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Prostate Disease

Sources Merck Manual 18th Edition     Croon’s Therapy 2002       Wikipedia



Prostate Disease

The normal prostate is walnut-sized organ composed of glandular tissue that makes ejaculatory fluid, its only known function.  Benign Prostatic hyperplasia (BPH) is nonmalignant adenomatus overgrowth of the periurethral prostate gland. Using size (. 30mL & urinary score) the prevalence of BPH in men aged 55-74 is 19%, but only 4% of them have urinary problems.  Based on autopsy studies BPH is found in 8% of the men aged 31-40; 40-50% for men 51-60, and > 80% in men over 80. 38% of men 40-79 experience moderate to severe symptoms, and one in 4 men in their 8th decade will require treatment for BPH.  On rectal examination the prostate usually is enlarged and has a rubbery consistency, and in many cses has lost the median furrow.  BPH causes elevated PSA in 30-50% of the time. 


Multiple fibroadenomatous nodules develop in the periurtheral region of the prostate rather than in the fibromuscular prostate, which is displaced by progressive growth of the peripheral nodules growth.  Overgrowth that obstructs the flow of urine will increase the risk of calculus formation in the bladder, infection in the bladder, prostate, and upper urinary tract, and hydronephrosis and compromised renal function.


*  accumulation of urine in the kidney because of an obstruction in the ureter.




BPH first develops in the transitional zone of the prostate.  The transitional zone lies immediately external to the preprostatic sphincter.  The Prostatic stromal {supporting framework or matrix of a cell} and epithelial cells maintain a paracrine* type of communication whereby the growth of the Prostatic epithelium can be regulated by cellular interaction with the basement membrane and stromal cells.  There is strong evidence that stromal cell production of an excretory protein regulates epithelial cell differentiation.  BPH may therefore be due to defect in a stromal component that normally inhibits epithelial proliferation.  Androgens play a permissive role in BPH; thus castrated boys, when they age, do not develop BPH.  However, administering exogenous testosterone is not associated with a significant increase in BPH.  Dihydrotestosterone (DHT), a metabolite of testosterone and a critical mediator of prostatic growth is synthesized in the prostate from circulating testosterone by the action of the enzyme 5α-reductase, type 2.  The enzyme is localized principally in the stromal cells.  DHT binds to the androgen receptors and signals the transcription of growth factors for the stromal cells, and in a paracine* fashion by diffusion to epithelial cells.  mitogenic to the epithelial and stromal cells.  The importance of DHT in causing nodular hyperplasia is supported by the clinical observations that an inhibitor of 5α-reductase, which reduces DHT content, is given for BPH, and it reduces the prostate volume and in many cases relieves BPH symptoms. 


An additional vector is probably estrogen.  This is based on the fact that BPH occurs when men generally have elevated estrogen levels and relatively reduced free testosterone levels, and when prostate tissue becomes more sensitive to estrogens and less responsive to DHT. 


*  Paracrine:  Of, relating to promoted by, or being a substance secreted by a cell and acting on adjacent cells.



Rectal examination (palpation of the prostate through the rectrum) may reveal a markedly enlarged prostate.

Often, blood tests are performed to rule out prostatic malignancy: elevated prostate specific antigen (PSA) levels needs further investigations such as reinterpretation of PSA results, in terms of PSA density and PSA free percentage, rectal examination and transrectal ultrasonography. These combined measures can provide early cancer detection.

Ultrasound examination of the testicles, prostate and kidneys is often performed, again to rule out malignancy and hydronephrosis.



Various medical interventions including 5α reductase inhibitors and α-adrenergic blockers and a combination of both have been tried with modest success.  Industry sponsored studies of α-adrenergic blockers show a 20-30% increase in urinary flow rate and a 20-50% improvement in symptom scores.  5α-reductase inhibitors (Finasteride) inhibits the conversion of testosterone to dihydrotestosterone in the prostate.  A 1-year placebo-controlled study of 1229 men with BPH demonstrated no improvement in IPSS (questionnaire) and flow rate over placebo, and only a small improvement in volume of prostate (Cronn 701).     Transuretheral resection of the prostate (TURP) is standard.  TURP results in Erectile dysfunction in 5-35%; incontinence 1%; and retrograde ejaculation in 5-10%.  Less invasive procedures include intraurethral stents, balloon dilation, microwave thermotherapy, high-intensity focused ultrasound thermotherapy, laser ablation, electrovaporization, and radiofrequency vaporization.  The choices among these less invasive treatments have not been firmly established, and long-term ability to alter the natural history of BPH is under study. 


In a study of 556 men with moderate symptoms of BHP a comparison of treatment with transurethral resection of the prostate (TURP) to that of watchful waiting.  During a 3-year follow up, 8% of the TURP & 17 of the watchful waiting failed treatment. 


Saw Palmetto (Serenoa repens) is the most common herbal treatment for health of prostate and bladder.  However, a randomized, placebo-controlled study showed that saw palmento was associated with epithelial cell contraction, especially in the transition zone.  However, no significant improvement in symptom score or flow rate was observed (Cronn 701).  




Prostatitis refers to a disparate group of disorders some result from bacterial infection, and others from a poorly understood combination of noninfectious inflammatory factors and/or spasm of the muscle of the urogential diaphragm.  Diagnosis is clinical, along with microscopic examination and culture of urine samples obtained before and after prostate massage.  If bacterial, the post-message sample will be positive for bacteria and white blood cells.  Treatment is with fluoroquinolone {antibiotic derived from quinolone} (300 mg po bid of ofloxacin) if cause is bacterial.  Urine samples for inflammatory will contain only WBC; non-inflammatory no WBC.  Non-bacterial causes are treated with warm sitz baths, muscle relaxants, and anti-inflammatory drugs or anxiolytics {preventing or reducing anxiety}.   



Non-bacterial cause of prostatitis is more common and can be inflammatory or non-inflammatory.  Acute bacterial prostatitis often produces systemic symptoms as fever, chills, malaise, and myalgias {muscle weakness}, while chronic may occur without symptoms.  For chronic possibly pelvic pain and tenderness on examination.  




For more on the prostate http://healthfully.org/cvt/id2.html


Prostate cancer http://healthfully.org/cvt/id3.html