PROSTATE GLAND

Dr.Rumsheed necholi
1ST M.D, REP

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 The prostate from Greek word prostates,
literally "one who stands before", "protector",
"guardian

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 Prostrate is a compound
tubuloalveolar exocrine gland of
the male reproductive system.

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 The prostate (approximately 3 cm long, 4
cm wide, and 2 cm in AP depth) is the
largest accessory gland of the male
reproductive system, The normal prostate
weighs approximately 20 g

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 Structure
A healthy human prostate is slightly larger
than a walnut. It surrounds the urethra just
below the urinary bladder and can be felt
during a rectal exam. It is the only exocrine
organ located in the midline in humans and
similar animals.
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 The ducts are lined with transitional
epithelium.
Within the prostate, the urethra coming from
the bladder is called the prostatic urethra and
merges with the two ejaculatory ducts. The
prostate is sheathed in the muscles of the
pelvic floor, which contract during the
ejaculatory process.
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  The prostate can be divided in two different ways: by zone,
or by lobe

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 Zones of prostrate
 The "zone" classification is more often used in pathology.
 Peripheral zone (PZ)
 Composes up to 70% of the normal prostate gland in young
men
It is from this portion of the gland that more than 64% of
prostratic cancers originate.

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  Central zone (CZ)
 Constitutes appro 25% of the normal prostate gland
 This zone surrounds the ejaculatory ducts. The central zone
accounts for roughly 2.5% of prostate cancers although these
cancers tend to be more aggressive and more likely to invade
the seminal vesicles

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  Transition zone (TZ)
 Responsible for 5% of the prostate volume at puberty.
 Prostate cancer originates in this zone in roughly 34% of
patients. is the region of the prostate gland that grows
throughout life and is responsible for the disease of
benign prostatic enlargement.

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  Anterior fibro-muscular zone (or stroma)

Accounts for appro: 5% of the prostatic

weight
This zone is usually devoid of glandular
components, and composed only, as its
name suggests, of muscle and fibrous
tissue
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 Lobes
 The "lobe" classification is more often used in anatomy.
 Anterior lobe (or isthmus)
roughly corresponds to part of transitional zone, lies
anterior to the urethra.

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  Posterior lobe
roughly corresponds to peripheral zone . lies posterior
to the urethra and inferior to the ejaculatory ducts it is
readily palpable by digital rectal examination.

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  Lateral lobes
spans all zones, on either side of the urethra form
the major part of the prostate
 Median lobe (or middle lobe)
roughly corresponds to part of central zone, lies
between the urethra and the ejaculatory ducts and is closely
related to the neck of the bladder

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 ARTERIES  
 The prostate is supplied by branches from the
 inferior vesical,
 internal pudendal and
 middle rectal arteries.

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 VEINS
The chief tributary is the deep dorsal vein of the penis and
drains into vesical and internal iliac veins.

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 lymphatics
Collecting vessels from the vas deferens end in the
external iliac nodes, while those from the seminal vesicle
drain to the internal and external iliac nodes.

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 INNERVATION
   The prostate has an abundant nerve supply from the
inferior hypogastric (pelvic) plexus
 

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 AGE CHANGES IN THE PROSTATE
At birth, the prostate has a system of ducts
embedded in a stroma which forms a large part of the gland.
Follicles are represented by small end-buds on the ducts.
Before birth there is hyperplasia and squamous metaplasia of
the epithelium of the ducts, colliculus seminalis and prostatic
utricle, possibly due to maternal oestrogens in the fetal
blood. This subsides after birth and is followed by a period of
quiescence lasting for 12-14 years.

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  At puberty, between the ages of approximately 14 and 18 years,
the prostate gland enters a maturation phase: it more than doubles
in size during this time. Growth is almost entirely due to follicular
development, partly from end-buds on ducts, and partly from
modification of the ductal branches. Morphogenesis and
differentiation of the epithelial cords starts in an intermediate part
of the epithelial anlage and proceeds to the urethral and
subcapsular parts of the gland; the latter is reached by the age of
17-18 years. The glandular epithelium is initially multilayered
squamous or cuboidal, and is transformed into a pseudostratified
epithelium consisting of basal, exocrine secretory (including
mucous) and neuroendocrine cells..

