Histology SPECIAL TOPIC: BENIGN PROSTATIC HYPERPLASIA

AY 2018-2019 Mark Luwiz M. Martinez, M.D

Module 8 04/23/2019

Editor’s note: This is from the online lecture video of doc. If

nagtataka kayo bakit konti lang yung audio, it’s because binabasa
lang po nya yung ppt 

Prostate: Gross Anatomy

 Is a fibromuscular glandular organ that surrounds the

prostatic urethra
 About 2 cm x 3 cm x 4 cm, roughly the size of a
walnut
 Weighs about 20g
 Surrounded by a fibrous capsule
 After the fibrous capsule is a fibrous sheath that is
part of visceral layer of pelvic fascia
Figure 3: Gross Anatomy of Prostate
Prostate Gland: Gross Anatomy

 Has a base (superior) which lies against the urinary

Prostate gland: Gross Anatomy
bladder
 Superior (Base): Urinary bladder
 The 2 ejaculatory ducts pierce the upper part of the
 Inferior (Apex): Urogenital Diaphragm
posterior surface to open into the prostatic urethra
 Anterior: Symphysisi pubis, and in between is the
 Has an apex (inferior) which lies against the
extraperitoneal fat in the retropubic space (Cave of
urogenital diaphragm
Retzius). The fibrous sheath of the prostate is
connected to pubic bones by the puboprostatic
ligaments
 Posterior: Anterior surface of rectal ampulla, and in
between is rectovesical septum (fascia of
Denonvillier)
 Lateral: anterior fibers of levator ani

Prostate gland: Gross Anatomy

 Arterial blood supply: Branches of the inferior

vesical and middle rectal arteries
 Venous blood supply: Prostatic venous plexus,
Figure 1: Gross Anatomy of Prostate
which receives blood from deep dorsal vein of the
penis and vesical veins, and drains into the
internal iliac veins
 Nerve supply: Inferior hypogastric plexus
 Lymph drainage: lymph vessels from prostate drain
into the internal iliac nodes
Prostate gland: Gross Anatomy

 Divided into 5 ill-defined lobes:

Figure 2: Gross Anatomy of Prostate
 Anterior: in front of urethra, has no glands
 Median/middle: wedge of gland between urethra
and ejaculatory ducts, rich in glands
 Posterior: behind the urethra, rich in glands
 Lateral lobes (R and L): lie on either side of the
urethra, rich in glands

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Prostate Gland: Histology

 A collection of 30-50 branched tubuloacinar glands

embedded in a dense fibromuscular stroma
 The ducts of the glands all empty into the prostatic
urethra
 The glands are lined by simple or pseudostratified
columnar epithelium
 The fibromuscular stroma is a blend of smooth
muscle and connective tissue fibers

Prostate Gland: Histology

The glands are arranged into three major zones around the
urethra:
 Transition zone: Contains periurethral mucosal
glands, surrounds the superior portion of the
urethra (5% of volume); site of benign prostatic Figure 4: Histology of Prostate
hyperplasia Corpus amylaceum (CA), conceretion and secretory
 Central zone: Contains periurethral submucosal epithelium (E), Thin lamina propria (LP), Thick smooth
glands with longer ducts, (25% of gland’s tissue) muscle (M)
 Peripheral zone : Contains glands with even longer
ducts, (70% of gland’s tissue); the site of
carcinoma of the prostate

Prostate gland: Histology

 Small spherical concretions (often partially

calcified) , called corpora amylacea, are normally
present in the lumens of the tubuloacinar glands
 They contain glycoproteins and keratan sulfate
 Seem to have no physiologic or clinical significance

Figure 5: Histology of Prostate: Actual Slide

Figure 6: Histology of Prostate: Actual Slide. (CA)

Figure 3: Histology of Prostate

Fibromuscular Stroma (S), Tubuloalveolar glands (G)

