All you want to know about the prostate

Exocrine gland of male reproductive system.  A healthy human prostate is classically said to be slightly larger than a walnut(Akhrot). The  weight of the "normal" prostate in adult males is about 15 grams. It surrounds the urethra just below the urinary bladder and can be felt during a rectal exam.

Function: The function of the prostate is to secrete a fluid, milky or white in appearance that is usually about 50% of the volume of the semen.

Prostatitis:

Prostatitis is inflammation of the prostate gland-  just as tonsillitis is inflammation of the tonsils and appendicitis .

Acute prostatitis is an illness with symptoms very similar to urinary tract infection, often associated with flu-like symptoms and a high temperature. It is usually treated with antibiotics. It can lead to life threatening infection or prostatic abscess if not treated properlyespecially in immunocompromised patients.

Chronic prostatitis, on the other hand, tends to develop slowly. The symptoms are variable and  may be difficult to diagnose. Because the symptoms are so variable the disease has been renamed by some people as “chronic pelvic pain syndrome”.

Most men suffering from prostatitis complain of pain. This is sometimes severe, but may be a nagging persistent ache. The pain is often in the perineum (the area between the testicles and anus) but may be in the penis, testicles, upper thighs, bladder area or low back. The pain varies in intensity – this is one of the hallmarks of the disease. It may be worst after or during sexual activity – particularly immediately after ejaculation, or while passing urine.

Many men also complain of urinary problems. These may be similar to the symptoms of infection with some burning or stinging; or similar to the symptoms of BPH with difficulty passing urine, frequency and urgency.Some men complain of passing blood with their sperm when they ejaculate.

What causes prostatitis: 

In many cases we don’t know. There may be an associated urinary infection, and this is usually the case in acute prostatitis. In chronic prostatitis it may be possible to find evidence of a urinary infection but this isn’t usually the case. However many people think that prostatitis is caused by an infection deep within the prostate, where it is difficult to diagnose. Specimens of semen or of prostate secretions which can be obtained by massaging the prostate at rectal examination may help in diagnosis.Cystoscopy/semen culture /urodynamic test can be done whenever needed. 

Prostate masssage to express the prostatic secretions for diagnosis of infection(contra-indicated in acute infection as it can lead to fulminant infection)

Management

 A long (2-3 months) course of antibiotics is needed, Anti-inflammatory drugs, allopurinol, are sometimes of benefit. Prulifloxacin has been our drug of choice because of excellent prostate penetration.

Alpha-blocker drugs, such as Tamsulosin, may help particularly if there are associated urinary problems.

In case of prostatic abscess either trans rectal drainage or endoscopic deroofing with placement of suprapubic catheter with appropriate antibiotic therapy may be needed.

Enlarged prostate- Benign prostatic hyperplasia(BPH)

Benign prostatic hyperplasia is a very common condition in men. Unlike other organs in the body, the prostate gland continues to grow during every man’s lifespan.

The prostate grows gradually after the age of about 50 and by the age of 70, approximately 8 out of 10 men have an enlarged prostate.

Symptoms of BPH

The prostate gland grows like a doughnut around the urethra, the tube or ‘water pipe’ through which urine flows. The affect of having an enlarged prostate is like a kink developing in a water pipe – it blocks the normal flow of water. Not everyone with an enlarged prostate will develop symptoms; it depends how the prostate presses upon the urethra and lower bladder. If left untreated, an enlarged prostate resulting in urinary symptoms can lead to infections and  kidney damage especially in diabetics.

·         A weak flow of urine and taking longer to empty the bladder

·         Hesitancy – having to wait at the toilet before the urine starts to flow

·         Problems emptying – feeling your bladder is not empty after you have been to the toilet

·         Frequency – having to pass urine more often than before, often needing to get up several times during the night

 

Diagnosis of BPH

The doctor examines your prostate to feel how big it is.The per-rectal examination is done .Usually urine tests to know underlying infection,uroflwometry-to know the urine flow to assess how much blockage is caused by the prostate and serum PSA tests are done to rule out malignancy.