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  The mucous cells are temporary, and are lost as the gland
matures. The remaining exocrine secretory cells produce a
number of products including acid phosphatase, prostate-
specific antigen and β-microseminoprotein. This growth of
the secretory component is associated with a condensation of
the stroma, which diminishes relative to the glandular tissue.
These changes are probably a response to the secretion of
testosterone by the testis

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 During the third decade the glandular epithelium grows by
irregular multiplication of the epithelial in foldings into the
lumen of the follicles.
  After the third decade the size remains virtually
unaltered until 45-50 years, when the epithelial foldings tend
to disappear, follicular outlines become more regular, and
amyloid bodies increase in number. All these changes are
signs of prostatic involution. .

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 After 45-50 years the prostate tends to develop BPH.
The nature of BPH has been outlined earlier in this chapter.
It is an age-related condition: if a man lives long enough then
it is inevitable, although it is not always symptomatic

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 Function
 1.The function of the prostate is to store and secrete a
slightly alkaline (pH 7.29) fluid, milky or white in
appearance, that usually constitutes 25-30% of the volume of
the semen along with spermatozoa and seminal vesicle fluid.
 2. The alkalinity of semen helps neutralize the acidity of the
vaginal tract, prolonging the lifespan of sperm.

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 3.The prostatic fluid is expelled in the first ejaculate fractions
together with most of the spermatozoa. In comparison with
the few spermatozoa expelled together with mainly seminal
vesicular fluid those expelled in prostatic fluid have better
motility, longer survival and better protection of the genetic
material (DNA).
 4.The prostate also contains some smooth muscles that help
expel semen during ejaculation.

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 Applied anatomy
PROSTATITIS
Inflammation of the prostate gland may be acute or
chronic.
It can be caused by the same bacteria that
are associated with UTI or, more commonly, may be 'non-
bacterial' .

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  Clinical features
 frequency, dysuria, perineal or groin pain, difficulty passing
urine and, in acute disease, considerable systemic
disturbance.
 O/E The prostate is enlarged and tender. Bacterial
prostatitis is confirmed by a positive culture from urine or
from urethral discharge obtained after prostatic massage

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 PROSTATE CANCER
Prostatic cancer is common in northern Europe and the USA
(particularly in the black population) but rare in China and
Japan. In the UK it is the second most common malignancy
in males, with a prevalence of 50 cases per 100 000
population, and is increasing in frequency. It rarely occurs
before the age of 50 and has a mean age at presentation of 70
years.

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  Prostate cancers arise within the peripheral zone of the
prostate and almost all are carcinomas. Metastatic spread to
pelvic lymph nodes occurs early and metastases to bone,
mainly the lumbar spine and pelvis, are common. Prostatic
specific antigen (PSA) is a good tumour marker and 40% of
patients with a serum PSA > 4.0 ng/ml will have prostate
cancer on biopsy.  

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  Clinical features  
Most patients present with lower urinary tract symptoms
indistinguishable from BPH.
Symptoms and signs due to metastases are much less
common and include back pain, weight loss, anaemia and
obstruction of the ureters.
 

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  On rectal examination the prostate often feels nodular and
stony hard,. However, 10-15% of tumours are not palpable.
 

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  Investigations
1.ultrasound scan and serum creatinine determination are
used to assess the urinary tract.
2. A plain X-ray of the pelvis and lumbar spine (to
investigate backache) may show osteosclerotic metastases as
the first evidence of prostatic malignancy.

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 3. radioisotope bone scan- for distant metastases
4.serum PSA (> 100 ng/ml) almost always indicate distant
bone metastases. PSA is most useful for monitoring response
to treatment and disease progression

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 BENIGN PROSTATIC HYPERPLASIA
 From 40 years of age the prostate increases in volume by 2.4
cm3 per year on average. The process begins in the
transitional zone and involves both glandular and stromal
tissue to a variable degree.
Associated symptoms are common from 60
years of age, and some 50% of men over 80 years will have
lower urinary tract symptoms associated with benign
prostatic hyperplasia (BPH).

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 Clinical features
The primary symptoms of BPH are due to the
prostate obstructing the urethra; they consist of hesitancy,
poor prolonged flow and a sensation of incomplete
emptying. Secondary (irritative) symptoms comprising
urinary frequency, urgency of micturition and urge
incontinence are not specific to BPH. .

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  Patients may present more dramatically with a/C urinary
retention when they are suddenly unable to micturate and
develop a painful distended bladder. This is often
precipitated by excessive alcohol intake, constipation or
prostatic infection. It is an emergency and requires the
bladder to be drained by a catheter to relieve the retention.

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  In c/C urinary retention the bladder slowly distends due to
inadequate emptying over a long period of time. This
condition is characterised by pain-free bladder distension
which may result in hydroureter, hydronephrosis and renal
failure. Patients with chronic retention can also develop
acute retention: so-called acute on chronic retention. They
require careful management because of their renal failure.

