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DISORDERS OF PROSTATE

Outline

? Introduction

? BPH

? Prostate cancer

? Prostatitis
v Acute bacterial

v prostatitis

Chronic bacterial

prostatitis

v Chronic pelvic pain (CPP)

(inflammatory/non-inflammatory)

syndrome




Prostate Overview

What is the Prostate?1

? Walnut sized gland at base

of male bladder

? Surrounds the urethra
? Produces fluid that transports

sperm during ejaculation

? Prostate grows to its normal

adult size in a man's early

20s; it begins to grow again

during the mid-40s


? the normal prostate measures between 3-4cm at its

widest portion; it is 4-6cm in length & 2-3cm in

thickness.

? Weight 17-25 gm

? In the early 1970's McNeal proposed a concept of

zonal anatomy.

? According to this concept, the glandular portion of the

prostate is composed of a large peripheral & a Small

central zone, which together constitute about 95% of

the gland.

Benign Prostate Hyperplasia


Incidence & Epidemiology

? I

The term BPH is a misnomer because the actual

change is a hyperplasia & not hypertrophy.

? TIhe initiation of BPH may not be environmental

or genetically influenced.

? It I is also suggested that the prevalence of BPH

increases with age in al male populations.

Etiology

? Two factors are necessary for BPH
1)Endocrine control(DHT)
2) Aging

Relative role of testosterone estrogen, DHT

is complex




Normal vs. Enlarged Prostate

? As the prostate enlarges,

pressure can be put on the

urethra causing urinary

problems (LUTS)1

? Prostate size does not

correlate with degree of

obstruction or severity of

symptoms.3

Normal Prostate

Enlarged Prostate

Pathophysiology Of Symptoms

Symptoms of BPH:

1) obstructive

?

decrease in force & caliber of the stream: due to urethral

compression is one of the early & constant features of BPH.

Hesitancy: occurs because the detrusor takes a longer time to

generate the initial increased pressure to overcome the urethral

resistance.

?

lntermittency: occurs because the detrusor is unable to sustain the

increased pressure until the end of voiding.

?

Terminal dribbling of urine & incomplete sense of bladder

emptying


Pathophysiology Of Symptoms

2) Irritative symptoms:

? Frequency:

-Incomplete emptying during each void results in shorter

intervals between voids.

-The presence of enlarged prostate provokes the bladder to

trigger a voiding response more frequently than in normal

individuals, especially if the prostate is growing intravesically.

? Nocturia: normal cortical inhibitors are lessened and also because

the normal urethral and sphincteric tone is reduced during sleep.

? urgency & dysuria: uncommon.

Pathophysiology Of Symptoms

?

Sy Istemic symptoms related to the UT:

- Vesicoureteral reflux

- Dilatation & hydronephrosis

- Renal failure & symptoms of uremia

? Symptoms unrelated to the UT:

- hernias, hemorrhoids and vesical calculus

- change in the caliber of bowl movements

? Symptoms related to complications:

- cystitis

- pyelonephritis

- bladder calculi

- micro or gross hematuria.


Signs of BPH

? If the disease is advanced & has resulted in renal failure.

Signs of renal failure include elevated BP, rapid puse &

respiration, uremic fetor, pericarditis & pallor of nail beds.

? Abdominal examination may reveal palpable kidney or

flank tenderness if there is hydronephrosis or pyelonephritis.

? A distended bladder may be noted on palpation or

percussion.

? DRE: Enlarged prostate. Median sulcus always present

How is an Enlarged Prostate Diagnosed?12

? Medical History
? Physical Exam*

Prostate Exam

? Digital rectal exam (DRE)

Urinary Output Testing

? Peak urinary flow (Qmax) testing
? Post-void urine volume testing

? Self Evaluation of Symptoms

American Urological Association Symptom Index (AUA-SI)
International Prostate Symptom Score (IPSS)
Quality of Life (QoL) Questions
Bladder Impact Index (BII)

*Additional testing is optional and may be done at physician's discretion and/or depending on patient symptoms


Laboratory Findings

? Urinalysis & microscopic examination: to R O

infection

?or tshe

er presence

um U/E

&of

c hemat

reatin u

i ri

n a.

e: to provide baseline

information

on

? renal

Uro fflunct

ow i

mon

etr &

y: met

At abol

a vol iuc st

me at

us.

of 125-150ml,

normal

individuals have average flow rates of 12ml/sec & peak

flow close to 20ml/sec.

