? Introduction
? BPH
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? Prostate cancer
? Prostatitis
v Acute bacterial
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v prostatitis
Chronic bacterial
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prostatitisv Chronic pelvic pain (CPP)
(inflammatory/non-inflammatory)
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syndrome
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Prostate Overview
What is the Prostate?1
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? Walnut sized gland at baseof male bladder
? Surrounds the urethra
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? Produces fluid that transportssperm during ejaculation
? Prostate grows to its normal
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adult size in a man's early
20s; it begins to grow again
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during the mid-40s? the normal prostate measures between 3-4cm at its
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widest portion; it is 4-6cm in length & 2-3cm inthickness.
? Weight 17-25 gm
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? In the early 1970's McNeal proposed a concept of
zonal anatomy.
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? According to this concept, the glandular portion of theprostate is composed of a large peripheral & a Small
central zone, which together constitute about 95% of
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the gland.
Benign Prostate Hyperplasia
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Incidence & Epidemiology
? I
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The term BPH is a misnomer because the actualchange is a hyperplasia & not hypertrophy.
? TIhe initiation of BPH may not be environmental
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or genetically influenced.
? It I is also suggested that the prevalence of BPH
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increases with age in al male populations.Etiology
? Two factors are necessary for BPH
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1)Endocrine control(DHT)2) Aging
Relative role of testosterone estrogen, DHT
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Normal vs. Enlarged Prostate? As the prostate enlarges,
pressure can be put on the
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urethra causing urinary
problems (LUTS)1
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? Prostate size does notcorrelate with degree of
obstruction or severity of
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symptoms.3
Normal Prostate
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Enlarged ProstatePathophysiology Of Symptoms
Symptoms of BPH:
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1) obstructive
?
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decrease in force & caliber of the stream: due to urethralcompression is one of the early & constant features of BPH.
Hesitancy: occurs because the detrusor takes a longer time to
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generate the initial increased pressure to overcome the urethral
resistance.
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?lntermittency: occurs because the detrusor is unable to sustain the
increased pressure until the end of voiding.
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?
Terminal dribbling of urine & incomplete sense of bladder
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emptyingPathophysiology Of Symptoms
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2) Irritative symptoms:? Frequency:
-Incomplete emptying during each void results in shorter
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intervals between voids.
-The presence of enlarged prostate provokes the bladder to
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trigger a voiding response more frequently than in normalindividuals, especially if the prostate is growing intravesically.
? Nocturia: normal cortical inhibitors are lessened and also because
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the normal urethral and sphincteric tone is reduced during sleep.
? urgency & dysuria: uncommon.
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Pathophysiology Of Symptoms?
Sy Istemic symptoms related to the UT:
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- Vesicoureteral reflux
- Dilatation & hydronephrosis
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- Renal failure & symptoms of uremia? Symptoms unrelated to the UT:
- hernias, hemorrhoids and vesical calculus
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- change in the caliber of bowl movements
? Symptoms related to complications:
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- cystitis- pyelonephritis
- bladder calculi
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- micro or gross hematuria.
Signs of BPH
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? If the disease is advanced & has resulted in renal failure.
Signs of renal failure include elevated BP, rapid puse &
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respiration, uremic fetor, pericarditis & pallor of nail beds.? Abdominal examination may reveal palpable kidney or
flank tenderness if there is hydronephrosis or pyelonephritis.
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? A distended bladder may be noted on palpation or
percussion.
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? DRE: Enlarged prostate. Median sulcus always presentHow is an Enlarged Prostate Diagnosed?12
? Medical History
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? Physical Exam*Prostate Exam
? Digital rectal exam (DRE)
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Urinary Output Testing
? Peak urinary flow (Qmax) testing
? Post-void urine volume testing
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? Self Evaluation of Symptoms
American Urological Association Symptom Index (AUA-SI)
International Prostate Symptom Score (IPSS)
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Quality of Life (QoL) QuestionsBladder Impact Index (BII)
*Additional testing is optional and may be done at physician's discretion and/or depending on patient symptoms
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Laboratory Findings
? Urinalysis & microscopic examination: to R O
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infection?or tshe
er presence
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um U/E
&of
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c hematreatin u
i ri
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n a.
e: to provide baseline
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informationon
? renal
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Uro fflunct
ow i
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monetr &
y: met
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At abol
a vol iuc st
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me atus.
of 125-150ml,
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normal
individuals have average flow rates of 12ml/sec & peak
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flow close to 20ml/sec.? Residual Urine: estimated by U S or catheterizations.