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  DETERMINING THE INTERNATIONAL PROSTATE
SYMPTOM SCORE (IPSS) AND QUALITY OF LIFE
SCORES

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IPSS NOT AT Less Less About More ALMOST
ALL ALWAYS
than 1 than half half the than
time in 5 the time
time half the
time
1. Straining 0 1 2 3 4 5

2. Weak 0 1 2 3 4 5
stream
3. 0 1 2 3 4 5
Intermittenc
y
4. 0 1 2 3 4 5
Incomplete
emptying
5. 0 1 2 3 4 5
Frequency
6. Urgency 0 1 2 3 4 5
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7. Nocturia 0 1 2 3 4 5
  Patients ring their scores.
 Total scores: 0-7 = mild symptoms;
 8-19 = moderate symptoms;
20-35 = severe symptoms
In addition, consider the quality of life score below

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  Quality of life due to urinary symptoms

QUALITY Delighte Pleased Satisfied Mixed Dissatisfie Unhapp Terrible

OF LIFE d d y

URINARY
SYMPTOM 0 1 2 3 4 5 6
S

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 Repertory part
 Synthesis repertory
 PROSTATE GLAND - CANCER of prostate - CON.
THUJ.
- pain, with crot-h.
PROSTATE GLAND – SWELLING - BAR-C.. CALC..
CHIM. CON.. DIG.. PULS.

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 PROSTATE GLAND - SWELLING - old people; in -
BAR-C.. DIG. SEL.

PROSTATE GLAND – INFLAMMATION - PULS.

- chronic- Aur.. Con. Ferr-pic.. Kali-bi. Lyc.
Merc.. Nit-ac. Nux-v.. Puls.. Sabal Sel.. Sep.. Staph.
Thuj. Trib

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  Sequalae of gonorrhea
 Induration of the prostate gland
When neither paralysis of the bladder nor inflammation of its
neck (in bad cases of gonorrhoea), nor a stone in the bladder,
is the cause of the retention of urine, and when the
introduction of the bougie or sound into the urethra detects
no stone nor stricture, and yet the urine will not flow in
spite of every effort, we may suspect a morbid condition of
the prostate gland.

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 . A finger moistened with oil is to be introduced into the
rectum and directed towards the pubic region. If this be the cause
of the retention, we shall here detect a hard body pressing in upon
the rectum, often of such a size that we are obliged to pass the
finger from one side to the other in order to ascertain the whole
magnitude of this indurated prostate gland.
We may easily imagine to what a considerable extent this
tumefied body must compress from both sides, and block up the
commencement of the urethra, and how dangerous retention of
urine may result therefrom.

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 . In such cases the ejaculation of the semen is very painful.
. A bougie 2 or catheter carefully introduced will easily draw
off the urine; but this is only a transient remedy. The best
plan is to insert an elastic catheter and to assist its passage
through the neck of the bladder by introducing a finger into
the rectum.

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  If we could with certainty disperse this glandular induration,
we should then be able to promise ourselves permanent
benefit, a cure. But as yet we know no remedy that can be
relied on.

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  The internal use of hemlock has sometimes been of use, also
burnt sponge, but especially burnt sea-weed and sea-bathing,
as this affection is often of a scrofulous nature. Poultices of
mandragora root frequently applied to the perinaeum are
said to have proved very efficacious in dispersing this
indurated gland. Purple foxglove, crude antimony, hartshorn
and electricity, perhaps also local fumigations with cinnabar,
might be tried.

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  A seton inserted and long maintained in the perinaeum the
openings of which were two inches distant, once succeeded
in reducing to a great extent an indurated prostate.

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  The best palliative remedy is, immediately after withdrawing
the bougie to insert in the bladder, according to Pichler's
plan, a catheter of gum elastic (without any spiral wire in its
cavity) to let the urine flow through it, to fasten it in front of
the glans and close up its extremity, only removing it about
once a week in order to remove the calculous concretion that
may be attached to it.

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  . If, in a case of swelling of this sort, the urine do not flow on
the introduction of an ordinary catheter, and if the
instrument encounter an obstacle just behind the neck of the
bladder (a rare affection which Hunter has best described), it
is to be apprehended that a small swollen portion of the
indurated prostate projecting into the bladder forms here a
sort of valve, which lies upon the mouth of the bladder and
obstinately prevents the egress of the urine.

