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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 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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LEARNING OBJECTIVES
Describe the anatomy of the prostate.
Explain the anatomical basis for the signs and symptoms associated with this case.
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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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Lateral (right and left)
Middle (median)
Anterior (isthmus)
Posterior
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