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Related Disease

Contracture of the bladder neck:-

  • Aetiology:- This condition usually occurs in men, but can rarely affect children of both sexes and women.
  • It may be a congenital muscular hypertrophy or due to muscular hypertrophy or fibrosis of the tissues at the bladder neck following chronic prostatitis in men or urethrotrigonitis in women or after operation on prostate.
  • Clinical syndromes:-
  • Owing to muscle hypertrophy or dyssynergia:- Marion described a series of cases in which muscular hypertrophy of the internal sphincter in a young person had resulted in the development of a vesicle diverticulum or hydronephrosis (Marion’s disease or prostatism sans prostate).
  • It is thought that dyssynergic contraction of the smooth muscle of the bladder neck (bladder neck dyssynergia ) may account for some cases of BOO.
  • Owing to fibrosis:- the symptoms are similar to those of prostatic enlargement but are a consequence of scarring after TURP.
  • Treatment:-the management of these patients depends on achieving an accurate diagnosis. For this, urodynamic investigation is often necessary, which should demonstrate raised voiding pressures and diminished flow rate.
  • Drugs:-The presence of alpha adrenergic receptors in the region of the bladder neck and prostatic urethra allow pharmacological manipulation of the outflow to the bladder by Alpha-Blocking drugs:- (Alfuzosin, doxazosin, indoramin, prazosin, terazosin,) can be very useful, causing relaxation of the bladder neck. These drugs are not target specific, and patients must be warned of the possibility of postural hypotension.
  • Transurethral incision:-Transurethral incision of the bladder neck is the operation of choice. Sometime symptoms recur, but this is usually due to inadequate division of the fibers of the bladder neck.

Prostatic calculi

  • Prostatic calculi are of two varieties: endogenous which are common, and exogenous which are comparatively rare.
  • Exogenous prostatic calculus is a urinary (commonly ureteric) calculus that becomes arrested in the prostatic urethra.
  • Endogenous prostatic calculi are usually composed of calcium phosphate combined with about 20% organic material.
  • Clinical features:-Prostatic calculi are usually symptomless being discovered on ultrasound scans, radiography of the pelvis, during prostatectomy or associated with carcinoma of the prostate or chronic prostatitis.
  • Treatment depends upon state of prostate
  • Conservative measures:- Associated chronic prostatic infection may be treated by means of antibiotics.
  • Operative treatment:-These small calculi are removed with prostate.
  • orpora amylaceae:-Corpora amylaceae  are probably the forerunners of endogenous prostatic calculi and are tiny calcified lamellated bodies found in the glandular alveoli of the prostates of elderly men.





Carcinoma of the prostate

  • Common malignant tumour in the men over 65 years.
  • Usually originates in the outer zone, so prostatectomy for benign enlargement of the gland confers no protection from subsequent carcinoma.
  • Presentation of prostate cancer may be asymptomatic and detection is by opportunistic PSA testing or detected in men describing LUTS or may present with symptoms from metastatic disease.
  • Histological appearance is of adenocarcinoma.
  • The following types of prostate cancer occur:-
    • Microscopic latent cancer found on autopsy or at cystoprostatectomy;
    • Tumours found incidentally during TURP (T1 and T1b ) or following screening by PSA measurement (T1c);
    • Early localised prostate cancer (T2);
    • Advanced local prostate cancer (T3 andT4 );
    • Metastatic disease, which may arise from a clinically evident tumour (T2, T3 or T4 ) or from an apparently benign gland (T0, T1), i.e. occult prostate cancer.
  • it should be noted that only the last two groups cause symptoms, and such tumours are not curable.
  • Only screening or the treatment of incidentally found tumours can result in cure of the disease.

 


Staging using the tumour, node, metastasis (TNM) system:-

  • T1a, T1b and T1c. These are incidentally found tumours in a clinically benign gland after histological examination of a prostatectomy specimen.
    • T1a is a tumour involving less than 5% of the resected specimen; these tumour are usually well or moderately well differentiated.
    • T1b is a tumour involving > 5% of the resected specimen.–
    • T1c tumours are impalpable tumours found following investigation of a raised PSA.
  • T2a disease presents as a suspicious nodule on rectal examination confined within the prostate capsule and involving one lobe. T2b disease involves both lobes.
  • T3 tumour extends through the capsule (T3a, uni or bilateral extension. T3b, seminal vesical extension).
  • T4 is a tumour that is fixed or invading adjacent structures other than seminal vesicles- rectum or pelvic side wall.