Volumes >150 ml are considered significant since they
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constitute approximately one-third of normal bladder
volume.
IMAGING
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? Ultrasound KUB-
Document :
?size of prostate
?Post void residual urine
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?HydronephrosisTreatment
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? Because BPH is not invariably progressive, the timingof intervention is variable
? Absolute indications for treatment include severe obstructive
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symptoms & renal insufficiency.
? Relative indications - moderate symptoms of
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prostatism, recurrent UTI,vesical calculus andhematuria.
? Until recently, surgery was the mainstay of therapy for
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BPH. In the last decade or so , there has been a
tremendous resurgence of interest in non surgical therapies.
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Treatment Options OverviewWATCHFUL WAITING/
MINIMALLY INVASIVE
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INVASIVE
MEDICAL THERAPIES
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SURGERYSURGERY
Alpha Blockers
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Microwave Therapy
(TUMT)
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Open Prostatectomy5 Alpha-Reductase
Laser
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Inhibitors
TURP
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(Monopolar, Bipolar,Button)
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Treatment OptionsWatchful Waiting/Medical Therapies
? Characteristics12
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Best for men with mild symptoms
Consists of yearly exams and no active intervention
No surgery
No drugs
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May involve lifestyle modification such as adjusting diet, evening fluid intake,medication use and exercise patterns
? Side Effects
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Symptoms may worsen or remain unchanged without lifestyle modification1
Medical Treatment
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? Obstruction secondary to BPH occurs becauseof 2 factors:
a.Dynamic component: a result of contraction
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of smooth muscles of the prostate
& prostatic urethra mediated mostly by adrenergic
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receptors.b.Mechanical component: related to the
presence of a mass which compresses& narrows
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the urethral lumen.
Alpha adrenergic agonist
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? Ideally suited for the treatment of thewithout impairing detrusor contractility
dynamic component of BOO because they
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can selectively reduce resistance along
the bladder outlet
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?Example:-Tamsulosin 0.4mg OD, Silodosin 8 mg
-Alfuzosin XL 10mg OD, Terazosin
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-Doxazosin4mgTID
alpha- reductase inhibitor 5
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? Agents that selectively blockade androgens atthe prostate cellular level are termed anti-
androgens.
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?
the prostate normally requires conversion of testosterone
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to dihydrotestosterone by the enzyme 5 alpha-reductase.?
In long term clinical trials, proscar has been
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shown to decrease prostatic size & improve urine
flow rates & symptoms of BPH.
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? Dutasteride and finasterideMINIMALLY INVASIVE
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SURGERY(Conventional)? TURP
? TUIP
? Laser Prostatectomy
? TUNA(Trans urethral needle ablation of
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prostate)
Conventional Surgical Therapy
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TURPThe principles of TURP are to remove the obstructing
adenomatous portion of the prostate via the urethra.
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?Overall morbidity: 18%.
?Current mortality: 0.2%.
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One preventable complication is TUR syndrome? Immediate complications: failure to void, post op
.
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haemorrhage, clot retention, & UTI.
? Late complications: impotence, incontinence, uretheral
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.stricture and retrograde ejaculation
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Instrumentinserted through
riesectoscope
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to remove the
prostate gland
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Before
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Af terTURP LOOP
TUIP
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Laser Prostatectomy
Treatment Options
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Invasive Surgery
Open Prostatectomy
Involves surgical removal of the inner portion of the prostate via a suprapubic or retropubic
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incision in the lower abdominal area.
