Bailey & Love Bailey & Love Bailey & Love

Bailey
PART&12 |Love Bailey & Love Bailey & Love
Genitourinary

CH A P T E R

84 The prostate and seminal vesicles

Learning objectives
To understand:
• The relationship of anatomical structure and biochemical • Which investigations are appropriate for benign and
function to the development and treatment of benign and malignant conditions of the prostate
malignant disease of the prostate • Clinical staging of carcinoma of the prostate and how
• The terminology used to describe lower urinary tract staging contributes to the complex decision making
symptoms and to know their causes as well as the
treatment options available

BENIGN PROSTATIC HYPERPLASIA Right half of bladder

Aetiology
Enlargement of
Hormones lateral lobe of
prostate
Serum testosterone levels slowly but significantly decrease
with advancing age; however, levels of oestrogenic steroids are
not decreased equally. According to this theory, the prostate
enlarges because of increased oestrogenic effects. It is likely
Prostatic
that the secretion of intermediate peptide growth factors plays urethra
a part in the development of benign prostatic hyper- Hypertrophy
of trigone
plasia (BPH). Metabolic syndrome and hereditary factors
have also been implicated in its development.
Enlargement of
Posterior lobe median lobe of
of prostate prostate
Summary box 84.1
Figure 84.1 Diagram of late-stage bladder outflow obstruction show-
ing enlargement of the prostate from benign prostatic hyperplasia,
Benign prostatic hyperplasia (BPH) trabeculation of the bladder with smooth muscle hypertrophy and
● Occurs in men over 50 years of age; by the age of 60 years, fibrosis.
50% of men have histological evidence of BPH
● It is a common cause of significant lower urinary tract
symptoms (LUTS) in men and the most common cause of Effects of benign prostatic hyperplasia
bladder outflow obstruction (BOO) in men >70 years of age
It is important to realise that the relationship between anatom-
ical prostatic enlargement, LUTS and urodynamic evidence of
BOO is complex (Figure 84.2).
Pathology
BPH affects both glandular epithelium and connective Summary box 84.2
tissue stroma to variable degrees. BPH typically affects the
Consequences of BPH
submucous group of glands in the transitional zone, forming a
● No symptoms, no BOO
nodular enlargement. Eventually, this overgrowth compresses
● No symptoms, but urodynamic evidence of BOO
the peripheral zone glands into a false capsule and causes the
● LUTS, no evidence of BOO
appearance of the typical ‘lateral’ lobes.
● LUTS and BOO
When BPH affects the central zone glands, a ‘middle’ lobe
● Others (acute/chronic retention, haematuria, urinary infection
develops that projects up into the bladder within the internal and stone formation)
sphincter (Figure 84.1).
 PART 12 | GENITOURINARY
Benign prostatic hyperplasia 1523

Symptoms

BPH BOO

Figure 84.2 Diagrammatic representation of the relation between

symptoms of prostatism, benign prostate hyperplasia (BPH) and Trabeculae
urodynamically proven bladder outflow obstruction (BOO).

Anatomically, the effects are as follows:

● Urethra. The prostatic urethra is lengthened, sometimes
to twice its normal length, but it is not narrowed anatom-
ically. The normal posterior curve may be so exaggerated
that it requires a curved catheter to negotiate it. When only
one lateral lobe is enlarged, distortion of the prostatic ure- Diverticula
thra occurs.
● Bladder. If BPH causes BOO, the musculature of the
bladder hypertrophies to overcome the obstruction and ap-
pears trabeculated (Figure 84.3). Significant BPH is asso- Figure 84.3 Pathological specimen of bladder and kidneys in a case
ciated with increased blood flow, and the resultant veins at of bladder outflow obstruction caused by benign prostatic hyperpla-
the base of the bladder are apt to cause haematuria. sia. Bladder trabeculation, bilateral hydroureter and hydronephrosis
can be seen.

Lower urinary tract symptoms ● intermittent stream – stops and starts;

In both sexes, non-specific symptoms of bladder dysfunction ● dribbling (including after micturition);
become more common with age, probably owing to impairment ● sensation of poor bladder emptying;
of smooth muscle function and neurovesical coordination. ● episodes of near retention.
Not all symptoms of disturbed voiding in ageing men should ● Storage:
therefore be attributed to BPH causing BOO. Urologists prefer ● frequency;
the term LUTS and discourage the use of the descriptive term ● nocturia;
‘prostatism’. ● urgency;
The following conditions can coexist with BOO, leading to ● urge incontinence;
difficulty in diagnosis and in predicting the outcome of treat- ● nocturnal incontinence (enuresis).
ment:
LUTS are usually assessed by means of scoring systems,
● idiopathic detrusor overactivity (see Chapter 83); which give a semiobjective measure of severity and may be
● neuropathic bladder dysfunction as a result of diabetes, helpful in assessing the outcome of the therapy.
stroke, Alzheimer’s disease or Parkinson’s disease (see Severe irritative symptoms are usually associated with
Chapter 83); degeneration of bladder smooth muscle giv- detrusor instability. Postmicturition dribbling is now known not
ing rise to impaired voiding and detrusor instability; to be a consequence of BOO and is not usually improved by
● BOO due to BPH. prostatectomy. It is due to retained urine in the urethra.
LUTS can be described as:
● Voiding: Bladder outflow obstruction
● hesitancy (worsened if the bladder is very full); This is a urodynamic concept based on the combination of
● poor flow (unimproved by straining); low flow rates in the presence of high voiding pressures. It can

Alois Alzheimer, 1864–1915, neurologist, worked at Heidelberg and Munich before being appointed Professor of Psychiatry at Breslau, Germany (now Wrocław,
Poland).
James Parkinson, 1755–1824, general practitioner of Shoreditch, London, UK, published An essay on the shaking palsy in 1817.

@ambidextrous_onc
 PART 12 | GENITOURINARY
1524 CHAPTER 84 The prostate and seminal vesicles

Flow Obstructed void

Flow rate (mL s-1) Detrusor pressure (cmH2O)

120

5 m/s (200) 80

(100) 40
100 mL
Volume
0
Scale change

20
Figure 84.4 Normal flow rate. The voided volume is well in excess of 10
350 mL, and the maximum flow rate is in excess of 25 mL/s. 0

0 1 2
Time (min)
Flow
5 m/s
Figure 84.6 Conventional urodynamic trace showing detrusor pres-
sure during voiding (voided volume 340 mL). There has been a change
in scale because the pressure was so high; voiding pressures are
increased with a low flow rate. This is diagnostic of bladder outflow
100 mL
Volume obstruction.