 Spread of CA prostate

  • Local spread:- May involve the prostatic urethra.
  • Locally advanced tumours tent to grow upwards to involve the seminal vesicles, the bladder neck and trigone and later the tumours tent to spread distally to involve the distal sphincter mechanism.
  • Further upward extension, obstruct one or both ureters later resulting in anuria.
  • The rectum may become stenosed by tumour infiltrating around it, but direct involvement is rare.
  • Spread by the bloodstream occurs particularly to bones (pelvic bones, lower lumbar vertebra, femoral head, rib cage, skull, etc.
  • Lymphatic spread may occur:-
    • Via lymphatic vessels passing along the sides of the rectum to the lymph nodes beside the internal iliac vein and in the hollow of the sacrum.
    • Via lymphatics that pass over the seminal vesicles and follow the vas deferens for a short distance to drain into the external iliac lymph nodes.
    • Form both above route to retroperitoneal lymph nodes than meditational nodes and occasionally the supraclavicular nodes may become implicated.

The natural history of prostate cancer:-

  • This depends on the stage and grade of disease:
  • T1 and T2–The progression rate of well-differentiated T1a prostate cancer is very low: 10-14% after 8 years. For moderately differentiated tumours, the rate is about 20%–For T1b and T2 tumours, the rate is in excess of 35%
  • T3 and T4 (MO)–About 50% progress to bony metastases after 3-5 years
  • M1–The median survival of men with metastatic disease is about 3 years

Clinical features:-

  • Clinical features:-Only advanced disease gives rise to symptoms, but even advanced disease may be asymptomatic.
  • Symptoms of advanced disease include:
    • –BOO;
    • –Pelvic pain and Haematuria;
    • –Bone pain, malaise, arthritis, anemia or pancytopenia;
    • –Renal failure;
    • –Locally advanced disease or even asymptomatic metastases, which may be found incidentally or investigation of other symptoms.
  • Early prostate cancer is asymptomatic and may be found:
    • –Incidentally following TRUP for clinically benign disease(T1);
    • –As a nodule (T2) on rectal examination.

Examinations

  • Rectal examination can detect nodules within the prostate and advanced disease.
  • Irregular indurations, characteristically stony hard in part or in the whole of the gland (with obliteration of the median sulcus), suggests carcinoma.
  • Extension beyond the capsule up into the bladder base and vesicles is diagnostic, as is local extension through the capsule.
  • TRUS may be used to access the local stage and can be combined with a needle core biopsy.
  • Prostatic biopsy:-If there is suspicion of prostate cancer, because of local findings, a raised PSA or metastatic disease, than a trine local transrectal biopsy is recommended.
  • If there are associated symptoms of BOO, then either, a TURP can be performed, which will provide diagnostic material and symptomatic relief.

Investigations

  • General blood test:-These are normal in early disease.
  • Liver function tests:-There will be abnormal if there extensive metastatic invasion of the liver.
  • The alkaline phosphates may be raised from either hepatic involvement or secondaries in the bone.
  • These can be distinguished by measurement of isoenzmes or garmm-glutamyltransferase.
  • Prostate-specific antigen:-Prostate-specific antigen (PSA) is a marker for prostate disease.
  • The levels increase with age, with prostate cancer and with BPH.
  • It is good at following the course of advance disease.
  • It is lacking in sensitivity and specificity in the diagnosis of early localised prostate cancer.
  • Nevertheless, the finding of a PSA>10 nmol ml is suggestive of cancer and > 35ng ml is almost diagnostic of advance prostate cancer.
  • A decrease in PSA to the normal range following hormonal ablation is a good prognostic sign.
  • Acid phosphates:-

