Recall what pathology involves each prostatic zone.
Central - Infections, prostatitis
Peripheral - Cancers
Transitional - BPH
Describe the normal histology of the prostate. What tissue types are present? What cells?
Normal prostate divided into stromal and glandular tissue.
Glandular tissue is lined by a double layer of secretory (columnar) and basal (stem) cells.
What are some typical causes of acute prostatitis?
Infections or irritants, often facilitated by reflux from the urethra.
Pathogens are usually gram-negative rods: E. Coli, P. Aeruginosa, K. Pneumoniae
Describe the pathogenesis of chronic prostatitis.
Chronic prostatitis is usually abacterial (culture-negative), but result from multiple bacterial infections causing bouts of acute prostatitis.
Chronic prostatitis is often culture-negative. What is this condition also known as, and what organs may actually be responsibile?
"Chronic Pelvic Pain Syndrome" (CPPS)
Chlamydia Trachomatis, Ureaplasma Urealyticum, and Trichomonas Vaginalis appear to be implicated. However, it is unclear if this is due to occult infection or residual damage.
Compare and contrast the clinical presentation of acute and chronic prostatitis.
Acute: Fever, pain (lower back, perineal, or suprapubic), swelling, and dysuria/hematuria.
Chronic: As above, but may be asymptomatic.
Note: PSA elevation in either (<4)
A patient presents several times for evaluation of prostatitis. Each time the culture comes back positive for UPEC. Urine microscopy reveals 12 wbcs per high-power field.
What is the diagnosis, and why is this happening?
Chronic bacterial prostatitis.
Calculi in the prostate may be colonized by bacteria--UPEC is especially adept at this.
Describe the appearance and some possible causes of granulomatous prostatitis.
Histology reveals epithelioid histiocytes.
Causes: Infectious (TB/opportunistic mycoses), non-infectious (post-surgery/BCG)
BPH is a disease of the glands and stroma of the ____ zone. By age 80, __% of men will have developed it. It manifests chiefly as a result of _____, and so may be treated by _____.
Describe the clinical syndrome it causes.
Transitional zone, affecting 90% of men over 80, chiefly due to DHT, so treat with 5a-reductase inhibitors (eg Finasteride)
Causes bladder outlet obstruction: Frequency, incomplete emptying, nocturia, dysuria (LUTS - Lower urinary tract symptoms)
What is the function of PSA?
What is it for in the context of prostatic diseases?
Name 3 conditions which may elevate it.
It is a proteolytic enzyme: Increases sperm motility by liquefying semen.
It is elevated in a wide range of prostate conditions (note that it is therefore nonspecific)
Prostatitis, BPH, Prostatic carcinoma.
What is TURP?
What benefit may it confer?
Trans-urethral resection of prostate.
May relieve urinary obstruction due to BPH, and may reveal occult formation of pancreatic cancer.
What is the precursor to prostatic cancer?
What risk does it signify?
High-grade prostatic intraepithelial neoplasia (HGPIN).
In combination with elevated PSA, portends a 25-30% risk of cancer.
Note: Does not elevate PSA itself.
What is the appearance of BPH on histology?
Nodules of both glandular and stromal tissue.
Describe the epidemiology of prostate cancer: How abundant is it? How dangerous? Who is at risk?
Lecture says #1 cancer in incidence; actually Lung cancer is.
Lecture says #2 cancer in deaths; this is true for men.
Age is the only mentioned risk factor.
How do we screen for prostatic cancer?
Describe the scheduling of this screening
PSA blood tests and digital rectal exams.
Screen annually starting at age 50 (if family history positive or african-american, start at age 40)
Describe the grading system for prostate cancer.
The Gleason grading system:
Each cancer gets two grades, one for the most common and one for the least common patterns. Each score is 1-5 based on architecture only; scoring tends to start at 3 however. Add the scores together.
Describe the histological appearance of the prostate as it progreses through Gleeson grades 3-5.
Grade 3: Small & separate glands, loss of the double-cell layer, and infiltrative patterning.
Grade 4: More gland fusion, prominent nucleoli.
Grade 5: Total loss of lumen spaces. Single cells.
What is grade 1 prostatic adenocarcinoma?
Why is it "graded" as "3"?
Atypical adenomatous hyperplasia.
Patterns 1, 2, and 3 all have the same biologic potential for cancer. Apparently.
Try to recall the subtle differences between each STAGE of prostate cancer:
T2a, T2b, T2c
T1a (incidental TURP finding, <5% of tissue), T1b (>5% of tissue)
T2a (confined to half a lobe), T2b (one lobe), T2c (both lobes)
T3a (extraprostatic fat invasion), T3b (seminal vesicle involvement)
T4 (invaded nearby structures)
Describe the pattern by which prostate carcinoma spreads.
What are some clinical consequences of this?
Spreads especially to seminal vesicles, but also external iliac nodes and lower axial skeleton (via Batson venous plexus)
Sample the external iliac nodes. Bony spread causes back/pelvic pain, elevated Alk-Phos, compression of spinal cord. Massive PSA increase?