10 s

Figure 84.5 Diagram of a low flow rate showing a rather low voided
volume of about 200 mL, but with a markedly decreased flow rate.
Such a flow rate could be caused by a urethral stricture, bladder
outflow obstruction or a weak detrusor.

be diagnosed definitively only by pressure–flow studies. This

is because symptoms are relatively non-specific and can result
from detrusor instability, neurological dysfunction and weak
bladder contraction. Even low measured peak flow rates (<10–
12 mL/s) are not absolutely diagnostic because, in addition
to BOO, weak detrusor contractions or low voided volumes
(owing to instability) can be the cause. Nonetheless, flow rates
provide a useful guide for everyday clinical management. Figure 84.7 An ultrasonogram showing a large postvoid residual urine.
Urodynamically proven BOO may result from:
● BPH;
● The bladder may decompensate so that detrusor contrac-
● bladder neck stenosis;
tion becomes progressively less efficient and a residual
● bladder neck dyssynergia or functional bladder neck ob-
urine develops, leading to chronic retention.
struction;
● The bladder may become more irritable during filling with
● bladder neck hypertrophy;
a decrease in functional capacity partly caused by detrusor
● prostate cancer;
overactivity (see Chapter 83), which may also be caused by
● urethral stricture;
neurological dysfunction or ageing, or may be idiopathic.
● functional obstruction due to neuropathic conditions.
Aside from symptoms, the complications of BOO are as
The primary effects of BOO on the bladder are as follows:
follows:
● Urinary flow rates decrease: for a voided vol-
● Acute retention of urine is sometimes the first symptom
ume >200 mL, a peak flow rate of >15 mL/s is normal
of BOO.
(Figure 84.4); one of 10–15 mL/s is equivocal; and one
● Chronic retention. In patients in whom the residual
<10 mL/s is low (Figure 84.5).
volume is >250 mL or so (Figure 84.7), the tension in the
● Voiding pressures increase: pressures >80 cmH2O
bladder wall increases owing to the combination of a large
are high (Figure 84.6); pressures between 60 and
volume of residual urine and increased resting and filling
80 cmH2O are equivocal; and pressures <60 cmH2O are
bladder pressures (a condition known as high-pressure
normal.
chronic retention). The increased intramural tension
The long-term effects of BOO are as follows: results in functional obstruction of the upper urinary
 PART 12 | GENITOURINARY
Assessment of the patient with lower urinary tract symptoms 1525

tract with the development of bilateral hydronephrosis

(Figures 84.8–84.10). As a result, upper tract infection
and renal impairment may develop. Such men may
present with overflow incontinence, enuresis and renal
insufficiency. These symptoms should alert the doctor to
the presence of this condition.
● Impaired bladder emptying. If the bladder decompensates
with the development of a large volume of residual urine,
urinary infection and calculi are prone to develop.
● Development of storage bladder symptoms secondary to
BOO that can be irreversible if BOO is not treated.
● Haematuria. This may be a complication of BPH. Other Figure 84.8 An abdomen with high-pressure urinary retention.
causes must be excluded by carrying out urine culture,
cytology, computed tomography (CT) urography and
cystoscopy.

ASSESSMENT OF THE PATIENT

WITH LOWER URINARY TRACT Median lobe
SYMPTOMS
History
Symptom score sheets such as the International Prostate
Symptom Score (IPSS) assign a score that gives information
regarding the severity of symptoms at the outset and changes
over time and following intervention. The IPSS assessment
should include an assessment of quality of life, which is a
reflection of the degree of ‘bother’ caused by a patient’s
symptoms. In addition to the IPSS, a frequency–volume
diary completed by the patient before attending the clinic is
invaluable in revealing fluid intake habits, diurnal variation in
outputs and low-volume, frequent voiding.

Summary box 84.3 Figure 84.9 Magnetic resonance image showing an enlarged prostate
and a median lobe projecting into the bladder and causing bladder
outflow obstruction.
Investigations of men with LUTS
Essential investigations
● Urine analysis by dipstick for blood, leukocyte esterase,
glucose and protein
● Urine culture for infection
● Serum creatinine
● Urinary flow rate and residual volume measurement

Additional investigations
● PSA if indicated
● Pressure–flow studies

Abdominal examination
Abdominal examination is usually normal. In patients with
chronic retention, a distended bladder will be found on palpa-
tion, on percussion and sometimes on inspection with loss of
the transverse suprapubic skin crease. General physical exam-
ination may demonstrate signs of chronic renal impairment
with anaemia, pedal oedema and dehydration. The external
urinary meatus should be examined to exclude stenosis and the Figure 84.10 Computed tomography scan showing bilateral hydro-
epididymides are palpated for signs of inflammation. nephrosis as a result of bladder outflow obstruction.
 PART 12 | GENITOURINARY
1526 CHAPTER 84 The prostate and seminal vesicles

Rectal examination Pressure-flow urodynamic studies

In benign enlargement, the posterior surface of the prostate is Details of these studies are outlined in Chapter 81. They
smooth, convex and typically elastic, but the fibrous element should be performed on the following patients:
may give the prostate a firm consistency. The rectal mucosa
● men with suspected neuropathy (Parkinson’s disease,
can be made to move over the prostate. It should be noted that,
dementia, longstanding diabetes, previous strokes, multi-
if there is a considerable amount of residual urine present, it
ple sclerosis);
pushes the prostate downwards, making it appear larger than
● men with a dominant history of irritative symptoms and
it is. It is not always possible to examine the cranial extreme
men with lifelong urgency and frequency;
of the very large prostate per rectum. An inability to get to the
● men with a doubtful history and those with flow rates in
prostate base implies a volume of at least 50 mL.
the near normal range (~ or >15 mL/s);
● men with invalid flow rate measurements (because of low
voided volumes);
The nervous system ● high residual/chronic retention;
The nervous system is examined to eliminate a neurological ● men with recurrence of LUTS after previous BPH surgery
lesion. Diabetes mellitus, tabes dorsalis, disseminated sclerosis, (in the absence of urethral or bladder pathology);
cervical spondylosis, Parkinson’s disease and other neuro- ● young men (<50 years) and older men (>80 years) with LUTS.
logical states may mimic prostatic obstruction. If these are
suspected, then a pressure–flow urodynamic study should be
carried out to diagnose BOO. Examination of perianal sensa-
Blood tests
tion and anal tone is useful in detection of an S2–4 cauda Serum creatinine, electrolytes and haemoglobin should be
equina lesion. measured.

Serum prostate-specific antigen Examination of urine

The urine is examined for glucose, leukocyte esterase and
After suitable counselling, measurement of serum PSA may
blood; a midstream specimen should be sent for bacteriological
be helpful. Men in whom a diagnosis of early prostate cancer
examination and cytological examination may be carried out
might influence treatment option (such as those under 70 years
if carcinoma in situ is thought possible.
or those with a positive family history who might be offered
radical treatment) should be offered a PSA measurement. If
the PSA range is 4–10 ng/L, a free-to-total PSA ratio of less Upper tract imaging
than 15% should be suspicious of malignancy. Multiparametric Most urologists no longer carry out imaging of the upper
magnetic resonance imaging (mpMRI) should be done, which tract in men with straightforward symptoms. Obviously, if
may show a suspicious index lesion. In this situation, transrectal infection or haematuria is present, then the upper tract should
ultrasound (TRUS)-guided or transperineal biopsies should be be imaged by means of intravenous urogram/CT urography
considered. or ultrasound scan.

Flow rate measurement Cystourethroscopy

For this to be meaningful, two or three voids should be Inspection of the urethra, the prostate and the urothelium
recorded using a special flow meter, usually found in urology of the bladder should be done immediately prior to prosta-
outpatient clinics; the voided volume should be in excess of tectomy to exclude a urethral stricture, a bladder carcinoma
150–200 mL. A typical history and a flow rate <10 mL/s (for a and the occasional non-opaque vesical calculus. This should
voided volume of >200 mL; Figure 84.5) will be sufficient for be based on the patient’s symptoms, signs and investigations.
most urologists to recommend treatment. Usually, a flow rate Direct inspection of the prostate is not used as an indicator to
measurement will be coupled with ultrasound measurement of establish the presence of BOO and the need for surgery.
postvoid residual urine.
There are pitfalls in the measurement of flow rates. The
machine must be accurately calibrated. The patient must void MANAGEMENT OF MEN WITH
volumes in excess of 150 mL and two or three recordings are BENIGN PROSTATIC HYPERPLASIA
needed to obtain a representative measurement. Decreased OR BLADDER OUTFLOW
flow rates and LUTS may be seen in:
OBSTRUCTION
● BOO;
Strong indications for treatment (usually prostatectomy) include:
● low voided volumes (characteristically in men with detru-
sor instability); ● Acute retention (see Chapter 83) in fit men with no
● men with weak bladder contractions (low pressure–flow other cause for retention (drugs, constipation, recent oper-
voiding), also known as underactive detrusor. ation, etc.) (accounts for 25% of prostatectomies).
 PART 12 | GENITOURINARY
Management of men with benign prostatic hyperplasia or bladder outflow obstruction 1527

