Benign prostatic hypertrophy is a disease of the prostate that occurs with increasing age in most men (Fig. 5.49B). It generally involves the more central regions of the prostate (see Fig. 5.48), which gradually enlarge. The prostate feels “bulky” on DRE. Owing to the more central hypertrophic change of the prostate, the urethra is compressed, and a urinary outflow obstruction develops in a number of patients. With time, the bladder may become hypertrophied in response to the urinary outflow obstruction. In some male patients, the obstruction becomes so severe that urine cannot be passed and transurethral or suprapubic catheterization is necessary. Despite being a benign disease, benign prostatic hypertrophy can therefore have a marked effect on the daily lives of many patients.
In the clinic
Ovarian cancer remains one of the major challenges in oncology. The ovaries contain numerous cell types, all of which can undergo malignant change and require different imaging and treatment protocols and ultimately have different prognoses.
Ovarian tumors most commonly originate from the ovarian surface (germinal) epithelium that is continuous at a sharp transition zone with the peritoneum of the mesovarium.
Many factors have been linked with the development of ovarian tumors, including a strong family history.
Ovarian cancer may occur at any age, but more typically it occurs in older women.
Cancer of the ovaries may spread via the blood and lymphatics, and frequently metastasizes directly into the peritoneal cavity. Such direct peritoneal cavity spread allows the passage of tumor cells along the paracolic gutters and over the liver from where this disease may disseminate easily. Unfortunately, many patients already have metastatic and diffuse disease (Fig. 5.52) at the time of diagnosis.
In the clinic
Imaging the ovary
The ovaries can be visualized using ultrasound. If the patient drinks enough water, the bladder becomes enlarged and full. This fluid-filled cavity provides an excellent acoustic window, behind which the uterus and ovaries may be identified by transabdominal scanning with ultrasound. This technique also allows obstetricians and technicians to view a fetus and record its growth throughout pregnancy.
Some patients are not suitable for transabdominal scanning, in which case a probe may be passed into the vagina, permitting close visualization of the uterus, the contents of the recto-uterine pouch (pouch of Douglas), and the ovaries. The ovaries can also be visualized laparoscopically. Many countries have introduced screening programs for cervical cancer where women are regularly called for smear tests.
In the clinic
A hysterectomy is the surgical removal of the uterus. This is usually complete excision of the body, fundus, and cervix of the uterus, though occasionally the cervix may be left in situ. In some instances the uterine (fallopian) tubes and ovaries are removed as well. This procedure is called a total abdominal hysterectomy and bilateral salpingo-oophorectomy.
Hysterectomy, oophorectomy, and salpingo-oophorectomy may be performed in patients who have reproductive malignancy, such as uterine, cervical, and ovarian cancers. Other indications include a strong family history of reproductive disorders, endometriosis, and excessive bleeding. Occasionally the uterus may need to be removed postpartum because of excessive postpartum bleeding.
A hysterectomy is performed through a transverse suprapubic incision (Pfannenstiel’s incision). During the procedure tremendous care is taken to identify the distal ureters and to ligate the nearby uterine arteries without damage to the ureters.
In the clinic
After ovulation, the unfertilized egg is gathered by the fimbriae of the uterine tube. The egg passes into the uterine tube where it is normally fertilized in the ampulla. The zygote then begins development and passes into the uterine cavity where it implants in the uterine wall.