What is Prostate? Prostate Diseases – Doç. Dr. Kadir Tepeler

What is Prostate?

The prostate is one of the male reproductive organs. It is the largest gland of the organs.

It consists of secretory cells (tubuloalveolar glands) and their supporting tissue.

It weighs 18-20 grams.


Where Is The Prostate Located In The Body?

The prostate is an organ that exists in every man. It is an organ that surrounds the urethra just below the bladder. Its shape and size are similar to chestnuts.

On the outside, there is a shell tissue called capsule. Nerves that provide erection pass around it and spread towards the penis. Beneath it are the muscles (sphincter) that prevent us from incontinence.

It is shaped like an inverted pyramid. Its base fits over the opening of the urinary bladder. On its back is the rectum, the last part of the large intestine. The lower end part ends by tapering. The urethra, called the urethra, passes through it. It has a capsule (shell) consisting of collagen and elastin that surrounds it from the outside.

What is the Internal Structure of the Prostate?

The secretory tissue makes up 70% of the prostate, and the supporting tissue called fibromuscular stoma makes up 30%. At the lower end, there is a channel called the verumontanum where the semen is expelled.

The prostate is anatomically divided into 5 layers. The transitional region surrounding the urethra (5%) and the region outside this region are the central region (25%).

Benign prostate enlargement usually occurs as a result of the growth of cells in the transitional region. The region surrounding these regions externally is the peripheral region (25%).

Prostate cancer usually originates in the peripheral region. Except for these regions, the anterior upper part of the prostate constitutes 30% and is called fibromuscular stroma. This region contains more muscle tissue.

What Does the Prostate Do? What is its Function in the Body?

90% of the fluid called semen that comes out after sexual intercourse or masturbation is produced from the prostate gland. Prostate secretions help sperm live in the female reproductive organs. Due to its location next to its secretory function, it also has a duty to control urine. The prostate is not a vital organ. There is a risk of deterioration of sexual functions and urinary control when taken.

When Does the Prostate Start to Grow?

The prostate is formed in male babies by the stimulation of male hormones in the womb. It does not change in size after birth until puberty. At puberty, it begins to increase in size with hormonal stimulation. It is around 20gr in an adult male.

After the age of 40, the growth of the prostate gland accelerates as a result of hormonal imbalance. It can cause complaints by compressing the urinary tube passing through the middle.

What is the Role of the Prostate?

The job of the prostate is to produce semen. About 10% of the semen is produced in the testicles, 60% in the seminal vesicle, another gland behind the prostate, and 30% in the prostate.

Prostate secretion makes semen alkaline. Thus, sperms are protected from the acidic environment in the vagina. Prostate secretions cause the semen to become thick and sticky and then to become fluid.

During sexual intercourse, the semen is stuck in the female genitals in a dark sticky state. Then, by becoming fluid, the sperms are activated and fertilization is ensured.

Is It Possible to Prevent Prostate Enlargement at Young Ages?

The prostate gland is an organ that is sensitive to the male hormone testosterone. It is present in men of all ages. After the age of 40, it begins to grow as a result of hormonal fluctuations or some metabolic events.

Prostate Enlargement - How to Differentiate Cancer?

Prostate cancer is the most common type of cancer in men after lung cancer. If cancer is suspected with a blood test called PSA and examination, prostate MRI (multiparametric prostate MRI) and biopsy are recommended for cancer diagnosis.

In recent years, our chance of success in diagnosing cancer has increased with fusion or smart biopsy, which is a special biopsy technique that we also apply. This subject is explained in detail in the prostate cancer topic.

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What are Benign Prostate Enlargement Symptoms?

The enlarged prostate tissue compresses the urethra.

Sometimes it even extends towards the urinary bladder (median lobe-middle lobe) and closes the urinary canal almost completely like a lid.

Difficulty urinating, impaired urine flow, weak urine, intermittent urination, frequent urination, getting up to urinate at night, feeling of incomplete emptying after going to the toilet, burning and bleeding in the urine can be seen.

Their complaints especially increase in cold weather and they may become unable to urinate over time.

Urine output is provided by inserting a catheter in patients with occlusion.

How to Evaluate a Patient with Prostate Enlargement? How is the diagnosis made?

As in every patient, the patient's complaints and additional diseases are evaluated in detail. Prostate enlargement is not the only reason for lower urinary tract voiding complaints. It should not be forgotten that diseases that impair bladder contraction, diabetes, some neurological diseases, urinary tract stenosis, infections also cause similar complaints.
Therefore, patients should be evaluated in detail before treatment.

Urinalysis, detailed evaluation of bladder, prostate and kidneys with ultrasonography, urine flow measurement with urination test, PSA blood test are the basic tests. The urine remaining in the bladder after urination with ultrasound must be measured.

In addition, the International Prostate Symptom Score (IPSS), in which patients evaluate themselves, also helps us to evaluate the severity of complaints.

