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PROSTATOMEGALY

Investigation Diagnosis

Management

by : Uwais

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

What is prostate?

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

Anatomy of prostate

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

A little bit more about the anatomy

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.

Structure

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

Functions

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.

Sex hormone and prostate

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

Benign Prostatic Hyperplasia

Zones of Prostate Pathology

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.

Symptoms and signs

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)

IPSS

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

“Watchful Waiting”

- 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

Investigations

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

Management

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

Medications

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.

Other medications

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.

Surgery

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

Surgery (HoLAP and HoLEP)

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.

Prostate Cancer

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.

Causes

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.

Causes

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.

Causes

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

Signs and symptoms

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

Investigations

TRUS

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

Gleason Grading system

Mainly TURP to relieve obstructive symptomsOther 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.

Management

Radical Prostatectomy

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.

Prostatitis

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

Signs and Symptoms

Acute Prostatitis : FBC - TWC (raised) Mid -stream urine (MSU) - shows growth. Blood C&S

Common bacterias are: Echerichiacoli,  Klebsiella, Proteus, Pseudomonas, Enterobacter, Enterococcus, Serratia, andStaphylococcus aureus

Chronic Prostatitis : Prostatic massage may yield secretions containing white

cells and occasionally orgasms Culture for TB in chronic prostatitis

Investigations

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

Management

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?

Things to know

Churchill’s Surgery Oxford Clinical Surgery World Wide Web

References

JAZAKUMULLAH KHEIR