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CASE 4.1 BENIGN PROSTATIC HYPERPLASIA

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Patient Presentation

A 65-year-old white male visits the family medicine clinic complaining of progressive difficulty urinating over the past 6 months.

Relevant Clinical Findings History

The patient reports the frequent need to urinate. His urine stream is weak, it starts and stops, and it "dribbles" at the end. At times, he also has a burning sensation when he urinates.

Physical Examination
  • Digital rectal examination (DRE) (Fig. 4.1.1) revealed an enlarged prostate, with a symmetrical, smooth, firm posterior surface that is without tenderness.

Laboratory Tests
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Test Value Reference value
Erythrocytes (count) 4.5 4.3–5.6 × 106/mm3
Hematocrit 40 38.8–46.4%
Leukocytes (count) 7.9 3.54–9.06 × 103/mm3
Prostate-specific antigen (PSA) 7 0.0–4.0 ng/mL
Clinical Note

PSA is a protein produced by the cells of the prostate gland. PSA levels can be elevated with prostatitis, benign prostate hyperplasia, or prostate cancer. However, PSA levels are not diagnostic between hyperplasia and cancer.

Clinical Problems to Consider

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Figure 4.1.1

Median sagittal view of the male pelvis showing a digital rectal examination. The posterior surface of the prostate, as well as the seminal glands, may be palpated through the anterior rectal wall.

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LEARNING OBJECTIVES

  1. Describe the anatomy of the prostate.

  2. Explain the anatomical basis for the signs and symptoms associated with this case.

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RELEVANT ANATOMY

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Prostate
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The prostate is the largest accessory gland of the male reproductive system. In the adult, the prostate measures 4 cm (transverse), 3 cm (superoinferior), and 2 cm (anteroposterior). The healthy adult prostate weighs about 20 g and is symmetrical and lacks palpable nodules. A median sulcus lies between the two lateral lobes. With aging, the prostate may enlarge: by age 40, it may reach the size of an apricot; by age 60, it may be the size of a lemon.

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The prostatic part of the urethra passes through the prostate; it receives not only the openings of the prostate glands but also those of the ejaculatory ducts.

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The prostate is contained within a fibrous capsule and is composed of numerous compound tubulo-alveolar glands arranged concentrically around the prostatic urethra:

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  • Mucosal glands are closest to the prostatic urethra

  • Submucosal glands are peripheral to the mucosal glands

  • Main prostatic glands are located toward the periphery of the prostate

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Prostatic excretory ducts (usually 20–30) open into the prostatic urethra.

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Anatomically, four prostatic lobes are defined (Fig. 4.1.2):

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  1. Lateral (right and left)

  2. Middle (median)

  3. Anterior (isthmus)

  4. Posterior

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Figure 4.1.2

Lobes and zones of the prostate. Hyperplasia of mucosal glands in the transitional zone is responsible for BPH. In ...

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