detailed disorders of prostate

1. SEVERING PROSTATE
-THE PERPETRATOR
DR.M.GUNASEKARAN M.S;FMAS;DIP MAS;FALS;FAIS
SENIOR RESIDENT
DEPT OF GENERAL SURGERY
GOVT ARIYALUR MEDICAL COLLEGE

2. PERPETRATOR….
1.BENIGN PROSTATIC HYPERPLASIA
2.PROSTATITIS
3.CANCER PROSTATE

3. SOME BASICS OF PROSTATE
• WALNUT SIZED GLAND AT BASE OF MALE BLADDER
• SURROUNDS THE URETHRA
• PRODUCES FLUID THAT TRANSPORTS SPERM
DURING EJACULATION
• PROSTATE GROWS TO ITS NORMAL ADULT SIZE IN
A MAN’S EARLY 20S,IT BEGINS TO GROW AGAIN
DURING THE MID 40S

4. • NORMAL PROSTATE MEASURES
3-4CM -WIDEST PORTION
4-6CM IN LENGTH
2-3CM IN THICKNESS
WEIGHING 17-25GM
• ACCORDING TO MCNEAL CONCEPT OF ZONAL ANATOMY OF
PROSTATE
THE GLANDULAR PORTION OF PROSTATE COMPOSED OF
LARGE PERIPHERAL AND SMALL CENTRAL ZONE WHICH TOGETHER
CONSTITUTE ABOUT 95% OF GLAND

6. BENIGN PROSTATIC
HYPERPLASIA

7. BENIGN PROSTATIC HYPERPLASIA
• BENIGN ENLARGEMENT OF PROSTATE GLAND
• MOST COMMON UROLOGICAL PROBLEM IN MALE
• MEN OLDER THAN 50 YEARS
• ABOUT 50 % OF ALL MEN IN LIFETIME WILL DEVELOP BPH
• NOT LIFE THREATENING ;SIGNIFICANTLY AFFECTS THE QUALITY OF LIFE
• RISK FACTORS
AGEING
FAMILY H/O / GENETIC FACTORS
OBESITY
HEART DISEASE
TYPE II DM
LIFE STYLE

8. PATHOPHYSIOLOGY
HORMONAL IMBALANCE WITH AGEING
• ANDROGEN
IN THE AGEING EPITHELIAL AND STROMAL CELLS IN THE PERIURETHRAL AREA OF PROSTATE-
TRANSITIONAL ZONE
TESTOSTERONE
5 ALPHA REDUCTASE TYPE 2
DIHYDROTESTOSTERONE
ANDROGEN RECEPTORS
GROWTH FACTORS

9. CONT….
• ESRTOGEN LEVEL INCREASES WITH AGEING
• INCREASED LEVEL OF PROGESTERONE RECEPTORS
BPH DOES NOT DEVELOP IN MEN CASTRATED
BEFORE PUBERTY

15. INVESTIGATIONS
• HISTORY
• GENERAL EXAMINATION
• URINE ANALYSIS
• BLOOD –RFT,PSA
• DIGITAL RECTAL EXAMINATION (DRE)
PROSTATE-LARGER & HARDER THAN NORMAL
RECTAL MUCOSA MADE TO MOVE OVER
PROSTATE
• URODYNAMIC TEST
UROFLOWMETRY
POSTVOIDAL RESIDUAL MEASUREMENT
• CYSTOURETHROSCOPE
• TRANS RECTAL ULTRASONGRAPHY

16. MANAGEMENT OF BPH
• WATCHFUL WAITING
• MEDICAL THERAPY
• MINIMALLY INVASIVE THERAPY
• SURGICAL THERAPY

17. Symptom
Assessment
Mild Mod /
Severe
Watchful
Waiting Medical therapies
Minimally
invasive therapies
• Urinary retention
• Recurrent urinary tract infection
• Recurrent or persistent gross
hematuria
• Bladder stones
• Renal insufficiency
• Diverticula
Surgery
MANAGEMENT OF BPH

