What Prostate Does and Prostate BPH

The Prostate Gland: Anatomy, What Prostate Does, Diseases And Treatments

The prostate gland is a reproductive organ seen in males. It is also the largest accessory reproductive male organ. It is situated inferiorly to the bladder and it produces enzymes, the proteolytic enzymes that help to fine-tune the semen and keep it in a fluid state for easy movement around the female reproductive system after ejaculation for fertilization to occur.

This article will focus on discussing the prostate gland, what prostate does, and its clinical relevance (1).

Anatomy Of The Prostate Gland

The prostate gland is a walnut-size gland located immediately below the bladder neck, above it is the urethral sphincter externally, and the levator ani muscle is located inferiorly and laterally to the prostate gland.

Behind the prostate is the ampulla of the rectum which allows for a good digital rectal examination to be done effectively in assessing the prostate by a physician. The prostate gland contains ducts called the prostatic ducts through which the proteolytic enzymes are secreted, passing through the prostatic urethra before releasing it into the semen just before ejaculation occurs.

Clinically, the prostate gland has been divided into three zones histologically, these are:

The central zone: The central zone is made up of one quarter, that is 25% of the entire prostate gland volume.
Transitional zone: The transitional zone amount to 10% of the total prostate gland volume and it goes around the urethral centrally. Benign prostatic hypertrophy, prostrate bph, commonly occurs at this transitional zone.
Peripheral zone: The peripheral zone is located behind and amounts to 65% of the total prostate gland volume. The peripheral zone is prone to a high level of inflammatory changes which has been linked by research to the high rate of prostate carcinoma occurring at the peripheral zone. During a digital rectal examination, DRE examines the prostate, the palpable area is usually the peripheral zone.

There is a fourth zone, scientifically referred to as the fibromuscular stroma, and has been argued not to be present in every prostate. The fibromuscular stroma is situated directly in front of the prostate and has a connection with the urogenital region, particularly the urogenital diaphragm (2).

What Prostate Does

There are quite several functions the prostate performed, however, it is not an organ required to stay alive as a man can live long with or without a prostate. But, the prostate gland is required for reproductive function. Some of its functions medically are:

Sperm production

The main function of the prostate gland is the production and secretion of prostatic fluid being transported to the semen. The prostate is responsible for the production of one-quarter of the total fluids that make up semen. The remaining 75% comes from the seminal vesicles and the testicles.

The fluid component of the semen ensures the free transport of sperm through the urethra toward the egg for fertilization to occur. The fluid from the prostate is mainly acidic, however, the other components of the semen make it basic (alkaline), another to protect the sperm from the acidic nature of the vagina which can harm the sperm and render it inactive.

Closure of urethral

Part of what prostate does is to ensure the closure of the urethra to permit only sperm movement during ejaculation. During ejaculation when contraction of the prostate takes place, it leads to the closure of the orifice lying between the bladder and the urethra permitting only the semen to be expelled at the time. Biologically, this information expatriate why it is difficult to ejaculate while urinating simultaneously.

Metabolism of hormones

In other, for the prostate to effectively perform its functions, it requires the use of testosterone, which is the male sex hormone. The enzyme 5-alpha reductase possessed by the prostate will help to synthesize the dihydrotestosterone from testosterone which is required for the development of the prostate gland and other secondary sexual characteristics (1).

Common diseases of the prostate gland: Prostate Cancer and Enlarged Prostate

The following are common diseases associated with the prostate gland:

Prostatitis
Prostate BPH, Beningn prostatic hyperplasia
Prostate cancer
Prostate with calcification (3)

1. Prostate conditions, such as Prostatitis

Inflammation of the prostate that usually occurs as a result of an infectious process is termed prostatitis. Prostatitis is a common disease among men, especially in middle age, and about 50% of men will be affected by prostatitis in their lifetime. Prostatitis is not an automatic risk factor for developing other prostate diseases.

Symptoms of prostatitis

The followings are the symptoms and signs often manifested by patients with prostatitis

Difficulty in urinating
Dysuria, which is pain while passing urine
Fever and chills
Body pain
Low back pain
Lower abdominal pain
Suprapubic pain
Sometimes, pain in the groin area
Urethra discharge
Low libido
Erectile dysfunction
Pain during ejaculation

Types of prostatitis and treatment

Acute bacterial prostatitis

Acute bacterial prostatitis is an inflammation of the prostate that started suddenly, by a bacteria pathogen, and is usually characterized by severe pain and fever. Sometimes, the patient can present with bloody urine and hematuria.

Acute bacterial prostatitis is not a common presentation at the clinic because most patients don’t present early. However, when it is picked earlier, it is the easiest to treat.

Prostate-specific antigen level, PSA should be done to screen out other prostate diseases, although the PSA level in prostatitis can also be mildly elevated.