? Residual Urine: estimated by U S or catheterizations.

Volumes >150 ml are considered significant since they

constitute approximately one-third of normal bladder
volume.

IMAGING

? Ultrasound KUB-
Document :
?size of prostate
?Post void residual urine
?Hydronephrosis


Treatment

? Because BPH is not invariably progressive, the timing

of intervention is variable

? Absolute indications for treatment include severe obstructive

symptoms & renal insufficiency.

? Relative indications - moderate symptoms of

prostatism, recurrent UTI,vesical calculus and

hematuria.

? Until recently, surgery was the mainstay of therapy for

BPH. In the last decade or so , there has been a

tremendous resurgence of interest in non surgical therapies.

Treatment Options Overview

WATCHFUL WAITING/

MINIMALLY INVASIVE

INVASIVE

MEDICAL THERAPIES

SURGERY

SURGERY

Alpha Blockers

Microwave Therapy

(TUMT)

Open Prostatectomy

5 Alpha-Reductase

Laser

Inhibitors

TURP

(Monopolar, Bipolar,

Button)


Treatment Options

Watchful Waiting/Medical Therapies

? Characteristics12

Best for men with mild symptoms
Consists of yearly exams and no active intervention
No surgery
No drugs
May involve lifestyle modification such as adjusting diet, evening fluid intake,

medication use and exercise patterns

? Side Effects

Symptoms may worsen or remain unchanged without lifestyle modification1

Medical Treatment

? Obstruction secondary to BPH occurs because

of 2 factors:

a.Dynamic component: a result of contraction

of smooth muscles of the prostate

& prostatic urethra mediated mostly by adrenergic

receptors.

b.Mechanical component: related to the

presence of a mass which compresses& narrows

the urethral lumen.


Alpha adrenergic agonist
? Ideally suited for the treatment of the

without impairing detrusor contractility

dynamic component of BOO because they

can selectively reduce resistance along

the bladder outlet

?Example:

-Tamsulosin 0.4mg OD, Silodosin 8 mg

-Alfuzosin XL 10mg OD, Terazosin

-Doxazosin4mgTID

alpha- reductase inhibitor 5

? Agents that selectively blockade androgens at

the prostate cellular level are termed anti-

androgens.

?

the prostate normally requires conversion of testosterone

to dihydrotestosterone by the enzyme 5 alpha-reductase.

?

In long term clinical trials, proscar has been

shown to decrease prostatic size & improve urine

flow rates & symptoms of BPH.

? Dutasteride and finasteride


MINIMALLY INVASIVE

SURGERY(Conventional)
? TURP
? TUIP
? Laser Prostatectomy
? TUNA(Trans urethral needle ablation of

prostate)

Conventional Surgical Therapy

TURP

The principles of TURP are to remove the obstructing

adenomatous portion of the prostate via the urethra.

?Overall morbidity: 18%.

?Current mortality: 0.2%.

One preventable complication is TUR syndrome

? Immediate complications: failure to void, post op

.

haemorrhage, clot retention, & UTI.

? Late complications: impotence, incontinence, uretheral

.

stricture and retrograde ejaculation


Instrument

inserted through

riesectoscope

to remove the

prostate gland




Before

Af ter

TURP LOOP

TUIP


Laser Prostatectomy

Treatment Options

Invasive Surgery

Open Prostatectomy
Involves surgical removal of the inner portion of the prostate via a suprapubic or retropubic

incision in the lower abdominal area.
Characteristics12

Side Effects12

? Typically is performed on patients with ?

A

ssociat

ed

wit

h

a

longer

hospit

al

larger prostate volumes (>80 - 100 mL)

stay

? Effective for men with:

? Risk of blood loss, transfusion

? Very enlarged prostate glands

significantly greater than with

? Bladder diverticula (pockets)

transurethral procedures

? Stones


Open prostatectomy

? Open prostatectomy can be done either Tranvesical, perineal

or Retropupic prostatectomy.