In some cases, it may be necessary to examine the urethra and bladder endoscopically (instrument with a camera).

This procedure can be performed in operating room conditions, or it can be performed in office conditions with a flexible cystoscope (a thin-camera device that can be bent).

Is Drug Treatment Effective in the Treatment of Prostate Enlargement?

Drugs that relax the urinary tract (alpha blockers) are given to reduce the complaints related to the enlarged prostate. The most common side effect of these drugs is the absence of semen output. When these drugs, which act by relaxing the muscles in the neck of the urinary bladder, are used, semen flows back into the bladder during intercourse and this is called retrograde ejaculation. This does not cause infertility. If you do not want to have children, there is no harm.

The second type of drug given to patients with a larger prostate (greater than 40ml) (5-alpha reductase inhibitors) prevents the conversion of testosterone to its more active form in the prostate. These drugs can cause erectile dysfunction.

Sometimes, patients with accompanying erectile dysfunction may be offered drugs (phosphodiesterase inhibitors) that will both relieve urinary complaints and improve their performance.

Another problem we encounter in our elderly patients with enlarged prostate is the deterioration in the smooth muscle structure of the bladder due to age or obstruction. In patients with involuntary bladder contraction (overactive bladder) and decreased bladder capacity, drugs that relax bladder smooth muscles (anti-muscarinics) may also be given.

The drug treatments described above may be used alone or in combination. This situation is decided by making a detailed evaluation.

Sudden Urinary Inability (Acute Urinary Retention)

Patients with an enlarged prostate become unable to urinate after concomitant infection, edema, anesthesia, stones in the bladder, chills or excessive fluid intake. Applications to the emergency department with severe abdominal-groin pain. On ultrasound, it is clearly seen that the bladder is full (globe vesical). First, the catheter is inserted by the emergency physician or urologist. Sometimes the prostate of the patients is very large and the probe cannot exceed the prostate and reach the bladder. In these cases, a probe extending from the skin to the bladder, called a percutaneous cystostomy, is applied under local anesthesia. Patients experiencing acute urinary retention are usually able to urinate after drug therapy. However, surgical treatment is definitely recommended in cases that are unable to urinate or recurrent retention after catheter removal.

When Is Surgery Necessary?

  • Patients who do not benefit from drug therapy or who do not use drugs
  • Quality of life due to urinary complaints - those whose social life is adversely affected
  • Patients who cannot urinate and have a catheter inserted
  • Patients suffering from urinary tract inflammation
  • Patients whose bladder or kidney begins to deteriorate because they cannot urinate and there is urine left.
  • Patients with stones in the urinary bladder
  • Patients with an enlarged prostate and bleeding into the urine

The above-mentioned conditions are definitely patients who need surgery. Each patient should be evaluated individually. The most appropriate treatment method is chosen for the patient by considering many factors such as co-morbidities, medications, general health status, expectations from the surgery, sexual life, social-work life. The technical possibilities and surgical experience of the surgeon are also very important. The surgical techniques are briefly summarized below.

What Are the Surgery Options?

  1. TUR-P: It is the process of cutting the prostate tissue, especially smaller than 80-100 grams, with the help of an electric wire by entering through the urinary canal with a camera device. Bipolar and plasmakinetic techniques using different electrical currents are widely used today. It is based on cleaning the prostate tissue that blocks the urinary tract. Since prostate tissue remains on the prostate shell (capsule), there is a risk of recurrence in the following years after surgery.
  2. HoLEP: It is the complete removal of enlarged prostate tissue using laser energy. The advantages compared to the tour method are much less bleeding. The risk of recurrence is negligible. It can be applied to prostates of all sizes. It is a candidate treatment option to become the gold standard method. It is the most appropriate surgical treatment option, especially for large prostates. It does not disturb the hardening. Probe time and hospital stay are short. No semen comes out after sexual intercourse
  3. Rezum: It is the destruction of prostate tissue under 100gr with steam energy. It can also be applied under local anesthesia. It is entered through the urinary canal with an instrument with a thin camera and steam is applied into the prostate. It does not require a stay in the hospital. The process takes 10 minutes. The effect will appear in the following days. It does not disturb the hardening and discharge.
  4. Urolift: It is the opening of a window that will enable urination by compressing the prostate tissue with the help of a needle into the prostate tissue under local anesthesia. Semen output is provided.
  5. Open prostatectomy: It is the process of removing the enlarged (over 100 g) prostate tissue with or without entering the bladder through an incision from the abdomen. There is a risk of bleeding and may require a long hospital stay. Probe time is longer. Returning to normal life takes time.
  6. Robotic prostatectomy: Open prostatectomy is performed laparoscopically through the abdomen with the help of a robot. It is made by entering into the abdomen and its cost is its disadvantages.
  7. Tuip: Especially in patients with a high bladder neck, it is entered with a camera device and cut with electric current or laser at 5 and 7 o'clock. The risk of semen not coming out is 10-50%.

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