PROSTATE GLAND

SURGERY SUBSPEC (UROLOGY)

DR LANTING
AUGUST 25 2016

Predominance of irritative symptoms should suggest voiding

PROSTATE GLAND: dysfunction other than BPH
 wall nut size structure below the bladder Incontinence is NOT a common symptom of BPH, although with
 inferior to the pubic bone advanced disease, a large residual urine results I a weak sphincter
 anterior to the rectum that opens to allow the escape of urine in small amounts
 envelopes the urethra
 PERIPHERAL ZONE- most common site of Ca Sample question: Which of the following is NOT
 TRANSITIONAL ZONE- most common site of prostate an obstructive s/sx of prostate enlargement?
enlargement a. Decrease in caliber of urine
b. Intermittency
Factors in BPH Development (What causes the c. Hesitancy
prostate to enlarge?) d. Frequency
1. Aging
2. Normal Testicular function Assessment of BPH: IPSS Score
Acinar and stromal cells of the prostate International Prostate Symptom Score
are influenced by hormones through  3 irritative
the following ways:  4 obstructive
a. Testosterone aromatization produces  Added quality of life
estrogenStimulates prostate development/ *the higher the score the more severe the symptoms the
enlargement more severe the symptoms dr has to treat patient
b. Testosterone aromatization action of 5-
alpha reductase produces 5-DHT *assess the quality of life by asking:
prostate development/enlargement (this is “If you were to spend the rest of your life with your urinary
the main hormonal cause for prostate condition just the way it is now, how would you feel about that?
enlargement) A:
TESTOSTERONE- causes the prostate to enlarge 0 = delighted
 5 alpha reductase- converted to 5 1 = Pleased
dihydrotestosterone(more potent testosterone that 2 = Mostly satisfied
increases prostate size) 3 = Mixed
 By AROMATIZATION- testosterone is converted to 4 = Mostly dissatisfied
estrogen that also increases prostate 5 = Unhappy
 90% of testosterone comes from the ventricles 6 = Terrible
 5-10%% comes from the adrenal gland Note: score of 4-6 = Treat the patient right
away
NATURAL HISTORY OF BPH
 15% DIGITAL RECTAL EXAM (DRE)
 30%- stable
3 PROSTATIC CONDITIONS THAT CAN BE THAT CAN BE
 55%- worsening of symptoms
DIAGNOSED WITH DRE
1. PROSTATITITS- Tenderness
How is BPH measured?
2. PROSTATE CA- hard nodule
1. Symptom score
3. BENIGN ENLARGEMENT- rubbery
2. DRE
3. PSA
PROPER POSITION- bent over table
4. Flow rate
PROCESS:
5. Residual urine determination
 Relax the rectum
Symptoms  Using gloved finger and lubricant- insert digit to rectal
A. Irritative vault and using a wiper motion feel for the consistency
1.Frequency contour and size
 normal adult voids 5-6 times a day Identifies prostate size, contour, and consistency
2. Urgency 18% is detected by suspect DRE irrespective of the PSA level
Maybe detected by DRE when volume is 0.2cc or more
 strong sudden impulse to void
A suspect DRE is a strong indication for prostate biopsy as it is
3. Nocturia
predictive for a more aggressive Pca (GS >7)
 Normal adult arise no more than twice at night
A suspect DRE in patient with PSA of 2ng/ml has a +
 Patient should wake up
predictive value of 5- 30%
 If awake- not nocturia
NOTE: DRE is mandatory in patients who complain of lower
B. Obstructive
urinary tract symptoms (irritative and obstructive) REGARDLESS of
1. Decrease in the force and caliber or stream
age.
 due to urethral compression The best way to detect Pca is a combination of PSA and DRE
 urine cant go out Normal consistency: About the size of a walnut, (comparable to
2. Hesitancy the consistency of the contracted thenar eminence of the thumb,
 the detrusor takes a longer time to generate the initial smooth, no area of increased hardness or bumpiness)
increased pressure to overcome urethral resistance. Abnormal: Rubbery, doughy or hard. Knobby
 Delay in starting and stone-hard consistency usually indicates
3. Intermittency carcinoma.
 the detrusor is unable to sustain the increase
pressure until the end of voiding
 Interruption
4. Incomplete emptying of the bladder

*Obstructive symptoms are common with enlarged prostates.

