TEACHING MBBS CLASS PURPOSE

1. BENIGN DISORDERS OF THE
PROSTATE

2. ANATOMY OF PROSTATE

4. PHYSIOLOGY
• Growth of prostate – action of testosterone and dihydrotestosterone
• Undergoes atrophy in absence of these hormones
• PSA – serine protease secreted by Prostate – facilitates liquefaction of
semen
• Serum PSA estimation done for evaluation of prostatic diseases

5. BENIGN PROSTATIC
HYPERPLASIA

6. PATHOPHYSIOLOGY
• Hyperplastic process – increase in cell number
• Estrogenic steroids in the presence of androgens promote this process in elderly
males
• BPH affects both glandular epithelium and connective tissue stroma (smooth
muscle and collagen)
• BPH typically affects the submucous glands in the transitional zone,
although other zones also affected
• This enlargement leads to 2 effects –
• Obstruction to flow of urine
• Secondary response to bladder outlet obstruction

7. PATHOPHYSIOLOGY
• OBSTRUCTIVE COMPONENT
 MECHANICAL : obstruction of bladder neck/urethral lumen
 DYNAMIC : increased autonomic alpha-adrenergic stimulation of prostatic stroma
• THIS LEADS TO THE FOLLOWING SYMPTOMS (VOIDING SYMPTOMS) -
Hesitancy
Straining to void
Poor stream
Sensation of incomplete voiding
Post void dribbling

8. PATHOPHYSIOLOGY
• SECONDARY RESPONSE TO B.O.O
Muscle hypertrophy
Collagen deposition
Detrusor instability
• THIS LEADS TO FOLLOWING SYMPTOMS (STORAGE SYMPTOMS)–
Frequency
Urgency
Nocturia

9. CLINICAL PRESENTATION
• Lower urinary tract symptoms (LUTS) = voiding + storage symptoms
• Acute retention of urine
• Hematuria
• Chronic retention of urine with overflow

10. EVALUATION
• History
• Clinical examination of abdomen and external genitalia
• Digital rectal examination (very important)

11. EVALUATION
• Urine – routine and microbiological examination, culture
• Renal function test
• PSA
• USG KUBP + POST VOID RESIDUE
• Uroflowmetry

12. MANAGEMENT OF ACUTE RETENTION
• Foley catheterization
 Steps of ideal
catheterization
• If not possible 
Suprapubic Cystostomy

13. Suprapubic cystostomy

14. MEDICAL MANAGEMENT
• SELECTIVE ALPHA BLOCKERS
• Tamsulosin
• Silodosin
• Alfuzocin
• Mechanism – smooth muscle relaxation
of prostatic stroma and bladder neck
• Adverse effects – orthostatic
hypotension, dizziness, headache, rhinitis,
retrograde ejaculation

15. MEDICAL MANAGEMENT
• 5 ALPHA REDUCTASE INHIBITORS
• Finasteride
• Dutasteride
• Mechanism – blocks 5AR enzyme, prevents conversion of
Testosterone to DHT, inhibits prostatic epithelial growth
• Adverse effects – erectile dysfunction, decreased libido,
gynaecomastia

16. SURGICAL MANAGEMENT
• INDICATION –
• Not responding to medication, persistant bothersome symptoms
• Recurrent hematuria
• Recurrent infections
• Coincident bladder stone
• BPH causing pressure changes
• PROCEDURES
• Trans Urethral Resection of Prostate (preferred and most commonly done)
• Laser enucleation/evaporation of prostate (upcoming)
• Open prostatectomy (only performed nowadays for large prostates >100g)

19. PROSTATITIS & PROSTATIC
ABSCESS

20. ACUTE PROSTATITIS
• MC organism – E. Coli
• Source of infection – hematogenous / secondary to AUR
• Clinical features – Lower urinary tract symptoms overwhelmed by
presence of fever/malaise/weakness, pain during micturition
• Firm but tender prostate on DRE clinches diagnosis
• Treatment – antibiotics, conservative mx