18. WATCHFUL WAITING
• UNCOMPLICATED BPH
• SYMPTOMS NOT BOTHERSOME (IPSS < 7)
• VOID WHENEVER THE URGE IS PRESENT, EVERY 2-3 HRS
• AVOID TAKING LARGE AMOUNT OF FLUID OVER SHORT TIME
• DECREASE CAFFEINE, ALCOHOL INTAKE
• AVOID BLADDER IRRITANTS-DAIRY PRODUCTS ,CARBONATED BEVERAGES

19. MEDICAL THERAPY
ALPHA ADRENERGIC BLOCKERS
• TAMSULOSIN
• ALFUZOSIN
• DOXAZOSIN
• TERAZOSIN
5 ALPHA REDUCTASE INHIBITOR
• FINASTERIDE
• DUTASTERIDE
COMBINATION THERAPY
ARREST DISEASE PROGRESSION & RAPIDLY RELIEVE
SYMPTOMS
ANTI CHOLINERGIC DRUGS
• OXYBUTYNIN
• TOLTERODINE

20. PHYTOTHERAPY
• PUMPKIN SEED
• CACTUS FLOWER
• PINE FLOWER
• SOUTH AFRICAN STAR GRASS
• SARO PALMETTO BERRY
NEWER STRATEGIES
• ENDOTHELIN ANTAGONIST
• NITRIC OXIDE INHIBITOR

21. MINIMALLY INVASIVE THERAPY
• TUMT
• TUNA
• INTRA PROSTATIC STENTS
• TEAP
• HOT WATER BALLOON
• BOTOX ETOH

22. TUMT
• TRANSURETHRAL MICROWAVE THERAPY
• USES HIGH TEMPERATURE HEAT TRANSMITTED
THROUGH TRANSURETHRAL ROUTE TO
PRODUCE NECROSIS OF OBSTRUCTING
PROSTATE TISSUE
TUNA
• TRANSURETHRAL NEEDLE ABLATION
• LOW LEVEL RADIOFREQUENCY ENERGY N OF
PROSTATEDELIVERED BY NEEDLE PLACED
TRANSURETHRALLY INTO THE PROSTATE-
PRODUCES LOCALIZED NECROSIS IN THE
HYPERPLASTIC TISSUE

23. INTRAPROSTATIC STENTS
• PERMANENT STENT
UNFIT FOR SURGERY
COMPLICATION HIGH
• TEMPORARY STENT
FOR SHORT TIME
REMOVED WITH EASE
TEAP
• TRANSURETHRAL ETHANOL ABLATION OF
PROSTATE
• INTRAPROSTATIC INJECTABLE

24. SURGICAL THERPY
• TURP
• TUVP
• TUIP
• HOLEP
• TRANSURETHRAL LASER VAPORIZATION
• TRANSURETHRAL LASER COAGULATION
• OPEN PROSTATECTOMY

25. TURP
• TRANSURETHRAL RESECTION OF
PROSTATE
• SMALL TO MEDIUM SIZED BPH
• GOLD STANDARD TREATMENT
FOR BPH
• GYRUS BIPOLAR SYSTEM
• RADIOFREQUENCY-320-450
KHZ
• VOLTAGE RANGE 254-350 V

26. TUVP
TRANSURETHRAL
VAPORIZATION OF
PROSTATE

27. TUIP
Transurethral
Incision of
prostate
For prostates
<30 gms and
young pt

28. HOLEP
TRANSURETHR
AL HOLMIUM
LASER
RESECTION

29. OPEN PROSTATECTOMY
Prostate> 100gm
CI : prostate cancer, small fibrous gland

30. PROSTATITIS

31. PROSTATITIS
• INFLAMMATION OF PROSTATE GLAND CAUSED BY
INFECTION /OTHER CONDITIONS
• BENIGN-DOESN’T INCREASES THE RISK OF PROSTATIC
CANCER
• AFFECT MEN OF ANY AGE; COMMON IN AGE BETWEEN 30-
50 YEARS

32. TYPES OF PROSTATITIS
• TYPE 1: ACUTE BACTERIAL PROSTATITIS
• TYPE 2: CHRONIC BACTERIAL PROSTATITIS
• TYPE 3: CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN
SYNDROME
• TYPE 4: ASYMPTOMATIC INFLAMMATORY PROSTATITIS

