Acute bacterial prostatitis presents with sudden onset of fever, chills, dysuria, perineal pain, and bladder outlet obstruction; it may be complicated by sepsis. If acute prostatitis is suspected, digital rectal examination is contraindicated, as pressure on the boggy, exquisitely tender prostate can cause bacteremia. Chronic bacterial prostatitis usually is associated with recurrent urinary tract infections bracketed by asymptomatic periods. Presenting manifestations include low back pain, dysuria, and perineal and suprapubic discomfort. Both acute and chronic bacterial prostatitis is treated with antibiotics. Chronic pelvic pain syndrome is characterized by chronic pain localized to the perineum, suprapubic area, and penis. Pain during or after ejaculation is a prominent finding. The etiology is uncertain, and it is a diagnosis of exclusion; indeed, it is not even clear if the pain is related to an abnormality of the prostate. Therapy for chronic pelvic pain syndrome is empirical and depends on the nature of the symptoms.
Bacterialprostatitismaybeacuteorchronic;theresponsibleorganismusuallyisE. coli oranothergram-negativerod.
Chronicpelvicpainsyndrome,despitesharedsymptomatologywithchronicbacterialprostatitis,isofunknownetiologyanddifficulttotreat.
Granulomatousprostatitismaybeeitherinfectious(e.g.,followingtreatmentwithBCG)ornoninfectious.
Benign prostatic hyperplasia (BPH) is an extremely common cause of prostatic enlargement resulting from proliferation of of stromal and glandular elements. It is present in a significant number of men by 40 years of age, and its frequency rises progressively thereafter, reaching 90% by the eighth decade of life. The enlargement of the prostate in men with BPH is an important cause of urinary obstruction.
Although the cause of BPH is incompletely understood, excessive androgen-dependent growth of stromal and glandular elements has a central role. BPH does not occur in males who are castrated before the onset of puberty or in males with genetic diseases that block androgen activity. Dihydrotestosterone (DHT), the ultimate mediator of prostatic growth, is synthesized in the prostate from circulating testosterone by the action of the enzyme 5α-reductase, type 2. DHT binds to nuclear androgen receptors, which regulate the expression of genes that support the growth and survival of prostatic epithelium and stromal cells. Although testosterone can also bind to androgen receptors and stimulate growth, DHT is 10 times more potent.
MORPHOLOGYBPH virtually always occurs in the inner transition zone of the prostate. Theaffectedprostateisenlarged,typicallyweighingbetween60and100g,andcontainsmanywell-circumscribednodulesthatbulgefromthecutsurface(
Fig.
18.11 ).Thenodulesmayappearsolidorcontaincysticspaces,thelattercorrespondingtodilatedglands.Theurethraisusuallycompressed,oftentoanarrowslit,bythehyperplasticnodules.Insomecases,hyperplasticglandularandstromalelementslyingjustundertheepitheliumoftheproximalprostaticurethraprojectintothebladderlumenasapedunculatedmass,producingaball-valvetypeofurethralobstruction.
Microscopically,thehyperplasticnodulesarecomposedofvariableproportionsofproliferatingglandularelementsandfibromuscularstroma.Thehyperplasticglandsarelinedbytall,columnarepithelialcellsandaperipherallayerofflattenedbasalcells(
Fig.18.12 ).Theglandularluminaoftencontainlaminatedproteinaceoussecretorymaterialknownascorporaamylacea.