The prostate gland is located below the bladder and surrounds the urethra. It secretes fluid that protects and nourishes sperm. The size and shape of the prostate can change with age due to conditions like benign prostatic hyperplasia (BPH) and prostate cancer. BPH involves noncancerous growth of the prostate and commonly causes urinary symptoms in older men. Prostate cancer develops from cells in the prostate and risks include family history and diet. Investigation may include a digital rectal exam and PSA testing while treatment options depend on cancer stage and severity of symptoms.

1. Investigation
Diagnosis
Management

2.  The prostate is Greek for "protector“ or
“to stand before” .
 It is an exocrine gland of the male
reproductive system in most mammals
 In 2002, female paraurethral glands, or
Skene's glands, were officially renamed
the female prostate by the Federative
International Committee on Anatomical
Terminology

3. The prostate is a firm, partly gland and partly muscular body, and is
placed immediately below the internal urethral orifice and around
the beginning of the urethra.
It is situated in the pelvic cavity, below the lower part of the symphysis
pubis, above the superior fascia of the urogenital diaphragm, and in
front of the rectum.
Size of a chestnut and conical in shape
Consist of a base, an apex, an anterior, a posterior and two lateral
surfaces.
 The base (basis prostatæ) is directed upward, and is attached to the
inferior surface of the bladder, The greater part of this surface is
directly continuous with the bladder wall; the urethra penetrates it.
 The apex (apex prostatæ) is directed downward, and is in contact
with the superior fascia of the urogenital diaphragm

4.  Vessels and Nerves - The arteries supplying the prostate are
derived from the internal pudendal, inferior vesical, and
middle hemorrhoidal. Its veins form a plexus around the
sides and base of the gland; they receive in front the dorsal
vein of the penis, and end in the hypogastric veins. The
nerves are derived from the pelvic plexus

5.  The "lobe" classification is sometimes used in anatomy.
 Anterior lobe (isthmus) roughly corresponds to part of
transitional zone. Posterior lobe roughly corresponds to
peripheral zone. Lateral lobes spans all zones. Median lobe
(or middle lobe) roughly corresponds to part of central zone
 Peripheral zone: This is the largest zone
and it touches the rectum.
 Transition zone: This is the small, inner part
that wraps around the urethra.
Problems here can pinch the urethra and
make it difficult to pass urine.
Central zone: This refers to the part
between the peripheral and transition zones.
The ejaculatory duct runs through this part.

6.  It secretes a slightly alkalic fluid, milky in appearance, that usually
constitutes 50–75% of the volume of the semen along with
spermatozoa and seminal vesicle fluid.
 Prostate secretion in human consist of proteolytic enzymes,
prostatic acid phosphatase, beta-microseminoprotein, prostate-
specific antigen and zinc (more than 500 times concentration than
in blood!)
 Spermatozoa which was expelled in prostatic fluid have better
motility, longer survival and better protection of the genetic
material.
 The prostate also contains some smooth muscles that help expel
semen during ejaculation

7.  Testosterone will be transformed into a more active form of
the hormone, called dihydrotestosterone (DHT) by 5-alpha-
reductase in the prostate.
 When men gets older, part of the transition zone in the
prostate which grows throughout lifes will still be reacted to
the hormone which will cause prostatomegaly.
 Adenomatous prostatic growth is believed to begin at
approximately age 30 years.
 An estimated 50% of men have histologic evidence of BPH by
age 50 years and 75% by age 80 years; in 40–50% of these
men, BPH becomes clinically significant.

8.  This affect most men over the age of 50 but
only 10% present with symptoms.
 The severity of symptoms depends on the
degree of encroachment on the prostatic
urethra.
 Anatomically, BPH is most strongly
associated with the posterior urethral glands
(PUG) and transitional zone (TZ) of the
prostate.
 However, the majority of growth eventually
occurs in the TZ.
 Since prostatic cancer also occurs in the PZ,
BPH nodules in the PZ are often biopsied to
rule out cancer

10. The cardinal symptoms are hesitancy and a poor stream.
Other symptoms are :
 nocturia
 Frequency
 Dribbling
 Incontinence
 acute retention
 Haematuria from ruptured dilated bladder neck veins
 Palpable bladder occosianally
 Smell of stale urine in patient
 Enlargement of kidney (hydronephrosis)
 Examination PR - smooth enlarged prostate, median sulcus,
enlarged lateral lobes.
 Signs of uraemia.