Most patients with acute prostatitis will do well on antibiotics medication for one to two weeks and the dose should be gradually tapered over time. And once treatment is successful, symptoms will subside and the PSA level will also gradually return to normal values

Chronic bacterial prostatitis

Chronic bacterial prostatitis often occurs from a poorly treated acute infection and the symptoms are often not specific as most of the patients present with recurrent infections of the bladder.

Treatment in chronic bacterial prostatitis is usually long-term compared to acute prostatitis. It should be treated for as long as three months till symptoms start subsiding and drugs thereafter should be tapered gradually.

Chronic pelvic pain syndrome in men

Chronic pelvic pain syndrome is a common type of prostatitis in men with the pathophysiology not well understood. It is not limited to middle age me, chronic pelvic pain syndrome can be seen in men of any age, as low as teenage years.

The pain is often described to be dull aching located around the groin or suprapubic region, on microscopy studies, infectious pathogens may be seen but bacteria are almost always not present.

Medication for the treatment of chronic pelvic pain syndrome is not limited to antibiotics, analgesics to ease pain can be given, especially NSAIDs, also patients can be placed on an alpha blocker to enhance the relaxation of the pelvic muscles to aid free and easier passage of urine.

Asymptomatic inflammatory prostatitis

In the asymptomatic type, patients do not present with any typical symptom of prostatitis, it is therefore usually detected during routine investigations such as in the management of infertility or routine screening for prostate carcinoma.

Can prostate be removed in the treatment of prostatitis? Prostatitis is not an indication of prostatectomy as it is an inflammatory condition that can solely be treated with the use of antibiotics and analgesics (4).

2. Prostate problem, such as Benign prostatic hyperplasia (BPH)

Prostate BPH also referred to as an enlarged kidney is a medical condition gotten via histological diagnosis and is described to occur when there is an increase in the number of the prostatic cellular element.

When the prostate is enlarged, it causes the bladder to be obstructed thereby causing retention of urine. Increased urinary retention will pull more string on the kidney and causes renal functions to be affected as well.

Prostate bph occurs with aging in men. Research showed that 50% of men in the united states manifest signs of prostate bph by 60 years of age and this increases to 90% from 85 years upwards.

Symptoms of prostate bph

The symptoms often manifested by patients with benign prostatic hypertrophy have been termed lower urinary tract symptoms, commonly called LUTS. It is worthy of importance to note that not all men that present with prostate bph will have LUTS and not all patients presenting to the clinic with LUTS have prostate bph.

The common lower urinary tract symptoms seen in patients with benign prostatic hypertrophy are:

Frequency: Urinary frequency is a very common presenting complaint in patients with prostate bph. There is an increasing need to visit the toilet more during the day to urinate. And when this occurs at night it is called nocturia.
Urgency: Patients with urinary urgency have a sudden immediate need to urinate and followed by uncontrolled loss of urine if delayed.
Hesitancy: Hesitancy is the opposite of urgency. Patients with hesitancy have difficulty initiating the micturition process. It is sometimes interrupted and may have to involve straining and poor urine stream.
The feeling of incomplete bladder emptying: Shortly or immediately after urinating, patients with BPH have a feeling that the bladder has not been emptied and they need to do so again.
Straining: This means there is a need to apply force from within to push the urine out of the bladder.
Dribbling: As a result of the weak stream of urine floor, there is an aftermath loss of a small amount of urine from the urethra subjectively.
Erectile dysfunction: Studies have revealed that patients with prostate bph and manifesting the LUTS are often compliant with erectile dysfunction after a long time. Hence, it is important to take a sexual history when meeting a patient with prostate bph for the first time (5)

Diagnosis of benign prostatic hypertrophy

To make an accurate diagnosis of prostate bph, it starts with the history of the patient, by asking the patient if any of the above symptoms are present, for how long, and what has been done so far.

A general physical examination of the patient as well as a digital rectal examination, DRE will help in making the diagnosis of prostate bph. To perform a digital rectal examination, the physician will insert his finger inside the rectum of the patient to feel for the prostate and examine the organ appropriately, with a DRE, the physician will be able to have an idea if the problem is benign or cancerous (6).

The next step is to do investigations to ascertain the diagnosis of benign prostatic hypertrophy. The following investigations will help in making the diagnosis of a prostate bph:

Prostate biopsy

Commonly, a prostate biopsy is a procedure done to take part of the prostate tissue for histological diagnosis. With a prostate biopsy, the physician will be able to tell if the prostate condition is cancerous or in a benign state.

Kinds of prostate biopsy procedure

There are two types of prostate biopsy procedures:

Transrectal prostate biopsy: The transrectal needle passes via the rectal wall and it is the most common type employed worldwide
Transperineal prostate biopsy: The needle is inserted via the perineal wall into the prostate to take out a small portion of the tissue for examination and histology.

How prostate biopsy is done

To perform the prostate biopsy procedure, the patient will be placed in the right position, lying down with the knee position facing the chest. The area will be cleaned thoroughly to ensure an aseptic procedure after which the ultrasound probe will be inserted first through the rectum with the aid of a gel, to guide the transrectal needle.

