Disorders of prostate

1. DISORDERS OF
PROSTATE
• SEMINAR SU 29.9
DESCRIBE THE CLINICAL FEATURES, INVESTIGATIONS,
AND PRINCIPLES OF MANAGEMENT OF DISORDERS OF
PROSTATE.
• PRESENTERS –
ANURAG HAZARIKA
NITESH SINGH
ABHISHEK SHARMA
ANAMIKA ROY

2. PROSTATE GLAND: ANATOMY
-The prostate is an ovoid (walnut sized) fibromuscular glandular organ in
males positioned inferior to the neck of the urinary bladder and is traversed
by the urethra.
-It is encapsulated by a true internal connective tissue capsule and a false
external capsule, which is a continuation of the pelvic fascia.
-Laterally, it is cradled by the pelvic floor muscles and inferiorly by the
urethral sphincter muscle.
-Posteriorly, Denonvilliers’ fascia separates it from the rectum. The broadest
part is referred to as the base of the prostate.

3. PROSTATE GLAND: ANATOMY
The prostate is divided into four anatomical lobes by the urethra
and the ejaculatory ducts as they pass through the organ.
Anterior lobe
Median lobe
Posterior lobe
Two lateral lobes.

4. PROSTATE GLAND: histology
Prostatic glands have lumens that are lined by connective
tissue folds. The connective tissue foldings result in the acini
lined by simple columnar or pseudostratified epithelium.
Prostatic concretions (precipitations of prostatic glandular
secretions) can also be found in the lumen of prostatic glands
as age advances.
Histologically the prostate is divided into three zones
(McNeal divisions) :
Central zone – surrounds the ejaculatory ducts, comprising
approximately 25% of normal prostate volume.

5. PROSTATE GLAND: histology
Transitional zone – located centrally and surrounds the urethra,
comprising approximately 5-10% of normal prostate volume.
Benign Prostatic Hyperplasia (BPH) arises from transitional zone.
Peripheral zone – makes up the main body of the gland
(approximately 65%) and is located posteriorly.
The peripheral zone is mainly the area felt against the rectum on
DRE. This is typically where prostatic adenocarcinomas can be
palpated as these tumors most often arise in the peripheral
zone.
The fibromuscular stroma is situated anteriorly in the gland. It
merges with the tissue of the urogenital diaphragm.

6. PROSTATE GLAND: vasculature and innervation
The arterial supply to the prostate comes from the prostatic arteries, which are mainly derived from
the internal iliac arteries. Some branches also arise from the internal pudendal and middle rectal
arteries.
Venous drainage of the prostate is via the prostatic venous plexus, draining into the internal iliac
veins. However, the prostatic venous plexus also connects posteriorly by networks of veins, to the
internal vertebral venous plexus through which prostatic carcinoma spread.
The prostate receives sympathetic, parasympathetic and sensory innervation from the inferior
hypogastric plexus. The smooth muscle of the prostate gland is innervated by sympathetic fibres,
which activate during ejaculation.

7. PROSTATE GLAND: lymphatics
The posterior lobe of the prostate is drained via:
The external iliac lymph nodes
The internal iliac nodes
The sacral lymph nodes.
The anterior lobe of the prostate drains into:
The external iliac lymph nodes, via the paravesical space.
Alternatively, some vessels drain into inferior gluteal lymph nodes.

8. PROSTATITIS

9. Inflammation of the prostate or prostatitis may be acute or chronic.
Acute Prostatitis :
• Aetiology :
• The infection may be Haematogenous from a distant focus or it may be secondary
to acute urinary retention.
• Due to instrumentation
• Organism involved- Staphylococcus aureus ,S.albus ,streptococcus faecalis,
Neisseria gonorrhoeae .

10. • Pain, frequency , fever with chill and rigor
• Retention of urine
• Perineal heaviness, rectal irritation, pain on defaecation
• Tender prostate on per rectal examination
Clinical Features :
• Urine C/S – the urine contains threads in the initial voided sample ,which should
be cultured.
• Ultrasound Abdomen.
Investigation :
• Prolonged treatment with an antibiotic that penetrates the prostate well is
indicated (trimethoprim or ciprofloxacin )
Treatment:

11. Chronic Prostatitis:
• This generally occurs due to
inadequate treatment of acute
prostatitis.
Clinical features :
• There is always associated
posterior urethritis
• Epididmyitis
• Pain in the perineium, low
backache radiating downwards
to the thigh
• Sexual dysfunction .

12. Diagnosis
• The three-glass urine test is valuable .If the first
glass with the initial voided sample shows urine
containing prostatic threads , prostatitis is
present.
• Rectal examination of the prostate may be
normal or show a soft ,boggy and tender
prostate
• Examination of the prostatic fluid obtained by
prostatic massage should show pus cells and
bacteria .
• Urethroscopy may reveal inflammation of
prostatic urethra and pus may be seen exuding
from prostatic ducts.

13. Treatment :
Antibiotic therapy
should be admnistrated
only in accordance with
bacteriological
sensitivity test
(trimethoprim or
ciprofloxacin penetrate
well into the prostate)

14. Benign prostatic hyperplasia

15. Benign prostatic hyperplasia is benign enlargment of prostate which occurs after 50 years usually between 60
and 70 years BPH affects both glandular epithelium and connective tissues stroma

16. Etiology
● Ageing
● Excessive accumulation of prostatic androgen
● Family history
● Diet increase animal fat and saturated fatty acids
● Reduce exercise and alcohol consumption

17. Pathogenesis of BPH

18. Clinical features
storage (irritative) symptoms:
● Increase frequency:earliest and most common symptom of BPH
● Nocturia
● Urgency:Sudden urge to pass urine.
● Urge incontinence:pass urine before reaching toilet.
● Nocturnal incontinence.
Voiding (obstructive) symptoms:
● Hesitancy :patient has to wait before urine comes out.
● Poor flow:narrow stream of urine.
● Intermittent stream :stops and start
● Dribbling event after micturition.
● Poor bladder emptying.
● Episodes of near retention.