11. Consist of 7 questions about symptoms and 1 question regarding
QOL
The 7 symptoms question is marked from 0-5:
 Feeling of incomplete voiding
 Frequency
 Intermittency
 Urgency
 Weak stream
 Straining
 Nocturia
The 8th question of QOL is assigned a score of 0-6
IPSS Result of 7 symptoms question : Total Score of 0-7 (Mildly
symptomatic) 8-19 (Moderately symptomatic) ; 20-35 (Severely
symptomatic)

12.  Suitable for patients where:
- low risk of progression
- sx not particularly bothersome
 Regular monitoring using IPSS score will
objectively identify deterioration
 Education
 Lifestyle advice
 Reassurance

13. - Per Rectal examination (PR) may reveal a markedly enlarged
prostate, usually affecting the middle lobe.
- Blood tests are performed to rule out prostatic malignancy:
Elevated prostate specific antigen (PSA) levels needs further
investigations such as reinterpretation of PSA results, in terms of
PSA density and PSA free percentage, rectal examination and
transrectal ultrasonography. These combined measures can provide
early detection.
- Ultrasound of the testicles, prostate, and kidneys is often
performed, to rule out malignancy and hydronephrosis.
- Other blood test and diagnostic procedures for BPH are similar to
those used for prostate cancer which includes :
 FBC - Hb
 ESR
 RP
 Creatinine

14. Lifestyle
Patients should decrease fluid intake before
bedtime, moderate the consumption of
alcohol and caffeine-containing products,
and follow timed voiding schedules.

15.  The two main medications for management of BPH are alpha blockers and
5α-reductase inhibitors.
 Commonest alpha blockers used for BPH include doxazosin, terazosin,
alfuzosin, and tamsulosin
 Alpha blockers relax smooth muscle in the prostate and the bladder neck,
thus decreasing the blockage of urine flow. Common S/E of alpha blockers
include orthostatic hypotension, ejaculation changes, nasal congestion, and
weakness.
 The 5α-reductase inhibitors finasteride and dutasteride effects may take
longer to appear than alpha blockers, but they persist for many years. S/E
include decreased libido and ejaculatory or erectile dysfunction.
Some common drug dose :Prazosin 0.5-10mg BID, Terazosin 1-20mg
OD, Doxazosin 1-16mg OD, Finasteride 5mg OD

16.  Antimuscarinics such as tolterodine may also be used,
especially in combination with alpha blockers.They act by
decreasing acetylcholine effects on the smooth muscle of the
bladder, thus helping control symptoms of an overactive
bladder.
 Sildenafil citrate shows some symptomatic relief, suggesting
a possible common etiology with erectile dysfunction.

17. When it is indicated?
 If medical treatment fails, and the patient elects not to try office-based
therapies or the physician determines the patient is a better candidate for
transurethral resection of prostate (TURP), surgery may need to be
performed. In general, TURP is still considered the gold standard of prostate
interventions for patients that require a procedure. This involves removing
(part of) the prostate through the urethra.
 Other sriugical option include Transurethral electrovaporization of the
prostate (TVP), laser TURP, visual laser ablation (VLAP), ethanol injection, and
others are studied as alternatives.

18.  Another procedure termed Holmium Laser Ablation of the Prostate (HoLAP)
has also been gaining acceptance around the world. The penetration depth of
Holmium lasers is <0.4 mm, so less complications to surround tissues.
 It also carry fewer risks compared with either TURP or open prostatectomy.
 HoLEP is largely similar to the HoLAP procedure; the main difference is that
this procedure is typically performed on larger prostates. Instead of ablating
the tissue, the laser cuts a portion of the prostate, which is then cut into
smaller pieces and flushed with irrigation fluid. As with the HoLAP procedure,
there is little bleeding during or after the procedure.
 Post surgery care often involves placement of a Foley catheter or a temporary
prostatic stent to permit healing and allow urine to drain from the bladder

19.  This is the commonest cancer in men. 52% of tumours at
presentation are localized to the prostate gland. It is rare below the
age of 50.
 Most prostate cancers are slow growing; however, there are cases of
aggressive prostate cancers. The cancer cells may metastasize
(spread) from the prostate to other parts of the body, particularly
the bones and lymph nodes.
 Spread occurs to adjacent organs, e.g. bladder, urethra and seminal
vesicles.
 Spread to the rectum is rare. Lymphatic spread is to the iliac and
para-aortic nodes. Blood spread occurs early, especially to the
pelvis, spine and skull (osteosclerotic lesion).
 Prostate cancer may cause pain, difficulty in urinating, problems
during sexual intercourse, or erectile dysfunction.

20. Genetic
 Men who have a first-degree relative (father or brother) with
prostate cancer have twice the risk of developing prostate
cancer, and those with two first-degree relatives affected
have a fivefold greater risk compared with men with no family
history.
 Mutations in BRCA1 and BRCA2, important risk factors for
ovarian cancer and breast cancer in women, have also been
implicated in prostate cancer. Other linked genes include the
Hereditary Prostate cancer gene 1 (HPC1), the androgen
receptor, and the vitamin D receptor.

21. Dietary
 Evidence supports little role for dietary fruits and vegetables
in prostate cancer occurrence.
 Red meat and processed meat also appear to have little effect
in human studies. Higher meat consumption has been
associated with a higher risk in some studies.
 Lower blood levels of vitamin D may increase the risk of
developing prostate cancer.
 Taking multivitamins more than seven times a week may
increase the risk of developing the disease.
 A 2009 study on folic acid supplements showed an
association with an increased risk of developing prostate
cancer.
 Obesity and elevated blood levels of testosterone may
increase the risk for prostate cancer.

