Prostate and Seminal Vesicles Benign Prostatic Hyperplasia Notes

Prostate and Seminal Vesicles

Surgical Anatomy Embryology And Lobes

• The prostate develops around the 12th week of intrauterine life. Primitive buds from the urethra form the glandular tissue and surrounding mesenchyme forms the fibromuscular stromDevelopmentally, the prostate has 5 lobes Anterior, posterior, middle and 2 lateral lobes.

Read And Learn More: Surgery of Urology Notes

• The middle lobe (median lobe) is situated between the two ejaculatory ducts and the urethrThe enlargement of this lobe in benign prostatic hypertrophy (BPH) is responsible for urethral obstruction. This lobe enlarges upwards into the bladder.

• In BPH, the glands of the inner adenomatous zone hypertrophy and lead to urinary outflow obstruction. Carcinoma usually occurs in the outer nonadenomatous zone.
• New terminology for the BPH-arising zone is the transitional zone and the carcinoma-arising zone is the peripheral zone. Based on McNeal’s zonal anatomy, in addition to the transition and peripheral zones, three more zones have been identified: The central zone, periurethral glandular tissue, and anterior fibromuscular stroma.

Structural Anatomy

• The prostatic urethra is surrounded by a fibroadenomatous glan
• Urethral glands open into the prostatic urethrThese submucosal glands are responsible for BPH.
• When the prostate enlarges, it compresses the outer zone, resulting in a false capsule.

• The outermost zone is the zone of prostatic glands proper, which is responsible for carcinoma prostate.
• Surrounding this, there is fascia of Denonvilliers which is a part of the pelvic peritoneum. This is also called the fascia that separates wind and water. (wind in the rectum and water in the bladder).
• Between the anatomical capsule and pelvic peritoneum, the prostatic venous plexus is present, which may give rise to massive haemorrhage, if injured.

Benign Prostatic Hyperplasia (BPH)

Aetiopathogenesis

• BPH is a true hyperplastic process.

Hormonal theory: Causes of BPH are multifactorial. However, it is mainly endocrinal. The prostate maintains its ability to respond to androgens throughout life.

• It has been compared to fibroadenosis in female patients.
• As age advances, the levels of androgens come down. There is a corresponding increase in oestrogen, which stimulates the prostatic gland and produces BPH.
• There is proliferation of all elements of the prostate (fibrous, muscular, and glandular) resulting in fibromyoadenoma.
• Stromal and epitheloid elements give rise to hyperplastic nodules.

Secondary Effects Of BPH

1. Urethral changes:

• Urethra gets compressed and, elongated and gets converted into a narrow, longitudinal slit.
• The effect is more with median lobe enlargement due to enlargement of the subcervical glands.
• Lateral lobes enlarge when there is involvement of the submucous glands.

2. Changes in the bladder:

• As a result of obstruction, the bladder musculature undergoes hypertrophy. Very prominent thick bundles of the muscle can be seen, which are called fasciculations or trabeculations.
• Between the fasciculations, there are depressed areas called sacculations.
• Since the sacculi are thin, as pressure increases, herniation occurs outside, resulting in diverticuli.
• In the diverticuli, there is stasis of urine, resulting in secondary infection and stone formation.

3. Changes in the ureter and kidney:

Bilateral hydronephrosis and bilateral hydro-ureter are the end result of BPH, which may result in renal failure

Clinical Features Of BPH

• Frequency, urgency, and hesitancy form the triad of BPH.
  • Frequency: Frequency is present during the daytime followed by during the day and night (5 10 times during the night). It is due to ineffective emptying of the bladder. It results in residual urine in the bladder and precipitates cystitis.
  • Urgency: As the prostate enlarges, there is vesical introversion of the sensitive mucous membrane of the prostatic urethra within the bladder. This causes the internal sphincter to stretch and prevents contraction. Resulting in a few drops of urine trickling down the posterior urethra, causing an urgent desire to pass urine (urgency).
  • Hesitancy: Hesitation to pass urine occurs because obstruction makes it ineffective.
• Haematuria is rare: It is due to congestion of the prostatic venous plexuses resulting in hyperaemia and haematuriIn a patient with haematuria and BPH, haema-turia can be due to other causes (e.g. co-existing bladder cancer). In such situations, the prostate is an innocent bystander, hence called “decoy prostate.”
• BPH with acute retention of urine: This occurs due to postponement of micturition, following alcohol or drugs like mydriatics.
• BPH with chronic retention of urine: Many patients present with chronic retention of urine, with painless enlargement of the urinary bladder.
• International Prostate Symptom Score (IPSS): It can range from 0–35. Mild: 0–7, moderate: 8–19, severe: 20–35.