? In recent years the suprapubic & retropubic approaches for

BPH have been limited to approximately 10% of patients.

? Indications for suprapubic prostatectomy are a gland size

greater than 100g, cystolithotomy or diverticulum excision.

? Most post op complications are similar to TURP, however,

wound infection & thromboembolism are additional

complications.


Prostate cancer

Prostate Cancer

Statistics

? Most common non-cutaneous

malignancy in men in North America

? 2nd most common cause of cancer-

related deaths in men

? 1 in 7 men will be diagnosed
? Lifetime risk of being diagnosed with

prostate cancer is 18% but risk of dying

of prostate cancer is only 3%


Prostate Cancer

Risk Factors

? Established

? Potential

? Advancing age

? High dietary fat

? Presence of

? Obesity

androgens

? Inherited mutations

? Family history

(BRCA1 or BRCA2

(1st degree

genes)

relative)

? Vitamin D or E

? African ancestry

deficiency

? Selenium

deficiency?

Prostate Cancer:

Presentation

? Early stages usually asymptomatic

? Most cases detected by serum PSA screening

? Palpable nodule or firmness on DRE

? Advanced stages

? Urinary retention/renal failure

? Bone pain

? Anemia

? Weight loss, fatigue

? Spinal cord compression


Disease Screening

? Goal

? To identify the presence of disease at a

stage when treatment can be given that

will cure it

? Use a combination of DRE and PSA

Digital Rectal Examination

? DRE (digital rectal exam) has a 50% positive

predictive value

? DRE alone is not a good screening tool
? BUT it is an important part of screening


What is PSA (Prostate Specific Antigen)?

? A Serine protease

(enzyme) found in the

prostate

? Secreted by prostate

epithelial cells

? Found in ejaculate
? As diagnostic tool for:

? Screening
? Staging
? Prognostic indicator
? Surveillance

Prostate Cancer:

Screening with PSA

? No clear cut-point between normal and abnormal

PSA levels. Even PSA cut-off of 1.1 ng/ml misses

up to 15% of prostate cancer (The Cancer Prevention

Trial ? 2003)

? Positive predictive value for PSA > 4ng/ml = 30%

(i.e. About 1 in 3 men with elevated PSA have

prostate cancer detected at time of biopsy

? PPV increases to 45-60% for PSA > 10ng/ml
? Nearly 75% of cancers detected in the grey zone

(PSA 4-10) are organ confined; potentially curable.

? <50% of prostate cancers organ confined if PSA

>10


Free/Total PSA Ratio:

A Way to Improve Specificity

? Prostate cancer maybe

associated with more

protein-bound PSA

BPH

(less free PSA) than in

BPH

? F/T ratio is lower in

Prostate Ca

patients with prostate

cancer

? Can improve test

specificity

? Useful when total PSA

in 4-10 ng/ml range

Prostate Cancer:

Diagnosis

? Indications for transrectal ultrasound (TRUS)

guided biopsy

? Palpable nodule on DRE
? Elevated serum PSA

? Biopsy involves 10-18 needle cores taken

mostly from the peripheral zone of the

prostate


Imaging

2) CT:

used only when extensive L.N. disease is suspected and it is

based only on the size of the nodes thus false

+ve and -ve are common.

3) MRI:

not useful because of the cost and the overlap in the

appearance of benign & malignant processes, but its more

accurate than TRUS for staging extracapsular extension and

seminal vesicle involvement.

4) Bone scanning:

- most common way to assess systemic metastasis.

- False +ve rate is less than 2?/o .

- Diagnosis is confirmed by plain radiographs, thin section CT or

MRI and bone biopsy

Prostate Cancer:

Pathology

? Adenocarcinoma
? Gleason "grade" is from 1-

5 based on glandular

architecture

? Gleason score is the total

primary grade (1-5) +

secondary grade (1-5) = 2-

10

? 4-6/10=well-differentiated
? 7/10=moderately

differentiated

? >8/10=poorly differentiated




Prostate Cancer:

Staging

? Can spread to adjacent organs (seminal

vesicles, bladder), lymph nodes, bone

? Most bone mets are osteoblastic
? Prior to initiating treatment consider

? Bone scan (PSA>10, Gleason Score >7)
? CT scan pelvis/abdomen (PSA >10, Gleason

Score >7))

? These tests are typically not required in

asymptomatic men with low risk prostate

cancer

1. The size and extent of the primary Tumor (T category)

? T1 - The tumor is not detectable with a digital rectal exam (DRE) or imaging but is

found in prostate tissue from a biopsy or surgical treatment.

