Property of Prof Dr. Ahmed Sakr, Department of Urology, Faculty of Medicine, University of Zagazig, Egypt

1. Prostate gland
Ahmed Sakr,
Urology MD
By
Zagazig Urology Department

2. Anatomy of the prostate
•
The prostate surrounds the bladder outlet & the
beginning of male urethra.
•
Its shape is like a chestnut or inverted cone.
•
It measures 3 × 4 × 2 cm & weighs about 18 gm.
•
Relations:

3. Zonal anatomy:
•
TZ (the commonest site for BPH)
•
CZ
•
PZ (the commonest site for
prostatic carcinoma)
•
Anterior fibro-muscular stroma
Clinically :
The prostate has 2 lat. Lobes separated by a
central sulcus and a median lobe which may
project into the cavity of the U.B.

4. Benign prostatic hyperplasia
“Senile enlargement of the prostate”
•
The commonest tumor of the prostate
•
Affects about ⅔ of men over 50 y.
Etiology:
1- Unknown
2- Aging
3- Normal testosterone
Pathology:
•
From TZ or peri-urethral region
•
As adenoma enlarges, it compresses the normal
prostatic tissue forming a false capsule with a line
of cleavage.

5. Histology:
•
Hyperplasic acini
•
Variable in size
•
Lined with one or more layers of cells
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some acini contain corpora amylacea
•
The fibro-muscular stroma shows hypertrophy
BPH Normal prostate

6. Pathologic effect:
•
Urethra: compressed, stretched, elongated & may
be tortuous

7. •
Bladder:
-
Bladder → Hypertrophied wall with ↑ pressure inside →
cellule & diverticula
-
Bladder decompensation → urine retention
(acute or chronic)

8. •
Upper tract: Hydroureter & hydronephrosis &
may lead to renal insufficiency

9. Clinical picture: (LUTS obstructive or irritative)
•
Obstructive : hesitancy, weak stream, interrupted
stream & urine retention
•
Irritative : ↑ frequency, urgency & urge
incontinence
-
Obstructive symptoms occur first but with infection
& stone formation irritative symptoms
become manifest

11. Physical examination:
•
Abdominal mass (hydronephrosis)
•
Pelvic mass (retained bladder)
•
DRE:
1. Symmetrical or asymmetrical enlargement
2. Preserved sulcus
3. Smooth surface
4. Sliding rectal mucosa over the gland
5. Consistency like that of contracted thenar
eminence

12. Investigations:
A. Basic investigations:
1. Urinalysis
2. Serum creatinine
3. PSA:
•
Normal level → 0-4 ngml
•
BPH → 4-10 ngml
•
> 10 ngml may indicate cancer
4. U/S:
•
Abdominal
•
TRUS

13. B. Additional investigations:
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IVP
•
Uroflowmetry
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Estimation of post-voiding residual urine
•
Cystoscopy

14. Complications:
1. Hematuria
2. Urine retention (acute or chronic)
3. Infection
4. Stone formation
5. uremia

15. Treatment:
1. Watchful waiting: ( in mild symptoms)
•
↓ fluid intake
•
Timed voiding
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Avoidance of constipation
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Avoid exposure to cold
•
Avoid diuretics & anti-cholinergic
•
Avoid sexual excitement

16. 2. Medical treatment:
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Indications: Bothersome symptoms with no complications
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Drugs:
•
α – adrenergic blockers (Doxazocin – Terazocin)
They act by ↓ the tension of the smooth
muscle of prostatic capsule
•
5 – α reductase inhibitors (Finasteride):
It inhibits the 5 – α reductase enzyme
responsible for conversion of
testosterone to DHT

17. 3. Surgical treatment:
•
Indications:
1. Recurrent attacks of acute retention
2. Hematuria
3. Recurrent urinary tract infection
4. Bladder stone or diverticula
5. Renal insufficiency
•
Routes of intervention:
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Open surgery: Transvesical or retropubic
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TUR-P
4. Minimally invasive techniques:
•
LASER prostatectomy
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Prostatic balloon ablation
•
Prostatic stents
•
Thermotherapy

18. Prostate cancer
Etiology: Unknown
Risk factors: Family history, high fat diet & racial
factors
Pathology:
-
Gross: Hard nodular prostate, may invade the
capsule or adjacent structures
-
Microscopic: Adenocarcinoma of varying degrees
Spread:
1. Direct spread
2. Lymphatic spread
3. Blood spread

19. Clinical picture:
•
Asymptomatic & discovered accidentally
•
Symptoms of metastasis without urinary symptoms
(occult carcinoma)
•
LUTS (shorter duration & progressive course)

20. Diagnosis:
1. DRE
2. Elevated PSA
3. Prostatic biopsy
4. Other markers as serum acid phosphatase & serum
alkaline phosphatase
5. Plain X-ray spine for metastasis
6. Isotopic bone scan
7. CT scan
8. Cystoscopy

21. Treatment:
1. Watchful waiting.
2. Radical surgery.
3. Radiotherapy: External or brachytherapy
4. Hormonal therapy: in advanced cases
Depends on androgen ablation by:
•
Bilateral orchiectomy
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Oral estrogen
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Antiandrogens