Complications Of BPH

• Stones: 8 times more common
• Diverticuli
• Renal failure
• Recurrent UTI: It is the most common cause of surgical intervention.

Diagnosis Of BPH

Digital rectal examination: Enlarged lateral lobes can be easily felt. Rectal mucosa is free and firm. (In an enlarged prostate, in case of carcinoma prostate, the mucosa of the rectum cannot be moved, if there infiltration into the rectum.)

Grading of prostate is as follows (Roger Barnes’ grading by digital rectal examination):

1. Prostatic lobes protrude minimally into the rectal lumen by 1–2 cm, and the median sulcus is palpable.
2. Prostatic lobes protrude 2–3 cm into the rectal lumen and the median sulcus is obliterated.
3. Prostatic lobes protrude 3–4 cm into the rectal lumen.
4. Prostatic lobes protrude >4 cm, and most of the rectal lumen is filled by the projecting prostatic lobes.

Investigations Of BPH

1. Blood urea and creatinine: Raised levels indicate renal failure.
2. Uroflowmetry: The person is asked to void urine from their full bladder into the flowmeter. The flow rate is assessed.
   • Peak flow rate:
     • Normal peak flow rate: >15 ml/sec.
     • Doubtful peak obstruction: 10–15 ml/sec.
     • Definite peak obstruction: ≤10 ml/sec.
     • Thus, the degree of bladder outlet obstruction (BOO) can be secured by uroflowmetry.
3. Ultrasonogram: To assess the size and weight of the prostate, assess the residual urine, and look for hydroureteronephrosis and, bladder wall changes.
4. Urodynamic studies/cystometrograms are performed to differentiate it from neurogenic bladder.

Treatment Of BPH

It can be classified into medical treatment and surgical treatment.

1. Medical Treatment of BPH:

If the patient has mere frequency of micturition and if the residual urine is not much (<150 ml), uroflowmetry shows ≥15 ml/sec of urine flow, and there are no back pressure effects on the kidney, the patient can be reassured, and advised to avoid heavy alcohol consumption which may lead to prostatic congestion and acute urinary retention. To avoid overdistension of the bladder, patients should void urine as and when they feel the urinary sensation of micturition, (i.e. they should not postpone micturition).

Drugs Of BPH:

1. Finasteride acetate 5 mg daily for 6 months. It is a 5α-reductase inhibitor. It helps in preventing hyperplasia of the prostate. It is given for large prostates. The other drug in this class is dutasteride, which is given in the dose of 0.5 mg once daily for 6–12 months.
2. Side effects include decreased libido/ejaculation and, impotence.
3. α-adrenergic blockers: They relax the internal sphincter for better bladder drainage. They are given as monotherapy when the prostate is ≤40 g (small) as measured by ultrasounTamsulosin (most selective), terazosin, and alfazocin are a few examples. Silodosin (4–8 mg once nightly) is the latest drug to enter this class. Side effects include orthostatic hypotension and retrograde ejaculation.
4. Combination therapy is useful in patients with large glands.

2. Surgical Treatment of BPH:

Indications for Surgery:

1. Acute urinary retention
2. Chronic urinary retention with postvoid residual urine ≥200 ml.
3. If the frequency of micturition disturbs normal daily activities.
4. Complications such as haematuria (due to congestion of prostatic venous plexuses), hydroureteronephrosis, prostatic diverticulosis, vesical calculus and recurrent infections.

Surgical Methods:

1. Transurethral resection of the prostate (TURP):

• This is the most popular method today and is referred to as the gold standard.
• A resectoscope is passed through the urethra, and under vision with constant irrigation with water or 1.5% glycine (best irrigation fluid), the prostate is resected into multiple pieces and removed.
• Haemostasis is obtained with cauterization.

