Diseases of Male Genital Organs-2 (Prostatic Disorders) PDF

Diseases of male genital organs- 2 (prostatic disorders) BY DR. HUSAMELDIN OMER MOHAMED OMER  Disorders of the prostate gland (DPG) Prostate disorders that are common in men include inflammation (prostatitis), enlarged prostate (benign prostatic hyperplasi...

Diseases of male genital organs- 2 (prostatic disorders) BY DR. HUSAMELDIN OMER MOHAMED OMER  Disorders of the prostate gland (DPG) Prostate disorders that are common in men include inflammation (prostatitis), enlarged prostate (benign prostatic hyperplasia (BPH), and prostate cancer. Inflammation of the prostate (prostatitis) Acute prostatitis: The organism reaches prostate from posterior urethra. The common causative organisms are: Gonococci, E coli, Klebsiella, Proteus, and Pseudomonas. Prostate gland Morphology:  Gross: the gland is enlarged, swollen and tender.  Microscopic: Infiltration of the prostatic tissue by many polymorphnuclear leucocytes, Edema. Vascular dilatation. Clinically:  Fever, chills, body aches, nausea, or vomiting  Dysuria.(burning when urinating, frequent, sudden, or urgent need to urinate.  Difficulty urinating, or a weak urine stream  Pain in lower abdomen and sometimes tender prostate. Chronic ( non specific) prostatitis:  May be asymptomatic or associated with pain in the genital area, lower abdomen, or lower back beside dysuria.  Men with chronic bacterial prostatitis often have repeated urinary tract infections (UTIs)  Examination of prostatic secretion after prostatic massage showed many leukocytes.  Histopathologic diagnosis is less crucial for diagnosis.  Most cases appear insidiously without previous acute prostatitis. Chronic specific granulomatous prostatitis:  TB.  Schistosomiasis. Chronic non specific granulomatous prostatitis:  Relatively common.  Represents a reaction to secretions from ruptured prostatic ducts and acini.  Microscopic: granulomatous reaction. Granulomatous prostatitis  Benign prostatic hyperplasia (BPH) Very common after the age of 50 years and then increase with age. Pathogenesis: The precise cause of BPH is not fully understood, though it is associated with the exposure of cells within the prostate to a hormone known as dihydrotestosterone in aging men. This hormone stimulates the proliferation of certain cells in the prostate, which results in an enlarged prostate gland. Morphology: Gross:  For gross assessment, the excisional biopsy is taken by the one piece prostatectomy method (now is rare).  The gland is enlarged by nodules of variable size.  The urethral lumen may be compressed and become very narrow.  The median lobe may project into the bladder making obstruction. Benign prostatic hyperplasia, gross Microscopic: Transurethral resection of prostate (TURP) is usually done for microscopic examination. However, rarely the prostatectomy is done with laparotomy as total one piece. The nodules are composed of hyperplastic glands and fibromuscular stroma with dilatation of the glands and cystic formation. Areas of squamous metaplasia and infarcts may occur. Prostatic chips by TUR BPH, microscopic Clinical effects and complications of BPH:  Frequent urination and nocturia (urination at night).  Difficulty in starting and stopping the stream of urine.  Attacks of cute urinary retention.  Chronic urinary stasis with resultant bacterial overgrowth and urinary tract infection.  Chronic obstruction may result in: hypertrophy of the urinary bladder and hydronephrosis  Carcinoma of the prostate  One of the most common malignant tumors in men.  Occurs predominantly in men over the age of 50 years.  Not related to benign prostatic hyperplasia.  Almost all prostate cancers are adenocarcinomas. Other rare types of cancer that can involve the prostate include, small cell neuroendocrine carcinoma, large cell carcinoma transitional cell carcinoma and sarcomas Etiology is unknown, but many factors may have a role:  Age; old age (often appears after 55 year old).  Race: common in blacks than whites.  Hormonal influences: high testosterone.  Genetic factors.  Environmental factors (i.e. high incidence in certain geographic areas).  