● Chronic retention and renal impairment: Special problems in the management

a residual urine of 200 mL or more, hydroureter or
hydronephrosis demonstrated on ultrasound, uraemic of chronic retention
manifestations and abnormal renal function (accounts for Men with chronic retention who have relatively low volumes
15% of prostatectomies). of residual urine and who do not have symptoms suggestive
● Complications of BOO: stone, infection and divertic- of coexisting infection and with good renal function do not
ulum formation. necessarily require catheterisation before proceeding to pros-
● Haemorrhage: these patients present with recurrent tatectomy on the next available list. For those who are uraemic,
haematuria with no obvious cause and a very vascular urgent catheterisation is mandatory to allow renal function
prostate can be seen on cystoscopy. to recover and stabilise. Haematuria often occurs following
● Elective prostatectomy for severe symptoms: catheterisation owing to collapse of the distended bladder and
this accounts for about 60% of prostatectomies. Frequen- upper tract, but settles within a couple of days.
cy alone is not a strong indication for prostatectomy. The Uraemic patients with chronic retention are often dehy-
natural progression of outflow obstruction is variable and drated at the time of admission. Owing to the chronic back
rarely gets worse after 10 years. Severe symptoms not pressure on the distal tubules within the kidney, there is loss
responding to drug therapy, a low maximum flow rate of the ability to reabsorb salts and water. The result, following
(<10 mL/s) and an increased residual volume of urine release of this pressure, may be an enormous outflow of salts
(100–250 mL) are relatively strong indications for opera- and water, which is known as postobstructive diuresis. It is for
tive treatment. this reason that a careful fluid chart, daily measurements of the
patient’s weight and serial estimations of creatinine and elec-
trolytes are essential. Intravenous fluid replacement is required
Summary box 84.4
if the patient is unable to keep up with this fluid loss. These
Options for treatment of LUTS secondary to BPH patients are often anaemic and may require a blood transfusion
once fluid balance is stabilised (if haemoglobin is <9 g/L).
● Conservative measures include watchful waiting in conjunction
with fluid manipulation (avoid fluid binge and late night intake)
and a reduction in caffeinated and alcoholic drinks
Considerations for elective treatment
● Drug therapy is with α-blockers or, in men with a large prostate,
a 5α-reductase inhibitor, or both; combination therapy has a in men with LUTS secondary to BPH
better outcome in glands bigger than 35 g
The following questions should be answered before considering
● Interventional measures include transurethral resection of the
prostate (TURP), which remains the gold standard; consider
a surgical treatment:
HOLEP (holmium laser enucleation of the prostate), open/ ● Have they failed a preliminary trial of medical therapy?
robotic simple prostatectomy for large glands; new minimally
invasive treatment options that are available to patients include
Commonly, men will have been treated with α-blockers or
prostate artery embolisation (PAE), water vapour prostate 5α-reductase inhibitors and will have failed treatment.
treatment (Rezūm), prostatic urethral lift (Urolift) and water jet ● Is BOO present? In many cases, the findings of significant
treatment (Aquablation) symptoms (assessed by symptom scoring) and a benign
enlarged prostate supplemented by the finding of a low
maximum flow rate (<10–12 mL/s for a good voided vol-
Acute retention ume [>150–200 mL]) – will suffice to make a reasonable
working diagnosis of BOO.
The management of retention is discussed in detail in Chapter
● How severe are the symptoms and what are the risks of do-
83. Once the bladder has been drained by means of a catheter,
ing nothing? Severe symptoms and a large residual volume
the patient’s fitness for treatment is determined. If retention
of urine will usually require treatment. Men with mild
was not caused by drugs or constipation, then prostatectomy
symptoms, good flow rates (>15 mL/s) and good bladder
would usually be the correct management. Unfit men or those
emptying (residual urine <100 mL) may be safely managed
with dementia may be treated by means of an indwelling
by reassurance and review; such patients rarely develop se-
urethral or suprapubic catheter. The role of α-adrenergic
vere complications such as retention in the long term.
drugs followed by a trial of a catheter has been tested and
● Is the man fit for operative treatment?
found to be successful in certain groups with a short history
● What treatments are available, what are the outcomes and
and a low residual volume of urine, but the recurrence rate
do the side effects justify treatment?
becomes cumulatively high. 5α-reductase is given to prevent
progression of symptoms in men with large (>35–40 mL)
prostates. Combination therapy (α-blocker and 5α-reductase)
is better for the larger gland. Patients who develop renal
impairment and/or hydronephrosis after urinary retention will
need to keep the catheter until definitive surgical treatment
is provided, usually not less than 6 weeks afterwards to allow
renal function recovery.
 PART 12 | GENITOURINARY
1528 CHAPTER 84 The prostate and seminal vesicles

Treatment 2 3

Men with symptoms attending for elective

treatment (excluding acute and chronic
retention)
Conservative treatment
It is in men with relatively mild symptoms, reasonable flow
rates (>10–15 mL/s) and good bladder emptying (residual
urine <100 mL) that careful discussion over the merits and
side effects of operative treatment is warranted. Waiting for a 1
period of 6 months after careful discussion of the diagnosis is
indicated. After this, a repeat assessment of symptoms and flow 4
rates and an ultrasound scan are helpful; many men with stable
symptoms will elect to leave matters be.

Drugs
In men who are very concerned about the development of Figure 84.11 The surgical approaches to the prostate. (For key see text.)
sexual dysfunction after TURP, the use of drugs may be
helpful. Two classes of drug have been used in the treatment
of men with BOO. α-adrenergic blocking agents inhibit the ● Erectile dysfunction. This occurs in about 5–10% of
contraction of smooth muscle that is found in the prostate. The men, usually in those whose potency is waning.
other class of drug is the 5α-reductase inhibitors, which inhibit ● Success rate. On the whole, men with acute and chron-
the conversion of testosterone to 1,5-dihydrotestosterone ic retention do well from the symptomatic point of view.
(DHT), the most active form of androgen. These drugs, when Ninety per cent of men undergoing elective operation for
taken for a year, result in a 25% reduction in the size of the severe symptoms and urodynamically proven BOO do well
prostate gland. Both groups of drugs are effective; however, in terms of symptoms and flow rates. Only about 65% of
α-blockers work more quickly and although the 5α-reductase those with mild symptoms or those with weak bladder con-
inhibitors have fewer side effects they need to be taken for traction as the cause of their symptoms do well. Men who
at least 6 months and their effect is greatest in patients with are unobstructed and have detrusor instability do not re-
large (>40 g) glands. Drug therapy results in improvements spond well to TURP; in fact, their storage symptoms could
in maximum flow rates by about 2 mL/s more than placebo accentuate postoperatively. Patients who have concomitant
and results in a mild (20%) improvement in symptom scores. BOO and secondary detrusor overactivity may need an
Another drug class that has improved patients’ symptom scores anticholinergic drug for a few months if they have per-
but not their maximum flow rate are the phosphodiesterase 5 sistent irritative symptoms.
inhibitors, which reduce smooth muscle tone and possibly the ● Risk of reoperation. After TURP, this is about 15%
inflammation in the prostate gland. These drugs are particu- after 8–10 years.
larly useful if patients have concomitant erectile dysfunction. ● Morbidity rate. Death after TURP is infrequent
TURP, however, results in improvements in maximum flow (<0.5%); severe sepsis is found in about 6%; and severe
rates from 9 to 18 mL/s and a 75% improvement in symptom haematuria requiring transfusion of more than 2 units of
scores. These drugs are expensive in comparison with their blood occurs in about 3%. After discharge, about 15–20%
effectiveness, and a significant proportion of men who try these of men subsequently require antibiotic treatment for
drugs will subsequently undergo surgical treatment. symptoms of urinary infection.
Operative treatment
● Incontinence. Although the risk is rare and is about 1%,
the risk is higher in older patients and those with a very
Apart from the strong indications for operative treatment large prostate.
mentioned above, the most common reason for TURP is a
combination of severe symptoms and a low flow rate of
<12 mL/s. The key is to assess the symptoms carefully and Methods of performing prostatectomy
to counsel men about side effects and likely outcome before The prostate can be approached (1) transurethrally (TURP);
advising operative treatment. (2) retropubically (RPP); (3) through the bladder (transvesically;
TVP); or (4) from the perineum (Figure 84.11).
Counselling men undergoing
Transurethral prostate surgery
prostatectomy
Transurethral resection of the prostate
Men undergoing prostatectomy need to be advised about the
TURP remains the most commonly performed procedure for
following:
the surgical correction of BOO. Perhaps the greatest advance
● Retrograde ejaculation or anejaculation. This in the history of transurethral surgery was marked by the
occurs in about 65–85% of men after prostatectomy. development of the rigid lens system of Professor Harold
 PART 12 | GENITOURINARY
Management of men with benign prostatic hyperplasia or bladder outflow obstruction 1529