Complications of TURP:

• TURP syndrome: It manifests as nausea, confusion, vomiting and visual disturbances.
• Incontinence (<1%)
• Retrograde ejaculation (15%)
• Impotence (5–10%)
• Bladder neck contracture.

2. Transvesical suprapubic prostatectomy (Frayer’s)

• This method is now restricted to glands ≥100 g in weight associated with a calculus.
• Ankylosis of hip/other orthopaedic conditions (difficulty in positioning).
• Through an extraperitoneal approach, the bladder is opened, the prostate is enucleated with a finger, and bleeding is controlled by inflating the Foley bulb with 30–50 ml of air and by ligatures.
• The bladder is drained by a Malecot’s catheter, which is wider than Foley’s, so that it can drain potential bleeding in the bladder.
• During the process, the prostatic urethra is also avulsed.
• After about 7–10 days, a tract develops along the length of the Foley catheter which heals by granulation and fibrosis, and forms the future prostatic urethra.

Transvesical suprapubic prostatectomy  Disadvantages:

• Blind resection
• Increased risk of haemorrhage.
• Stricture of prostatic urethra.

3. Retropubic prostatectomy (Millin’s): It is performed by an extraperitoneal approach without opening the bladder by pushing the bladder to one side and excising the prostate.

4. Perineal prostatectomy (Young’s): Not done nowadays.

Newer Treatments:

Holmium:YAG laser. It is the best laser for patients with ≥100 g prostate or in patients with increased bleeding.

Intraurethral stents—in men who are grossly unfit (ASA Grade IV) for surgery.

Carcinoma Of The Prostate

• Carcinoma of the prostate is common after the age of 65 years, and its incidence increases with age.
• In Western countries, it is the second most common type of carcinoma in males after ≥65 years of age (first is bronchogenic carcinoma).
• Prostatectomy done for BPH does not protect against the development of prostate carcinoma because during prostatectomy the outer zone is left undisturbed (not resected).
• The most common type is adenocarcinoma.

Carcinoma Of The Prostate Clinical Features

1. Histological surprise: It is asymptomatic in early cases because it is in the peripheral zone. Prostatectomy is done for BPH, but histology reveals carcinoma of the prostate.
2. Multiple bone pains, which are often confused for rheumatism, are due to multiple metastasis.
3. Rectal examination: Reveals a hard nodule on the anterior wall of the rectum and obliteration of the median sulcus. The rectal mucosa cannot be moved over the prostate, but it is not ulcerated (fascia of Denonvilliers prevents the spread of carcinoma prostate into the rectum).
4. Elderly man with bilateral sciatica with metastasis in the thoracolumbar vertebrae.
5. Acute retention of urine occurs in 5–10% of cases.
6. Difficulty in passing urine and painful micturition (sometimes with haematuria) are due to involvement of the prostatic urethra.

Carcinoma Of The Prostate Spread

1. Haematogenous spread:

• This is due to retrograde tumour embolisation which occurs through the prostatic venous plexus, which communicates through the emissary veins with the bone (Batson’s paravertebral plexus of veins)

Peculiarities of secondary deposit from carcinoma prostate:

• They are multiple
• Moth-eaten appearance
• Osteoblastic (in most other secondaries, they can also be osteolytic).
• Most common site of origin for skeletal metastases.

2. Lymphatic spread:

• Prostatic chain of lymphatics drain into the internal iliac nodes.
• When spread occurs along the seminal vesicle, the external iliac nodes are enlarged.
• From this group of nodes, the para-aortic, mediastinal, left supra-clavicular nodes get involved.

3. Local spread:

• On the medial side, it can involve the prostatic urethra and cause urinary retention.
• When it spreads upwards, the bladder can get involved, resulting in painful haematuria.
• Superiorly, it can also involve the seminal vesicle.
• The rectum is involved very late in carcinoma prostate because of the tough Denonvilliers’ fascia.

Carcinoma Of The Prostate Investigations

• Best screening protocol is prostate-specific antigen (PSA) and digital rectal examination (DRE).

1. Transrectal ultrasound-guided trucut biopsy: It is done in patients with abnormal rectal examination findings or if PSA is ≥10 ng/ml. Report—adenocarcinoma.

