The document summarizes information about the prostate gland and benign prostatic hyperplasia (BPH). It discusses the anatomy and function of the prostate gland. It describes how the size of the prostate increases with age due to BPH in many men. Common symptoms of BPH include frequent urination and weak urine stream. Treatment options for BPH include watchful waiting, medications, and surgery. The risk of prostate cancer also increases with age and it is a major health concern for older men.

1. ORHAN HAKLI, NP

3. 
The gland is located posterior to the pubic symphysis, superior to the
perineal membrane, inferior to the bladder, and anterior to the
rectum.

A normal prostate gland is approximately 20 g in volume, 3 cm in
length, 4 cm wide, and 2 cm in depth.

As men get older, size of the prostate gland varies due to secondary
to benign prostatic hyperplasia

4.  The
main function of the prostate gland is to
secrete an alkaline fluid that makes up
approximately 70% of the seminal volume.
 The secretions produce lubrication and
nutrition for the sperm.
 Prostatic secretions also contains seminal
plasmin that is an antibiotic that prevents UTIs
in males.
 The muscular tissue provides the force to push
these secretions into the prostetic urethra.

5. 




BPH is a noncancerous enlargement of the prostate gland.
It is considered a normal part of the aging process in men
and is hormonally dependent on testosterone and
dihydrotestosterone (DHT) production.
An estimated 50% of men demonstrate BPH by age 60
years. This number increases to 90% by age 85 years
(Deters& Costabile,2013).
As many as 14 million men in the United States have
symptoms of BPH (Deters et al. 2003).
The prevalence of BPH in white and African-American men
is similar. However, BPH tends to be more severe and
progressive in African-American men, possibly because of
the higher testosterone levels (Deters et al. 2003).

6. 




Prostate gland makes its first growth
around puberty and reaches to the
average size of 20g
The gland again undergoes a second
growth spurt during the fifth decade.
This growth is characterized by
localized proliferation in the
periureteral region.
BPH is characterized as a
hyperplastic process. The hyperplasia
results in enlargement of the
prostate that may restrict the flow of
urine from the bladder, resulting in
clinical manifestations of BPH.
The prostate enlarges with age in a
hormonally dependent manner.
Males who are unable to make
testosterone do not develop BPH.

7. 
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

8. 
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

9. 




Bladder
 CA
 Stones
 Trauma
 Neurogenic Bladder
Urethral Strictures
UTI
Cystitis
Prostatitis

10. 
Hx

DRE


UA


To exclude infectious causes
Prostate- Spesific Antigen (PSA)


Look for ; blood, leukocytes, bacteria, protein, or glucose.
Urine Culture


To see size and condition of the gland
To r/o CA (note: people with large prostates may have slightly elevated
PSA)
BMP with BUN and CRE

to r/o renal insufficiency.

Ultrasound of abdominal, renal, transrectal

To determine bladder and prostate size and the degree and any presence of
renal involvement

Cystoscopy


To determine the size, location and degree of obstruction
Urine Flow study

to check any reduction in urine flow

11. 
WATCHFUL WAITING

Patients with mild to moderate symptoms

Pts not bothered by the symptoms

Pts not experiencing complications of BPH
re-examine the pt annually, see the size and condition of the gland

Utransurethral Resection of the Prostate (TURP)

Pharmacological approach(Rx)

To reduce morbidity and prevent complications

alpha-adrenergic blockers,

Phenoxybenzamine (Dibenzyline)

Prazosin (Minipress)

Alfuzosin (UroXatral)

Terazosin (Hytrin)

Tamsulosin (Flomax)

Doxazosin (Cardura, Cardura XL)

5-alpha-reductase inhibitors

They inhibit the conversion of testosterone to DHT, causing DHT levels to drop and helps with
decreaseing prostate size

Finasteride (Proscar)

Dutasteride (Avodart)

12. 
Prostate cancer is the most common noncutaneous cancer in men
in the United States.

An estimated 1 in 6 white men and 1 in 5 African American men
will be diagnosed with prostate cancer in their lifetime, with the
likelihood increasing with age (Chodak & Krupski, 2013).


It is the second most common cause of cancer death in males
Currently, with PSA screening, most prostate cancers are
diagnosed at an asymptomatic stage
RISK FACTORS

Advancing age(65 and up, rare in younger than 40)

African- American race

Family Hx of Prostate CA

13. 
The most common type is adenocarcinoma

Develops in the acinar glands that is located in the posterior
peripheral zone of the prostate

Tumors can develop in one or both lobes of the prostate and can
spread in the prostate gland

14. EARLY STAGES

The majority of patients with prostate cancers, are
asymptomatic.

Diagnosis in such cases is based on abnormalities in a screening
prostate-specific antigen (PSA) level or findings on digital rectal
examination (DRE).

Also can be incidental when tissue is removed after TURP for BPH
LATER STAGES

urinary complaints or retention

back pain

Hematuria

Weight loss and loss of appetite

Anemia

Bone pain

Lower extremity pain and edema due to obstruction of venous
and lymphatic system

15. 
A firm nodule on rectal exam; induration; or a stony , asymmetric
prostate should make health care provider suspicious for prostate
CA

In early stages, PE tends to be normal that is why it is
recommended to do DRE routinely on ;
 patients 50 and over
 45 years old and over African American male
 40 and over with pts who have family hx

BPH/Bladder Outlet Obstruction

UTI

Prostatic abscess

Prostatitis (bacterial/nonbacterial)

Prostate Calculi

16. 
PSA WITH DRE

Most sensitive diagnostic tool
AGE
Normal PSA range in mcg/L

40-49 0-2.5.

50-59 0-3.5

60-69 0-4.5

70-79 0-6.5
REFER PT TO A UROLOGIST WHEN A SUSPICIOUS FINDING IS FOUND ON DRE OR
PSA IS ELEVATED

17. 
Make your decisions based on;

Stage

Prognostic features of the tumor

Pt’s age/medical condition/preferences
Standard treatments for clinically localized prostate cancer

Watchful waiting

Cryotherapy

Radical prostatectomy


Radiation therapy


For stage A and B long term survival rate 80% to 90%
For stage A and B long term survival rate 80% to 90%
Hormone therapy

For symptomatic pts with advanced disease

Hormone therapy for prostate cancer is also known as androgen deprivation therapy
(ADT). It may consist of surgical castration (orchiectomy) or medical castration. Agents
used for medical castration include luteinizing hormone–releasing hormone (LHRH)
analogues or antagonists, antiandrogens, and other androgen suppressants.
Consider pain management and palliative care for more advanced cases

18. 
Buttaro, T.M. , Trybulsky, J., Bailey,P.P. ,Cook, J.S. (2008). Primary Care a
Collaborative Practice. Philadelphia, PA: Elsevier.

Chodak, G.W., Krupski, T.L. (2013).
http://emedicine.medscape.com/article/1967731-overview. Retrieved from
www.medscape.com: http://emedicine.medscape.com

Deters, L., Costabile, R.A., . (2013).
http://emedicine.medscape.com/article/1967731-overview. Retrieved from
www.medscape.com: http://emedicine.medscape.com/article/1967731overview

Martini, F., Timmons, M.,Tallitsch, R. (2003). Human Anatomy. New Jersey:
Prentice Hall.
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