PROSTATE GLAND
• The prostate gland is the male organ most commonly afflicted with
either benign or malignant neoplasms.
. Three distinct zones have been identified. The peripheral zone
accounts for 70% of the volume of the young adult prostate, the
central zone accounts for 25%, and the transition zone accounts for
5%.
.These anatomic zones have distinct ductal systems but, more
important,are differentially afflicted with neoplastic processes.
• Sixty to seventy percent of carcinomas of the prostate
(CaP)originate in the peripheral zone, 10–20% in the transition
zone, and 5–10% in the central zone .Benign prostatic hyperplasia
(BPH) uniformly originates in the transition zone .
BENIGN PROSTATIC HYPERPLASIA
• BPH is the most common benign tumor in men,
and its incidence is age related.
• Risk factors for the development of BPH are
poorly understood.
• The etiology of BPH is not completely
understood, but it seems to be multifactorial and
endocrine controlled.
• The prostate is composed of both stromal and
epithelial elements,and each, either alone or in
combination, can give rise to hyperplastic
nodules.
Pathology
• BPH develops in the transition zone. It is truly
a hyperplastic process resulting from an
increase in cell number. Microscopic
evaluation reveals a nodular growth pattern
that is composed of varying amounts of
stroma and epithelium.
• Stroma is composed of varying amounts of
collagen and smooth muscle.
Pathophysiology
• The symptoms of BPH to either the
obstructive component of the prostate or the
secondary response of the bladder to the
outlet resistance.
• The obstructive component can be
subdivided into the mechanical and the
dynamic obstruction.
• The prostatic stroma, composed of smooth
muscle and collagen, is rich in adrenergic
nerve supply.
• The irritative voiding complaints of BPH result
from the secondary response of the bladder to
the increased outlet resistance.
Clinical Findings
• A. Symptoms:
The symptoms of BPH can be
divided into obstructive and irritative
complaints.
• Obstructive symptoms include: hesitancy,
decreased force and caliber of stream,
sensation of incomplete bladder emptying,
double voiding (urinating a second time within
2 hours of the previous void), straining to
urinate, and postvoid dribbling.
• Irritative symptoms include urgency,
frequency, and nocturia
• IPSS is perhaps the single most important tool
used in the evaluation of patients with BPH
and is recommended for all patients before
the initiation of therapy.
• An IPSS of 0–7 is considered mild, 8–19 is
considered moderate, and 20–35 is
considered severe.
B. Signs
• A physical examination, DRE, and focused
neurologic examination are performed on all
patients.
• C. Laboratory Findings:
A urinalysis to exclude
infection or hematuria and serum creatinine
measurement to assess renal function are
required. Serum PSA assesment.
Differential Diagnosis
• 1.
Other obstructive conditions of the lower
urinary tract, such as urethral stricture,
bladder neck contracture, bladder stone,or
CaP.
• 2.
Hematuria and pain are commonly
associated with bladder stones.
• 3
.CaP may be detected by abnormalities on
the DRE or an elevated PSA.
• 4.
Urinary tract infection.
• 5.
irritative voiding complaints are also
associated with carcinoma of the bladder.
• 6.
neurogenic bladder disorders may have
many of the signs and symptoms of BPH.
Treatment
• A. Watchful Waiting:
For those with mild
symptoms(IPSS score, 0–7), watchful waiting is
generally advised. Men with moderate or
severe symptoms can also be managed in this
fashion if they so choose.
.
B. Medical Therapy:1
. Alpha-Blockers:the
human prostate and bladder base containing
alpha 1-adrenoreceptors.
•
Alpha-blockers
•
1-Nonselective
•
Phenoxybenzamine 10 mg twice a day
•
2-Alpha-1, short-acting
•
Prazosin 2 mg twice a day
•
3-Alpha-1, long-acting
•
Terazosin 5 or 10 mg daily
•
Doxazosin 4 or 8 mg daily
•
4-Alpha-1a selective
•
Tamsulosin 0.4 or 0.8 mg daily
•
Alfuzosin 10 mg daily
•
5-alpha-reductase inhibitors
•
Finasteride 5 mg daily
•
Dutasteride 0.5 mg daily
•
Side effects of alpha blockers:
•
--Dizziness.
•
--Tiredness.
•
--Retrograde ejaculation.
•
--Rhinitis.
•
--Headach.
•
5-Alpha-reductase inhibitors—Finasteride is a
5-alpha-reductase inhibitor that blocks the
conversio of testesterone to
dihydrotestosteron
•
-Six months therapy -→20% reduction in
prostate size.
•
-Side effects include→decrease
libido,decrease ejaculation volume and
impotence.
•
C.combination therapy
:which include alpha
blocker and 5 alpha reductase inhibitor.
•
D.phytotherapy:
use of plant extract like saw
palmetto berry and the bark of pygeum
affricanum.
3-Conventional Surgical Therapy
•
1-Transurethral resection of
prostate(TURP):
95% of simple protatectomy
can be done endoscopically.
•
*Risk of TURP include:retrograde
ejaculation,impotence and incontenence.
•
*Complications include:bleeding,urethral
stricture,bladder neck contracture,perforation
of prostate capsule and TURP syndrome.
•
*TURP syndrome resulting from
hypervolemic,hyponatremic state due to
absorption of hypotonic irrigation solution.
•
*Clinical features of TURP
syndrom:nausia,vomiting,confusion,hypertent
ion,bradycardia,and visual disturbances.
•
*treatment include diuresis and in sever cases
hypertonic saline administration.
•
2-Transurethral incision of prostate.
•
3-Open simple prostatectomy:
when the
prostate gland is too large to remove
endoscopically,an open enucleation is
necessary.
•
*It done either by suprapubic (transvesical) or
retropubic approach.
INDICATIONS OF SURGERY
•
1-Refractory urinary retention.
•
2-Recurrent UTI from BPH.
•
3-Recurrent gross haematuria from BPH.
•
4-Bladder stones from BPH.
•
5-Renal insufficiency from BPH.
•
6-Large bladder diverticulum.
D-MINIMAL INVASIVE THERAPY
•
1-
Laser therapy:(Nd.YAG and holmium YAG).
•
2-
Transrectal electrovaporization of the
prostate.
•
3-
Hyperthermia(microwave hyperthermia is
most commonly delivered with atransurethal
catheter).
•
4-
Transurethral needle ablation of prostate.
•
5-
High intensity focused ultrasound.
•
6-
Inraurethral stent.
•
7-
Transurethral balloon dilatation of prostate.