Prostate

The Prostate Gland

• It is an accessory gland of male reproductive
system.
• It is composed of glandular tissue embedded in
fibromuscular stroma.
• The prostate is located in front of the rectum
and just below the neck of urinary bladder.
• It surrounds the first 3 cm of the urethra.
Lobes
• It is composed of 5 lobes—anterior, posterior, 2 lateral, 1
middle/median lobe.
• Primary carcinoma is said to begin in posterior lobe.
• Middle lobe produces an elevation in the lower part of
the trigone of bladder (uvula vesicae). Adenoma is more
common here due to more amount of glandular tissue.
Capsules
• True capsule:
– Formed by the condensation of the peripheral part of the
gland; continues with the stroma of the gland.
• False capsule:
– Derived from the pelvic fascia.
– On each side prostatic venous plexus are embedded in it.
 McNeal Divided Prostate into Three Zones

• Peripheral zone:
– Mostly posterior area prone to develop
cancer
• Periurethral transition zone:
– Periurethral area from which most benign
prostatic hyperplasia (BPH) arises
• Central zone
– Posterior to urethral lumen and above the
ejaculatory ducts.
Figure: Sagittal diagram of the prostate just lateral to the urethra showing the
division into the different zones described by McNeal.
The transitional zone is the area from which most benign prostatic hyperplasia
(BPH) arises.
• Scientists do not know all the prostate's
functions.

• One of its main roles, though, is to squeeze

fluid into the urethra as sperm move
through during sexual climax.

• This fluid, which helps make up semen,

energizes the sperm and makes the vaginal
canal less acidic.
 BENIGN PROSTATIC HYPERPLASIA (BPH)
• It is common for the prostate gland to become enlarged as a man
ages.
• As a man matures, the prostate goes through two main periods of
growth.
• The first occurs early in puberty, when the prostate doubles in
size.
• At around age 25, the gland begins to grow again. This second
growth phase often results, years later, in BPH.
• Though the prostate continues to grow during most of a man's life,
the enlargement doesn't usually cause problems until late in life.
• BPH rarely causes symptoms before age 40, but more than half of
men in their sixties and as many as 90 percent in their seventies
and eighties have some symptoms of BPH.
• As the prostate enlarges, the layer of tissue surrounding it
stops it from expanding, causing the gland to press against
the urethra like a clamp. The bladder wall becomes thicker
and irritable.
• The bladder begins to contract even when it contains
small amounts of urine, causing more frequent urination.
• Eventually, the bladder weakens and loses the ability to
empty itself, so some of the urine remains in the bladder
(post-void residual urine).
• The narrowing of the urethra and partial emptying of the
bladder cause many of the problems associated with BPH.
• Prostate enlargement is as common a part of aging as gray
hair. As life expectancy rises, so does the occurrence of
BPH.
 Aetiology

• Theories
• It is involuntary hyperplasia due to disturbance of the
ratio and quantity of circulating androgens and
estrogens.
• Hypothalamus → pulsatile release of LHRH → release
of luteinising hormone (LH) from anterior pituitary →
stimulates Leydig cells of testes → releases
testosterone (TS) → reaches prostate → releases 5α
reductase type II of prostate → converts TS to DHT
(dihydrotestosterone) for its effects.
• DHT is five times more potent than TS. 90% TS is from
testes. Remaining 10% TS is from adrenal cortex.
• Throughout their lives, men produce both testosterone,
an important male hormone, and small amounts of
estrogen, a female hormone.

• As men age, the amount of active testosterone in the

blood decreases, leaving a higher proportion of
estrogen.

• Studies done on animals have suggested that BPH may

occur because the higher amount of estrogen within the
gland increases the activity of substances (These include
epidermal growth factor, insulin-like growth factors,
basic fibroblast growth factor and transforming growth
factors alpha and beta.) that promote cell growth.
 Another theory focuses on
• Dihydrotestosterone (DHT), a substance derived
from testosterone in the prostate.
• However, some research has indicated that even
with a drop in the blood's testosterone level,
older men continue to produce and accumulate
high levels of DHT in the prostate.
• This accumulation of DHT may encourage the
growth of cells. Scientists have also noted that
men who do not produce DHT do not develop
BPH.
 Pathology

• BPH usually involves median and lateral lobes or one of them.