- T1a - Cancer is found in 5% or less of the removal tissue.

- T1b - Cancer is found in more than 5% of the removed tissue.

- T1c - Tumors are found by needle biopsy done for a high PSA.

? T2 - The tumor is detectable with a DRE or imaging but is confined to the prostate.

- T2a - Cancer is in no more than one half of one side of the prostate.

- T2b - Cancer is in more than half of one side of the prostate.

- T2c - Cancer is in both sides of the prostate.

? T3 - Cancer has grown outside the prostate and may have grown into the seminal

vesicles.

- T3a - Cancer has spread outside the prostate but not to the seminal vesicles.

- T3b - Cancer has spread to the seminal vesicles.

? T4 - Cancer has grown into other nearby tissues, such as the urethral sphincter,

rectum, bladder or wall of the pelvis


Whether the cancer has spread to nearby lymph Nodes (N Category)

? NX - The lymph nodes have not been assessed for cancer.
? N0 - There is no cancer in nearby lymph nodes.
? N1 - Cancer has spread to nearby lymph nodes.

The absence or presence of cancer outside the prostate, or Metastasis (M

Category)

? MX - It is unknown if cancer has spread to distant sites.
? M0 - The cancer has not spread to distant sites.
? M1 - Cancer has spread to distant sites.

- M1a - Cancer has spread to distant lymph nodes.

- M1b - Cancer has spread to bones.

- M1c - Cancer has spread to distant organs

Prostate Cancer

Treatment

? Considerations

? Patient's age
? Co-morbid health

conditions

? Tumor stage
? Tumor grade (Gleason

score)

? Often a patient choice
? Surgery and


Early Stage Prostate Cancer


Treatment

? Early stage Cancer

1. Radical Prostatectomy
2. External Beam Radiotherapy
3. Radioactive Seeds (Brachytherapy)
4. Active Surveil ance
5. Observation ? Watchful Waiting

Prostate Cancer Treatment:

1. Radical Prostatectomy

? Radical Prostatectomy

? Complete surgical removal of entire prostate,

seminal vesicles

? Considered a good treatment for men <70

years of age with clinically organ confined

cancer who are healthy

? Open or laparoscopic/robotic approaches


Prostate Cancer Treatment:

1. Radical Prostatectomy

Prostate Cancer Treatment:

Radiotherapy

? Radiotherapy Options

? External Beam

? Brachytherapy (seed implant)

? Concept of maximizing dose to the tumor and

minimizing collateral damage

? Curative options for patients at high risk for

morbidity from radical prostatectomy

? Age, medical co-morbidities

? Patient preference




Prostate Cancer Treatment:

2. External Beam Radiotherapy

Prostate Cancer Treatment:

3. Brachytherapy


Prostate Cancer Treatment:

4. Active Surveil ance

? Observing low grade tumors in men <70 yrs and

>10 yr life expectancy

? Delay definitive treatment until it is necessary and

cancer is stil curable

? Goal is to delay potential treatment-related

morbidity

? Monitor DRE, PSA, and periodic repeat biopsy
? Ideal candidate:

? PSA < 10
? Normal DRE
? Gleason <7 (low grade)
? Only 1-3 / 12 biopsy cores positive

Prostate Cancer. Treatment:

5. Watchful Waiting

? Observing low grade tumors in men >70

yrs or <10 yrs life expectancy

? Institute hormonal therapy when patient

becomes symptomatic

? No curative intent


Advanced or Metastatic Prostate

Cancer
? Not curable disease
? Goals shift to disease control
? Development of cancer cells unresponsive

to androgen deprivation

? Typically occurs slowly over time, although

it can occur rapidly

Advanced Prostate Cancer:

Treatment

? Androgen Deprivation

(Hormonal Rx)