Characteristics12
Side Effects12
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? Typically is performed on patients with ?
A
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ssociated
wit
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h
a
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longerhospit
al
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larger prostate volumes (>80 - 100 mL)
stay
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? Effective for men with:? Risk of blood loss, transfusion
? Very enlarged prostate glands
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significantly greater than with
? Bladder diverticula (pockets)
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transurethral procedures? Stones
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Open prostatectomy? Open prostatectomy can be done either Tranvesical, perineal
or Retropupic prostatectomy.
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? In recent years the suprapubic & retropubic approaches for
BPH have been limited to approximately 10% of patients.
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? Indications for suprapubic prostatectomy are a gland sizegreater than 100g, cystolithotomy or diverticulum excision.
? Most post op complications are similar to TURP, however,
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wound infection & thromboembolism are additional
complications.
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Prostate cancer
Prostate Cancer
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Statistics? Most common non-cutaneous
malignancy in men in North America
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? 2nd most common cause of cancer-
related deaths in men
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? 1 in 7 men will be diagnosed? Lifetime risk of being diagnosed with
prostate cancer is 18% but risk of dying
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of prostate cancer is only 3%Prostate Cancer
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Risk Factors? Established
? Potential
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? Advancing age
? High dietary fat
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? Presence of? Obesity
androgens
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? Inherited mutations
? Family history
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(BRCA1 or BRCA2(1st degree
genes)
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relative)
? Vitamin D or E
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? African ancestrydeficiency
? Selenium
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deficiency?
Prostate Cancer:
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Presentation? Early stages usually asymptomatic
? Most cases detected by serum PSA screening
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? Palpable nodule or firmness on DRE
? Advanced stages
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? Urinary retention/renal failure? Bone pain
? Anemia
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? Weight loss, fatigue
? Spinal cord compression
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Disease Screening
? Goal
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? To identify the presence of disease at astage when treatment can be given that
will cure it
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? Use a combination of DRE and PSA
Digital Rectal Examination
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? DRE (digital rectal exam) has a 50% positivepredictive value
? DRE alone is not a good screening tool
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? BUT it is an important part of screeningWhat is PSA (Prostate Specific Antigen)?
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? A Serine protease(enzyme) found in the
prostate
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? Secreted by prostate
epithelial cells
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? Found in ejaculate? As diagnostic tool for:
? Screening
? Staging
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? Prognostic indicator? Surveillance
Prostate Cancer:
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Screening with PSA? No clear cut-point between normal and abnormal
PSA levels. Even PSA cut-off of 1.1 ng/ml misses
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up to 15% of prostate cancer (The Cancer Prevention
Trial ? 2003)
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? 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
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? 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.
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? <50% of prostate cancers organ confined if PSA
>10
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Free/Total PSA Ratio:
A Way to Improve Specificity
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? Prostate cancer maybeassociated with more
protein-bound PSA
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BPH
(less free PSA) than in
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BPH? F/T ratio is lower in
Prostate Ca
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patients with prostate
cancer
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? Can improve testspecificity
? Useful when total PSA
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in 4-10 ng/ml range
Prostate Cancer:
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Diagnosis? Indications for transrectal ultrasound (TRUS)
guided biopsy
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? Palpable nodule on DRE
? Elevated serum PSA
? Biopsy involves 10-18 needle cores taken
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mostly from the peripheral zone of the
prostate
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Imaging
2) CT:
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used only when extensive L.N. disease is suspected and it isbased only on the size of the nodes thus false
+ve and -ve are common.
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3) MRI:
not useful because of the cost and the overlap in the
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appearance of benign & malignant processes, but its moreaccurate than TRUS for staging extracapsular extension and
seminal vesicle involvement.
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4) Bone scanning:
- most common way to assess systemic metastasis.
