Introduction
The prostate is a walnut-sized gland located below the bladder and in front of the rectum, surrounding the urethra. It produces seminal fluid that nourishes and transports sperm. Prostate conditions become increasingly common with age and include benign prostatic hyperplasia (BPH), prostatitis, and prostate cancer.
Benign Prostatic Hyperplasia (BPH)
Pathophysiology
| Aspect | Description |
|---|---|
| Definition | Non-malignant enlargement of the prostate due to hyperplasia of stromal and glandular elements |
| Prevalence | 50% of men by age 60; 90% by age 85 |
| Hormonal factors | Dihydrotestosterone (DHT) drives prostate growth; aging-associated hormonal changes |
| Location | Transition zone of prostate (periurethral) |
| Mechanism of symptoms | Physical compression of urethra + increased smooth muscle tone (alpha-adrenergic) |
Symptoms (LUTS - Lower Urinary Tract Symptoms)
| Category | Type | Symptom |
|---|---|---|
| Storage | Irritative | Urinary frequency (daytime) |
| Storage | Irritative | Nocturia (waking to urinate) |
| Storage | Irritative | Urinary urgency |
| Storage | Irritative | Urge incontinence |
| Voiding | Obstructive | Hesitancy (difficulty starting) |
| Voiding | Obstructive | Weak urinary stream |
| Voiding | Obstructive | Intermittency (stop-start flow) |
| Voiding | Obstructive | Straining to void |
| Post-void | Incomplete emptying | Sensation of residual urine |
| Post-void | Dribbling | Post-void dribbling |
AUA Symptom Score (International Prostate Symptom Score - IPSS)
| Symptom | Not at all (0) | Less than 1 in 5 (1) | Less than half (2) | About half (3) | More than half (4) | Almost always (5) |
|---|---|---|---|---|---|---|
| Incomplete emptying | 0 | 1 | 2 | 3 | 4 | 5 |
| Frequency (<2 hours) | 0 | 1 | 2 | 3 | 4 | 5 |
| Intermittency | 0 | 1 | 2 | 3 | 4 | 5 |
| Urgency | 0 | 1 | 2 | 3 | 4 | 5 |
| Weak stream | 0 | 1 | 2 | 3 | 4 | 5 |
| Straining | 0 | 1 | 2 | 3 | 4 | 5 |
| Nocturia | 0 (none) | 1 (1 time) | 2 (2 times) | 3 (3 times) | 4 (4 times) | 5 (5+ times) |
| Total Score | Category |
|---|---|
| 0-7 | Mild symptoms |
| 8-19 | Moderate symptoms |
| 20-35 | Severe symptoms |
BPH Evaluation
| Test | Purpose |
|---|---|
| History (AUA/IPSS) | Quantify symptom severity |
| Digital rectal exam (DRE) | Assess prostate size, consistency, nodules |
| Urinalysis | Rule out infection, hematuria |
| PSA | Rule out prostate cancer (optional, shared decision) |
| Post-void residual (PVR) | Assess urinary retention; >100-150 mL abnormal |
| Uroflowmetry | Peak flow rate (Qmax); <10-15 mL/s suggests obstruction |
| Cystoscopy | If complex symptoms, prior surgery, or before minimally invasive therapy |
| Upper tract imaging | If hematuria, stones, or renal insufficiency |
Medical Treatment
| Drug Class | Examples | Mechanism | Improvement in Symptoms | Time to Effect | Side Effects |
|---|---|---|---|---|---|
| Alpha-1 blockers | Tamsulosin (Flomax), alfuzosin (Uroxatral), doxazosin (Cardura), terazosin (Hytrin), silodosin (Rapaflo) | Relax prostatic smooth muscle by blocking alpha-1 adrenergic receptors | 4-6 point AUA score reduction | 2-4 weeks | Dizziness, orthostatic hypotension (doxazosin/terazosin), retrograde ejaculation (tamsulosin/silodosin), rhinitis |
| 5-alpha-reductase inhibitors | Finasteride (Proscar), dutasteride (Avodart) | Inhibit conversion of testosterone to DHT, reduce prostate size (20-30% volume reduction) | 3-4 point AUA score reduction | 3-6 months | Decreased libido (5%), erectile dysfunction (8%), decreased ejaculate volume (4%), gynecomastia (1%) |
| Combination therapy | Alpha blocker + 5-ARI | Additive effect | Greater improvement than monotherapy | As above | Combined side effects |
