Diseases of Prostate

Dr. Mahdi Aljamal, DMD

General and Laparoscopic Surgeon, Assistant Professor
Head Of General Surgery Department, FOM, AAUP
Anatomy of prostate
• The prostate is divided into
several lobes: the anterior
lobe, the median lobe, the
lateral lobes (left and right
lobes), and the posterior
lobe.
• The prostate is also
divided, into different
zones according to their
function: the central zone
(CZ), peripheral zone (PZ),
and transitional zone
Anatomy of prostate
• The prostate's most important function is the production of a fluid that,
together with sperm cells from the testicles and fluids from other
glands, makes up semen.

• The muscles of the prostate also ensure that the semen is forcefully
pressed into the urethra and then expelled outwards during ejaculation
Benign prostatic Hypertrophy
Benign Prostatic hyperplasia BPH
• Progressive enlargement of
prostate = due to an
increase in number of size
of epithelial cells and
stroma tissue.
Benign Prostatic hyperplasia BPH
• Typically in men > 40 years
• At the age of 60 years, 50% of men have BPH
- at 85 years, 90% have BPH
• 2nd most common cause of surgical intervention in men older
than 60 years
• Risk factors = aging, excessive accumulation of prostatic
androgen, family hx, diet increase animal fat and saturated
fatty acids, reduced exercise, smoking, heart disease, DM,.
BPH pathophysiology:
• The cause is uncertain, but related to estradiol levels in males
with testosterone above median.

• Hypertrophied lobes may obstruct the vesical neck \ prostatic

urethra → incomplete bladder emptying, and urinary
retention → hydroureter \ hydronephrosis \ UTI
BPH complications”
• Acute retention
• UTI
• Renal stones \ bladder stones
• Decompensation \ damage of bladder
• Hydronephrosis \ pyelonephritis
• Sexual dysfunction
• Urinary incontinence, which type?
Assessment and diagnosis
• History ?
- surgical procedure, hematuria, UTI, DM, current
medications (anticholinergics can impair bladder contractions
or sympathomimetics that increase outflow resistance)
• PE = DRE for sphincter tone and enlarged prostate and to rule
out any neurological problems.
Assessment and diagnosis
• Urine analysis = R\O UTI and hematuria
• Urine culture and sensitivity
• Creatinine
• PSA
• Transrectal US
• Uroflowmetry and urodynamics = To evaluate flow-rate
• Post-void residual ultrasound
• Pressure flow studies to distinguish urethral obstruction and
impaired detrusor contractility
• Filling cystometry – for bladder capacity and compliance
Assessment and diagnosis
• Cystourethroscopy = visualize prostatic urthera and bladder
• CBC and coagulation profile
- as hemorrhage complication of prostatic surgeries
- clotting defects to be corrected
• Asses general condition of the patient as old age patients.
Medical management
• Main goals =
- restore bladder function
- relieve signs and symptoms
- prevent and treat complications.

• If the patient is admitted on an emergency basis because he

can not void → urgent catheterization.

• Dietary management = decrease caffeine and artificial

sweeteners, limit spicy and acidic foods
Medical management
• Pharmacological management =
- alpha-adrenergic blockers (doxazosin, tamsulosin) = relaxes
smooth muscles of bladder neck, and prostate to facilitate
voiding.
- 5-alfa reductase inhibitors (finasteride) and dutasteride =
anti-androgen effect on prostatic cells and can reverse or
prevent hyperplasia
- aromatase inhibitors
- symptomatic management
Surgical management
• Depending on size, severity of obstruction, age, co-
morbidities
• Transurethral, suprapubic, retropubic, and perineal
approaches.
- newer approach = balloon dilatation of prostate under
endoscopy and TUIP (transurethral incision of the prostate)

• Indications = acute urinary retention, recurrent infection,

recurrent hematuria, azotemia
TURP
Prostatic CA
Cancer of prostate
• Abnormal proliferation of cells of the prostate
• The most common CA in men over 65 years
• Unknown cause
• May be asymptomatic at an early stage
• May have symptoms of obstruction = hesitancy, straining on
voiding, frequency, nocturia, diminution in size & force of
stream
• Symptoms may be due to mts = pain at the lumbosacral area
radiating to hips and down legs, perineal and rectal
discomfort.
Clinical manifestations:
• Anemia, weight loss, weakness, nausea, oliguria, hematuria
• Lower extremities edema in case of pelvic node involvement
and venous return compromised.

