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Prostate

Acute bacterial prostatitis. Clin. Manifest.


Fever, chill, dysuria.
Prostate is tender and boggy on palpation.
Bacteria are similar in type and incidence to
those that cause UTI: E. coli, other gram
(-).

Prostate
Acute prostatitis. Clin. Manifest.
Organisms implanted in the prostate by
intraprostatic reflux of bladder urine,
lymphohematogenous route or surgical
manipulation on the urethra (catheter),
bladder or prostate.

Kidney

Prostate
Acute prostatitis. Pathology
Neutrophilic infil. Into glandular spaces.
Edema, congestion
Abscess of varying size
The lesion may subside completely or leave
fibrous scar or calcification.

Prostate
Chronic bacterial prostatitis. Pathology
Lymphs, plasma cells, PMN, macrophages.
Chronic bacterial prostatitis. Clin manifest
Low back pain, dysuria, perineal or
suprapubic discomfort
History of UTI. Disease appears insidiously
without obvious provocation.

Prostate
Chro. abacterial prostatitis. Clin. Manifest
Similar to chronic bacterial prostatitis. No
history of recurrent UTI.
Usually affect sexually active men:
Chlamydia trachomatis, ureaplasma
urealyticum

Prostatitis: Lab findings


Specimen collection for the diagnosis of
chronic prostatitis.
Urine collection prior to prostate massage
Prostatic massage through rectum and
collection one to two drops of expressed
prostatic secretion (EPS).
Collection of urine after prostate massage

Prostatitis: Lab findings

All three specimens are submitted for


cultures
A smear from the EPS is examined: PMN,
macrophages.
Urine sediment is examined to rule out UTI

Prostate
Prostatitis. Lab findings
No pyuria in the premassage sample.
Pyuria in prostate secretion specimen
obtained by transrect. prost. Massage:
PMN, macrophages.
Bacte count by cult. is significant higher in
the EPS than in the urine.

Prostate
HIV-related prostatitis
15% of AIDS patients
Most often opportunistic organisms
HIV virion have been detected in prostate
epithelial cells.

Prostate
Nodular hyperplasia: Central zone
20% of men 40 years of age
70% by age 60
90% by the eighth decades of life
TURP(transurethral resection of prostate):
Whites 6.72: 1,000. Blacks 6.58:1,000.

Prostate
Nodular hyperplasia. Etiology
DHT which is synthesized in the stromal
cells by the action of 5-reductase binds to
nuclear receptors (stromal, glandular)
cell proliferation
Estradiol increases and sensitizes the
prostate to growth promoting effects of
DHT.

Prostate
Nodular hyperplasia. Path. Gross
60-100 g. Discrete nodules in periurethral
area compressing urethra.
Nodules: Proliferation of glands, stromal or
muscle cells with predominance of one or
more than one components.

Prostate
Nodular hyperplasia. Path. Micro
Stromal nodule
Muscle nodule
Glandular nodule
Nodule composed of varying combination
of stroma, muscle and glands

Prostate

Predominantly glandular nodule: Yellow


pink with prostatic fluid oozing out.
Predominantly fibromuscular nodule:
Tough, pale gray.

Prostate
Nodular hyperplasia. Clin. Manifestations
Difficulty in starting and stopping of the
urine stream, dribbing, dysuria, nocturia.
Sudden acute urinary retention of unknown
cause
30% of patients older than 50 are
symptomatic.

Mechanism of symptoms in BPH

Mechanical effects of hyperplastic nodules


Tension of smooth muscle (40% of the
gland) in the prostate.

Symptomatic Rx of BPH

Decrease of size of nodules by reductase


inhibitor with Dustasteride (Avodart) or
transurethral resection (TURP)
Tension of smooth muscle with
adrenergic blocker with Tamsulosin
(Flomax)

Prostate
Nodular hyperplasia. Complications
Bladder hypertrophy, trabeculation
(hypertrophy of detrusor in some areas),
diverticulosis (weakening of the wall in
others).
UTI
Hydronephrosis
Renal failure.

Prostate cancer
Epidemiology
Incidental finding in autopsy and prostate
removed for other reasons.
20% in fifth decade of life.
70% in eighth decade of life.

Prostate cancer
Epidemiology
Genetic: Different rate in different race.
Hong Kong Chinese: 1:100,000
Japanese 3:100,000. Higher for Japanese
in USA.
Whites: 60:100,000. Blacks: Higher.

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Prostate cancer: Etiology


Genetic factors
Loss of tumor suppressor genes on
Chromosome 8q, 10q, 13q and 16q.
Mutation that turn off tumor suppressor
gene (p53 and PTEN)
Inheritance of susceptibility gene 1q24-25

Prostate cancer: Etiology

Genetic factors: One first degree relative


has cancer the risk is twofold. Two first
degree relative the risk is fivefold.
Overexpression of Her2/neu, hepsin,
transmembrane serine protease, -methyl
acyl COA, hypermethylation of gluthatione
S transferase gene promotor on 11q13
(90% of cases).