33. ACUTE BACTERIAL PROSTATITIS
• PRESENT WITH SUDDEN SEVERE SYMPTOMS
• CAUSED BY COMMON STRAINS OF BACTERIA
ECOLI (COMMON) ENTEROBACTER
KLEBSIELLA PROTEUS
PSEUDOMONAS GONORRHOEA
• BACTERIA SPREADS FROM
URETHRA
BLADDER
INVASION THRO BLOOD STREAM/LYMPHATIC
CHANNEL
• PROSTATIC MANIPULATION
CYSTOSCOPE
URETHRAL CATHETERIZATION
TRANSRECTAL PROSTATE BIOPSY ETC..

34. CHRONIC BACTERIAL PROSTATITIS
• RECURRENT BACTERIAL INFECTIONS LAST FOR > 3 MONTHS
• LESS SEVERE SYMPTOMS
• SAME CAUSE AS ACUTE BACTERIAL INFECTION-OCCURS WHEN TREATMENT FAILS
TO KILL ALL BACTERIA

35. CHRONIC PROSTATITIS/CHRONIC PELVIC
PAIN (CPPS)
ONGOING /RECURRENT PELVIC PAIN & RECURRENT URINARY TRACT SYMPTOMS
NO EVIDENCE OF INFECTION
MULTIPLE FACTORS
• PREVIOUS INFECTION/ STD
• NERVOUS SYSTEM DYSFUNCTION
• IMMUNE SYSTEM DYSFUNCTION
• STRESS/ SEXUAL BEHAVIOUR
• IRREGULAR HORMONAL ACTIVITY

36. ASYMPTOMATIC INFLAMMATORY
PROSTATITIS
• SIGNS OF INFLAMED PROSTATE
• GENERALLY FOUND ONLY DURING EXAMINATION FOR OTHER MEDICAL
CONDITIONS
• NO KNOWN CAUSE
• NO SYMPTOMS
• NO TREATMENT

37. CLINICAL MANIFESTATIONS
• DIFFICULTY IN URINATION
• FREQUENCY
• URGENCY
• HESITANCY
• NOCTURIA
• INTERMITTENCY
• PAINFUL EJACULATION
• PERENNIAL DISCOMFORT
• PAIN IN LOWER ABDOMEN, LOWER BACKPAINS
• ACUTE RETENTION
• FEVER,CHILLS,MUSCLE ACHE OTHER FLU LIKE SYMPTOMS( ACUTE BACTERIAL
PROSTATITIS)

38. COMPLICATIONS
ACUTE/CHRONIC BACTERIAL PROSTATITIS
• BACTEREMIA/SEPSIS
• EPIDIDYMITIS
• PYELONEPHRITIS
• PROSTATIC ABSCESS
• INFECTION SPREAD TO UPPER PELVIC BONE/LOWER SPINE
CHRONIC PROSTATITIS
• ERECTILE DYSFUNCTION
• INFERTILITY
• ANXIETY/DEPRESSION

39. INVESTIGATIONS
HISTORY
PHYSICAL EXAMINATION
• DISCHARGE FROM URETHRA
• ENLARGED/TENDER LYMPH NODES IN THE GROIN
• SWOLLEN/TENDER SCROTUM
DIGITAL RECTAL EXAMINATION
• ACUTE-SWOLLEN/TENDER PROSTATE
• MASSAGE PROSTATE- SQUEEZE SMALL AMOUNT OF FLUID IN
URETHRA-COLLECTED & INVESTIGATED

40. CONT…
• URINE ANALYSIS; CULTURE
• BLOOD-CULTURE; PSA; RFT
• URETHRAL SWAB-GONORRHOEA/CHLAMYDIA
• SEMEN ANALYSIS
• URODYNAMIC TEST
• TRANSRECTAL USG
• CYSTOSCOPY

