Benign Prostatic Hyperplasia (BPH)

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Benign prostatic hyperplasia affects most males over the age of 70 years.
Benign prostatic hyperplasia is the most common disorder of the prostate. It affects almost all men over the age of 70 years, but is found with increasing frequency and severity from about the age of 45 years onwards.
Clinically it presents with difficulty with micturition, due to compression of the prostatic urethra by the enlarging prostate gland. In most cases it is the two lateral lobes that are markedly enlarged. However, in some cases the posterior lobe shows the greatest enlargement, which may obstruct the urinary outflow tract at the internal urinary meatus at the bladder neck. Prolonged prostatic obstruction is the most common cause of chronic obstructive uropathy, and may lead to marked hypertrophy of the bladder wall, with trabeculation of bladder muscle, and acute or chronic retention of urine in the bladder. In such cases the failure to empty the bladder may lead to reflux of urine into the pelvicalyceal system, producing megaureter and hydronephrosis and predisposition to infection.

The pathogenesis of benign prostatic hyperplasia is not known, but it is believed to be due to androgen-oestrogen imbalance.
The area that is hormone sensitive, and that undergoes this pattern of hyperplasia, is the periurethral group of prostatic glands, not the true prostatic glands at the periphery. Continuing enlargement of the periurethral glands compresses the peripheral true prostatic glands, leading to their collapse, leaving only their fibrous supporting stroma behind. 

Macroscopically the hyperplastic component of the prostate shows a nodular pattern of hyperplastic glandular acini separated by fibrous stroma .
Some of the nodules are cystically dilated and contain a milky fluid. Other nodules contain numerous calcified concretions (corpora amylacea). Histologically the acini are hyperplastic and tightly packed, lined by tall columnar epithelial cells with small basal nuclei, and the epithelium is sometimes thrown up into irregular papillary folds. Another component of the prostatic enlargement is muscular hypertrophy, particularly in the region of the bladder neck.

Carcinoma of the prostate is the second most common type of cancer in males

Carcinoma of the prostate is an important and common cause of malignancy in men, occurring with increasing frequency over the age of 55 years.
Carcinoma of the prostate is an adenocarcinoma with varying degrees of differentiation, which arises in the true prostatic glands at the periphery of the prostate. Local spread is therefore most likely to occur through the prostatic capsule, before the tumour infiltrates medially towards the urethra. For this reason, attempts to obtain biopsy samples of prostate to establish a diagnosis of malignancy by using the transurethral route may give false negative results; a needle biopsy of the outer prostate using a transrectal approach is more likely to be successful.

The aetiology of this type of tumour is uncertain and, although tumours are often under endocrine control by testosterone, there is no evidence that endocrine imbalance is a primary causative factor. In the absence of any firm causative factors, no primary preventive strategies offer themselves for carcinoma of the prostate; efforts are therefore being directed to develop strategies for screening to detect early-stage disease.
Because of its peripheral origin, prostatic cancer is often well-established before the patient develops symptoms of difficulty with micturition due to urethral obstruction, and some tumours may remain silent, even in the presence of widespread metastases. Prostatic cancers can be divided into three groups on the basis of their behaviour:
1 Invasive prostatic carcinomas. Clinically important since they invade locally and metastasize.
2 Latent prostatic carcinoma. These are small foci of well-differentiated carcinoma, frequently an incidental finding in the prostatic glands of elderly men. They appear to remain confined to the prostate for a long period.
3 Occult carcinomas are clinically not apparent in the primary site, but present as metastatic disease.

Macroscopically, carcinomas of the prostate appear as diffuse areas of firm, white tissue, which merge into the fibromuscular prostatic stromal tissues.
Distortion and extension outside the capsule of the prostate is common, producing a firm, craggy mass that can be palpated on rectal examination. Histologically, most lesions have a differentiated glandular pattern (good prognosis), a smaller proportion being composed of poorly differentiated sheets of cells having no acinar pattern (poor prognosis) 

Carcinoma of the prostate metastasizes to bone and nodes and invades the bladder base
Prostatic carcinomas spread by three main routes:
Direct spread to base of bladder and adjacent tissues. 
This causes obstruction of the urethra (difficulty in micturition) and may block the ureters, causing hydronephrosis. 
Lymphatic spread to pelvic and para-aortic nodes. 
Vascular spread to bone. Bone metastases by prostatic carcinoma may be sclerotic with bone production (dense on radiograph), rather than lytic with bone destruction.

Occasionally, the first manifestation of disease is from metastatic spread, for example compressing the spinal cord after vertebral metastasis. The pathological diagnosis of metastatic prostatic carcinoma is assisted by immunohistochemical detection of prostate-specific antigen and prostate-specific acid phosphatase in biopsy material. These may also be used as serum markers for disease, levels being particularly raised when there is metastatic disease.
As many prostatic carcinomas are dependent on testosterone for growth, orchidectomy, or treatment with oestrogenic drugs or agonists of luteinizing hormone-releasing hormone, may induce tumour regression.
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Revised: 02-11-2014.