Prostatic intraepithelial neoplasia (PIN). Clinical diagnosis Based on patient symptoms, the doctor may advise a digital rectal exam (DRE), blood tests such as the prostate-specific antigen (PSA) test, and a urinalysis. Symptoms of Prostate Cancer include; ❖ Difficulty starting urination and weak interrupted flow of urine. ❖ Frequent urination and nocturia. ❖ Pain or burning during urination and during ejaculation. ❖ Blood in the urine or semen. ❖ Pain in the back, hips, or pelvis that doesn't go away. Digital rectal exam (DRE) Morphology: Gross: The tumor arises most commonly in the periphery of the gland especially in the posterior part and often not involve the whole gland It forms nodular masses (solitary or multifocal), yellowish gray homogeneous on cut surface. Prostatic carcinoma, gross Microscopic: Clinical and radiological features neither sensitive nor specific This examination often preceded by nontargeted needle biopsies investigating raised serum prostate specific antigen (PSA) Most prostatic carcinomas are adenocarcinoma, ranging from well differentiated lesions to poorly differentiated neoplastic cells. The main diagnostic histological changes include the followings; ❖ The presence of small glands that closely packed together ❖ Absence of basal cell layer at parts of the glands ❖ Infiltrative architecture (loss of polarity) ❖ Large hyperchromatic nuclei and nucleolar prominence (increase in size and number of nucleoli) ❖ Amphophilic cytoplasm (staining with both acid and basic dyes) ❖ Circumferential perineural invasion ❖ Appearance of some intraluminal contents (crystalloids, blue mucin, pink amorphous material) Prostatic carcinoma, microscopic Normal prostate carcinoma of prostate Prostatic carcinoma high power Grading of the tumor:  is now made according to the modified Gleason score (instead of the original old scoring of 5). It depends on the over all glandular pattern including cellular atypia (assessed by low power microscopy) without regard to cytologic features only as usually done in other systems of grading that based on high power views.  The modified Gleason grading system refers to how likely the cancer is expected to advance and spread. A lower grade means that the cancer is slower growing and is less aggressive and in better prognostic degree.  The old scoring was based on the score of atypia of the glandular pattern from 1 to 5 in this way Grade 1 means that the glands look almost like normal prostate glands. Grade 5 means that the glands look and situated very different from normal prostate glands. The modified Gleason score is determined by adding the two most common grades together. For example, the most common grade atypia of tissue sample may be grade 3 followed by grade 4. The modified Gleason score for this sample would be 7. Based on these differences of atypia in this newer system the prostate cancers is braked into 5 grade groups in this way; Grade group 1 = Gleason 6 or less (the best group) Grade group 2 = Gleason 3 + 4 = 7. Grade group 3 = Gleason 4 + 3 = 7. Grade group 4 = Gleason 8. Grade group 5 = Gleason 9 or 10. (the worst group) Staging of the tumor: It is made according to TNM system: Stage T1: refers to cancer found incidentally during TURP. This stage is further divided into T1a, T1b, T1c. Stage T2: is organ-confined tumor. Stage T3a & T3b: shows extra-prostatic extension, with or without seminal vesicle invasion. Stage T4: reflects direct invasion of contiguous organs. Prognosis of prostatic carcinoma:  It depends on the grading and staging of the tumor . Grade group 5 = Gleason 9 or 10. is the worst group  T1 & T2 tumors are treated by surgery and radiotherapy, with a 15 year survival rate of 90%.  Advanced tumors with metastasis have poor prognosis. Prostate specific antigen (PSA):  Its measurement is used in diagnosis and management of prostatic carcinoma.  PSA is a product of prostatic epithelium, its normal level in the serum is about 4 ng/ml.  PSA is organ specific, but not cancer specific.  Monitoring PSA levels is useful in assessing response to therapy or progression of the disease.