Diseases of the Prostate Flashcards
Which zone of the prostatic gland can be felt during a DRE examination?
The peripheral zone is mainly palpated
What are the functions of the prostate?
Ejaculation
What is the histology of the prostatic gland like?
Inner luminal cells and outer basal cells in basement membrane
What do luminal cells of the prostate produce?
Prostate-specific antigen (PSA) which helps liquify semen after ejaculation
What is prostatitis?
Inflammation of the prostate
What causes acute bacterial prostatitis?
Same organisms associated with other acute urinary tract infections
What causes chronic bascterial prostatitis?
Caused by common uropathogens as well
What are the different cases of chronic pelvic pain syndrome?
Can be inflammatory cases, which is associated with leukocytes in prostatic secretion and noninflammatory cases, in which leukocytes are absent
If acute bacterial prostatitis was to be caused by Chlamydia trachomatis or Neisseria gonorrhoea, what would be the target population?
Young sexually active adults
If acute bacterial prostatitis was to be caused by E. coli and proteus, what would be the target population?
Older adults
What are the lab findings of acute bacterial prostatitis?
Leukocytosis, pyuria and bacteriuria
What are the clinical manifestations of acute bacterial prostatitis?
Patient is ill –> dysuria, fever, chills and pelvic or perineal pain
What are the findings of acute bacterial prostatitis in a DRE?
Prostate is tender, firm and boggy
What are the common complication of acute bacterial prostatitis?
Bacteremia, prostatic abscesses, and metastatic infections
How is the causative organism of bacterial prostatitis identified?
Urine culture
What is chronic prostatitis?
Uncommon, recurrent UTI bracketed by asymptomatic periods
What are the clinical manifestations of chronic prostatitis?
Low back pain
Dysuria
Perineal and suprapubic discomfort
What is granulomatous prostatitis?
Fungal infection which has to be followed by BCF treatment for bladder cancer
What is non specific granulomatous prostatitis?
Foreign body giant cell reaction, diagnosis of exclusion
What is chronic pelvic pain syndrome?
Clinical syndrome which is defined primarily by pelvic pain with or without urinary symptoms. The most common diagnosis in men presenting with prostatitis
What are the clinical manifestation of chronic pelvic pain syndrome?
Chronic pain is localized to the perineum, suprapubic area, and penis. Pain during or after ejaculation is a prominent finding
What is the etiology of chronic pelvic pain syndrome?
Unknown
How is a diagnosis of chronic pelvis pain syndrome made?
Diagnosis of exclusion
What are the findings of urine and prostatic secretion cultures like?
They are both negative
What is Benign Prostatic Hyperplasia?
Hyperplasia of both glands and stroma, one of which may dominate
When is BPH experienced?
Age-related change: most men > 40 years, 90% are affected by their 80s
Is BPH associated with cancer risk?
No increased risk of cancer
Where does BPH occur? What is the result of it?
In the periurethral (transitional) zone –> as a result, it compresses the urethra
What is the pathogenesis of BPH?
Excessive androgen-dependent growth of stromal and glandular elements
–> Prostatic cells rely on androgens (like testosterone and dihydrotestosterone) for survival and to prevent apoptosis
–> With age, testosterone decreases, but 5-a reductase is more potent, leading to an increase in dihydrotestosterone formation, –> increase in proliferation, and a decrease in apoptosis
–> Prostate enlarges uniformly with multiple firm hyperplasticity nodules
What is the function of 5a-reductase?
To convert testosterone into dihydrotestosterone, which is a more active androgen
What are the clinical features of BPH? (5)
- Weak and inconsistent stream of urine (dribbling)
- Strain to urinate
- Pain when urinating
- Trouble initiating urination
- Urine builds up in the bladder –> sense of incomplete bladder emptying
When do the symptoms of BPH start?
When the prostatic urethra is obstructed
What is the result of complete urinary obstruction?
Painful distention of the urinary bladder, if not treated –> hydro-ureter and hydronephrosis
How is BPH diagnosed?
- Digital rectal examination –> significant for enlarged and nodular prostate
- Prostate-specific antigen (PSA) slightly elevated
- Imagine as US and MRI
- Urodynamic test
What is the treatment of BPH?
- Medical treatment to release the obstruction and allow urine to flow
- a1 antagonists to relax smooth muscle
- 5-a reductase inhibitor (blacks conversion to DHT)
- Surgical treatment
What are the side effects of 5-a reductase inhibitors for BPH treatment?
Gynecomastia and sexual dysfunction
What is the surgical treatment for BPH?
TURP (Transurethral resection of the prostate)
What is the gross appearance of BPH?
Enlarged gland with multiple nodules
What is the microcopy of BPH?