2. X-ray of bones, which are likely to be involved (already mentioned).

3. Prostatic acid phosphatase:

• The enzymes which split organic phosphates are concentrated in the prostate and are responsible for acidic pH in the prostatic urethra.
• Normally, they are drained in the urine so that they are not detectable in the serum.
• In carcinoma prostate, it gets absorbed into the blood due to ductal blockage. Thus, high levels are reached, especially with metastasis.
• 1 to 3 King-Armstrong units—suggestive of carcinoma of prostate.

Requirements before the estimation of acid phosphatase:

• Early morning blood sample
• On empty stomach
• Avoid fatty food
• Per-rectal examination should not be done before drawing the blood sample.

Significance of acid phosphatase: Levels come down with the treatment of carcinoma prostate, especially when bone metastasis disappears.

4. Serum alkaline phosphatase: It is increased, if there is extensive liver or bone metastasis.

5. Prostate-specific antigen:

• Prostate-specific antigen (PSA) is a neutral protease, elaborated by columnar prostatic acinar epithelial cells.
• If it is ≥4 nmol/ml, carcinoma is to be suspected; 10 nmol/ml is suggestive of prostatic carcinoma; 35 nmol/ml is suggestive of: disseminated carcinoma.
• The highest PSA concentration occurs in the lumen of the prostatic acini and ducts (up to million times more than in systemic circulations). Prostatic luminal cells are normally surrounded by basal cells, the prostatic basement membrane, and prostatic stroma.
• A number of diseases disrupt some barriers to absorption, resulting in elevation of serum PSA, notably prostatic cancer, prostatic inflammation, and infarction. PSA is also transiently elevated (up to 24 hours) after ejaculation and cycling.
• PSA measurement is the most efficient screening test for prostate cancer and it increases further, if the measurement is combined with digital rectal examination (DRA).
• PSA measurement is also vital in staging prostate cancer and assessing the response to treatment. PSA is organ-specific but not cancer-specific.

6. Abdominal and transrectal USG: To stage the disease.

7. Bone scan: It is indicated in cases of carcinoma prostate, especially in those who have bony pains, elevated alkaline phosphatase, and very high PSA levels (>20 ng/ml)

8. CT or MRI scan: These are done before proceeding to radical surgery to assess the extent of the tumour.

9. Gallium-68 PSMA PET scan: This is regarded as a one-stop work-up for prostatic cancer as it can provide information on both the primary tumour as well as metastases. It is a molecular imaging that targets the prostate-specific membrane antigen.

Diagnosis of Carcinoma Prostate:

• High index of suspicion in men >50 years of age.
• PSA >10 nmol/ml and abnormal findings on digital rectal examination.
• Proceed with TRUS guided prostatic 12 core biopsy.

Histopathological Examination:

• Gleason scoring system used
• Gleason score varies from 1–5
• Two scores are used to grade the disease
  • The most common histological variant
  • The highest grade
• The final scores varies from 2–10
• Gleason score
  • >6 suggests of malignancy
  • 7 suggests—intermediate risk
  • 8–10 suggests—high-risk disease

Treatment Of Carcinoma Of Prostate

It can be classified under the following headings—early malignancy and late malignancy.

1. Early Malignancy:

It refers to T1 or T2, N0, M0.

1. Early prostatic malignancy with PSA levels ≤20 nmol/ml:

• Radical prostatectomy is done for T1 and T2 and in men with a life expectancy >10 years. Metastasis should be excluded by a negative bone scan, chest radiograph, and serum PSA <20 nmol/ml. Radical prostatectomy involves pelvic lymphadenectomy and removal of the prostate and seminal vesicle including the distal the urethral sphincter followed by anastomosis of urethra to the bladder neck.
• Most commonly injured vessel—dorsal venous complex.
• Radical radiotherapy for prostate and pelvic nodes is given postoperatively.
• Disadvantages of radical prostatectomy: Impotence and stress incontinence may complicate the surgery.

2. Early prostatic malignancy with PSA ≥20 nmol/ml and the patient is already ≥65–70 years of age, surgery is not favoureRadical radiotherapy is given.

2. Late Malignancy:

It refer to T3 lesions, involvement of regional nodes, or the presence of metastasis.

Hormonal Therapy (Androgen Deprivation Therapy—ADT):

Indicated in patients with locally advanced and metastatic carcinoma prostate.