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  In this case a very much curved, large-sized bougie
introduced into the bladder has sometimes proved
serviceable, the urine flowing past it. If this should not be
effectual, we should carefully introduce a catheter, and
whenever it has reached this valve-like projection, press it
with the handle downwards, whereby its further bent
extremity will almost always slip past and to the outside of
the abnormal body into the bladder, and permit the urine to
flow off.

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 Benzoic acid
 Enuresis nocturna of delicate children; dribbling urine of old
men with enlarged prostate; strong characteristic odor;
excesses of uric acid.
 Catarrh of bladder after suppressed gonorrhoea.
 A gouty, rheumatic diathesis engrafted on a gonorrhoeal or
syphilitic patient.
 Urine dark brown, and the urinous odor highly intensified.

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 Conium mac
 Great difficulty in voiding urine; flow intermits, then flows
again; prostatic or uterine affections.

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 iodum
 Hypertrophy and induration of glandular tissue_thyroid,
mammae, ovaries, testes, uterus, prostate or other glands
Persons of a scrofulous diathesis, with dark or black hair and
eyes; a low cachectic condition, with profound debility and
great emaciation
Ravenous hunger; eats freely and well, yet loses flesh all
the time

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 Merc dulcis
 Acute affections of prostate after maltreated stricture.

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 staphisagra
 Urging to urinate, has to sit at urinal for hours; in young
married women; after coition; after difficult labor (Op.);
burning in urethra when not urinating; urging and pain after
urinating in prostatic troubles of old men; prolapse of
bladder.

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 alfalfa
 Its pronounced urinary action suggests it clinically in diabetes
insipidus and phosphaturia; and it is claimed to allay vesical
irritability of prostatic hypertrophy.

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 Barosma crenulatum
 * Marked specific effects on genito-urinary system; muco-
purulent discharges.
 * Irritable bladder, with vesical catarrh; prostatic disorders.

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 Barayta carb
 Diseases of old men when degenerative changes begin; -
cardiac vascular and cerebral; - who have hypertrophied
prostate or indurated testes, very sensitive to cold, offensive
foot-sweats, very weak and weary, must sit or lie down or
lean on something.
 Diminished desire and premature impotence.
 - Enlarged prostate.

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 Carbolic acid
 Irritable bladder in old men with frequent urination at night,
of probable prostatic nature.
 - Use 1x.

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 chimaphilia
 Acute prostatitis, retention, and feeling of a ball in
perineum. [Cann. ind.] Fluttering in region of kidney
 Loss of prostatic fluid.
 - Prostatic enlargement and irritation.

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 Eryngium aquaticum
 Irritable bladder from enlarged prostate gland, or from
pressure of uterus.
 - Discharge of prostatic fluid from slight causes.

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 Fabinana imbricata
 Useful in the uric acid diathesis, cystitis, gonorrhoea,
prostatitis, dysuria, vesical catarrh with suppurative prostatic
conditions; post-gonorrhoeal urinary conditions;
cholelithiasis and liver affections.

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 Gaultheria procumbens
 * Cystic and prostatic irritation, undue sexual excitement,
and renal inflammation.

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 Sebal serrulatta
 Sabal is homoeopathic to irritability of the genitourinary
organs.of unquestioned value in prostatic
enlargement,epididymitis and urinary difficulties.
acts on the membrano-prostratic portion of the
urethra
Prostatic troubles, enlargement, discharge of prostatic fluid.
Constant desire to pass urine at night. Difficult urination.
Cystitis with prostatic hypertrophy.

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 digitalis
 In old cases of enlarged prostate gland I do not know what I
would do without Digitalis.
 It diminishes the size of the prostate gland and has many
times cured.
 now remember the liver and the heart symptoms, the
jaundice, the slow pulse, the awful sinking in the stomach,
the enlargement of the prostate gland, the gray stool, and
you have the principal symptoms of Digitalis

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  Enlarged prostate. Dropsical swelling of genitals. Continued
urging to urinate, in drops, dark, hot, burning, with sharp
cutting or throbbing pain at neck of bladder, as if a straw was
being thrust back and forth, worse at night. Full feeling after
urination

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 Spiraea ulmaria
 Relieves irritation of the urinary passages; influences the
prostate gland; checks gleet and prostatorrhoea

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 Stigmata maydis
 Has marked urinary symptoms, and has been used with
success in organic heart disease, with much oedema of lower
extremities and scanty urination.
 * Enlarged prostate and retention of urine.

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 Triticum repens
 - Catarrhal and purulent discharges. [Pareira.]
 - Strangury, pyelitis; enlarged prostate.
 - Chronic cystic irritability.
 - Incontinence; constant desire.
 - Urine is dense and causes irritation of the mucous surfaces.

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