ijdcarmona 1
QUESTION: Phytotherapy
Patient 35 yeaars old came in with irritative symptoms Use of plants for medicinal purposes
(frequency, urgency, nocturia, difficulty, and hesitancy) what will Use is growing as a result of patient driven enthusiasm
you do with this paitient? Mechanism of action: antiinflammatory, inhibit growth factor
a) DRE Eg. Saw palmento, pygeum aftricanum
*PROSTATITIS- most common in 40 years old and below More commonly used in Europe than in US
 Tenderness (DRE) NOTE: The best treatment for BPH will reduce the symptoms,
reduce the cause and improve the quality of life
There are 3 conditions of the prostate that are assessed via DRE:
1. BPH – prostate has a consistency that is the same as the tip of
the nose MINIMALLY INVASIVE PROCEDURES
2. Prostate Ca (Pca) – stoney/knobby 1. Laser Coagulation
3. Prostatitis –presence of tenderness 2. Prostatic Stent
 Put stent inside the urethra and open
PROSTATE SPECIFIC ANTIGEN  compress the sides of the prostate thereby
– is organ-specific BUT NOT cancer-specific. increasing the outflow of urine.
o Serene protease produced almost exclusively by the  Problem: after 6 mos tissues grow over the stent
epithelial cells of the prostate and cause reobstruction
o May be elevated in BPH, prostatitis, Ca and non-  Rarely used because it is too expensive
malignant conditions 3. Laser Prostatectomy
o The level of PSA as an independent variable is a 4. Transurethral microwave thermotherapy of the prostate
better predictor for Pca than suspicious findings on  Heat up the prostate at 55 degrees centigrade for 1
DRE and TRUS. hour then remove it
o   Decreases the size of the prostate improve the
Assessment of BPH: Value of PSA symptoms by:
0-4 ng/ml – normal o it kills the alpha receptors
4-9 ng/ml – 20% chance of CA o producing apoptosis
>10 ng/ml – 50% chance of CA 5. Transurethral resection of the prostate (TURP)
Note: if you suspect something, like if PSA is about > 4ng/ml but  Gold standard of treating prostate enlargement
DRE is negative, request for transrectal UTZ.  scrape all the obstructive portion of prostate.

 Advantage: NO INCISION, acquires tissue for biopsy
Other assessment methods
thermotherapy doesn’t acquire tissue for biopsy,
Optional: Investigation of the upper urinary tract (IVP or UTZ)
patient can void within 5 days
Cystourethroscopy –endoscopic evaluation of the prostate.
 needs to stay in the horpotal for 3-5 days
INSTRUCTIONS AFTER TREATMENT:
TREATMENT
Any treatmeant should meet at least one of  No strenuous activity for at least a month
these aims: o Driving
1. Improving symptoms o Sexual contact
2. Reduce obstruction o Heavy objects
3. Prevent long term complications (stone formation, obstruction, 6. Open prostatectormy
uremia, urinary incontinence)  last resort
Note: Most common type of incontinence that presents as a long
term complication of BPH or any obstructive type of disease in the Note: Step-ladder treatment is:
urinary tract – overflow incontinence Medical thermotherapy Surgical Or
Watchful waiting provided that the patient is cancer free
Treatment options
1. Watchfull waiting OTHER OPTIONS IN BPH MANAGEMENT:
2. Medical therapies 1. Watchful waiting
3. Interventional therapies 2. Medical mngt by use of alpha blockers, alpha
reductase (decrease size),
Medical Management Options 3. DRE – mandatory
1. Alpha blocking agents
2. Alpha reductase inhibitors Take home message
3. Hormonal Therapy Many options are available in BPH management
4. Phytotherapy –Growth factor inhibitors Digital Rectal Examination is mandatory
Earyl detection of prostate cancer is the main concern of the
Alpha Blocking Agents shared care program
- Alpha receptors: We are partners in BPH management
o Sympathetic stimulates alpha-receptors
o Increase smooth muscle contraction
o Increased pressure in bladder neck and urethra RECALL!!!
o Obstruction - 47% o Peripheral- Most common location of prostate ca
o Keeps the tension inside the bladder o Transitional- Most common location of BPH
-alpha blockers –the dynamic component, meaning, it relaxes the o Better in detecting prostate ca
muscle of the bladder and the urethra . In combination with alpha o PSA
reductase inhibitors, it aids to let the urine pass through. o Transrectal UTZ of the prostate
o NOTA
Alpha Reductase Inhibitors *if combined better detection rate
Blocks testosterone to 5-DHT o 3 conditions detected in using DRE
Finasteride o Prostatitis – enlarged tender
Dutasteride –combination of 2 drugs o Prostate ca – stony hard
Delayed improvement o BPH – rubbery smooth
Works probably b adenomatous (big) big prostate o TREATMENT
Note: Alpha reductase inhibitors may cause decrease in libido and o TURP
impotence because of testosterone inhibition. However,  Gold standard
dermatologists use these drugs for hair regrowth.

ijdcarmona 2