Pathology of the Prostate

Pathology of the Prostate

Objectives

  • Identify and describe commonly encountered pathologies on sonographic images of the prostate gland.

  • Differentiate the etiology, clinical indications, and sonographic appearance of prostatic pathologies including:

    • Prostatitis

    • Cysts

    • Calcifications

    • Benign prostatic hyperplasia (BPH)

    • Prostate malignancies

    • Seminal vesicle pathology

  • Identify and describe a TURP (Transurethral Resection of the Prostate) on sonographic images of the prostate.

  • Correlate laboratory values and clinical indications associated with prostate abnormalities, disease, and pathology.

Prostatitis

  • Inflammation and swelling of the prostate gland.

  • Four types/categories:

    • I. Acute bacterial prostatitis

    • II. Chronic bacterial prostatitis

    • III. Chronic non-bacterial prostatitis / chronic pelvic pain syndrome (CPPS)

      • IIIa. Inflammatory CPPS

      • IIIb. Non-inflammatory CPPS

    • IV. Asymptomatic inflammatory prostatitis

Categories of Prostatitis Syndromes (NIH Classification)

Category

Symptoms

I. Acute bacterial prostatitis

Associated with severe symptoms of prostatitis, systemic infection, and acute bacterial urinary tract infection.

II. Chronic bacterial prostatitis

Caused by chronic bacterial infection of the prostate with or without symptoms of prostatitis and usually with recurrent urinary tract infections caused by the same bacterial strain.

III. Chronic pelvic pain syndrome (CPPS)

Characterized by symptoms of chronic pelvic pain and possibly symptoms on voiding in the absence of urinary tract infection. This category is subdivided into inflammatory (category IIIA) and noninflammatory (category IIIB) prostatitis.

IV. Asymptomatic inflammatory prostatitis

Characterized by evidence of inflammation of the prostate in the absence of genitourinary tract symptoms; an incidental finding during evaluation for other conditions, such as infertility or elevated serum prostate-specific antigen levels.

Prostatitis - Acute Bacterial

  • Common among men over 50 years, especially if immunocompromised (HIV/AIDS, diabetes).

  • Consider STD in younger men.

  • Causes:

    • Ascending infection: Bacteria from urine refluxing into the prostate or ascending urethral infection.

    • Direct extension or lymphatic spread from the rectum.

    • Hematogenous spread.

    • Post-procedure (biopsy, catheter).

  • Signs and Symptoms (S&S):

    • Severe prostatitis symptoms.

    • Urinary frequency, urgency, and dysuria.

    • Urinary retention.

    • Acute UTI.

    • Systemic infection.

  • Sonographic Appearance:

    • Hypoechoic areas on TRUS (Transrectal Ultrasound).

Prostatitis - Chronic Bacterial

  • Primary voiding dysfunction problem (structural or functional).

  • Recurrent UTI (same bacterium) for typically more than 3 months.

  • S&S:

    • Intermittent dysuria.

    • Intermittent lower urinary tract symptoms.

    • Recurrent UTI with same organism.

Prostatitis - Abscess

  • Extraprostatic spread may be noted.

Prostatitis - CPPS (Chronic Non-Bacterial Prostatitis / Chronic Pelvic Pain Syndrome)

  • Diagnosed based on pain with negative UTI.

  • Sexual dysfunction, pelvic pain, and persistent voiding issues for > 3 months.

  • Can be inflammatory or non-inflammatory depending on the presence/absence of leukocytes in prostatic secretions.

Prostatitis - Asymptomatic Inflammatory

  • Inflammation of the prostate, but no genitourinary symptoms.

  • Often only diagnosed following examination of prostate tissue (i.e., biopsy).

Cysts

  • Usually an incidental finding.

  • Asymptomatic.

  • Etiological factors:

    • Chronic prostatitis (lateral cyst).

    • Congenital disease (midline cyst; Mullerian duct cyst, prostatic utricle cyst).

Calcifications

  • Incidental finding.

  • Usually associated with inflammation or post trauma/injury/biopsy.

  • S&S:

    • Most often asymptomatic.

    • May have haematuria/dysuria/pelvic or perineal pain.

    • Obstruction – may even pass one!

Benign Prostatic Hyperplasia (BPH)

  • AKA benign prostatic enlargement and benign prostatic hypertrophy.

  • Sometimes referred to as prostatomegaly, but prostates can be enlarged for other reasons.

  • Benign, very common.

  • Transitional zone enlargement; compresses PZ & CZ.

  • Incidence increases with age after 40 years: by 60 years, 50% of men have BPH; by 90 years, 90% have BPH.

  • S&S:

    • Difficulty voiding.

    • Weak urine stream.

    • Dribbling urine once you have stopped urinating.

    • Constant feeling of having to urinate.

    • Nocturnal urgency.

    • Increase in UTIs.

    • Bladder or kidney calculi.

TURP (Transurethral Resection of the Prostate)

  • Removes hyperplastic tissue around the prostatic urethra to relieve compression.

Prostate Malignancies

  • Most primary prostate cancers are adenocarcinomas.

  • Other cancers that originate in the prostate include neuroendocrine carcinomas (including small cell carcinomas), transitional cell carcinomas, and sarcomas – rare.

  • Most start in PZ; <20% start in TZ.

  • Slow-growing.

  • Can spread to adjacent tissues (bladder, rectum).

  • Can metastasize (LNs, bone).

  • S&S:

    • Painful or burning sensation on urination or ejaculating.

    • Increased frequency of urination, especially nocturnal.

    • Difficulty stopping or starting urination.

    • Sudden erectile dysfunction.

    • Haematuria, haematospermia.

    • Palpable hard lump on rectal examination (Stage II onward).

  • Sonographic Appearance:

    • Tumour is hypoechoic relative to normal prostatic tissue.

Seminal Vesicle Pathology

  • Seminal vesicle enlargement

  • Seminal vesiculitis

  • Seminal vesicle cyst

  • Seminal vesicle calcifications

Semen Analysis

  • Laboratory Tests analyze:

    • Volume of semen

    • Macroscopic appearance

    • Semen viscosity (thickness)

    • Sperm concentration

    • Total number of sperm

    • Sperm motility (percentage that are able to move, as well as how vigorously and straight the sperm move)

    • Number of normal and abnormal (defective) sperm

    • Coagulation and liquefaction (time it takes the semen to go from a gel to a liquid state)

    • Fructose level (a sugar in semen)

    • pH (acidity)

    • Number of immature sperm

    • Haematospermia

    • Leukospermia

Laboratory Tests

  • Semen analysis:

    • Positive correlation between prostatic calcifications and haematospermia following a prostate biopsy.

    • If referral says haematospermia, ask if the patient has had a prostate biopsy!

  • Blood test:

    • Prostate-specific antigen (PSA) – protein produced by both normal and malignant cells in the prostate.

    • PSA is elevated when malignancy is present but also with benign prostatic hyperplasia and prostatitis.

Review

  • Describe using sonographic terminology pathologies mentioned in this lecture.

  • Describe the four classifications of prostatitis and the sonographic appearances of each.

  • Describe what BPH is, who is susceptible to developing it, and how it can appear on ultrasound.

  • Describe the layout of the prostatic zones including which zone is closest to the transducer when doing a transrectal ultrasound.