| PDE5 inhibitors | Tadalafil (Cialis) 5 mg daily | Relaxation of detrusor, prostatic, and urethral smooth muscle | 2-3 point AUA reduction | 2-4 weeks | Headache, dyspepsia, back pain, myalgia |
Minimally Invasive and Surgical Treatment
| Procedure | Description | Best For | Advantages | Disadvantages |
|---|---|---|---|---|
| Transurethral resection of prostate (TURP) | Resection of prostatic tissue via resectoscope | Moderate-large prostates (30-100 mL) | Gold standard; durable (10+ years) | Bleeding, TUR syndrome, retrograde ejaculation (65-75%) |
| Holmium laser enucleation (HoLEP) | Laser enucleation of prostatic adenoma | All sizes (including large >100 mL) | Works for large prostates; less bleeding; shorter catheter time | Requires specialized equipment; steep learning curve |
| Photoselective vaporization (PVP, GreenLight) | Laser vaporization of prostatic tissue | Moderate prostates; anticoagulated patients | Less bleeding; good for high-risk | Less effective for very large prostates |
| UroLift | Permanent implants retract prostatic lobes | Small-moderate prostates (30-80 mL), no median lobe | Preserves ejaculatory function; quick recovery | Less durable; not for large prostates or significant median lobe |
| Rezum | Convective water vapor thermal therapy | Small-moderate prostates | Preserves ejaculatory function; office procedure | Delayed improvement (months) |
| Prostatic artery embolization (PAE) | Embolization of prostatic artery | Large prostates; poor surgical candidates | No general anesthesia; preserves ejaculation | Emerging data; variable results |
| Open/robotic simple prostatectomy | Enucleation of adenoma | Very large prostates (>80-100 mL) | Definitive; works for very large | Longer recovery; invasive |
Acute Urinary Retention (AUR)
| Aspect | Management |
|---|---|
| Definition | Inability to void (acute onset) |
| Initial management | Foley catheter placement (16-18 Fr, 5-10 mL balloon) |
| Trial without catheter (TWOC) | After 1-3 days of catheter drainage + alpha blocker |
| TWOC success predictors | Age <65, PVR <1 L, prior retention for <24 hours, no neurologic disease |
| Failed TWOC | Continue catheter, schedule surgery |
| Prevention | Start alpha blocker before stopping catheter |
Prostatitis
Classification (NIH)
| Category | Name | Prevalence | Key Feature |
|---|---|---|---|
| I | Acute bacterial prostatitis | 2-5% of prostatitis | Acute UTI symptoms + fever |
| II | Chronic bacterial prostatitis | 5-10% | Recurrent UTIs, same organism |
| IIIA | Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) - inflammatory | 60-80% | Pelvic pain for 3+ months of last 6; WBCs in EPS |
| IIIB | CP/CPPS - non-inflammatory | Same as IIIA | Pelvic pain; no WBCs in EPS |
| IV | Asymptomatic inflammatory prostatitis | 10-15% | Incidental finding on biopsy/semen analysis |
Acute Bacterial Prostatitis (NIH I)
| Aspect | Details |
|---|---|
| Symptoms | Dysuria, frequency, urgency, fever, chills, malaise, perineal/pelvic pain, acute urinary retention |
| DRE | Tender, swollen, warm prostate; DRE should be gentle to avoid bacteremia |
| Diagnosis | Urinalysis, urine culture, CBC, blood cultures (if febrile); avoid prostate massage |
| Pathogens | E. coli (most common), Klebsiella, Proteus, Pseudomonas, Enterococcus |
| Treatment | Empiric antibiotics: fluoroquinolone (ciprofloxacin, levofloxacin) or TMP-SMX or third-gen cephalosporin; adjust based on culture; treat for 4-6 weeks |
| Hospitalization | If sepsis, high fever, unable to tolerate PO, urinary retention |
| Complications | Prostatic abscess, bacteremia, sepsis, acute urinary retention |
Chronic Bacterial Prostatitis (NIH II)