Prostate tissue
Prostate is removed Resectoscope
Figure 84.12 For transurethral resection of the prostate
the resectoscope is inserted transurethrally. Electric
current is passed through a diathermy loop at the end of
the instrument. The surgeon moves this back and forth
to create a cavity using diathermy to cauterise as they
go. The resultant chips are washed out of the bladder
intermittently throughout the procedure. A visual image of
the operative field is transmitted through lenses running
in the middle of the resectoscope. Around this lens,
irrigating fluid is instilled and flows out, washing blood
away from the operative field. The procedure is complete
when an adequate channel has been created through the
prostate.

Hopkins. His lenses, illuminated by a fibreoptic light source, the adenoma to the false capsule and simultaneously coagulate
permit unparalleled visualisation of the working field. Men any of the small vessels crossing the relatively avascular plane
with indwelling catheters, those with recent urinary infection, between the peripheral and transitional zones of the prostate
those with chronic retention or those with prosthetic material while the tip of the cystoscope is used, much like the surgeon’s
or heart valves benefit from prophylactic antibiotics in addition finger in Millin’s prostatectomy, to enucleate the transitional
to the standard for clean surgery at induction of anaesthesia. zone adenoma. The enucleated adenoma is pushed into the
Strips of tissue are cut from the bladder neck down to bladder, where it is morcellated and extracted via the cysto-
the level of the verumontanum (Figure 84.12). Cutting is scope. Damage to the external sphincter is avoided provided
performed by a high-frequency diathermy current, which is the verumontanum is used as a guide to the most distal point
applied across a loop mounted on the hand-held trigger of of the resection/vaporisation/enucleation.
the resectoscope. Coagulation of bleeding points can be accu-
rately achieved. The ‘chips’ of prostate are then removed from
the bladder using an Ellik evacuator. Resection proceeds at
Complications of prostatectomy
1 g/minute in experienced hands. The duration of resection Local
for monopolar TURP is limited to 1 hour due to the risk of Haemorrhage is a major risk following prostatectomy what-
resorption of water if 1% glycine is used as an irrigant. The ever the surgical approach. Care should be taken in applying
advent of bipolar TURP where normal saline is used as an diathermy to arterial bleeding points after TURP, and to any
irrigant permits resection of larger prostates. Following TURP, bleeding vessels at the bladder neck; they are often better seen
careful haemostasis is performed, and a three-way, self-retain- when the rate of inflow of fluid is decreased. Some of the
ing catheter irrigated with isotonic saline is introduced into the venous bleeding due to deep resection can only be stopped by
bladder to prevent any further bleeding from forming blood gentle traction via a Foley catheter balloon inflated to 30–40 mL
clots. Irrigation is continued until the outflow is pale pink, and and kept in the bladder. Sustained traction is applied by taping
the catheter is usually removed on the second or third postop- the catheter to the anterior abdominal wall or thigh for 12–24
erative day. In men with small prostates or bladder neck dys- hours. This causes compression of the prostatic tissue and
synergia or stenosis, it is better to divide the bladder neck and veins and thus stops the bleeding. In the recovery room, one
prostatic urethra with a Collins knife or laser. should check that the bladder is draining adequately; if it is
not, this may indicate that a clot is blocking the eye of the
Laser prostatectomy catheter. The bladder should be promptly washed out using
Laser can be used to ablate or vaporise (e.g. green light laser) or a strict aseptic technique. The catheter should be changed by
enucleate (e.g. HOLEP) the prostate. Photoselective vaporisa- the surgeon. Only rarely is it necessary to return the patient to
tion of the prostate or green light laser has the advantage that the operating room.
vaporisation is haemostatic and this procedure can be performed Secondary haemorrhage tends to occur several days after
even while patients are anticoagulated; however, it is unsuitable the patient has been discharged. All men should be warned
for a very large gland. In holmium laser enucleation of the about this possibility and given appropriate advice to rest and
prostate (HOLEP), laser is used to cut all the attachments of to have a high fluid intake. It is usually minor in degree but if

Harold Horace Hopkins, 1918–1994, Professor of Applied Optics, University of Reading, Reading, UK, invented the rigid rod endoscope (Hopkins’ rod, 1954)
and contributed to the development of the fibres for flexible endoscopes.
Milo Ellik, 1905–1975, American urologist, developed the Ellik evacuator in 1937.
Terence John Millin, 1903–1980, surgeon, Westminster Hospital, London, UK, and honorary surgeon, All Saints’ Hospital for Genitourinary Diseases, London,
UK, described the operation of retropubic prostatectomy in 1945. He was regarded as ‘the greatest of Irish urologists’ and ‘the pioneer of the retropubic space’. To
facilitate his operation, he devised a self-retaining retractor that goes by his name and the ‘boomerang’ needle to close the prostatic capsule. He used to be invited all
over the world to operate on VIPs. He was a former President of the Royal College of Surgeons in Ireland. He gave up operating at the age of 57 to enjoy his farm
in County Wicklow, where he died of laryngeal carcinoma. He played international rugby for Ireland.
Frederic Eugene Basil Foley, 1891–1966, urologist, Ancker Hospital, St Paul, MN, USA.
 PART 12 | GENITOURINARY
1530 CHAPTER 84 The prostate and seminal vesicles