PSA measurement has superseded measurement of serum acid phosphatase

  • Radiological examination:-Radiography of the chest may reveal metastases in either the lung fields or the ribs.
  • An abdominal radiography may show the characteristics sclerotic metastases in lumbar vertebrae and pelvic bones.
  • Nevertheless, osteolytic metastases are very common in prostate cancer and may coexist with sclerotic ones.
  • Information about the upper urinary tracts can be obtained by excretion urography or ultrasound.
  • Magnetic resonance imaging (MRI) is the most accurate method of staging local disease.
  • Transrectal ultrasound scanning (TRUS) can also be used.
  • TRUS plus rectal examination and measurement of PSA will detect only 30-50% of cancers that are known to be present on autopsy studies (although it may detect the larger, more significant cancers).
  • Bone scan is indicated to stage the disease especially the diagnosis has been established and PSA were > 10 nmol ml or if the biopsy showed high-grade cancer or on clinical grounds.
  • Bone marrow aspiration sometimes may reveal the presence of metastatic carcinoma cells.

Treatment of carcinoma of the prostate:-

  • Treatment options for prostate cancer depends on stage of disease, like expectancy of the patient and patient preference.
  • Early disease:-Localised cancer can be treated by radical prostatectomy, radiation therapy and active monitoring
  • Curative treatment can only be offered to patients with early disease (T1a, T1b, T1c and T2).
  • T1a disease found incidentally at TURP is by definition low volume and usually well differentiated. This stage can often be managed by active surveillance, with 3- to 6-monthly digital rectal examination (DRE) and PSA measurement, considering treatment if there is evidence of disease progression.
  • The option available for T1b, T1c and T2 disease need to take into account patient age, performance status and lifestyle preferences.
  • The treatment of patients with advance disease (T3, T4 or any MO) is only palliative and hormone ablation remains the first-line therapy
  • A transrectal biopsy can be carried out. If the diagnosis is positive and there is locally advanced disease, then hormone ablation can provide good symptomatic relief without the need for operation.
  • Radical prostatectomy:-Radical prostatectomy is only suitable for local disease (T1 and T2) and should be carried out only in men with a life expectancy of > 10 years.
  • Exclusion of metastases would require a negative bone scan, chest radiography and a serum PSA < 20 nmol ml.
  • It results in a high incidence of importance, but a low incidence of severe stress incontinence (<2%), which may require the fitting of an artificial urinary sphincter.
  • It involves removal of the prostate down to the distal sphincter mechanism in addition to the seminal vesicles. The bladder neck is reconstituted and anastomosed to the urethra.
  • Radical radiotherapy for early prostate cancer:-External beam radiotherapy (EBRT) can be administered in fields that conform to the contours of the prostate, thereby limiting exposure of adjacent tissues.
  • Survival rates following the treatment of T1 and low-volume T2 disease are not greatly different from those following radical prostatectomy, although histological evidence of persistent tumour is found within the prostate in about 30% of treated patients.
  • Patients with locally advanced disease (T3) may be treated by radiotherapy, but most urologists treat such patients by means of androgen ablation.
  • Some local complication are inevitable, namely irritation of the bladder with frequency, urgency and sometimes urge incontinence and similar problem affecting the rectum with diarrhea and, occasionally, late radiation prostatic.
  • Development of erectile dysfunction occurs less frequently than following radical prostatectomy, but is present in up to 30% of cases.
  • Brachytherapy:-Under transrectal ultrasound guidance, radioactive seeds are permanently implanted into the prostate.
  • Brachytherapy is gaining widespread acceptance for the treatment of lower grade low-volume T1 disease.