• Investigations :
- DRE = hard nodule
- Bx = pathological exam
- Trans-rectal US
- PSA 4-10 ng\ml suspect , > 10 indicates CA
Clinical manifestations:
• Periodic PSA determination and examination for evidence of mts.
• Symptomatic management
- analgesic and narcotics to relieve pain
- TURP to relieve obstruction
- suprapubic cystostomy
• Surgical = radical prostatectomy = prostate + capsule + seminal
vesicle + pelvic LNs
• cryosurgery of prostate freezes prostatic tissue
• Radiation
• Hormonal therapy = palliative = antiandrogen, LH analogues,
bilateral orchidectomy
Prostitis
Prostatitis
• Inflammation of prostate
• The most common prostate problem in men under the age of
50 years.
• Classified as = bacterial prostatitis, non-bacterial prostatitis
• 4 types of bacterial prostatitis =
- Type 1 acute by GI \ STD bacteria
- type 2 chronic by GI (gram-negative)
- type 3 chronic pelvic pain syndrome
- type 4 asymptomatic inflammatory prostatitis
Pathophysiology \ etiology
• Invasion of the prostate from reflux of infected urine in
ejaculatory and prostatic duct or secondary to urethritis or
rectal examination when bacteria are present.
- usually gram-negative bacteria (pseudomonas) , gram-
positive ( streptococcus, staphylococcus)
• Chronic bacterial prostatitis = ascending infection from the
urethra, due to gram-negative.
- Bacteria E.coli, proteus, klebsiella, pneumonia and
pseudomonas aeruginosa.
• Non-bacterial prostatitis = may be a complication of urethritis
Clinical management:
• Sudden chills and fever with body aches with acute prostatitis
• More subtle symptoms with chronic prostatitis
• Bladder irritability, frequency, dysuria, nocturia, urgency,
hematuria
• Pain in the perineum, rectum, lower back and lower
abdomen, and penile head.
• Pain after ejaculation, symptoms of urethral obstruction
Investigations:
• Urine culture
• DRE = tender, painful swollen prostate, warm to touch in acute
cases
• Elevated WBCs

• Management = antimicrobial therapy 10-14 days

- suprapubic cystostomy (avoid urethral catheterization)
- antipyretics
- antispasmodic to relieve urinary frequency and urgency.
- warm sitz bath = relieve pain and promote muscular relaxation of
pelvic floor
- stool softners, high fibers diet to prevent constipation|
- bed rest
Clinical scenario
A 40-year-old male complains of feeling unwell with pyrexia of 39°C. He
has rigors with aches all over and has flu-like symptoms in general. He
has rectal irritation, pain on defecation
and perineal discomfort. He has pain on micturition and passes threads
in his urine. Rectal examination reveals a tender, swollen prostate.
Investigations:
A 70-year-old male complains of poor stream, frequency of micturition
both in the day and at night, hesitancy, intermittent stream, a feeling of
incomplete emptying, and terminal hematuria. These symptoms of BOO
have been there for about 4 months. More recently he has had backache
localized to the small of his back. On clinical examination, no
abnormality is found. On rectal examination, he has a generalized hard,
nodular prostate with overlying fixed rectal mucosa.
Investigations:
A 72-year-old man has come to the A&E department with severe acute
pain in his lower abdomen not having passed urine for almost 10 hours.
He has been on some medicines which he bought across the counter for
cold and flu. This has also made him constipated. On examination, he is
in severe pain from a large mass in his sub-umbilical region arising from
his pelvis. The mass is dull to percussion.
Investigations:
A 70-year-old man complains of urgency, frequency, and hesitancy of
micturition with a feeling of incomplete emptying. He also has poor flow,
intermittent stream, and post-micturition dribbling. These symptoms have
been going on for 2 years and are gradually getting worse. Clinical
examination reveals no abnormality. On rectal examination, he has an
enlarged smooth prostate with overlying mobile rectal mucosa and the
median vertical groove is easily felt.
Investigations:
A 75-year-old male complains of general malaise, lethargy, abdominal
distension, and urinary incontinence. On examination, he has a large
painless mass in his subumbilical region arising from the pelvis and has
continuous urinary dribbling. The mass is dull on percussion. He is a type
2 diabetic and is on medication.
Thank You ☺