41. MANAGEMENT
ACUTE BACTERIAL PROSTATITIS
• ANTIBIOTIC COURSE FOR 10-14 DAYS-HOSPITALIZE (IV)
• ANALGESICS & ANTISPASMODICS
• LOCAL HEAT THERAPY
• SITZ BATH/STOOL SOFTNERS
CHRONIC BACTERIAL PROSTATITIS
• DIFFICULT TO TREAT-3MONTHS COURSE
• ANTIBIOTICS
FLUROQUINOLONES
TRIMETHOPRIM-SULFAMETHAXONE
3RD GENERATION CEPHALOSPORINS -CEFTRIAXONE
• ALPHA ADRENERGIC BLOCKERS

42. CONT
…
CHRONIC PROSTATITIS/CPPS
• ALPHA ADRENERGIC BLOCKERS
• 5 ALPHA REDUCTASE INHIBITORS
• NEUROMODULATORS
AMITRYPTYLLINE
GABAPENTIN
• KEGEL/PELVIC FLOOR EXERCISES
• PSYCHOSOCIAL COUNSELLING
ASYMPTAMATIC CHRONIC PROSTATITIS
• NO TREATMENT

43. CANCER PROSTATE

44. CANCER PROSTATE
THE SECOND MOST COMMON CAUSE OF CANCER IN MEN
THE SIXTH LEADING CAUSE OF CANCER DEATH AMONG MEN
WORLDWIDE
MORE THAN 75% OF CASES OCCUR IN MEN OVER AGE 65
95% -ADENOCARCINOMA
5% -TCC, NEUROENDOCRINE, SARCOMA

46. EARLY SYMPTOMS ADVANCED
SYMPTOMS
•constant back, hip
or pelvic pain
•feeling very tired
•Loss of weight,appetite
•Unexplained weight
loss
•Dizziness
•Shortness of breath

47. SCREENING OF PROSTATE CANCER
Screening is
recommended :
•Annually begins from
50 yrs of age
•family history of
prostate cancer-
screening from 40 yrs of
age
•African–American

49. PSA-PROSTATE SPECIFIC ANTIGEN
• PSA IS A SINGLE CHAIN GLYCOPROTEIN
• ORGAN SPECIFIC AND NOT DISEASE SPECIFIC
• UPPER LIMIT OF NORMAL 4NG/ML
• DISCRIMINATION FROM BPH AND CANCER BY PERCENT
OF FREE PSA-CUT OF 22%-MAXIMISES CANCER
DETECTION

50. PSA- PROSTATE SPECIFIC ANTIGEN

51. • TUMOR GRADING AND STAGING DEFINES THE PROGRESS OF CANCER
AND WHETHER IT HAS SPREAD
• TUMOR GRADING - GLEASON SCORE
- BASED ON THE GLANDULAR PATTERN OF THE
TUMOR UNDER LOW
POWER
• TUMOR STAGING - TNM SYSTEM
DRE
ULTRASOUND
CT SCAN
MRI BONE SCAN

53. TNM STAGING

55. STAGING
• LOCALIZED CA
-LOW RISK - T1-T2A & GLEASON SCORE 2-6 & PSA
<10NG/ML
-INTERMEDIATE RISK - T2B-T2C & GLEASON SCORE 7 & PSA 10-
20NG/ML
-HIGH RISK -T3A & GLEASON SCORE 8-10 & PSA
>20NG/ML
• LOCALLY ADVANCED -T3B-T4
• METASTATIC -ANY T,N1 OR ANY T ,ANY N,M1

56. TREATMENT OPTIONS
NON SURGICAL
EARLY LOCALIZED
-ACTIVE SURVEILLANCE
-WATCHFUL WAITING
-ANDROGEN ABLATION
-EBRT
-BT
-CRYOTHERAPY
LOCALLY ADVANCED-
-WATCHFUL WAITING
-ANDROGEN ABLATION
-EBRT
-BT

57. SURGICAL
EARLY LOCALIZED
RP-RETROPUBIC
-PERINEAL
-LAPAROSCOPIC
-ROBOTIC ASSISTED LAP
LOCALLY ADVANCED
-NEOADJUVANT RT
-SALVAGE –PSA FAILURE