Advance disease:-

  • The options are androgen deprivation at diagnosis or careful review, reserving active treatment for the later development of symptoms.
  • Patient with poorly differentiated disease are at risk of a catastrophic event such as spinal cord compression; in these patients, early androgen ablation can prolong the time to complication.
  • Also, patients with local or general symptoms should be offered androgen deprivation.
  • Orchidectomy:-Orchidectomy is performed to carry out androgen ablation in the treatment of locally advanced (T3 or T4) disease or of metastatic disease.
  • Bilateral orchidectomy, whether total or subcapsular, will eliminate the major source of testosterone production.
  • Medical castration:-very of stilbestrol.
  • The other commonly available treatment to reduce testosterone levels to the castrate range is LHRH agonists.
  • LHRH agonists may be given by monthly or 3-monthly depot injection.
  • In general, oral anti-androgen monotherapy has not been shown to be as good as LHRH agonists or orchidectomy.
  • Complete androgen blockade:-Complete androgen blockage has been advocated as being likely to result in increased life expectancy and an increased time to progression in a fitter sub-group of men with advance prostate cancer.
  • The concept is that of abolishing the testicular secretion of testosterone by means of orchidectomy or the use of LHRH therapy and then inhibiting the effects of adrenal androgenic steroids by means of androgen receptor blockade with flutamide, bicalutamide or the use of cyproterone acetate.
  • General radiotherapy:-Radiotherapy for symptomatic metastases is an excellent form of palliative treatment, often producing dramatic pain relief in men with hormone-relapsed prostate cancer that can last up to 6 months.
  • When multiple sites are involved, intravenous radiopharmaceuticals such as strontium-89 can be employed.
  • Strontium is a bone-seeking isotope that delivers effective radiotherapy to metastatic areas.
  • It appears to be as effective as hemi body irradiation in the treatment of men with metastatic hormone relapsed disease; however, the duration of response has been disappointing.
  • Chemotherapy:-Cytotoxic agents in the treatment of these men have proved disappointing, but whether this is because the tumour is inherently insensitive or because these elderly men will not tolerate effective doses is uncertain.
  • Recent trials of docetaxel have shown improvements in survival, but only by a few months.

Summary of treatment

  • Incidentally, diagnosed T1a and T1b disease.
    • –For men in their 70s, conservation treatment would usually be the correct approach.
    • –Radical surgical treatment might be considered in the younger (< 70 years) men with this form of the disease, although even in this group, some men will elect to pursue a conservative course when counselled about risks vs. benefits.
  • localised, T1c and T2 disease,
    • –in younger fitter men (< 70 years), this may be treated by radical prostatectomy or radical radiotherapy.
    • –Active monitoring remains an option, particularly for more elderly patients with low-grade disease.
    • –In the elderly patient with outflow obstruction, transurethral resection with or without hormone therapy is indicated.
    • –The benefit of radical treatment  over a conservative approach is likely to be about 25% given that progression to metastatic disease is of this order of magnitude after 10 years.
  • Locally advanced T3 and T4 disease.
    • –These patients are at significant risk of disease progression.
    • –Early  androgen ablation is favoured if close follow-up is not possible.
    • –For the sexually active, a careful conservative approach with the adoption of androgen ablation when symptoms arise is reasonable.
    • –Androgen ablation coupled with radiotherapy is standard treatment for younger men with T3 disease.
  • Metastatic disease.
    • –Once metastatic have developed, the out-look is poor.
    • –For patients with symptoms, there is no dilemma; androgen ablation will provide symptomatic relief  in over two- thirds of patients.
    • –For patients with asymptomatic metastases, the timing of treatment is less clear.
    • –Systemic chemotherapy with docetaxel should be considered in younger, fitter men.

Prostatitis:-

  • In both acute and chronic prostatitis, the seminal vesicles and posterior urethra are usually involved.
  • Acute prostatitis:-
  • Etiology:-
  • Acute prostatitis is common, but under diagnosed.
  • The usual organism responsible is Escherichia coli but Staphylococcus aureus, Staphylococcus albus, Staphylococcus faecalis, Neisseria gonorrhoeae or Chlamydia may be responsible.
  • This infection may be haematogenous from a distant focus, or it may be secondary to acute urinary infection.
  • Clinical features:-General manifestations overshadow the local: the patient feels ill, shivers, may have a rigor, has ‘aches’ all over, especially in the back, and may easily be diagnosed as having influenza.
  • The temperature may be up to 39˚C.
  • Pain on micturition is usual, but not invariable.
  • The urine contains threads in the initial voided sample, which should be cultured.
  • Perineal heaviness, rectal irritation and pain on defecation can occur; a urethral discharge is rare.
  • Frequency occurs when the infection involves the bladder.
  • Rectal examination reveals a tender prostate; one lobe may be swollen more than the other, and the seminal vesicles may be involved.
  • A frankly fluctuant abscess is uncommon.
  • Treatment
    Treatment must be rigorous and prolonged or the infection will not be eradicated and recurrent attacks may ensue.
  • Spread of infection to the epididymides and tests may occur.
  • Prolonged treatment with an antibiotic that penetrates the prostate well is indicated (trimethoprim or ciprofloxacin).