Hyperplastic nodules of fibromuscular connective tissue stroma and glands lined by two layers of epithelium.
Small cysts represent dilated acini; some contain laminated concertion (corpora amylacea)
What is the epidemiology of prostate carcinoma?
The most frequent cancer diagnosis is made in men and is the second leading cause of death in the US
Incidence and mortality are related to age
Which race has the highest incidence rates and most aggressive types of prostate cancers?
African american
What is the most important risk factor of prostatic cancer?
Age
What are the risk factor so prostatic cancer?
Age
Family history
Environmental factors such as diet
Acquired genic aberration
What is the relation between androgens and carcinogenesis?
No tumour develop in males who are castrated before puberty –> no evidence that androgens initiate carcinogenesis
What is acquired genetic aberration when it comes to prostatic cancer?
Most common acquired mutations create TPRSS2-ETS fusion genes or act to enhance PI3K/AKT signaling, which promotes tumor cell growth and survival
What are the clinical features of prostatic cancer?
Initially asymptomatic
Can compress the urethra –> nonspecific urinary symptoms such as dysuria, or pain with ejaculation, hematospermia, hematuria, inability to void, incontinence, erectile dysfunction, weight loss, anemia
Why are prostatic tumors initially asymptomatic?
They arise in the peripheral zone
What is the metastasis of prostatic cancer like?
It can spread to the lumbar spine and pelvis, –> osteoblastic metastasis –> hip and back pain
–> Increase in alkaline phosphatase, PSA and prostatic acid phosphatase
What are the diagnostic methods of prostatic cancers?
DRE
Transrectal US or MRI
PSA > 10μg/L, decreased free PSA, which increases over time
How could prostatic screening be done?
Prostatic screening by DRE and PSA
Who should be screened for prostatic cancer?
Everyone but specifically patients wih family history
Which procedure is done in order to confirm final diagnosis?
Prostatic biopsy
What is the most common prostatic cancer?
Prostatic adenocarcinoma
What is the histology of prostatic adenocarcinoma?
Small invasive glands with prominent nucleoli
How does the Gleason grading system work?
- Multiple regions are assessed as architecture varies from one area to another
- A score of 1 to 5 is assigned for the two most common areas & added to produce a final score (2 to 10)
- The higher the score –>, the worse the prognosis
What is the grading system for prostatic cancers?
Gleason grading system
What is the importance of a grading system?
Grading and staging affects treatment and can predict the diagnosis and correlated mortality
What are the findings of the prostatic adenocarcinoma microscopically?
Glands with cells having prominent nucleoli and glands lined by SINGLE cell layer and are back-to-back
What is a score 1 on the Gleason’s pattern scale?
Small, uniform glands
What is a score 2 on the Gleason’s pattern scale?
More space (stroma) between glands
What is a score 3 on the Gleason’s pattern scale?
Distinctly infiltration of cells from glands at margins
What is a score 4 on the Gleason’s pattern scale?
Irregular masses of neoplastic cells with few glands
What is a score 5 on the Gleason’s pattern scale?
Lack of or occasion glands, sheets of cells
What is the treatment for prostatic cancer?
If the tumor is confined to the prostate and has not metastasized: “watchful waiting” –> active surveillance, routine tumor marker measurement & imagine –> ensure cancer remains confined to prostate
If the tumor spreads:
a. Surgery
b. Radiation therapy
c. Chemotherapy
d. Hormonal therapy
How are advanced metastatic carcinomas treated?
Androgen deprivation, either by orchiectomy or by administration of synthetic agonists of LHRH
What is prostatic intraepithelial neoplasia (PIN)?
Neoplastic growth of epithelial cells within pre-existing benign prostatic acini or ducts
Why is high grade-prostatic intraepithelial neoplasia considered a precursor to prostate cancer?
PIN satisfies almost all requirements for a premalignant condition, 1/3 of patients develop cancer within 10 years
–> Patients are followed up by PSA monitoring
What is PSA?
A protein produced by the prostate gland cells, circulated through the body in two ways
What are the two ways with which PSA can circulate around the body?
Either bound to other proteins or on its own (free PSA)
What is the PSA assay?
The most widely used test in the diagnosis and management of prostate cancer, but it suffers a few limitations
What are the limitations of the PSA assay?
It is nonspecific and can be increased due to increased production like in cases such as BPH or trauma to the prostate
What is the normal range of PSA?
Normal range usually increases with age (up to 2.5 in men < 50 years of age and up to 6.5 in men > 70 years of age)
What are serial measurements of PSA?
They are measurements taken a series of times; they are very important and of great value in assessing the response to therapy
What would a rising PSA level be after radical prostatectomy or radiotherapy indicate?
Recurrency or disseminated disease