22. Others
 Use of the cholesterol-lowering drugs ( statins )may also decrease
prostate cancer risk.
 Infection or inflammation of the prostate (prostatitis) may increase
the chance for prostate.sexually transmitted infections chlamydia,
gonorrhea, or syphilis seems to increase risk.
 There is an association between vasectomy and prostate cancer
however more research is needed to determine if this is a causative
relationship.

23.  Asymptomatic
 Hard craggy mass and nodule in prostate on rectal examination
- the median sulcus between the lobes may be obliterated
 Incontinence
 Dysuria
 Haematuria
 Hesitancy
 Dribbling
 Retention
 Bone pain - pathological fractures
 Sciatica
 Anaemia
 Weight loss
 Palpable bladder
 Tenderness over bone
 Hepatomegaly

24.  Hb-FBC
 ESR
 U&Es
 Creatinine
 PSA - PSA Density (PSAD) - the blood PSA level divided by the size of the
prostate, as determined by TRUS - can help distinguish between BPH and
prostate cancer. Basically, with BPH, the PSA level should not be more
than 15 percent of the size of the prostate. PSA levels exceeding 15
percent of the size of the prostate are more likely to indicate the
presence of prostate cancer -- and the need for a biopsy.
 Transrectal Ultrasound (TRUS) scan and guided biopsy
 CXR : metastases in lungs or ribs
 Bone radiograph : sclerotic deposits in pelvis, spine or skull
 Bone scan is sensitive indicator of early metastases
 Ultrasound Spectral (USS) : residual urine, upper urinary tract
obstruction, and useful in prostate Ca grading.
Grade I - 3.0 to 3.8 cms 30 Gms.
Grade II - 3.8 to 4.5 cms 30- 50 Gms.
Grade III- 4.5 to 5.5 cms 50- 80 Gms.
Grade IV - 5.5. cms 85 Gms

25.  Is used to help evaluate the prognosis of men with prostate
cancer.
 It grades tumors on a scale of 1-5. You may have different
grades of ca in one biopsy sampel.
 The 2 main grades are added together.
- The higher the score,the higher the probability of the ca to
spread past the prostate.
 Scores 2-5 : Low grade prostate
 Scores 6-7 : Intermedieate (most prostate fall into this group)
 Scores 8-10:High grade ca

26. Mainly TURP to relieve obstructive symptoms
Other treatment for Prostatic Cancer depends on staging.
 For cancer localized to prostate - observation with routine monitoring of
PSA, external beam radiotherapy or radical prostatectomy.
 For metastatic disease, hormonal manipulation is used, such as
Luteinizing releasing hormone releasing hormone (LHRH) agonist E.g.
cyproterone acetate or bicalutamide and silboestrol,which is rarely used
nowadays (causes gynaecomastioa and fluid retention)
 Local radiotherapy is used for bony metastatic pain
PROGNOSIS :
Variable - Depends on stage at presentation. Patients with clinically
localized tumor treated radically may expect a normal life expectancy.
Those with metastatic disease at presentation have a median 3-year
survival.

29.  This occurs most commonly in young adults.
 Acute bacterial prostatitis ususally presents as an
acute febrile illness.
 Chronic prostatitis presents with recurrent UTIs.
 If there is a past history of TB anywhere in the
body, suspect TB prostatitis.

30. Acute Bacterial Prostatitis :
 Fever
 Low back pain
 Perineal pain
 Bladder irritation
 Outflow obstruction
 Enlarged tender prostate
Chronic Prostatitis :
 Sx of UTI - but mild or sometimes absent
 Dull perineal ache
 Normal or indurated irregular prostate

31. Acute Prostatitis :
 FBC - TWC (raised)
 Mid -stream urine (MSU) - shows growth.
 Blood C&S
Common bacterias are:
Echerichiacoli, Klebsiella, Proteus, Pseudomonas, Enterobacter, Ente
rococcus, Serratia, andStaphylococcus aureus
Chronic Prostatitis :
 Prostatic massage may yield secretions containing white cells
and occasionally orgasms
 Culture for TB in chronic prostatitis

32. Acute Prostatitis :
 Bed rest
 Hydration
 Antibiotics (I.V) eg. Ciprofloxacin, Co-trimoxazole and
tetracyclines such as doxycycline
 Analgesics
 Patients with urinary retention are best managed with a
suprapubic catheter or intermittent catheterization.
Chronic Prostatitis :
 Long term antibiotics eg. Ciprofoloxacin for 4-8weeks
 Escherichia coli extract and cranberry have a
potentially preventive effect
 Prostatic massage (may be effective)
TB Prostatitis :
 Anti - TB

33.  What is prostate?
 What prostate does?
 What are the causes for enlargement of
prostate?
 How do we differentiate between each
cause?
 What are the treatment of BPH, Prostate
Ca and Prostatitis?

34.  Churchill’s Surgery
 Oxford Clinical Surgery
 World Wide Web