clot retention occurs the patient will need to be readmitted, a the presence of the resectoscope in the urethra for too long a
catheter passed and the bladder washed out. period. These strictures arise either just inside the meatus or in
Perforation of the bladder or the prostatic capsule can the bulbar urethra. An early stricture can usually be managed
occur at the time of transurethral surgery. This usually occurs by simple dilatation or urethrotomy if dense fibrosis is present.
from a combination of inexperience in association with a large If the stricture recurs then urethroplasty is considered. The use
prostate or heavy blood loss. If the field of vision becomes of an Otis urethrotomy in the tight urethra prior to TURP can
obscured by heavy blood loss, it is often prudent to achieve reduce the incidence of postoperative stricture.
adequate haemostasis and abandon the operation, swallowing
one’s pride on the understanding that a second attempt may Bladder neck contracture
be necessary. A large perforation with marked extravasation Occasionally, a dense fibrotic stenosis of the bladder neck
may require the insertion of a small suprapubic drain. Rectal occurs following overaggressive resection of a small prostate.
perforation should be extremely rare. It may be due to the overuse of coagulating diathermy. This
usually happens in the early postoperative period. Transurethral
Sepsis incision of the scar tissue is necessary using laser or diathermy.
Bacteraemia is common even in men with sterile urine and
occurs in over 50% of men with infected urine, prolonged General complications
catheterisation or chronic retention. Sepsis can occur in these
patients shortly after operation or when the catheter is removed. Death occurs in about 0.2–0.3% of men undergoing elective
Routine use of prophylactic antibiotics is recommended based prostatectomy. In very elderly men, in men with prostate cancer
on local antimicrobial sensitivity profiles. The most worrying admitted as an emergency with acute or chronic retention or
aspect of infection is the early rigor following surgery. If left in those with very large prostates, the 30-day death rate may
undetected and untreated, this may progress to septic shock be of the order of 1%.
with profound hypotension. A blood culture should be taken
and antibiotics given parenterally (e.g. amoxicillin plus cefurox- Cardiovascular
ime, or gentamicin). Pulmonary atelectasis, pneumonia, myocardial infarction,
congestive cardiac failure and deep venous thrombosis are
Incontinence all potentially life-threatening conditions that can affect this
Incontinence is rare after BPH surgery; however, it is inevitable elderly and often frail group of men.
if the external sphincter mechanism is damaged. The bladder
neck is rendered incompetent by any prostatectomy and, Water intoxication
therefore, an intact distal sphincter mechanism is essential for Absorption of water into the circulation at the time of trans-
continence. The verumontanum marks the proximal margin urethral resection can give rise to congestive cardiac failure,
of the external sphincter. In some patients, detrusor instability hyponatraemia and haemolysis. Accompanying this, there is
contributes to the incontinence. The use of anticholinergic frequently confusion and other cerebral events often mimick-
agents such as mirabegron/solifenacin/tolterodine may help. ing a stroke. The incidence of this condition has been reduced
Mild degrees of stress incontinence usually recover in a few since the introduction of isotonic glycine for irrigating during
days to a few weeks. If physiotherapy is ineffective, then full resection, and further still with the development of bipolar
assessment with cystoscopy and pressure studies including TURP where saline is used as an irrigant. The treatment
video urodynamics should be carried out before proceeding consists of fluid restriction.
with offering the patient the insertion of an artificial urinary
sphincter or a sling to increase the resistance of the urethra. BLADDER OUTFLOW OBSTRUCTION
One should usually wait for 6 months to 1 year before any sling
or sphincter is implanted.
CAUSED BY THE BLADDER NECK

Retrograde ejaculation and erectile Aetiology

dysfunction This condition usually occurs in men but can rarely affect
Men with prior good sexual function are less likely to have children of both sexes and women. It may be due to muscular
erectile dysfunction following BPH surgery, but retrograde hypertrophy or fibrosis of the tissues at the bladder neck
ejaculation occurs commonly (>75%) because of disruption to following TURP.
the bladder neck mechanism; occasionally, anejaculation can
occur as a result of disruption of the ejaculatory ducts. This Clinical syndromes
should be discussed with all men before the surgery.
Owing to muscle hypertrophy or dyssynergia
Urethral stricture Marion described a series of cases in which muscular hyper-
This may be secondary to prolonged catheterisation, the use trophy of the internal sphincter in a young person had
of an unnecessarily large catheter, clumsy instrumentation or resulted in the development of a vesical diverticulum or hydro-
Fessenden Nott Otis, 1825–1900, nineteenth century American urologist.
Jean Baptiste Camile Marion, 1869–1932, Professor of Urology, The Faculty of Medicine, Paris, France.
 PART 12 | GENITOURINARY
Carcinoma of the prostate 1531

nephrosis (Marion’s disease or ‘prostatism sans prostate’). It is

thought that dyssynergic contraction of the smooth muscle of
the bladder neck (bladder neck dyssynergia) may account for
some cases of BOO. It is also known as functional bladder
neck obstruction.

Owing to fibrosis
The symptoms are similar to those of prostatic enlargement
but are a consequence of scarring after TURP or radical
prostatectomy (usually compounded by external beam radio-
therapy [EBRT]).

Treatment
The management of these patients depends on achieving an
accurate diagnosis. For this, urodynamic investigation is often
necessary, which should demonstrate raised voiding pressures
and diminished flow rate.

Drugs
The presence of α-adrenergic receptors in the region of the
bladder neck and prostatic urethra allows pharmacological
manipulation of the outflow to the bladder.

α-blocking drugs
Alfuzosin (10 mg once daily), tamsulosin (0.4 mg once daily),
doxazosin (1 mg at night, up to a maximum of 8 mg/day), Figure 84.13 Endogenous prostatic calculi.
indoramin (20 mg twice daily, increased to a total maximum
of 100 mg/day in divided doses), prazosin (2.5 mg twice daily,
maintenance up to 2 mg/day) terazosin (1 mg at night, to a from carcinoma. On radiographs or ultrasound scans, these
total maximum of 10 mg/day) and Silodosin (4 to 8 mg once stones are often seen to form a horseshoe (Figure 84.13) or a
a day) can be very useful, causing relaxation of the bladder circle. It is postulated that they are associated with BOO.
neck. These drugs are not target specific, and patients must
be warned of the possibility of postural hypotension, which is Treatment of prostatic calculi
usually limited to the first few doses.
Prostatic calculi usually require no treatment.
Transurethral incision
Transurethral incision of the bladder neck is the operation of Conservative measures
choice. Sometimes symptoms recur, but this is usually due to Associated chronic prostatic infection may be treated by means
inadequate division of the fibres of the bladder neck. of ciprofloxacin or trimethoprim.

Congenital valves of the prostatic urethra Transurethral resection

See Chapter 85. Transurethral resection will often release small calculi as the
strips of prostatic tissue are excised. Others are passed through
the urethra at a later date. Any associated benign prostatic
PROSTATIC CALCULI enlargement is treated in the same sitting with TURP.
Prostatic calculi are of two varieties: endogenous, which are
common, and exogenous, which are comparatively rare. An
exogenous prostatic calculus is a urinary (commonly ureteric)
Corpora amylaceae
calculus that becomes arrested in the prostatic urethra. Corpora amylaceae are tiny calcified lamellated bodies found
Endogenous prostatic calculi are usually composed of calcium in the glandular alveoli of the prostates of elderly men and
phosphate combined with about 20% organic material. apes, but not in the prostates of animals lower in the phylo-
genetic scale than anthropoids. Corpora amylaceae are prob-
Clinical features ably the forerunners of endogenous prostatic calculi.

