Prostate Anatomy,physiology & Pathology

Prostate Anatomy,physiology & Pathology

1. السلام علیکم

2. Dr Khesal Ahmad PG Scholar, NIUM PROSTATE Anatomy , Physiology & Pathology

3. CONTENTS Prostate…….. Anatomy Surface , Lobes, Relations Size, weight Physiology Functions, PSA Pathology BPH Prostatitis (Acute & Chronic) Prostatic Abscess BOO CA Prostate

4. Definition : Prostate is a fibromuculoglndular structure situated between the neck of the bladder and external urethral sphincter and surround the prostatic urethra, it is conical in shape Surface It has 3 surfaces 1. Anterior 2. posterior 3. Two inferio -lateral Lobes it has 5 lobes 1.Anterior 2.Posterior 3.Median 4.Two Lateral Anatomy

5. Size: About 3cm vertically , 4cm Transversally at base and about 2cm antero-posteriorly. Weight: 15-20 gm Note Adenoma usually occurs in medial and lateral lobes, it never occurs in ant & pos lobe because they are mainly of fibromuscular tissue & devoid of glandular structures

6. Parts of prostate

7. The prostate is related to the two capsules and one fascia behind Capsule: 1. True Capsule Formed by the condensation of the prostate at periphery 2. False Capsule Formed by the visceral layer by the pelvic fascias (The prostatic venous plexus lies between these capsules) 3. Surgical Capsule Formed by the non adenomatous tissue of the prostate which is pushed by the hypertrophied gland to the periphery Fascia Behind the Prostate it is also known as rectovesical , prostatoperitonial,denivillier’s fascia Fascial Relations

8. inside and around the prostate Urethra is divided into three parts Prostatic urethra(Widest and most dilatable part) Membranous urethra (Shortest and least dilatable part) Spongy Urethra Sphincters A. Internal Sphincter(Sphincter Vesicae ) at the neck of Bladder External Sphincter or sphincter urethrae Structures

9. Base Neck of Bladder Inferior External Urethral sphincter Posterior Danovillir’s fascia Lateral Levator ani Blood Supply Internal Iliac artery(Inferior Vesical and middle rectal arteries) Venous drainage : Same as via posterior venous plexus but some drainage also occurs valve less vertebral plexus which is responsible for haematogenous spread of Ca of prostate to the bones of vertebra etc Lymphatic Drainage Internal Iliac Lymph Node Relations

10. The testicular hormone regulate the prostate, Testosterone is secreted by leydig cells of the testes, in the absence of the both testis (Testicular hormones) the prostate fails to develop. The prostate secrete the specific fluid (Prostatic fluid( which provide 10-20% volume of ejaculation, it contains the prostaglandin enzymes and acid phosphates, it has anti bacterial property which helps to prevent UTI. Prostate also secretes a glycoproteinous fluid which is known as PSA, The PSA actually liquefies the semen and allows the sperm to swim freely, and it is the best tumor marker for Ca prostate Physiology of the Prostate

11. Normal Value of PSA Less than 4 nmol /ml Normal 4-8 nmol /ml BPH 9-10 nmol /ml Diagnostic for BPH & suggestible for CA More than 10 mol/ml Suggestive for CA Prostate

12. BPH

13. Benign prostatic hyperplasia is the histological pattern of the prostate, characterized by proliferation of smooth muscle and epithelial cells within the prostatic transition zone. This may lead to prostatic enlargement. It is considered a normal part of aging in men and is hormonally dependent on testosterone and DHT production. 50% of men develop BPH by age 60 years and 90% by age 85 years. Benign Prostatic Hyperplasia

14. It is involuntary hyperplasia due to disturbance of the ratio and quantity of circulating androgens and estrogens . BPH is a benign neoplasm, also called as fibromyoadenoma . With age TS level drops slowly. But fall of oestrogen level is not equal. So prostate enlarges through intermediate peptide growth factor . BPH arises from submucosal glands of periurethral transitional zone with stromal proliferation and adenosis . It eventually compresses the peripheral zone and enlarges as lateral lobe . BPH arising from subcervical glands of central zone enlarges as middle lobe projecting up into the bladder. CAUSES

15. International prostate symptom score 1-7 = mild 8-19 = moderate 20-35 = severe

16. American Urological Association

17. Per rectal examination Size- upper pole is easily reached/with difficulty/not reachable. Consistency- Rubber/soft/firm/hard. Rectal mucosa- Gliding/fixed Surface- Smooth/nodular. Tenderness- Absent/Present Median Sulcus - Prominent/palpable/obliterated