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- False +ve rate is less than 2?/o .- Diagnosis is confirmed by plain radiographs, thin section CT or
MRI and bone biopsy
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Prostate Cancer:
Pathology
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? Adenocarcinoma? Gleason "grade" is from 1-
5 based on glandular
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architecture? Gleason score is the total
primary grade (1-5) +
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secondary grade (1-5) = 2-
10
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? 4-6/10=well-differentiated? 7/10=moderately
differentiated
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Prostate Cancer:Staging
? Can spread to adjacent organs (seminal
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vesicles, bladder), lymph nodes, bone
? Most bone mets are osteoblastic
? Prior to initiating treatment consider
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? Bone scan (PSA>10, Gleason Score >7)
? CT scan pelvis/abdomen (PSA >10, Gleason
Score >7))
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? These tests are typically not required in
asymptomatic men with low risk prostate
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cancer1. 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
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found in prostate tissue from a biopsy or surgical treatment.
- T1a - Cancer is found in 5% or less of the removal tissue.
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- 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.
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- 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.
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- T2c - Cancer is in both sides of the prostate.? T3 - Cancer has grown outside the prostate and may have grown into the seminal
vesicles.
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- T3a - Cancer has spread outside the prostate but not to the seminal vesicles.
- T3b - Cancer has spread to the seminal vesicles.
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? T4 - Cancer has grown into other nearby tissues, such as the urethral sphincter,rectum, bladder or wall of the pelvis
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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.
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The absence or presence of cancer outside the prostate, or Metastasis (M
Category)
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? 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.
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- M1b - Cancer has spread to bones.
- M1c - Cancer has spread to distant organs
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Prostate CancerTreatment
? Considerations
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? Patient's age
? Co-morbid health
conditions
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? Tumor stage
? Tumor grade (Gleason
score)
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? Often a patient choice
? Surgery and
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Early Stage Prostate CancerTreatment
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? Early stage Cancer1. Radical Prostatectomy
2. External Beam Radiotherapy
3. Radioactive Seeds (Brachytherapy)
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4. Active Surveil ance5. Observation ? Watchful Waiting
Prostate Cancer Treatment:
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1. Radical Prostatectomy? Radical Prostatectomy
? Complete surgical removal of entire prostate,
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seminal vesicles
? Considered a good treatment for men <70
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years of age with clinically organ confinedcancer who are healthy
? Open or laparoscopic/robotic approaches
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Prostate Cancer Treatment:
1. Radical Prostatectomy
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Prostate Cancer Treatment:
Radiotherapy
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? Radiotherapy Options? External Beam
? Brachytherapy (seed implant)
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? Concept of maximizing dose to the tumor and
minimizing collateral damage
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? Curative options for patients at high risk formorbidity from radical prostatectomy
? Age, medical co-morbidities
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? Patient preference
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Prostate Cancer Treatment:
2. External Beam Radiotherapy
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Prostate Cancer Treatment:3. Brachytherapy
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Prostate Cancer Treatment:4. Active Surveil ance
? Observing low grade tumors in men <70 yrs and
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>10 yr life expectancy
? Delay definitive treatment until it is necessary and
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cancer is stil curable? Goal is to delay potential treatment-related
morbidity
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? Monitor DRE, PSA, and periodic repeat biopsy
? Ideal candidate:
? PSA < 10
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? Normal DRE? Gleason <7 (low grade)
? Only 1-3 / 12 biopsy cores positive
Prostate Cancer. Treatment:
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5. Watchful Waiting
? Observing low grade tumors in men >70
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yrs or <10 yrs life expectancy? Institute hormonal therapy when patient
becomes symptomatic
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? No curative intent
Advanced or Metastatic Prostate
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Cancer
? Not curable disease
? Goals shift to disease control
? Development of cancer cells unresponsive
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to androgen deprivation
? Typically occurs slowly over time, although
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it can occur rapidlyAdvanced Prostate Cancer:
Treatment
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? Androgen Deprivation
(Hormonal Rx)
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? Orchidectomy? LHRH analogues
? Antiandrogens
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? Supportive therapies
? Analgesics
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? Steroids? Bisphosphonates/Vitamin D/Calcium
for bone health
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? Chemotherapy
? Taxotere, Docetaxel
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? Last line of treatmentProstate Cancer
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Prognosis? Depends upon grade, stage and treatment
? Early stage/well-differentiated Ca treated
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by radical prostatectomy:? 85% + 10 year survival
? Metastatic disease
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? <10% 5 year survival
PROSTATITIS
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Definition
? Infection &/ or inflammation of the prostate
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Epidemiology? Overall prevalance in men is 5
? higher risk age 20 ? 50 & >70
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Pathogenesis
? Tissue around prostatic acini become
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infiltrated by inflamatory cells.? Organisms:
? G-ve (E.coli, pseudomonas, klebsiella , serratia,
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Enterobacter aerogenes.)