? Orchidectomy

? LHRH analogues

? Antiandrogens

? Supportive therapies

? Analgesics

? Steroids

? Bisphosphonates/Vitamin D/Calcium

for bone health

? Chemotherapy

? Taxotere, Docetaxel

? Last line of treatment


Prostate Cancer

Prognosis

? Depends upon grade, stage and treatment
? Early stage/well-differentiated Ca treated

by radical prostatectomy:

? 85% + 10 year survival

? Metastatic disease

? <10% 5 year survival

PROSTATITIS


Definition

? Infection &/ or inflammation of the prostate

Epidemiology

? Overall prevalance in men is 5
? higher risk age 20 ? 50 & >70


Pathogenesis

? Tissue around prostatic acini become

infiltrated by inflamatory cells.

? Organisms:

? G-ve (E.coli, pseudomonas, klebsiella , serratia,

Enterobacter aerogenes.)

? G+ve 5-10 %
(staph aureus, saprophyticus, streptococcus

faecalis)

? Aetiology ???

Risk factors

? UTI
? Acute epididymitis.
? Urethral catheters.
? Transurethral surgery
? Intraprostatic duct

reflux

? Phimosis
? Prostatic stones


Segmented urine cultures

? Localize bacteria to specific part of the

urinary tract.

? first voided 10ml ---------- urethritis &

prostatitis VB1

? Midstream urine -------------cystitis VB2
? Prostatic massage
? 10 ml post massage---------- prostatitis

VB3

? EPS ------------------------------ prostatitis

Classification

? Class 1: acute

? Class 3: chronic

bacterial prostatitis

pelvic pain syndrome

? 3a inflammatory non-

? Class 2: chronic

bacterial : wbc in EPS,

bacterial prostatitis.

VB3 or semen.

? 3b non-inflammatory :

no wbc in Eps , vb3 or

semen.

? Class 4:

Asymptomatic

inflammatory

prostatitis


Evaluation

? Class 1: acute bacterial prostatitis

? E.coli common
? Associated with LUT infection.

Class 1

? Acute onset fever.

? Signs:

? Chil s

? Systemic toxicity

? Nausea &vomiting

? Suprapubic

? Perineal & sp pain

tenderness.

? Irritative urinary

? Palpable bladder with

symptoms (

UR

frequency, urgency,

? Tender DRE

dysuria)

? Obstructive

(hesitancy, strangury,

UR, intermittency)


Class 1

? Systemically well

? Systemically unwell

? Oral quinolone

? I.V antibiotic

ciprofloxacin 500 BID

? Aminoglycoside+3rd

? 2-4 weeks

generation

cephalosporins

? Pain relief

Class 1

? Prostatic abscess

oPersistant symptoms:

oFever while on antibiotic.

oTRUS ???? PAIN

oTransurethral management


Class2

? Previous history of recurrent UTI
? Chronic episodes of pain & voiding

dysfunction

? DRE: tender, enlarged & boggy prostate

Class 3

? Chronic pelvic pain

? ED

syndrome

? Symptoms can recur

? Both types present

over time

with:

? Affect patient's quality

? >3 months localized

of life

pain.

(perineal, suprapubic,

penile , groin or ext.

genitalia)

Pain with ejaculation.

LUTS


Class 4

? Incidental histological Dx in prostate

specimens.

Evaluation

? Hx
? NIH- CPI questionnaire:
? Pain ( location, severity, frequency)
? Voiding (obstructive , irritative symptoms)
? Impact on quality of life.


Evaluation

? Segmented urine culture & EPS

? Cultures ?ve
? high Leucocyte count >10/ HPF
? Favor Dx inflammatory chronic pelvic pain

syndrome

Treatment

? Alpha- blockers: improve urinary flow,&

reduce intraprostatic ductal reflux

? Anti inflammatory drugs NSAID
? 5 alph reductase inhibitors :improve

intraprostatic ductal reflux.

? Microwave heat therapy




Non- inflammatory chronic pelvic

pain syndrome
? Treatment:

? Drugs: analgesia ( tricyclic antidepressent,

anti inflammatory, muscle relaxants, 5- alpha

reductase inhibitors

? Biofeedback.
? psychological

Thank You