• It involves adenomatous zone of prostate, i.e. submucosal
glands.
• Median lobe enlarges into the bladder.
• Lateral lobes narrow the urethra causing obstruction.
• Bladder initially takes the pressure burden causing
– trabeculations
• characterized by thick wall and hypertrophied muscle bundles. Typically
seen in instances of chronic obstruction.
– Sacculations and later diverticula formation.
• Enlarged prostate compresses the prostatic venous plexus
causing congestion, called as vesical piles leading to
haematuria.
Figure:A transverse section of the prostate.
The peripheral zone is the area from which most prostate cancers
arise.
The ‘adenomatous’ zone comprises the central and transitional
zones.
• Kidney and ureter: Backpressure causes
hydroureter and hydronephrosis.
• Secondary ascending infection can
cause acute or chronic pyelonephritis.
• Often severe obstruction can lead to
obstructive uropathy with renal failure.
• BPH causes impotence
 Presentation
• History
– Onset and duration of symptoms
– General health issues (including sexual history)
– Fitness for any possible surgical interventions
– Severity of symptoms and how they are
affecting quality of life
– Medications
– Previously attempted treatments
Common symptoms:
• Urinary frequency - The need to urinate frequently during the day or
night (nocturia), usually voiding only small amounts of urine with
each episode.
• Urinary urgency - The sudden, urgent need to urinate, owing to the
sensation of imminent loss of urine without control.
• Hesitancy - Difficulty initiating the urinary stream; interrupted, weak
stream.
• Incomplete bladder emptying - The feeling of persistent residual
urine, regardless of the frequency of urination.
• Straining - The need strain or push (Valsalva maneuver) to initiate
and maintain urination in order to more fully evacuate the bladder.
• Decreased force of stream - The subjective loss of force of the
urinary stream over time.
• Dribbling - The loss of small amounts of urine due to a poor urinary
stream.
• Pain in suprapubic region and in loin due to
cystitis and hydronephrosis respectively.
• Impaired bladder emptying with its problems
like cystitis, urethritis, stone formation and
residual urine.
• Haematuria.
• Renal failure
• Features of urinary infection like fever, chills,
burning micturition.
 Physical Examination
• Conduct a focused physical examination to assess the
suprapubic area for signs of bladder distention and a
neurological examination for sensory and motor deficits.
• The digital rectal examination (DRE):
– It is an integral part of the evaluation in men with presumed BPH.
– During this portion of the examination, prostate size and contour
can be assessed, nodules can be evaluated, and areas suggestive
of malignancy can be detected.
– The normal prostate volume in a young man is approximately 20 g.
– Decreased anal sphincter tone or the lack of a bulbocavernosus
muscle reflex may indicate an underlying neurological disorder.
– In addition, pelvic floor tone, the presence or absence of
fluctuance (ie, prostate abscess), and pain sensitivity of the gland
(prostatodynia/prostatitis) can be assessed.
 Investigations
• Urine for microscopy and C/S.
• Blood urea and serum creatinine.
• USG:
– Ultrasonography (abdominal, transrectal) are useful for helping
determine bladder and prostate size and the degree of
hydronephrosis (if any) in patients with urinary retention or
signs of renal insufficiency. 
– If there is a suspicion of prostate cancer, rectal ultrasound with
prostate biopsy is done.
• Urodynamics:
– Urine flow rate > 15 ml/sec is normal. 10-15 ml is equivocal; <
10 ml is low.
– Voiding pressure < 60 cm of water is normal; 60-80 is
equivocal; > 80 is high.
• Cystoscopy.
• Acid phosphatase.
• Prostate specific antigen (PSA).
• IVU—to see kidney function.
• Serum electrolytes.
ACID PHOSPHATASE:
• It is the enzyme that splits organic phosphates.
• It is found in many human tissues, but more concentrated in
prostate.
• It is active at pH 5.
• Acid phosphatase secreted by prostate drains into the urethra
through prostatic ducts and so blood levels of this enzyme remain
low.
• Serum acid phosphatase estimation should be done on empty
stomach because heavy meals alter the level of the acid
phosphatase.
• Normal value is 0-5 King Armstrong units per 100 ml of serum.
• It is raised signifi cantly in carcinoma prostate with metastases.
• It does not increase in BPH.
• Slight increase in acid phosphatase level occurs in acute
prostatitis, Paget’s disease of bone and hepatic cirrhosis.
PROSTATE SPECIFIC ANTIGEN (PSA)
• It is a protease, produced from the prostatic epithelium secreted in the
semen to cleave and liquefy the seminal coagulum formed after ejaculation.
• PSA is organ specific. Normal value is 4 ng/ml of plasma.
• More than 10 ng/ml is significant.
• PSA elevation occurs not only in carcinoma but also in prostatic hyperplasia
and prostatitis.
• But the increase is much more in carcinoma than in benign conditions.
• Serial estimation of PSA is very useful to suspect spread and recurrence after
treatment.
• 25% of men with PSA 4-10 ng/ml show prostate carcinoma.
• 20% of men with normal PSA (1-4 ng/ml) will show prostate carcinoma.
• PSA more than 10 ng/ml is suggestive of carcinoma prostate.
• PSA more than 35 ng/ml is almost diagnostic of advanced carcinoma of
prostate.
• Decrease in PSA after therapy suggests adequate ablation.
• Men aged > 50 years with PSA > 3 ng/ml should undergo prostatic biopsy.
 Treatment
• Men who have BPH with symptoms usually need
some kind of treatment at some time.
• Instead of immediate treatment, regular
checkups to watch for early problems.
• If the condition begins to pose a danger to the
patient's health or causes a major inconvenience
to him, treatment is usually recommended.
• Since BPH can cause urinary tract infections,
treatment with antibiotics is needed before
treating the BPH itself.
 Drugs Used for BPH