18. Grading of BPH By P/R Examination Grade I---Upper pole easily reachable Grade II---Upper pole reachable with difficulty Grade III--- Can’t be reachable By Weight Normal Weight --------18-20 gm Grade I up to -------- upto 25gm Grade II upto -------- upto 50gm Grade III upto -------- upto 70gm Grade IV upto -------- upto 80 gm Grade V upto -------->80 gm

19. Secondary changes due to prostate enlargement. Changes in the urethra : E nlargement of the prostatic urethra Exaggeration of the normal posterior curvature of the prostatic urethra Urethra compressed laterally reducing it to an A-P slit Changes in the urinary Bladder: Compensatory hypertrophy of the vesical detrussor Trabeculation of bladder wall. Hypertrophy of the trigone . Formation of diverticula Formation of pool of residual urine- cystitis,calculus Changes in ureters and kidney: Hydroureter and Hydronephrosis Vesicoureteric reflux- Ac. & Chr. Pyelonephritis

20. PROSTATITIS Types Acute or chronic. Causes: Due to instrumentation. Ascending infection from below. Haematogenous. Descending infection from above. Bacteria involved: E. coli, Klebsiella , Proteus. Staphylococcus. Streptococcus faecalis . Gonococcus Acute Prostatitis

21. Clinical features: Pain, frequency, fever with chills and rigors. Retention of urine. Perineal heaviness, pain on defaecation . Tender prostate on per rectal examination. Initial fraction of urine is turbid which is sent for culture and sensitivity.

22. Caused by E. coli, Staphylococcus, Streptococcus, Trichomonas , Chlamydia. There is always associated posterior urethritis . Epididymitis . Pain in the perineum, rectum, low back pain, leg pain. Fever. Sexual dysfunction. Per rectal examination shows tender prostate. Prostatic fl uid obtained by prostatic massage shows 15 or more pus cells/HPF. Chronic Prostatitis

23. It is infection, suppuration and pus formation in the prostate gland . Presentation is fever, rigors, perineal pain, urinary disturbances, and tender Soft fluctuant swelling in the prostate on rectal examination. Often presentation may be retention of urine. Total count will be increased. Urine will show pus cells. US is diagnostic. US is often done over perineum also. Treatment is antibiotics; US guided aspiration transperineally in lithotomy position or transperineal incision and drainage. Suprapubic cystostomy is better in case of retention of urine. After drainage antibiotics are needed for longer period of 6 weeks to prevent recurrent infection. Prostatic Abscess

24. BLADDER OUTLET OBSTRUCTION (BOO ) It is low urinary flow rate with the presence of high voiding pressure . It is an urodynamically confirmed entity. It is diagnosed by urodynamic pressure flow study. Flow rate will be les than 10 ml/second with voiding pressure more than 80 cm of water. Eventually detrusor inefficiency occurs causing significant residual urine.

25. Causes of BOO —BPH; bladder neck hypertrophy or stenosis ; carcinoma of prostate; urethral stricture; functional bladder neck obstruction. Effects of BOO —acute retention of urine; chronic retention of urine; impaired bladder emptying; uraemia ; infection; stone formation, haematuria . US; renal function tests; IVU; PSA are the investigations. Management is by treating the cause by cystoscopic bladder neck incision, urethrotomy ; TURP, etc.

26. It is the most common malignant tumour in men over 65 years. Carcinoma prostate occurs in peripheral zone in prostatic gland proper, i.e. commonly in posterior lobe. So prostatectomy for BPH does not confer protection against development of carcinoma prostate. Incidence of prostate cancer in men over 80 years is 70%. CARCINOMA PROSTATE

27. Microscopically latent Tumours incidentally found either by TURP or by PSA estimation Early localised carcinoma Advanced local prostatic carcinoma Metastatic carcinoma either into the bone commonly or other organs Types of carcinoma prostate Histology: It is an adenocarcinoma , wherein there is loss of myoepithelial cell layer which normally surrounds the prostatic glands (Gleason). Glands here appear in confluence . Grading of carcinoma is based on dedifferentiation as proposed by Gleason .

28. Staging of carcinoma prostate Occult—Diagnosed after investigation due to sus picion Stage I— Tumour confi ned to prostate/local nodule Stage II— Tumour involving capsule or diffuse type Stage III— Tumour involving seminal vesicle Stage IV—Extension into adjacent tissue Staging of Ca prostate (A) Occult, (B) Stage I , ( C) Stage II, (D) Stage III, (E) Stage IV. A E D C B

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