Prostatic calculi are usually symptomless, being discovered on

TRUS, on radiography of the pelvis, during prostatectomy or CARCINOMA OF THE PROSTATE
associated with carcinoma of the prostate or chronic prostatitis. Carcinoma of the prostate is the most common malignant
In cases associated with severe chronic prostatic infection, the tumour in men over the age of 65 years. In the UK in 2017,
associated fibrosis and nodularity are difficult to differentiate more than 48 000 men were diagnosed with, and more than
 PART 12 | GENITOURINARY
1532 CHAPTER 84 The prostate and seminal vesicles

11 800 died from, prostate carcinoma; the corresponding detection in 18 men per 1000 men screened, increased compli-
figures in the USA were 190 000 and 33 000, respectively. cations from prostate biopsies and can lead to overdiagnosis.
If histological section of prostates at autopsy is performed,
increasingly frequent foci of microscopic prostate cancers are Summary box 84.5
found with increasing age. These foci of prostate cancer have
variable potential for progressing clinically to metastatic disease. Screening for prostate cancer
About 10–15% of younger men who develop prostate cancer The results of several large-scale randomised clinical trials
have a positive family history of the disease, but the aetiology evaluating the role of PSA screening for prostate cancer suggest
is unclear. Throughout the world, rates of microscopic foci that, at present, screening the entire population with serum PSA
of prostate cancer are constant, but rates of clinically evident is not cost-effective as a large number of men must be screened,
disease are low in men in Japan, China and India. Carcinoma biopsied and treated in order to prevent each death from prostate
of the prostate usually originates in the peripheral zone of cancer
the prostate, so ‘prostatectomy’ for benign enlargement of the
gland confers no protection from subsequent carcinoma.
Local spread
Pathology Locally advanced tumours tend to grow upwards to involve the
seminal vesicles, the bladder neck and trigone and, later, the
Serial sections of prostates obtained at routine necropsy tumours tend to spread distally to involve the distal sphincter
demonstrate prostate carcinoma in 25% of men between 50 mechanism. Further upward extension obstructs the lower end
and 65 years of age. The incidence in men over 80 years is of one or both ureters, with obstruction of both resulting in
in the region of 70%. Most of these neoplasms are tiny and anuria. The rectum may become stenosed by tumour infiltrat-
(if life had continued) might have remained latent for years. ing around it, but direct involvement is rare.
Most men die with the prostate cancer rather than because
of cancer. Spread by the bloodstream
The following types of prostate cancer occur: Spread by the bloodstream occurs particularly to bone;
● microscopic latent cancer found on autopsy or at cysto- indeed, the prostate is the most common site of origin for
prostatectomy; skeletal metastases, followed in turn by the breast, the kidney,
● tumours found incidentally during TURP (T1a and T1b) the bronchus and the thyroid gland. The bones involved most
or following screening by PSA measurement (T1c); frequently by carcinoma of the prostate are the pelvic bones
● early, localised prostate cancer (T2); and the lower lumbar vertebrae. The femoral head, ribcage
● locally advanced and high-risk prostate cancer (T3 and and skull are other common sites.
T4);
● metastatic disease, which may arise from a clinically evi- Lymphatic spread
dent tumour (T2, T3 or T4) or from an apparently benign Lymphatic spread may occur via (i) lymphatic vessels passing
gland (T0, T1) (i.e. occult prostate cancer). to the obturator fossa or along the sides of the rectum to the
lymph nodes beside the internal iliac vein and in the hollow of
It should be noted that only the last two groups cause symp- the sacrum and (ii) lymphatics that pass over the seminal vesicles
toms, and such tumours are not curable. Only screening or and follow the vas deferens for a short distance to drain into the
the treatment of incidentally found tumours or early prostate external iliac lymph nodes. From retroperitoneal lymph nodes,
cancer (T1 and T2) can result in cure of the disease. The prob- the mediastinal nodes and occasionally the supraclavicular
lem is that many such tumours would never progress during nodes may become implicated.
the patient’s lifetime and only a few will grow and metastasise;
herein lies the problem with prostate cancer.
Staging using the tumour–node–
Screening for prostate cancer metastasis (TNM) system
The TNM staging system for prostate cancer is shown in
Prostate cancer screening with PSA is controversial and the
Figure 84.14.
test does not fulfil the World Health Organization’s (WHO)
criteria for an adequate screening programme. Screening trials ● T1a, T1b and T1c. These are incidentally found
are limited by contamination of patients who have already had tumours in a clinically benign gland after histologi-
prior PSA tests, and most include mainly white men. Most cal examination of a prostatectomy specimen. T1a is a
screening trials do not include high-risk groups of men (family tumour involving less than 5% of the resected specimen;
history of prostate cancer, Africans) and screening can lead these tumours are usually well or moderately well differ-
to overdiagnosis of insignificant disease. The four largest entiated. T1b is a tumour involving >5% of the resected
randomised trials include in total around 700 000 patients; they specimen. T1c tumours are impalpable tumours found fol-
have shown that screening did not improve overall mortality, lowing investigation of a raised PSA.
but there is a small improvement in prostate cancer-specific ● T2a disease presents as a suspicious nodule (Figure 84.15)
mortality. However, screening increased prostate cancer on rectal examination that is confined within the prostate
capsule and involves one lobe.
 PART 12 | GENITOURINARY
Carcinoma of the prostate 1533

T0 T1

T2b T2a

T2c Figure 84.15 Transrectal ultrasound scan of a T2 nodule in the pros-

tate.

● BOO;
● pelvic pain and haematuria;
T4 T3 ● bone pain, malaise, ‘arthritis’, anaemia or pancytopenia;
● renal failure;
Figure 84.14 Tumour–node–metastasis staging system for prostate ● locally advanced disease or even asymptomatic metastases,
cancer. which may be found incidentally on investigation of other
symptoms.
● T2b means that the cancer is in more than half of one Early prostate cancer is asymptomatic and may be found:
side of the prostate gland, but not both sides.
● T2c means that the cancer is in both sides but is still inside ● incidentally following TURP for clinically benign disease
the prostate gland. (T1a and b);
● T3 tumour extends through the capsule: ● T1c – because of serum PSA screening;
● T3a, uni- or bilateral extension;
● as a nodule (T2) on rectal examination.
● T3b, seminal vesical extension.
● T4 is a tumour that is fixed or invading adjacent structures Summary box 84.7
other than seminal vesicles – levator muscles, external
sphincter, rectum or pelvic side wall. The presentation of men with prostate cancer
● Often men are asymptomatic and detection is by opportunistic
PSA testing
Summary box 84.6 ● Cancer is detected in men describing LUTS or may present
with symptoms of metastatic disease
The natural history of prostate cancer
This depends on the stage and grade of disease:
● T1 and T2 Rectal examination
● The progression rate of well-differentiated T1a prostate
Rectal examination can detect nodules within the prostate and
cancer is very low: 10–14% after 8 years. For moderately
differentiated tumours, the rate is about 20%. For T1b and advanced disease. Irregular induration, characteristically stony
T2 tumours, the rate is in excess of 35% hard in part or in the whole of the gland (with obliteration of
● T3 and T4 (M0) the median sulcus), suggests carcinoma. Extension beyond the
● About 50% progress to bony metastases after 3–5 years capsule up into the bladder base and vesicles (Figure 84.16)
● M1 is diagnostic, as is local extension through the capsule
● The median survival of men with metastatic disease is (Figure 84.17).
about 3 years

Multiparametric magnetic resonance

imaging
Clinical features mpMRI is an investigation to diagnose an early prostate
Only advanced disease gives rise to symptoms, but even cancer that might reduce overdiagnosis of insignificant pros-
advanced disease may be asymptomatic. Symptoms of tate cancer. Here dynamic contrast is given and should have
advanced disease include: four sequences: T1-weighted imaging, T2-weighted imaging,
 PART 12 | GENITOURINARY
1534 CHAPTER 84 The prostate and seminal vesicles

Bladder

Transperineal Anterior
needle
Prostate

Posterior
Transrectal
needle

Rectum

Figure 84.18 The prostate is commonly biopsied by two routes. The

biopsy needle can be inserted through the skin between the scrotum
and anus (perineum) or through the rectum. In both cases the passage
of the needle is usually guided to the correct place with transrectal
ultrasound. Transrectal ultrasound is not good for sampling the
anterior prostate, particularly when the prostate is large. Transperineal
Figure 84.16 Transrectal ultrasound scan showing normal seminal biopsy is gaining popularity as an alternative to conventional tran-
vesicles. srectal biopsy.

transrectally, although increasingly the transperineal approach

is being used. Broad-spectrum antibiotic cover is given to all
patients to reduce the incidence of sepsis, which is greater
with transrectal than with transperineal biopsy. Transperineal
biopsy usually involves sedation or general anaesthetic while
transrectal biopsy can be performed under local anaesthetic.
Increasingly, areas appearing suspicious for prostate cancer on
mpMRI can be targeted for biopsy to increase the diagnostic
yield. Nowadays, fusion biopsy is becoming popular; this is
where mpMRI and TRUS images are fused with the help of
software and a biopsy is taken very accurately from the index
lesion.