| Aspect | Details |
|---|---|
| Symptoms | Recurrent UTIs with same pathogen; chronic pelvic pain; irritative voiding symptoms |
| Diagnosis | Positive culture of expressed prostatic secretions (EPS) or post-massage urine |
| Pathogens | Same as acute (E. coli common); biofilm formation |
| Treatment | Fluoroquinolone (ciprofloxacin 500 mg BID or levofloxacin 750 mg daily) for 4-6 weeks; TMP-SMX for 6-12 weeks if resistant |
| Refractory | Prostatic massage; transurethral resection of prostate (to remove infected foci) |
Chronic Prostatitis/Chronic Pelvic Pain Syndrome (NIH III)
| Aspect | Details |
|---|---|
| Symptoms | Pelvic/perineal/genital pain >3 months; variable voiding symptoms; sexual dysfunction; no documented UTI |
| Etiology | Multifactorial: infection trigger, inflammation, neuromuscular dysfunction, pelvic floor tension, psychological factors |
| Evaluation | Urinalysis, urine culture, EPS/post-massage culture, AUA score, pain mapping, consider cystoscopy |
| Treatment approach | Multimodal (no single therapy highly effective) |
| Treatment Category | Options |
|---|---|
| Alpha blockers | Tamsulosin, alfuzosin (moderate improvement in symptoms) |
| Antibiotics | Trial of fluoroquinolone for 4-6 weeks (controversial; may help if occult infection) |
| Anti-inflammatories | NSAIDs, COX-2 inhibitors |
| Phytotherapy | Quercetin, pollen extract (Cernilton), saw palmetto (limited evidence) |
| Pelvic floor physical therapy | Myofascial release, trigger point therapy, biofeedback |
| Neuromodulators | Amitriptyline, gabapentin, pregabalin |
| Psychological | CBT, stress reduction, pain coping strategies |
| Minimally invasive | Transurethral needle ablation, microwave thermotherapy (limited evidence) |
| Lifestyle | Avoid prolonged sitting, warm baths, regular ejaculation, bladder training |
Prostate Cancer
Epidemiology
| Statistic | Value |
|---|---|
| Most common cancer in men (excluding skin) | Yes |
| Lifetime risk | 1 in 8 |
| Median age at diagnosis | 66 |
| Second leading cause of cancer death in men | Yes |
| 5-year survival (localized) | >99% |
| 5-year survival (metastatic) | 32% |
| Racial disparity | African American: 1.7x incidence, 2.1x mortality |
Risk Factors
| Factor | Risk | Notes |
|---|---|---|
| Age | Increases with age | Rare <40; 60% diagnosed >65 |
| Race (African American) | Highest risk | Highest incidence and mortality globally |
| Family history (1st degree) | 2-3x | Risk increases with number and closeness of affected relatives |
| BRCA2 mutation | 3-5x | More aggressive phenotype |
| Lynch syndrome | 2-3x | Elevated risk |
| Diet (high fat, red meat, dairy) | 1.2-1.5x | Limited evidence |
| Obesity | 1.2x | Associated with more aggressive disease |
| Smoking | 1.2x | Associated with recurrence and mortality |
Prevention
| Intervention | Evidence |
|---|---|
| Finasteride/dutasteride (5-ARIs) | 25% reduction in prostate cancer risk (PCPT/REDUCE trials); may reduce detection of low-grade but not high-grade |
| Aspirin | Possible reduction in risk (observational) |
| Lycopene (tomatoes, cooked) | Possible reduction in risk (observational) |
| Selenium and vitamin E | No benefit (SELECT trial); vitamin E may increase risk |
| Mediterranean diet | Possible benefit |
| Exercise | May reduce risk of aggressive disease |
PSA Screening
| Aspect | Recommendation |
|---|---|
| USPSTF (2018) | Ages 55-69: individual decision (C recommendation); Age 70+: do not screen (D) |
| ACS | Individual decision starting at 50 (45 for high risk; 40 for highest risk) |
| AUA | Ages 55-69: shared decision-making; Ages 40-54: consider for high risk; 70+: select healthy |