19. Investigation
● Urine for microscopy and C/S.
● Ultrasound abdomen-look for presence of residual urine.
● Urodynamics:
○ Urine flow rate>15ml/sec is normal. 10-15mL is equivocal, <10mL is low.
○ Voiding pressure <60 cm of water is normal, 60-80 is equivocal, >80 is High.
● Cystoscopy
● Transrectal ultrasound is useful to find out nodules/possibility of carcinoma prostate.
● Prostate specific antigen.

20. Medical management
● Alpha1 adrenergic blocking agents-which inhibit smooth muscle contraction of prostate. They reduce
the bladder neck resitance so as to improve the Urine flow.
○ Short acting drugs are prazosin
○ Long acting Drug are terazocin
● 5-alpha reductase inhibitor inhibits conversion of testosterone to dihydrotestosterone. Ex-finasteride.
● PSA levels in a patient on 5 alpha reductase inhibitor should be assessed carefully as they reduce PSA,
levels.
● Best Medical management: combination therapy.

21. Surgical management:
Indications:
● Upper ut involvememt
● Not responding to medicines.
● Acute/chronic retention of Urine.
● Multiple episodes of UTI.
● One episode of gross hematuria.
● Flow rate <10mL/S and pressure >80cm of water.
Surgery:
● Transurethral resection of prostate(TURP) -most common surgery
○ Using cystoscope With fluid like glycine irrigating
continuously, enlarged prostate is identified and resected
using a loop with a hand control.

22. Complications of TURP
● Hemorrhage
● Water intoxication with congestive cardiac faliure -TURP syndrome.
● Hyponatremia
● Infection
● Incontinence
● Perforation of the bladder or prostatic capsule
● Stricture urethra
● Retrograde ejaculation and impotence
● Recurrence

23. ● Millin’s retropubic prostactomy:it is done without opening the bladder.
● Laser treatment, using holmium laser.
● Transurethral ballon dilation of the prostate.
● If patient presents with acute retention of Urine, initial urethral catheterization is done. If not possible
then open SPC is done. Once patient’s obstructive uropathy is under control, TURP is done after7-14
days after evaluation.

24. CARCINOMA OF PROSTATE

25. INTRODUCTION
• Carcinoma of prostate is the most common malignant tumour in men
over the age of 65 year .
• The incidence of prostate cancer in men over 80 year is 70% .
• Carcinoma of prostate occurs in peripheral zone in prostate gland
proper so prostatectomy for BPH does not confer protection against
development of carcinoma prostate

26. RISK FACTORS OF CA PROSTATE

27. HISTOPATHOLOGY
• Carcinoma prostate is an adenocarcinoma .
• First changes Associated with CA prostate is loss of basement
membrane with Gland appearing to be confluence.
• As the cell type become less differentiated ,more solid sheets of
carcinoma cells are seen .

29. SPREAD
• Local spread : seminal vesicles, bladder neck , trigone and later into
both ureters and distal sphincter .
• Blood spread : pelvic bone ,lumber vertebrae, femoral head ribs , skull
. Rarely spread to liver and lung
• Lymphatic spread: Obturator lymph node, internal iliac lymph node
,external iliac and retroperitoneal lymph node, mediastinal ,
supraclavicular lymph node

30. CLINICAL FEATURES
• Symptoms – Commonly asymptomatic .
Bladder outlet obstruction and retention of urine .
Haematuria , frequency.
Pelvic pain , back pain , arthritic pain in sacroiliac joint
Features of renal failure
• Sign - Tumors incidentally found after TURP or after PSA analysis
- On DRE prostate feels hard, nodular , irregular often with loss
of median grove.

33. INVESTIGATION
1. Serum PSA level : finding of > 10ng/ml is suggestive and > 35
ng/ml is diagnostic for carcinoma of prostate .
2. Digital rectal examination :- Detect nodule within prostate
gland and advance disease . Irregular induration , stony hard
in part or whole of the gland suggest prostate cancer.
3. General blood examination :
- In early Disease blood finding is normal
- In metastatic disease there maybe leukoerythroblastic
anemia , thrombocytopenia , DIC , increased fibrinogen
degradation products seen .

34. 4. Prostatic biopsy
- The prostate is commonly biopsed by
two routes -1. Transrectal approach
2. Transperineal approach
- In both cases the Passage needle is
guided by transrectal ultrasound .
- Transperineal biopsy need GA while
transrectal biopsy can be performed
under LA
- In transrectal biopsy about 12 biopsy
core are obtained

35. 5. Radiological examination
• Pain X – ray: chest , KUB,
abdomen
• Ultrasound abdomen .
• MRI
• Bone scan

36. Management
• Early Disease :
1. Watchful wait /active surveillance
2. Radical prostatectomy: It involves removal of prostate gland ,
seminal vesicles and distal sphincter .The bladder neck is
then reconstituted and anastomoses with urethra.
3. Radical radiotherapy
4. Brachytherapy : Under transrectal ultrasound guidance
radioactive seeds are permanently implanted into prostate .

37. Advanced disease
1. Androgen deprivation therapy :
• Medical – LHRH agonist (goserelin , leuprolide ), androgen
receptor blocking agent (flutamide )
• Surgical –Bilateral Orchidectomy
2.Chemotherapy
3.Tumor vaccine