Principle: Testosterone-lowering therapy (castration).

• Surgical: Bilateral orchidectomy
  • Advantage:
    • Simple and cheap
    • Quickest way to achieve castration level
  • Disadvantage: Irreversible
• Medical
  • Estrogens: Oral diethylstilbesterol (DES—not used)
    • Advantage: Not associated with bone loss
    • Disadvantage: Thromboembolic complications
• LHRH agonists: Leuporolide Currently, it is the main form of ADT
  • Depot injections at 1, 2, 3, and 6 months and at 1 year
  • It suppresses FSH and LH secretions
  • Disadvantages: Flare-up phenomenon due to initial testosterone surge. Hence, antiandrogen therapy is given concurrently.
• LHRH antagonists:
  • Binds to LHRH receptors and rapidly decreases testosterone without any flare.
  • Disadvantage: Lack of long-acting depot formulations.
• Complete androgen blockade:
  • Surgical/medical + anti-androgen therapy

Chemotherapy:

• Docitaxel is the drug of choice, 75 mg/m², given in 6 cycles
• Cabazitaxel

Radiotherapy:

• Used for bony metastases with impending fracture and risk of neurological damage

Hormone Naïve Metastatic Carcinoma Prostate:

• Standard of care is ADT with docitaxel chemotherapy

Castration Resistant Carcinoma Prostate:

Castration Resistant Definition: Serum testosterone <50 ng/dl with either of the following:

• Biochemical progression: 3 consecutive rises in PSA and PSA >2 ng/ml
• Radiological progression: Appearance of a new metastatic lesion
  • ≥2 Bony lesions on bone scan, or
  • New soft tissue metastasis

Castration Resistant Treatment:

1st line treatment:

• Abirataterone
• Enzulatamide
• Docetaxel
• Sipuleucel-T

2nd line treatment:

• Cabazitaxel
• Radium 223

Prostatitis

• Inflammation of the prostate can be acute or chronic.
• However, in both types, the seminal vesicles and posterior urethra are also involved.
• The diagnosis is often delayed due to varying symptoms attributed to a different cause that are being wrongly treated.
• If the treatment is in effectively given, infection persists and becomes difficult to eradicate later.

Acute Prostatitis

Prostatitis Aetiology:

• Causative organisms are Escherichia coli (most common), Staphylococcus aureus and Staphylococcus albus.
• The infection is usually due to haematogenous spread from a distant focus or secondary to urinary tract infection.
• Instrumentation or invasive urological procedures are also factors. Catheterisation is contraindicated.

Prostatitis Clinical Features

• The patient is ill with high-grade fever and chills and rigors.
• Pain all over the body, which is more in the back.
• Perineal heaviness or pain, rectal irritation, and urethral discharge are other features.
• Pain on micturition is common, and initial samples of urine contain ‘threads’.
• Rectal examination: Tender, boggy, enlarged prostate. Fluctuation indicates prostatic abscess (rare).

Prostatitis Treatment:

• Hospitalisation, intravenous fluids, antipyretics.
• Antibiotics, such as ciprofloxacin or trimethoprim/ sulfamethoxazole should be given for 4–6 weeks.
• Otherwise, recurrent attacks may occur.
• If abscess is suspected, the diagnosis can be confirmed by transrectal ultrasound and, can be drained by transurethral unroofing of the abscess cavity (similar technique to TURP).

Chronic Prostatitis

Chronic prostatitis results from inadequately treated acute prostatitis.

Prostatitis Clinical Features:

• Elderly men are affected and complain of perineal heaviness, perineal discomfort or pain on sexual intercourse.
• Intermittent fever is also a feature.
• Rectal examination may reveal a boggy and tender prostate.
• Low backache.

Prostatitis Diagnosis:

Prostatic massage is done by a bidigital method—index finger in the rectum and the thumb in the perineum to one side. The patient is then asked to void urine. Presence of prostatic threads or mucopus in the postprostatic massage urine is diagnostic of chronic prostatitis.

Prostatitis Treatment:

Chronic antibiotic suppression for 3–4 months— norfloxacin, trimethoprim and metronidazole are used.

