Zonal anatomy:• TZ (the commonest site for BPH)• CZ• PZ (the commonest site for prostatic carcinoma)• Anterior fibro-muscular stroma

Clinically :The prostate has 2 lat. Lobes separated by a central sulcus and a median lobe which may project into the cavity of the U.B.

Benign prostatic hyperplasia“Senile enlargement of the prostate”

• The commonest tumor of the prostate • Affects about ⅔ of men over 50 y. Etiology:

1- Unknown2- Aging3- Normal testosterone Pathology:

• From TZ or peri-urethral region• As adenoma enlarges, it compresses the

normal prostatic tissue forming a false capsule with a line of cleavage.

Histology:• Hyperplasic acini• Variable in size • Lined with one or more layers of cells• some acini contain corpora amylacea• The fibro-muscular stroma shows hypertrophy

BPH Normal prostate

Pathologic effect:• Urethra: compressed, stretched, elongated & may be tortuous

• Bladder: - Bladder → Hypertrophied wall with ↑ pressure inside →

cellule & diverticula- Bladder decompensation → urine retention

(acute or chronic)

• Upper tract: Hydroureter & hydronephrosis & may lead to renal insufficiency

Clinical picture: (LUTS obstructive or irritative)

• Obstructive : hesitancy, weak stream, interrupted stream & urine retention• Irritative : ↑ frequency, urgency & urge

incontinence- Obstructive symptoms occur first but with infection & stone formation irritative symptoms become manifest

Physical examination:

• Abdominal mass (hydronephrosis)• Pelvic mass (retained bladder)• DRE:

1. Symmetrical or asymmetrical enlargement2. Preserved sulcus3. Smooth surface4. Sliding rectal mucosa over the gland5. Consistency like that of contracted thenar

eminence

Investigations:

A. Basic investigations:1. Urinalysis2. Serum creatinine3. PSA:

• Normal level → 0-4 ng\ml• BPH → 4-10 ng\ml• > 10 ng\ml may indicate cancer

4. U/S:• Abdominal• TRUS

B. Additional investigations:

• IVP• Uroflowmetry• Estimation of post-voiding residual urine• Cystoscopy

Complications:

1. Hematuria2. Urine retention (acute or chronic)3. Infection4. Stone formation5. uremia

Treatment:

1. Watchful waiting: ( in mild symptoms)• ↓ fluid intake• Timed voiding• Avoidance of constipation• Avoid exposure to cold• Avoid diuretics & anti-cholinergic• Avoid sexual excitement

2. Medical treatment:

- Indications: Bothersome symptoms with no complications- Drugs:

• α – adrenergic blockers (Doxazocin – Terazocin) They act by ↓ the tension of the smooth muscle of prostatic capsule

• 5 – α reductase inhibitors (Finasteride): It inhibits the 5 – α reductase enzyme responsible for conversion of testosterone to DHT

3. Surgical treatment:• Indications:

1. Recurrent attacks of acute retention2. Hematuria3. Recurrent urinary tract infection4. Bladder stone or diverticula5. Renal insufficiency

• Routes of intervention:- Open surgery: Transvesical or retropubic- TUR-P

4. Minimally invasive techniques:• LASER prostatectomy• Prostatic balloon ablation• Prostatic stents• Thermotherapy

Prostate cancer

Etiology: UnknownRisk factors: Family history, high fat diet & racial factorsPathology: - Gross: Hard nodular prostate, may invade the capsule or adjacent structures- Microscopic: Adenocarcinoma of varying degreesSpread:

1. Direct spread2. Lymphatic spread3. Blood spread

Clinical picture:

• Asymptomatic & discovered accidentally• Symptoms of metastasis without urinary symptoms (occult carcinoma)• LUTS (shorter duration & progressive course)

Diagnosis:

1. DRE2. Elevated PSA3. Prostatic biopsy4. Other markers as serum acid phosphatase & serum

alkaline phosphatase5. Plain X-ray spine for metastasis6. Isotopic bone scan7. CT scan8. Cystoscopy

Treatment: 1. Watchful waiting.2. Radical surgery.3. Radiotherapy: External or brachytherapy4. Hormonal therapy: in advanced cases Depends on androgen ablation by:

• Bilateral orchiectomy• Oral estrogen• Antiandrogens