58. ACTIVE SURVEILLANCE

59. WATCHFUL WAITING
• LESS INVOLVED SYSTEM OF
MONITORING THE CANCER WITHOUT
TREATING IT
• IT DOES NOT INVOLVE REGULAR
BIOPSIES OR OTHER ACTIVE
SURVEILLANCE TOOLS
• OPTION FOR
OLDER ADULTS
LIFE-THREATENING ILLNESSES
LIFE EXPECTANCY < 5 YEARS
• IF CANCER CAUSES SYMPTOMS, SUCH
AS PAIN OR BLOCKAGE OF THE URINARY
TRACT, THEN TREATMENT MAY BE
RECOMMENDED

60. SURGERY
• RETROPUBIC OPEN RADICAL PROSTATECTOMY WITH NERVE SPARING
SURGICAL REMOVAL OF THE ENTIRE PROSTATE AND THE SEMINAL VESICLES
AND LYMPH NODES IN THE PELVIC AREA
PRESERVING AS MUCH OF THE SURROUNDING NERVE STRUCTURES
RESPONSIBLE FOR PENILE ERECTIONS.
• LAPAROSCOPIC OR ROBOTIC ASSISTED RADICAL PROSTATECTOMY
• TURP- NOT TO TREAT CANCER BUT RELIEVES SYMPTOMS
• THE GOAL OF SURGERY IS TO GET A PSA VALUE OF LESS THAN 0.1 NG/ML FOR
10 YEARS
• GOOD CHOICE IF PROSTATE CANCER HAS NOT SPREAD BEYOND THE
PROSTATE
• COMPLICATIONS : BLEEDING ;INFECTION; ERECTILE DYSFUNCTION; URINARY
INCONTINENCE

63. RADIATION THERAPY
• THERE ARE TWO PRIMARY KINDS OF
RADIATION THERAPY
EXTERNAL BEAM RADIATION
THERAPY
- HYPO FRACTIONATED RADIATION THERAPY-RECEIVES A
HIGHER DAILY DOSE OF RADIATION THERAPY GIVEN OVER A SHORTER
PERIOD, INSTEAD OF LOWER DOSE GIVEN OVER A LONGER PERIOD.
BRACHYTHERAPY (INTERNAL
RADIATION)
- LOW DOSE RATE / HIGH DOSE RATE
• SIDE EFFECT :INCONTINENCE; BOWEL PROBLEMS; ERECTILE
DYSFUNCTION

64. FOCAL
THERAPY
• FOCAL CRYOABLATION
IS THE CONTROLLED FREEZING OF THE
PROSTATE GLAND- FREEZING DESTROYS
CANCER CELLS
COMMONEST SIDE EFFECT- FISTULA
• HIGH-INTENSITY FOCUSED ULTRASOUND
(HIFU)
• IRREVERSIBLE ELECTROPORATION.

65. HORMONAL
THERAPY
• ALSO KNOWN AS ANDROGEN DEPRIVATION
THERAPY (ADT)
• IT USES DRUGS TO BLOCK OR LOWER
TESTOSTERONE AND OTHER MALE SEX
HORMONES THAT FUEL CANCER
• USED TO SLOW CANCER GROWTH IN CANCERS
THAT ARE ADVANCED / DURING AND AFTER
RADIATION THERAPY
• LHRH AGONIST/ANTAGONIST
• ANDROGEN RECEPTOR INHIBITOR
• ANDROGEN SYNTHESIS INHIBITOR

66. CHEMOTHERAPY
• USED WHEN CANCER HAS
METASTASIZED
• USED FOR AGGRESSIVE
CANCER OR CANCER THAT HAS
STARTED GROWING OUTSIDE
THE PROSTATE
• USED TO TREAT CASTRATE-
RESISTANT PROSTATE CANCER

67. IMMUNOTHERAPY
• HELPS TO SLOW CANCER
GROWTH IN MEN WITH
ADVANCED PROSTATE
CANCER
• STIMULATE A PERSON’S OWN
IMMUNE SYSTEM TO
RECOGNIZE AND DESTROY
CANCER CELLS
• PD 1 INHIBITOR-
PEMBROLIZUMAB
• SIPULEUCEL-T (PROVENGE) -