Managment:

Active monitoring

In some cases, it is best to monitor the patient and undertake regular assessments of the symptoms and their impact on the patient’s lifestyle. Immediate treatment may not be necessary; however it is important to assess the patient on a regular basis.

Medical treatment

Medication can be used to relax the muscle tissue around the bladder and in most cases, there is some improvement within days, with full benefits evident by six weeks. Patients may experience side-effects and different combinations of medicines are often used to ensure the greatest benefit. It is therefore critical that the medication is managed by a specialist in prostate disorders.

Surgery

Laser surgery is an effective, minimally invasive and treatment of choice for BPH. Comparing traditional TURP laser treatment results in much reduced blood loss, minimal pain, quicker recovery and much safer in cardiac patients, patients on anticoagulants and other comorbidities.

We in our hospital have state of art Thulium LASER for prostatectomy.it ensures prostate removal nothwithstanding the size(largest size we have removed is 230 gm),minimal blood loss,no TUR syndrome and can be done in cardiac frail patients who are on antiplatelet agents.   

Role of open surgery:

We do occasional open prostatectomies. We recently removed 460 gm prostate by suprapubic Freyers method in a gentleman.This , as per literature review is the second biggest gland in India and biggest gland in South India.  

Open surgery being performed by enucleation from suprapubic incision.

Prostate cancer

One of the most common cancer affecting male patients

Cancer in the prostate, like cancer in other parts of the body. These cancer cells can invade and destroy tissue surrounding them.

Men with the condition often have no symptoms of prostate cancer .This means that some men with fast-growing cancers are not diagnosed in time for curative treatment

Prostate cancer risk

We do not know exactly why some men develop prostate cancer and others do not, but it is clear that both genetic and lifestyle factors are significant

Risk factors for prostate cancer include:

Age

The older men get, the more likely they are to develop cancer in their prostate.

Obesity

This is understood to influence the type of prostate cancer you may develop, increasing your risk of having more aggressive forms of the disease.(Metabolic syndrome).

Diet

Studies show there is a link between diet and prostate cancer risk.(High fat diet)

Symptoms of prostate cancer

Very often, men do not experience any prostate cancer symptoms. Equally, it is very important to bear in mind that symptoms associated with prostate cancer are also likely to be caused by other conditions, particularly benign prostatic hyperplasia (BPH)also known as the enlarged prostate.

These are the symptoms you need to be aware of:

·         blood in the urine

·         frequent need to go to the toilet, particularly at night

·         weak urine flow that stops and starts

·         inability to urinate (urinary retention)

·         persistent pain in the back, thighs and pelvis(bony pain)

·         

Bone scan showing bony spread; prostate cancer has affinity for bony archetecture. So bony pains can sometimes be only symptoms in aged people.

Assessment of prostate cancer

Digital rectal examination for any palpable nodules or asymmetry in the prostate. 

Serum PSA testing. 

The PSA test for prostate cancer is an important tool in understanding prostate cancer risk and diagnosis of prostate cancer in combination with TRUS guided biopsy of the prostate. In addition CT or MRI and bone scan may be required for determination of local and systemic spread of prostate cancer.

We conduct TRUS guided biopsy under sedation (10-12 core biopsy) ; being performed by urologist and monitored by the anaesthetist.It is made totally painless and antibiotic cover is given to prevent post biopsy infections. 

Treatment of prostate cancer

Treatment of prostate cancer depends on age of the patient, local and systemic involvement with  prostate and general well being of the patient.

Options include Radical prostatectomy, HIFU, radiotherapy, Hormonal therapy and chemotherapy.

We render comprehensive care for prostate cancer.We routinely perform laparoscopic prostatectomies.

  Our centre is the only centre providing facility for HIFU.It is noninvasive ultrasonic ablation of the prostate gland with a robotic arm.( http://drramayyas.blogspot.in/2010/03/hifunew-hope-for-early-prostate-cancer.html)