| NCCN | Baseline PSA at 45; start screening at 40-45 for high risk; 45-75 for average risk |
PSA Interpretation
| PSA Level (ng/mL) | Interpretation |
|---|---|
| 0-2.5 | Low risk (for age <50); normal for most men |
| 2.5-4.0 | Normal but could be higher than expected for young men |
| 4.0-10.0 | Gray zone: 20-30% probability of cancer |
| >10.0 | High risk: 50-70% probability of cancer |
| >20.0 | Very high risk; likely advanced disease |
PSA Derivatives
| Test | Calculation | Utility |
|---|---|---|
| PSA density | PSA / prostate volume (mL) | >0.15 ng/mL/cc suggests cancer |
| PSA velocity | Change in PSA over time | >0.35-0.75 ng/mL/year concerning |
| Free PSA ratio | Free PSA / total PSA | <10%: 50% cancer risk; >25%: <10% cancer risk |
| PSA doubling time | Time for PSA to double | Shorter doubling time suggests aggressive disease |
Gleason Score (Grade Group)
| Grade Group | Gleason Score | Risk Category |
|---|---|---|
| 1 | 6 (3+3) | Very low to low risk |
| 2 | 7 (3+4) | Favorable intermediate |
| 3 | 7 (4+3) | Unfavorable intermediate |
| 4 | 8 (4+4, 3+5, 5+3) | High risk |
| 5 | 9-10 (4+5, 5+4, 5+5) | Very high risk |
Risk Stratification (NCCN)
| Risk Group | Criteria | Treatment Options |
|---|---|---|
| Very low | PSA <10, GS 6, T1c, <3 cores positive, <50% in any core | Active surveillance |
| Low | PSA <10, GS 6, T1-T2a | Active surveillance or treatment |
| Favorable intermediate | PSA 10-20, GS 7 (3+4), T2b-c | Active surveillance (select) or radical prostatectomy or radiation |
| Unfavorable intermediate | PSA 10-20, GS 7 (4+3), T2b-c | Radical prostatectomy or radiation + ADT (4-6 months) |
| High | PSA >20, GS 8-10, T3a | Radiation + ADT (1-3 years) or radical prostatectomy (select) |
| Very high | T3b-T4, primary pattern 5 | Radiation + ADT (2-3 years) + abiraterone |
| Metastatic | Any T, any N, M1 | ADT + abiraterone/prednisone or docetaxel or enzalutamide |
Treatment by Modality
| Treatment | Indications | Side Effects |
|---|---|---|
| Active surveillance | Very low/low-risk | None (but anxiety; follow-up biopsies) |
| Radical prostatectomy | Localized disease (intermediate-high risk) | Incontinence (5-15% at 1 year), erectile dysfunction (50-80%), surgical risks |
| External beam radiation (IMRT/IGRT) | Localized disease | Dysuria, proctitis, impotence, secondary malignancy (late) |
| Brachytherapy (seed implant) | Low/favorable intermediate | Urinary symptoms, impotence |
| Stereotactic body radiation (SBRT) | Low/favorable intermediate | Similar to external beam |
| Cryotherapy | Salvage after radiation | Impotence, urethral sloughing |
| High-intensity focused ultrasound (HIFU) | Localized (evolving) | Limited long-term data |
Androgen Deprivation Therapy (ADT)
| Type | Agents | Side Effects |
|---|---|---|
| LHRH agonists | Leuprolide (Lupron), goserelin (Zoladex), triptorelin (Trelstar) | Hot flashes, fatigue, decreased libido, impotence, osteoporosis, sarcopenia, metabolic syndrome, cognitive changes, gynecomastia |
| LHRH antagonists | Degarelix (Firmagon), relugolix (Orgovyx) | Same as agonists; no flare effect |
| Anti-androgens | Bicalutamide (Casodex), enzalutamide (Xtandi), apalutamide (Erleada), darolutamide (Nubeqa) | Fatigue, hypertension, fall risk |
| CYP17 inhibitor | Abiraterone (Zytiga) + prednisone | Hypertension, hypokalemia, fluid retention, hepatotoxicity |
| Chemotherapy | Docetaxel, cabazitaxel | Nausea, fatigue, neuropathy, myelosuppression |
| Radiopharmaceutical | Radium-223 (Xofigo) | Bone marrow suppression, for bone metastases |
| PARP inhibitors | Olaparib, rucaparib, niraparib | For BRCA1/2, ATM-mutated metastatic CRPC |
| PSMA-targeted therapy | Lu-177 PSMA-617 (Pluvicto) | For PSMA-positive metastatic CRPC |