The images from the ultrasound will serve as a guide for the needle about to be inserted, after which local anesthesia is injected to prevent the patient from feeling the pain. The images also guided the spring-loaded transrectal needle that will be inserted to take the required number of samples.

Generally, an appropriately done prostate biopsy should be able to take about ten to twelve different samples before ending the procedure. This procedure is not usually comfortable for the patient, hence, adequate explanation and consent should be taken from the patient before a prostate biopsy. The above-detailed information is how prostate biopsy is done in an ideal setting (7).

Prostate-specific antigen (PSA)

Although PSA is not a specific investigation for prostate bph, it is usually done to screen for prostate cancer in men. However, studies reveal that men at risk of prostate cancer are also predisposed to prostate bph. That is, their risk factors are similar (5).

A PSA value of 4ng/ml is considered to be within the normal range. However, there have been cases where an individual within the normal range also have histology result showing they have cancer while there are people with an elevated PSA level without cancer (8).

Prostate volume

The prostate volume is usually calculated using the prostate volume calculator. The prostate volume calculator is a software-developed tool used to determine an actual prostate size. It requires the use of the length, height, and breadth of the prostate.

Aside from the prostate, it can also be used to determine the size of the bladder and ellipsoidal lesions. In BPH, the prostate volume may be high due to hypertrophy. The prostate volume calculator is used to determine both the ellipsoid and bullet volume of the prostate gland. It can help to differentiate prostate cancer from prostate bph (9).

Other investigations required in patients with BPH are:

Blood test: This will help to check the blood level of the patient as well as rule out infections in case of suspected prostatitis
Electrolyte, urea, and creatinine: These tests will help to check the kidney functions of the patient because a patient with bladder outlet obstruction from a prostate bph is at risk of kidney disease.

Treatment of prostate BPH

Watchful waiting

This is usually done in young patients, patients with mild to moderate symptoms severity, and patients who have symptoms but without complications.

Medications

a) Alpha-blockers: This works by relaxing the smooth muscles of the prostate and the bladder neck. A good example is tamsulosin (Flomax).
b) 5-alpha reductase inhibitor: These medications work to drastically reduce the size of the prostate. An example is finasteride (Proscar).
c) Combination therapy: This involves the use of both an alpha-blocker and a 5-alpha reductase inhibitor.
d) Tadalafil: This medication is used in the treatment of associated erectile dysfunction.

Surgery

The following surgical procedures can be performed in a patient with prostate bph:

a) Transurethral prostate resection: Resectoscope is inserted via the urethra to get rid of the enlarged prostate tissue.
b) Transurethral incision of the prostate: An incision is made around the prostate to expand the lumen of the urethral in other to improve the urine stream.
c) Transurethral electrovaporization: An electrode is used on the prostate tissue with the aid of heat, to reduce the size.
d) Laser therapy: Laser is used to reduce the size and effect of the prostate.
e) Prostate urolift: This is a minimally invasive surgical procedure that helps to separate the enlarged prostate around the prostatic urethra so that the urethral is more patent and urination or micturition is made easier. A special urology instrument called urolift is used in carrying out this procedure (6).

3. Prostate cancer – talk with your doctor

Prostate cancer is commonly seen in American men and the risk of having prostate cancer is dependent on aging, a family history of prostate cancer, being black, and consuming a diet rich in fat.

The diagnosis of prostate cancer follows the same pattern as in prostate bph. From examination during DRE, the physician may feel for a hard, lobulated, lumpy mass that may or may not be tender (3).

Similar investigations are usually carried out. The PSA level is usually very high and prostate volume is significantly elevated. The prostate 4k test is usually required in investigated patients with an abnormal DRE. The prostate 4k test has four components which are the total PSA level and values for the free PSA level. Others are the intact PSA level and the Human kallikrein 2 level. The four tests together comprise the prostate 4k test (10).

The definitive investigation for the diagnosis of prostate cancer is the use of prostate biopsy. The histology result from a prostate biopsy gives the final verdict on the diagnosis.

Which prostate cancer treatment is the best?

The treatment for prostate cancer depends on whether the cancer is still limited to the prostate or has spread to other areas.

The treatment for prostate cancer includes watchful waiting, surgery, chemotherapy, radiation therapy, and hormonal therapy.

Can prostate be removed in prostate cancer? Yes, especially in an early stage of cancer when it is still limited to the prostate, a prostatectomy can be done to remove the prostate, after which the procedure is followed by chemotherapy and radiotherapy (3).

4. Prostate with calcification

Prostate with calcification is commonly seen in men from the age of 50 years. This can occur single or clustered together. The majority of the prostate with calcifications seen in men were recorded during incidental findings during routine checkups. When symptomatic, they present alongside urinary symptoms like dysuria, hematuria, and obstructive symptoms (11).

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