MRCS B Prostate Gland
Stem: A 68-year-old man presents to his GP with a 6-month history of increasing urinary frequency, nocturia, and a weak urinary stream with hesitancy. He denies any haematuria or weight loss. On examination, his abdomen is soft and non-tender, with no palpable bladder.
What are the superior and inferior relations of the prostate gland?
SpoilerSuperior – neck of the bladder
Inferior – external urethral sphincter
Describe the zonal anatomy of the prostate. Which zone is most commonly affected by carcinoma, and which by benign hyperplasia?
SpoilerPeripheral zone – largest zone, most common site of prostate carcinoma, palpable on DRE
Transition zone – surrounds the urethra, most common site of benign prostatic hyperplasia
Central zone – surrounds the ejaculatory ducts
What is the arterial supply to the prostate?
SpoilerInferior vesical artery, from the anterior division of the internal iliac artery.
What is the venous drainage of the prostate and how is it implicated in prostatic malignancy?
SpoilerProstatic venous plexus
Has a connection with the valveless vertebral veins, which may be a passage of spread of malignancy.
Prostate symptoms can be classified as storage or voiding symptoms, give two examples of each.
Storage
SpoilerFrequency
Nocturia
Urgency
Incontinence
Voiding
SpoilerTerminal dribbling
Slow stream
Slow to start voiding
What is an important part of the examination of a male patient with storage or voiding symptoms? How may we distinguish between benign or malignant pathology?
SpoilerDigital rectal examination.
May feel a smooth enlargement suggestive of benign disease, or a craggy, hard mass, which would suggest malignant disease.
What tumour marker is used to help diagnose and monitor prostate cancer, and what are its limitations?
SpoilerProstate-specific antigen (PSA)
Not specific to malignancy – can also be raised in BPH, prostatitis, and after instrumentation (e.g. catheterisation, DRE)
Lacks sensitivity and specificity, so used alongside DRE and biopsy rather than as a standalone diagnostic test
Give two options for the pharmacological management of benign prostatic hyperplasia.
Spoiler5-alpha reductase inhibitors – e.g. Finasteride.
Anticholinergic agents – e.g. Tolterodine
Alpha blockers can also be used.
Give two risk factors for prostate cancer.
SpoilerEthnicity – more common in people of black ethnicity.
Age – people aged over 50 are much more likely to have prostate malignancy.