Prostatitis Miscellaneous

Prostatic calculi: They occur in middle-aged and early men. They represent calcified corpora amylaceConsist of calcium phosphate, and lie at the periphery of the transition zone.

Prostate and Seminal Vesicles Multiple Choice Questions

Question 1. The following are true regarding the surgical anatomy of the prostate except:

1. Developmentally, it has 5 lobes
2. Median lobe enlargement causes carcinoma prostate
3. It develops around the 12th week of intrauterine life
4. Between the prostate and rectum, Denonvilliers’ fascia is present

Answer: 2. Median lobe enlargement causes carcinoma prostate

Question 2. The following are changes that occur in the urinary bladder due to BPH except:

1. Fasciculations
2. Sacculations
3. Diverticuli
4. Carcinoma

Answer: 4. Carcinoma

Question 3. Vesical introversion of the sensitive prostatic urethra within the urinary bladder causes:

1. Frequency
2. Urgency
3. Hesitancy
4. Haematuria

Answer: 3. Urgency

Question 4. The following are complications of benign prostatic hypertrophy except:

1. Stones
2. Renal failure
3. Recurrent urinary tract infection
4. Carcinoma urinary bladder

Answer: 4. Carcinoma urinary bladder

Question 5. Which of the following drugs is used to treat benign prostatic hypertrophy?

1. α-adrenergic blockers
2. β-adrenergic blockers
3. Oral stilboestrol
4. Oral prednisolone

Answer: 1. α-adrenergic blockers

Question 6. The following are true regarding the role of ultrasound in benign prostatic hypertrophy except:

1. It can assess the size
2. It can assess the weight
3. It can assess residual urine
4. It can assess the urinary flow rate

Answer: 4. It can assess the urinary flow rate

Question 7. The following are true regarding digital rectal examination of carcinoma prostate except:

1. Hard nodule is felt
2. Median sulcus is obliterated
3. Rectal mucosa cannot be moved
4. Ulcerated mucosa is present

Answer: 4. Ulcerated mucosa is present

Question 8. Early spread from carcinoma prostate to bones occurs through:

1. Batson’s plexus
2. Santorini plexus of veins
3. Waldeyer’s plexus of veins
4. Denonvilliers’ plexus of veins

Answer: 1. Batson’s plexus

Question 9. The following are features of bone secondaries from carcinoma prostate except:

1. Thoracolumbar vertebrae are involved
2. Moth-eaten appearance on X-ray
3. Osteolytic lesions
4. Multiple bones are affected

Answer: 3. Osteolytic lesions

Question 10. Which structure is affected late in carcinoma prostate?

1. Prostatic urethra
2. Seminal vesicles
3. Rectum
4. Urinary bladder

Answer: 3. Rectum

Question 11. Which of the following is not true for acid phosphatase?

1. It is responsible for acidic pH in prostatic urethra
2. High values suggest carcinoma prostate
3. It is elevated not only in carcinoma prostate but also in other conditions
4. Early morning urine samples are best measuring this

Answer: 4. Early morning urine samples are best measuring this

Question 12. The following are true for prostate-specific antigen except:

1. It is released from columnar prostatic acinar epithelial cells
2. ≥4 nmol/ml suggests carcinoma prostate
3. Prostatitis can also increase its levels
4. It does not help in assessing treatment response

Answer: 4. It does not help in assessing treatment response

Question 13. Which of the following is not done in cases of carcinoma prostate?

1. Radical prostatectomy
2. Radical radiotherapy
3. High orchidectomy
4. Stilboestrol therapy

Answer: 4. Stilboestrol therapy

Question 14. What is the treatment following prostatectomy for BPH if it is reported as carcinoma prostate?

1. Orchidectomy
2. Stilboestrol
3. Bisphosphonates
4. Local radiotherapy

Answer: 4. Local radiotherapy

Question 15. The following are true for acute prostatitis except:

1. It is usually a haematogenous infection
2. Instrumentation can also cause this
3. It is usually mild and self-limiting
4. Urine samples may contain ‘threads’

Answer: 4. Urine samples may contain ‘threads’

Question 16. Which of the following is true regarding posterior urethral valves?

1. They are acquired
2. Bladder is thin-walled and more prone to rupture
3. Renal failure is uncommon
4. They are symmetrical

Answer: 2. They are symmetrical