21. PROSTATIC ABSCESS
• Symptoms similar acute prostatitis + high grade fever with chills
• Mostly associated with acute urinary retention
• DRE – enlarged tender fluctuant prostate
• Management – urgent drainage by trans-urethral or per rectal route

22. CHRONIC PROSTATITIS AND PROSTODYNIA
• Non specific lower urinary tract symptoms for long duration -
Suprapubic pain, perigenital pain, testicular pain, prostatic pain
exacerbated by sexual intercourse
• Etiology – infective / inflammatory
• Diagnosis – of exclusion
• Treatment - prolonged antibiotics, anti-inflammatory drugs,
antidepressants (difficult to treat)

23. MALIGNANT DISEASE OF
PROSTATE

24. • Most common tumor in men >65yrs
• Prevalence increases with age
• Mostly asymptomatic
• TURP done for BPH does not prevent malignancy – carcinoma usually
arises in peripheral zone

25. RISK FACTORS

26. PATHOLOGICAL TYPES

27. MODES OF SPREAD
• LOCAL – seminal vesicle, bladder
neck, pelvic wall
• BLOOD – mc skeletal metastasis
(osteoblastic in nature), lung, liver
• LYMPHATICS – local and distant
lymph nodes

28. TNM STAGING

29. GLEASON SCORING SYSTEM
• Multiple growth patterns identified
in biopsy specimen, each designated
a grade(1 – 5) according to degree of
differentiation
• most common and highest-grade
patterns on a given core were added
to result in the Gleason score

30. HOW IS THIS DISEASE DETECTED?
• Mostly asymptomatic
• Usually detected by raised
serum PSA during evaluation
for LUTS
• May also present late with
advanced disease symptoms
(pelvic pain, bone pain,
fractures)
• SCREENING for early detection

31. EVALUATION
FOR DIAGNOSIS
• History and clinical examination
• Digital rectal examination
• Serum PSA
• Urinalysis, RFT, LFT
• Trans Rectal USG guided biopsy
FOR STAGING
• Multi-parametric MRI
• Whole Body Bone scan
• PSMA PET

32. SERUM PSA ESTIMATION
• PSA is organ specific, but not
disease specific
• Used for screening
• >4ng/ml – considered increased
risk for malignancy
INDICATION FOR BIOPSY
 PSA >4ng/ml
Palpable abnormality in DRE

33. TRUS BIOPSY

34. • MRI done to assess local spread
of tumor and spread to pelvic
lymph nodes
• Bone scan done to assess
metastasis to bones
• All these investigations help to
stage the disease into the
following categories :-
• LOCALIZED
• LOCALLY ADVANCED
• METASTATIC
MRI
BONE SCAN

35. TREATMENT OPTIONS
Radical
prostatectomy
Androgen
deprivation
therapy
Radiotherapy
Concept of Watchful
waiting & Active
Surveillence

36. RADICAL PROSTATECTOMY
• Indicated in patients with early
localized disease and expected
life expectancy >10yrs
• Can be done
OPEN/LAPAROSCOPIC/ROBOTIC

37. RADIOTHERAPY
• Can be primary modality of
treatment in localized disease
• As a part of multimodal therapy
for locally advanced cases
• Salvage/palliative for advanced
cases
• Types :-
• External beam radiotherapy
• Brachytherapy

38. ANDROGEN DEPRIVATION
THERAPY
• SURGICAL – bilateral orchidectomy
• MEDICAL – refer to figure
• Combination for drugs/ drugs +
surgery used for completely
androgen blockage
• Primary treatment option in
advanced/metastatic disease
• Used as adjuvant/neo-adjuvant
setting in locally advanced cases,
for recurrences

39. PALLIATIVE THERAPY FOR METASTATIC DISEASE
• BONE PAIN – opoid analgesics, antidepressants, radiotherapy
• INCREASED FRACTURE RISK – calcium, vit D, bisphosphonates
• CORD COMPRESSION – steroids, radiation, surgical stabilization
• optimization of side effects of ADT