Histological appearances
The prostate is a glandular structure consisting of ducts and
Figure 84.17 Transrectal ultrasound scan showing local extension of acini; thus, the histological pattern is one of an adenocarci-
a T3 prostate cancer. noma. The prostatic glands are surrounded by a layer of
myoepithelial cells. The first change associated with carcinoma
diffusion-weighted imaging and dynamic contrast-enhanced is the loss of the basement membrane, with glands appearing
imaging and spectroscopic imaging. The accuracy of mpMRI to be in confluence. As the cell type becomes less differentiated,
in localising and staging prostate cancer shows a high degree more solid sheets of carcinoma cells are seen. A classification
of variation between reporting radiologists. Interpretation of the histological pattern based on the degree of glandular
and reporting of mpMRI must be carried out following stan- dedifferentiation and its relation to stroma has been devised
dardised scoring systems (such as Prostate Imaging Reporting by Gleason. Prostate cancers exhibit heterogeneity within
and Data System [PI-RADS] v.2). A score of 3 or above is tissue, and so two histological areas of prostate are each scored
indicative of malignancy. between 3 and 5. Grades 1 and 2 are now not reported as their
outcome is similar to grade 3. Grade 3 cancers almost never
metastasise. The scores are added to give an overall Gleason
Prostatic biopsy score of between 6 and 10; this (and the volume of the cancer)
If there is suspicion of prostate cancer, because of local appears to correlate well with the likelihood of spread and the
findings, a raised PSA or metastatic disease, then a prostate prognosis. The International Society of Urological Pathology
biopsy using an automated gun under TRUS guidance is (ISUP) and WHO have recommended a simplified grading
recommended (Figure 84.18). This is usually performed system composed of five prognostic grade groups. Each group

Donald F Gleason, 1920–2008, pathologist, University of Minnesota, Minneapolis, MN, USA, published the Gleason System in 1966. He spent his last 20 years
sailing, baking bread and playing bridge.
 PART 12 | GENITOURINARY
Carcinoma of the prostate 1535

prostatectomy the serum PSA should fall to undetectable

levels (the limit for detection for modern supersensitive assays
is <0.03 ng/mL).

Radiological examination
Radiographs of the chest may reveal metastases in either the
lung fields or the ribs. An abdominal radiograph may show
the characteristic sclerotic metastases in lumbar vertebrae and
pelvic bones (Figure 84.19). The bone appears dense and
coarse, and it is sometimes difficult to distinguish the change
from that in Paget’s disease of bone. Nevertheless, osteolytic
metastases are very common in prostate cancer and may
coexist with sclerotic ones.

Cross-sectional imaging with magnetic

resonance imaging and transrectal
Figure 84.19 Osseous metastases of the pelvic bones in carcinoma of
the prostate (courtesy of LN Pyrah, Leeds, UK). ultrasound
MRI with a high-tesla magnet (1.5–3 T) is the most accurate
has prognostic significance and a higher grade group has a method of staging local disease. mpMRI is used preoperatively
poorer prognosis. to assess pelvic lymph nodes as well as local stage, although the
Grade groups are as follows: sensitivity of mpMRI to detect small areas of capsular spread
is limited, even in the best hands. As well as preoperative
● 1 = Gleason score 3 + 3 = 6 staging, mpMRI plays an important role in active surveillance
● 2 = Gleason score 3 + 4 = 7 and localisation of recurrent prostate cancer after surgery.
● 3 = Gleason score 4 + 3 = 7 Low-grade tumours are frequently not seen on MRI and are
● 4 = Gleason score 8 (4 + 4 = 8, 3 + 5 = 8, 5 + 3 = 8) often clinically insignificant.
● 5 = Gleason score %9 (4 + 5 = 9, 5 + 4 = 9, 5 + 5 = 10) TRUS scanning can also be used to stage prostate cancer.
Locally extensive disease (T2) can be diagnosed with increased
General blood tests sensitivity by TRUS (Figure 84.15) compared with rectal
examination, but many tumours will still be missed. This prob-
These are normal in early disease but, in metastatic disease, lem remains a real one in screening for early prostate cancer; in
there may be leukoerythroblastic anaemia secondary to comparison with breast cancer, with mammography detecting
extensive marrow invasion, or anaemia may be secondary to 70–80% of tumours, TRUS plus rectal examination and mea-
renal failure. There may be thrombocytopenia and evidence surement of PSA will detect only 30–50% of cancers that are
of disseminated intravascular coagulopathy with increased known to be present on autopsy studies (although it may detect
fibrinogen degradation products. the larger, more significant cancers).

Liver function tests Bone scan

These will be abnormal if there is extensive metastatic invasion Once the diagnosis has been established, if metastatic spread
of the liver. Alkaline phosphatase may be raised from either is suspected (on the basis of a high PSA [>10 ng/mL],
hepatic involvement or secondaries in the bone. These can locally advanced disease or presence of Gleason 7 or higher)
be distinguished by measurement of isoenzymes or gamma- a bone scan should be carried out. If, however, the PSA
glutamyltransferase. is <10 ng/mL, then a bone scan would be performed only
on clinical indications. The bone scan is performed by the
Prostate-specific antigen injection of technetium-99m, which is then monitored using
a gamma camera. It is more sensitive in the diagnosis of
This is discussed earlier in this chapter. It is good at follow- metastases (Figure 84.20) than a skeletal survey, but false
ing the course of advanced disease; however, it is lacking in positives occur in areas of arthritis, osteomyelitis or a healing
sensitivity and specificity in the diagnosis of early localised fracture.
prostate cancer. Nevertheless, the finding of a PSA >10 ng/mL
is suggestive of cancer and >35 ng/mL is almost diagnostic of
advanced prostate cancer, in the absence of active urinary tract
Positron emission tomography scan
infection. A decrease in PSA to the normal range following In prostate cancer gallium-labelled prostate-specific membrane
hormonal ablation is a good prognostic sign. Following radical antigen (PSMA) has been increasingly used in positron

Sir James Paget, 1814–1899, English surgeon and pathologist, best known for his description of Paget’s disease of the bone.
 PART 12 | GENITOURINARY
1536 CHAPTER 84 The prostate and seminal vesicles

Summary box 84.8

Treatment and stage

● Treatment options for prostate cancer depend on stage of
disease, life expectancy of the patient and patient preference
● PSA, DRE and biopsy Gleason grade are used to predict
pathological stage
● Localised cancers can be treated by radical prostatectomy,
radiation therapy and active monitoring (surveillance)
● Treatment of advanced disease is palliative, and hormone
ablation remains the first-line therapy; once it starts failing,
chemotherapy is used with short-term success