? G+ve 5-10 %
(staph aureus, saprophyticus, streptococcus
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faecalis)
? Aetiology ?
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Risk factors? UTI
? Acute epididymitis.
? Urethral catheters.
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? Transurethral surgery? Intraprostatic duct
reflux
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? Phimosis? Prostatic stones
Segmented urine cultures
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? Localize bacteria to specific part of the
urinary tract.
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? first voided 10ml ---------- urethritis &prostatitis VB1
? Midstream urine -------------cystitis VB2
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? Prostatic massage? 10 ml post massage---------- prostatitis
VB3
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? EPS ------------------------------ prostatitisClassification
? Class 1: acute
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? Class 3: chronic
bacterial prostatitis
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pelvic pain syndrome? 3a inflammatory non-
? Class 2: chronic
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bacterial : wbc in EPS,
bacterial prostatitis.
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VB3 or semen.? 3b non-inflammatory :
no wbc in Eps , vb3 or
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semen.
? Class 4:
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Asymptomaticinflammatory
prostatitis
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Evaluation
? Class 1: acute bacterial prostatitis
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? E.coli common
? Associated with LUT infection.
Class 1
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? Acute onset fever.
? Signs:
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? Chil s? Systemic toxicity
? Nausea &vomiting
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? Suprapubic
? Perineal & sp pain
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tenderness.? Irritative urinary
? Palpable bladder with
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symptoms (
UR
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frequency, urgency,? Tender DRE
dysuria)
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? Obstructive
(hesitancy, strangury,
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UR, intermittency)Class 1
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? Systemically well? Systemically unwell
? Oral quinolone
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? I.V antibiotic
ciprofloxacin 500 BID
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? Aminoglycoside+3rd? 2-4 weeks
generation
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cephalosporins
? Pain relief
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Class 1? Prostatic abscess
oPersistant symptoms:
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oFever while on antibiotic.
oTRUS ? PAIN
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oTransurethral managementClass2
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? Previous history of recurrent UTI? Chronic episodes of pain & voiding
dysfunction
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? DRE: tender, enlarged & boggy prostateClass 3
? Chronic pelvic pain
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? ED
syndrome
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? Symptoms can recur? Both types present
over time
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with:
? Affect patient's quality
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? >3 months localizedof life
pain.
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(perineal, suprapubic,
penile , groin or ext.
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genitalia)Pain with ejaculation.
LUTS
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Class 4
? Incidental histological Dx in prostate
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specimens.
Evaluation
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? Hx? NIH- CPI questionnaire:
? Pain ( location, severity, frequency)
? Voiding (obstructive , irritative symptoms)
? Impact on quality of life.
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Evaluation
? Segmented urine culture & EPS
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? Cultures ?ve
? high Leucocyte count >10/ HPF
? Favor Dx inflammatory chronic pelvic pain
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syndromeTreatment
? Alpha- blockers: improve urinary flow,&
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reduce intraprostatic ductal reflux
? Anti inflammatory drugs NSAID
? 5 alph reductase inhibitors :improve
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intraprostatic ductal reflux.
? Microwave heat therapy
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Non- inflammatory chronic pelvic
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pain syndrome? Treatment:
? Drugs: analgesia ( tricyclic antidepressent,
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anti inflammatory, muscle relaxants, 5- alphareductase inhibitors
? Biofeedback.
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? psychologicalThank You