• 5-alpha reductase inhibitor

– Finasteride, FDA-approved in 1992, and dutasteride, FDA-approved in 2001,
inhibit production of the hormone DHT, which is involved with prostate
enlargement.
– The use of either of these drugs can either prevent progression of growth of
the prostate or actually shrink the prostate in some men.

• Alpha 1 adrenergic blocking agents:

– Terazosin, doxazosin, tamsulosin, and alfuzosin for the treatment of BPH.
– These drugs act by relaxing the smooth muscle of the prostate and bladder
neck to improve urine flow and to reduce bladder outlet obstruction.
– Recently found that using finasteride and doxazosin together is more effective
than using either drug alone to relieve symptoms and prevent BPH
progression.
– The two-drug regimen reduced the risk of BPH progression by 67 percent,
compared with 39 percent for doxazosin alone and 34 percent for finasteride
alone
 Minimally Invasive Therapy
• Because drug treatment is not effective in all
cases
• Researchers in recent years have developed a
number of procedures that relieve BPH
symptoms but are less invasive than
conventional surgery.
 Transurethral microwave procedures
• Transurethral microwave procedures. In 1996, the FDA approved a
device that uses microwaves to heat and destroy excess prostate tissue.
• In the procedure called transurethral microwave thermotherapy
(TUMT), the device sends computer-regulated microwaves through a
catheter to heat selected portions of the prostate to at least 111
degrees Fahrenheit.
• The procedure takes about 1 hour and can be performed on an
outpatient basis without general anesthesia.
• TUMT has not been reported to lead to erectile dysfunction or
incontinence.
• Although microwave therapy does not cure BPH, it reduces urinary
frequency, urgency, straining, and intermittent flow.
• It does not correct the problem of incomplete emptying of the bladder.
• Ongoing research will determine any long-term effects of microwave
therapy and who might benefit most from this therapy.
 Transurethral needle ablation

• Minimal invasive transurethral needle ablation

(TUNA) system for the treatment of BPH.
• The TUNA system delivers low-level
radiofrequency energy through twin needles to
burn away a well-defined region of the enlarged
prostate.
• The TUNA system improves urine flow and
relieves symptoms with fewer side effects when
compared with transurethral resection of the
prostate (TURP).
• No incontinence or impotence has been
observed.
Transurethral needle ablation
 Transurethral Surgery (TURP)
• A procedure called transurethral resection of the
prostate (TURP) is used for 90 percent of all prostate
surgeries done for BPH.
• With TURP, an instrument called a resectoscope is
inserted through the penis.
• The resectoscope, which is about 12 inches long and
1/2 inch in diameter, contains a light, valves for
controlling irrigating fluid, and an electrical loop that
cuts tissue and seals blood vessels.
 Laser surgery
• One advantage of laser surgery over TURP is
that laser surgery causes little blood loss.
• Laser surgery also allows for a quicker recovery
time.
• But laser surgery may not be effective on larger
prostates.
• The long-term effectiveness of laser surgery is
not known.
 Open surgery
• Open surgery.
– In the few cases when a transurethral procedure cannot be used,
open surgery, which requires an external incision, may be used.
– Open surgery is often done when the gland is greatly enlarged.
• Freyer’s suprapubic transvesical prostatectomy.
– Before TURP, it was a popular and was the procedure of choice
for enlarged prostate.
– Complications are haemorrhage, infection, stricture urethra,
incontinence, impotence, bladder neck contracture.
• Millin’s retropubic prostatectomy.
– It is done without opening the bladder. (It is not commonly prac
ticed).
 Specific Problems after Surgical Intervention of Prostate

• Retrograde ejaculation—65%.
• Erectile dysfunction—5%.
• Failure, recurrence of symptoms and enlargement
—10%.
• Need for re TURP/surgery in 10 years—15%.
• Severe sepsis—6%.
• Recurrent late urinary infection—20%.
• Postoperative haematuria—3% needs transfusion.
• Mortality in TURP is 0.5%.