Summary of treatment for carcinoma of

the prostate
● Low-risk disease. For men in their seventies, conser-
vative treatment would usually be the correct approach.
Radical surgical treatment might be considered in younger
(<70 years) men with this form of the disease and/or with a
family history, although, even in this group, some men will
elect to pursue a conservative course (active surveillance)
when counselled about risks versus benefits (impotence/
Figure 84.20 Bone scan showing multiple hot spots suggestive of
metastatic disease in a man with prostate cancer.
incontinence).
● Intermediate-risk disease. In younger (<70 years),
fitter men, this may be treated by radical prostatectomy
emission tomography (PET) scans. It is sensitive in detecting or radical radiotherapy. Active monitoring remains an
lymph node metastasis and may be superior to MRI; however, option, particularly for more elderly patients towards the
smaller lymph nodes can be missed on PSMA-PET. If avail- lower end of the risk spectrum. In elderly patients with
able, this test offers an additional and highly sensitive modality outflow obstruction, transurethral resection with or with-
for detecting metastasis prior to offering treatment. It also has out hormone therapy is indicated. The benefit of radi-
an increasing role in restaging after treatment relapse. cal treatment over a conservative approach is likely to be
about 25%, given that progression to metastatic disease is
Treatment of this order of magnitude after 10 years.
● High-risk disease. These patients are at significant
Patients are counselled on their treatment options based on risk of disease progression. They need multimodal therapy.
an estimated risk of a localised cancer spreading and causing Early androgen ablation is favoured if close follow-up is
death. The patient’s life expectancy and comorbidities should not possible. For the sexually active, a careful conservative
be taken into consideration. The strongest risk factors for approach with the adoption of androgen ablation when
metastasis are PSA level, Gleason grade and clinical stage. symptoms arise is reasonable. Androgen ablation coupled
Tables and nomograms are available using these three param- with radiotherapy, perhaps with surgery (radical prostatec-
eters to predict lymph node involvement and risk of metastasis. tomy plus salvage radiotherapy) as part of a multimodal
approach, is standard treatment for younger men with T3
Early disease disease.
Curative treatment can only be offered to patients with early ● Metastatic disease. Once metastases have developed,
disease. Low-risk prostate cancer (low PSA, small foci of Glea- the outlook is poor. For patients with symptoms, there is
son 6 disease) can be managed by active surveillance. Here, no dilemma; androgen ablation will provide symptomatic
with 3-to 6-monthly digital rectal examination (DRE) and PSA relief in over two-thirds of patients. For patients with
measurement, mpMRI yearly or 2-yearly and repeated pros- asymptomatic metastases, the timing of treatment is less
tate biopsy, a proportion can safely avoid the toxicity of radical clear. Systemic chemotherapy with docetaxel should be
treatment. However, one-third of patients embarking on this considered in younger, fitter men.
approach will require radical treatment within a few years. The
options available for T1, T2 or some T3 disease need to take
into account the patient’s age, performance status and lifestyle PROSTATITIS
preferences. The treatment of patients with advanced disease In both acute and chronic prostatitis, the seminal vesicles and
(T4 or any nodal or distant metastases) is only palliative. posterior urethra are usually also involved.
 PART 12 | GENITOURINARY
Further reading 1537

Acute prostatitis ● prostatic massage showing pus cells with or without bacte-
ria in the absence of urinary infection.
Aetiology
Acute prostatitis is common, but underdiagnosed. The usual Aetiology
organism responsible is Escherichia coli, but Staphylococcus aureus, This is thought to be the sequela of inadequately treated acute
Staphylococcus albus, Streptococcus faecalis, Neisseria gonorrhoeae prostatitis. While pus is present in the prostatic secretion, the
or Chlamydia may be responsible. The infection may be responsible organism is often difficult to find. Other organisms
haematogenous from a distant focus or it may be secondary to such as Chlamydia species may be responsible for chronic
acute urinary infection. abacterial prostatitis.

Clinical features Clinical features

General manifestations overshadow the local: the patient feels The clinical features are extremely varied. Only men with
ill, shivers, may have a rigor, has ‘aches’ all over, especially in symptoms of posterior urethritis, prostatic pain and perigenital
the back, and may easily be diagnosed as having influenza. The pain accompanied by intermittent fever and pus cells or bacte-
temperature may be up to 39°C. Pain on micturition is usual, ria in the postprostatic massage specimen should be diagnosed
but not invariable. The urine contains threads in the initial as having chronic prostatitis.
voided sample, which should be cultured. Perineal heaviness, Diagnosis
rectal irritation and pain on defecation can occur; a urethral
discharge is rare. Frequency occurs when the infection involves The three-glass urine test is valuable. If the first glass with
the bladder. Rectal examination reveals a tender prostate; one the initial voided sample is clear and the second and third
lobe may be swollen more than the other, and the seminal vesi- glasses show urine containing prostatic threads and leukocytes,
cles may be involved. A frankly fluctuant abscess is uncommon. prostatitis is present. Rectal examination of the prostate may
be normal or may show a soft, boggy and tender prostate.
Treatment Examination of the prostatic fluid obtained by prostatic
Treatment must be rigorous and prolonged or the infection will massage should show pus cells and bacteria. Urethroscopy may
not be eradicated and recurrent attacks may ensue. Spread of reveal inflammation of the prostatic urethra, and pus may be
infection to the epididymides and testes may occur. Prolonged seen exuding from the prostatic ducts. The verumontanum is
treatment with an antibiotic that penetrates the prostate wall likely to be enlarged and oedematous. In many men with the
is indicated (trimethoprim, ciprofloxacin or aminoglycoside). symptoms described above, all investigations are normal.
Treatment
Prostatic abscess Antibiotic therapy should be administered only in accor-
In addition to the foregoing symptoms and signs, the advent dance with bacteriological sensitivity tests. Trimethoprim or
of a prostatic abscess is heralded by the temperature rising ciprofloxacin penetrate well into the prostate. If Trichomonas
steeply with rigors. Antibiotics disguise these features. Severe, or anaerobes are the responsible agent, a rapid response is
unremitting perineal and rectal pain with occasional tenesmus obtained from administration of metronidazole (200 mg
often cause the condition to be confused with an anorectal three times daily for 7 days to both partners). If Chlamydia is
abscess. Nevertheless, if a rectal examination is performed, the suspected, doxycycline is the antibiotic treatment of choice.
prostate will be felt to be enlarged, hot, extremely tender and α-blockers and anti-inflammatory drugs have been used with
perhaps fluctuant. TRUS or MRI may aid diagnosis. Reten- some success. There is little evidence that prostatic massage
tion of urine is likely to occur and, in such men, suprapubic helps in eradicating the infection.
catheterisation is best.
Treatment Prostatodynia
The abscess should be drained without delay by transurethral This diagnosis is made by the presence of perigenital pain
resection (unroofing the whole cavity) or using a needle via in the absence of any objective evidence of prostatic inflam-
the transrectal or perineal route. Injectable antibiotics such as mation. Whether the syndrome has any relationship with the
aminoglycoside or a third-generation cephalosporin is often prostate is unclear. The syndrome is part of the chronic pelvic
required for a week. pain syndrome spectrum and often has psychological and stress
components.
Chronic prostatitis
Many urologists find the diagnosis of chronic prostatitis FURTHER READING
and ‘prostatodynia’ very difficult as many men present with Mundy AR, Fitzpatrick J, Neal DE, George NJ (eds). The scientific basis
perigenital pain, testicular pain, prostatic pain exacerbated of urology, 3rd edn. London: Informa Healthcare, 2010.
by sexual intercourse or pain that apparently renders sexual Partin AW, Peters CA, Kavoussi LR, Dmochowksi RR, Wein AJ.
intercourse out of the question. Psychosexual dysfunction in Campbell–Walsh–Wein urology, 12th edn. Philadelphia, PA: Elsevier,
such patients may be the underlying problem. The diagnosis 2021.
of chronic prostatitis has to be based on: Scardino PT, Linehan WM, Zelefsky MJ, Vogelzang NJ. Comprehensive
textbook of genitourinary oncology, 4th edn. Philadelphia, PA:
● persistent threads in voided urine; Lippincott Williams & Wilkins, 2012.