Prostate cancer, etiology

Androgens bind to AR and induce


expression of pro growth and pro survival
genes.
AR (X-linked) has codon CAG of variable
stretches
Shortest strectch has high sensivity to
androgen

Prostate cancer, etiology

African Americans have shortest stretch of


CAG
Whites have intermediate length
Asians have longest length

Prostate cancer, etiology

Rearrangement of ETS transcription factor


gene lead to an over expression in an
androgen fashion: Prostate cancer more
invasive.

Prostate cancer: Etiology


Environmental:
High fat diet risk of Ca.
Lycopen, Vit A, Vit E, soy products risk

Prostate cancer
Pathology
Gross: Peripheral and transitional zone,
Yellow, firm and gritty.
Micro: Most frequently adenocarcinoma
Glands lined by a single layer of cells with
enlarged nuclei with prominent nucleoli with
pale or eosinophilic cytoplasm. Crystalloids
Absence of basal layer.

Prostate cancer

Glands are smaller than benign glands.


Glands with papillary or cribriform pattern.
WD cancer: Glands readily are recognized
PD cancer: Tumor cells in nests, cords,
sheets.

Prostate carcinoma: Gleasons G

G1: Single, separate, closely packed


uniform glands.
G2: Single, separate, loosely arranged
fairly uniform glands.
G3: Single, separate, irregularly spaced
very variable glands and/or circumscribed
mass of cribriform or papillary epithelium.

Prostate carcinoma: Gleasons G

G4: Raggedly infiltrating masses of fused


glandular epithelium.
G5: Anaplastic tumor and/or comedo
carcinoma

Prostate carcinoma: Gleasons G

Mitoses are uncommon.


Stromal reaction is mild or marked
scirrhous like consistency.
Tumor may shows capsular, lymphatic,
vascular or perineural invasion.

Prostate carcinoma. Gleasons G


Combined Gleasons grade:
Each tumor has different degree of
differentiation in different areas.
Combined Gleason is the sum the score of
the most differentiated area and that of the
least differentiated area.

Prostatic intraepithelial neoplasia

No evidence of invasion

Prostate cancer staging

Stage T1 Clinically inapparent tumor


neither papable nor visible by imaging
T1a: Tumor occupies < 5% of tissue
T1b: Tumor occupies > 5% of tissue
T1c: Tumor identified by needle
biopsy because of PSA elevation

Prostate cancer staging

Stage T2: Organ confined


T2a: Unilateral, involving <1/2
T2b: Unilateral, involving > 1/2
T2c: Bilateral disease

Prostate cancer staging

Stage T3
T3a: Extraprostatic extension
T3b: Seminal vesicle invasion
Stage T4: Invasion of the urinary bladder
and or colon

Prostate carcinoma. Prognosis


Depends on
Grade
Stage
DNA ploidy of tumor cells. Worse
prognosis with aneuploid and tetraploid
tumors

Prostate carcinoma. Prognosis

T1a:
Most do not progress with 10 years of
follow up
5-25% will develop local spread or
metastasis
T1b: 30-50% will progress with fatality rate
of 50%

Prostate carcinoma
Clinical evaluation
Rectal digital examination
Transrectal ultrasonography for early
detection and assessment of local spread.
CT scan and MRI for evaluation of lymph
nodes.
PSA and PAP.

Prostate carcinoma
Clinical evaluation
PAP is increased in cases tumor extending
beyond the capsule and metastasis.
PSA in localized, advanced disease,
hyperplasia and infarct. With a given
volume cancerous tissue yields higher level
than other diseases probably because
greater diff. from M. acini to stromal BV.

Prostate cancer
Clinical evaluation
Elevated PAS after prostatectomy indicates
disseminated disease.
Elevated PAS after initial control indicates
recurrence disease.

Prostate cancer
Treatment
Surgery
Radiotherapy
Hormonal therapy:
Orchiectomy
Agonists of LHRH
Synthetic LHRH

Screening of prostate cancer

PSA
Digital rectal examination
Transrectal sonography: Cancer may be
hypoechoic.

Screening of prostate cancer


PSA
40-49 years of age: 2.5 ng/ml
50-59

: 3.5 ng/m
60-69

: 4.5 ng/ml
70-79

: 6.5 ng/ml
25 % of prostate Ca: No of PSA

Screening of prostate cancer


PSA velocity
Three measurements in 18 months
Normal PSA elevation: 0.75 ng/year
Work-up is needed if there is significant rise
of PSA above the baseline

Screening of prostate cancer


Percentage of free PSA
PSA = Free PSA and PSA bound to 1
antichymotrypsin
Ratio of free PSA/Total PSA greater than
25%: Low risk of cancer
Ratio of free PSA/Total PSA less than 10%:
High risk of cancer