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Prostate Gland: Function

 The prostate glands secrete a thin, milky fluid that

contains citric acid, calcium, phosphate ion, a
clotting enzyme and profibrinolysin
 This secretion makes up 30-50% of seminal fluid
volume
 This slightly alkaline fluid helps neutralize the
acidity of other seminal fluids and the vagina, thus
enhancing motility and fertility of sperm
 The prostate depends on the levels of androgens,
esp testosterone for its structure and function
 Another important product of the prostate is the
prostate specific antigen (PSA), which if levels are
elevated may indicate carcinoma or inflammation
Lamellar nature of Corpus amylaceum (CA), Benign Prostatic Hyperplasia(BPH)
Lamina Propria (LP)
 An extremely common disorder of men
 Starting at 40, 20% of men may have BPH, and
 By 80, 90% of men may have BPH
 Disorder characterized by hyperplasia of prostatic
stromal and epithelial cells, resulting in the
formation of large, discrete nodules (Nodular
hyperplasia) in the periurethral region of the
prostate (Transition zone)
 These nodules, if they become large can compress
and narrow the urethral canal, causing partial to
complete obstruction of the urethra
 Impaired cell death of the stromal and epithelial
cells is believed to contribute to the hyperplasia of
the prostate, (and not increased cell growth)
 Dihydrotestosterone, formed in the prostate by
Figure 8: Histology of Prostate: conversion of testosterone by type 2 a-reductase of
Supporting stroma (SS), Gland (G) the stromal cells is believed to contribute to its
pathogenesis
Benign Prostatic Hyperplasia (BPH)

 common disorder of the prostate

 Grossly in enlargement of the prostate, the glands
weighs 60-100g, with nodules, initially mostly
stromal but later also epithelial in the transition
zone or the area around the urethra
 Thus the urethra can be compressed to an almost
slit-like orifice
 Clinically, median lobe hypertrophy can be
appreciated, wherein there is a hemispheric mass
beneath the floor of the urethra
 On cross section, the nodules can be pale gray
and tough (stromal nodules) or yellow pink with soft
consistency with a milky white fluid oozing out of it
(epithelial nodule), or a mixture of both
 Histologically, you can see aggregations of small to
Figure 9: Histology of Prostate Gland large cystically dilated glands, lined by two layers,
Urethra (U), Fibrous Stroma (St), Ejaculatory ducts (ED),
an inner columnar and an outer cuboidal or
Transition zone (TZ), Peripheral zone (PZ), Central zone
flattened epithelium
(CZ), Capsule (Cap), Urethral Crest (C)

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BPH: Clinical Features

 In performing DRE, usually patients are placed in the

lateral recumbent position
 Make sure you observe the anal opening
 observe for lesions, hemorrhoids and fissures
 Make sure you use KY jelly
 to decrease patient dicsomfort
 There is no need to force the finger into the anus, just
let it slide in slowly
 finger should be oriented anteriorly, prostate should
Figure 10 : Histology of Benign Prostatic Hyperplasia be smooth, when prostate is nodular it can be
(BPH) indicative of prostatic carcinoma.
 Your prostate is anterior to the rectum
 Sweep the finger inside the rectum
 Check for rectal tone
 Check for blood in the finger
 Rectal tone: intact or collapsed
 Intact: pocket of hair inside, initially there is resistance then
followed by easing.
 Collapsed: resistance is all through out, no easing.