Chronic prostatitis:-

  • Etiology:-This is thought to the sequel of inadequately treated acute prostatitis.
  • Clinical features
    • –Men with symptoms of posterior urethritis, prostatic pain and perigenital pain, having persistent thread in voided urine.
  • Diagnosis:-The three-glass urine test is valuable.
    • –If the first glass with the initial voided sample shows urine containing prostatic threads, prostatitis is present.
    • –Rectal examination may be normal or may show a soft, boggy and tender prostate.
    • –Examination of the prostatic fluid obtained by prostatic massage should show pus cells and bacteria.
    • –Urethroscopy  may reveal inflammation of the prostatic urethra, the verumontanum is likely to be enlarged and oedematous and pus may be seen exuding from the prostatic ducts.
  • Treatment:-Antibiotic therapy should be administered only in accordance with bacteriological sensitivity tests.
    • –Trimethoprim penetrates well into the prostate.
    • –If trichomonas or anaerobes are the responsible agent, a rapid response is obtained from administration of flagyl (metronidazole, 200 mg t.d.s for 7 days to both partners).
    • –If Chlamydia is suspected, doxycyline is the antibiotic treatment of choice.
    • –It is uncertain whether prostatic massage helps in eradicating the infection.

Prostatic abscess

  • Prostatic abscess Severe unremitting perineal and rectal pain with occasional tenesmus often cause the condition to be confused with an anorectal abscess.
  • There is usually steeply rising temperature with rigors.
  • Antibiotics disguise these features.
  • On rectal examination the prostate will be felt to be enlarge, hot extremely tender and perhaps fluctuant.
  • Treatment The abscess should be drained without delay either by perurethral resection, or through perineal route.
  • Retention of urine is likely to occur and, in such men, suprapubic catheterization is best.

Affections of the seminal vesicles

  • Acute seminal vesiculitis occurs in association with prostatitis and treated with antibiotic.
  • Chronic seminal vesiculitis usually presents with haematospermia and pain on intercourse, diagnosed with U/S and MRI if needed and treated on same line as for chronic prostatitis.
  • Tuberculous seminal vesiculitis:- Discussed below.
  • Diverticulum of the seminal vesiculitis:-
    • –Diverticulum of the seminal vesicle occurs occasionally.
    • –In such cases, the kidney of that side is absent, and the diverticulum represents an abortive ureteric bud.
    • –It is a cause of persistent infection.
  • Cyst of the seminal vesicle:-
    • –A cyst of the seminal vesicle is uncommon and rarely requires treatment.
    • –It may be removed by dissection through an incision similar to that for perineal prostatectomy, if it is large or giving rise to symptoms.

Tuberculosis of the prostate and seminal vesicles:-

  • It is rare and associated with renal tuberculosis and chronic tuberculous epididymitis.
  • On rectal examination, the affected vesicle is found to be nodular and tender.
  • When the prostate is involved, rectal examination reveals nodules in one or both lateral lobes.
  • Patients with tuberculous prostatitis usually present with the following:
    • –Urethral discharge;
    • –Painful, sometimes blood-stained ejaculation;
    • –Mild ache in the perineum;
    • –Infertility;
    • –Dysuria;
    • –Abscess formation.
  • Special forms of investigation Radiography sometimes displays areas of calcification in the prostate and/or the seminal vesicles.
  • Bacteriological examination of the seminal fluid yields positive cultures for tubercle bacilli.
  • Treatment The general treatment is that for tuberculosis.
  • If a prostatic abscess forms, it should be drained transurethrally.