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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
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