BPH: Differential Diagnosis

The following diseases can present with lower urinary tract
symptoms, and so appear to be similar to BPH:
Figure 11: Histology of Benign Prostatic Hyperplasia (BPH)  Urethral stricture
 UTI
BPH: Clinical Features  DM
 Stroke, Multiple Sclerosis, Parkinsons
 BPH presents with lower urinary tract symptoms in  Use of anticholinergics and sympathomimetics
men  Prostate CA
BPH: Laboratory procedures
 Symptoms divided into two types: Obstructive and Irritative
 Prostate specific antigen
 Obstructive:  Urinalysis
– Urinary hesitancy, straining, weak stream,  to rule out UTI
terminal dribbling, prolonged voiding,  Ultrasound
incomplete emptying  Urodynamic studies:
 Urine flow rate determination
 symptoms experienced during voiding  Pressure flow testing
 Irritative:  Frequency volume charts
– Urinary frequency, urgency, nocturia, urge  Cystourethroscopy
incontinence, small voided volumes  Prostate specific antigen
 To assess for the possibility of prostate carcinoma
 experienced in between voiding  Normal levels are affected by age:
- 40: 2.5 ng/ml or less is normal
 If BPH is becoming complicated, it can also present
- 60: 4.5 ng/ml or less is normal
with
- 70: 6.5 or less is normal
 Hematuria and urinary retention
 As a screening tool: for 40 y.o and above with life
 Urinary retention: Urine retained in the bladder, does not expectancy of 10 years
come out.
- For 70 y.o- as needed
 On abdominal examination you can find an enlarged,
palpable bladder
Ultrasound:
 On Digital Rectal Exam, you can appreciate an
 Transabdominal
enlarged prostate
 Look at residual urine
 Digital Rectal Exam: technique used to palpate the  Assess initially and as response to treatment
prostate and a part of the rectum.

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BPH: Laboratory procedures BPH: Treatment

Urodynamic studies:
 To assess degree of obstruction Complications:
 To determine appropriate management:  Urinary stone disease
 Medical vs Instrumentation or more invasive  Hematuria
procedures  Urinary retention
 Pressure flow urodynamic testing:  Urinary tract infection
 Gold standard in diagnosing BPH  Bladder diverticula
 Renal insufficiency or renal failure
BPH: Treatment
Semen Analysis
 Asymptomatic patients do not need treatment
 Watchful waiting for patients with little or no symptoms  Semen is the liquid released from the penis containing
 Lifestyle changes: secretions form the prostate, seminal vesicles and
 Restricting fluid intake other glands
 Fluid intake decrease in bed time  May be performed as part of infertility testing
 Avoiding caffeine
 Weight reduction Components:

Significant symptoms:  Volume: 2-5 ml

 Alpha blockers: to reduce bladder tone
 Suitable for all patients regardless of size
 Tamsulosin 0.4 mg cap once a day
 Terazosin 1 mg tab once a day
 Alfusozin, Doxazosin, Silodosin
 5a-reductase inhibitors:
- 5a-reductase coverts testosterone to
dihydrotestosterone
 It reduces prostate size, so suitable for large prostates
 Finasteride 5mg tab once a day
 Dutasteride 0.5 mg cap once a day
Combination:
- Dutasteride/Tamsulosin cap once a day
BPH: Treatment
 Anticholinergics: can be used for those with mainly
irritative symptoms:
 Tolterodine 2mg tab once day, 1 mg for those with
significant renal and hepatic disease
 Fesoterodine 4mg tab once a day can increase to 8
mg
 Solifenacin, Darifenacin, Oxybutynin, Trospium
 Liquefaction time: 20-30 mins after collection
 Appearance: whitish in color
 Motile/ml: 10M or greater
 Sperm/ml: 20M or greater
 Viscosity: 3 or greater
Semen Analysis
 Supravital: equal to 75% live or greater
 Fructose: positive
 pH: 7.12-8
 Sperm count: 20M/ml or greater
 Sperm motility: 50% at 1 hr or greater
 Sperm morphology: greater than 30% normally
shaped
REFERENCES
-Doc Martinez ppt and lecture video
-Junquiera’s: Basic Histology, Textbook and Atlas

BPH: Treatment

 Phosphodiesterase inhibitors: for those with

concomitant erectile dysunction
 Tadalafil 5mg tab once a day
 Urinary retention: insert an in-dwelling foley catheter
BPH: Treatment

 Surgery: for patients with renal insufficiency, gross

hematuria, recurrent UTIs, poor response to medical
therapy, bladder stones
 Transurethral resection of the prostate (TURP) ; gold
standard
 access is in the urethral canal, urethral meatus.
 Open prostatectomy

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