A Tour around the Prostate Gland

(Date of publication 06 June 2005)

Although the prostate gland is modest in size, it is highly important to the adult male (and indirectly the pornographic industry!) because the fluid it produces not only helps to nourish and protect sperm during intercourse, but also forms the main bulk of ejaculate. Comprised of 30 – 50 individual glands which are arranged in acini and empty into the urethra, the gland may be divided into a peripheral, transitional and central zone, although the function of these different zones is not clear. Here is a more detailed diagram and description of its anatomy, while this site for medical students incorporates a number of relevant photomicrographs and some humorous asides; for example, 'any student who calls this the "prostrate" gland will have her/his rubber glove confiscated.' The relevance of this remark will become crystal clear when we cover diagnosis.

For an organ that only weighs about 28 gm, the prostate can cause significant medical problems, particularly for males aged over 40 years. Enlargement (benign prostatic hyperplasia, or BPH) eventually develops in approximately 80% of all men. Prostate cancer occurs in 1 out of 10, the likelihood increases with age, and in the USA it is second only to lung cancer as the leading cause of cancer death in males. More than 120,000 American men develop prostate cancer each year and more than 30,000 ultimately die from it.

However, the most common urological disorder in men over 50 is inflammation of the prostate gland, or prostatitis, which can lead to painful urination and ejaculation. There are four different types: acute bacterial, chronic bacterial, nonbacterial, and prostatodynia. Acute bacterial prostatitis usually produces the most severe symptoms, which may include chills, fever, joint and muscle pain, and frequent urination. As with other conditions of the prostate, diagnosis involves a digital rectal examination, in which the clinician inserts a gloved finger into the patient's rectum to palpate the gland through the rectal wall. The objective is to determine whether the gland is swollen and tender, and to detect the presence of nodules, lumps or hardness, which could indicate neoplasia. A comprehensive description of the procedure can be found here. Depending upon the type of prostatitis, treatment may involve a variety of medications such as antibiotics, alpha blockers, analgesics and muscle relaxants, as well as physical therapy or surgery.

In BPH, enlargement of the gland has the effect of squeezing the urethra and causing progressive difficulty in urinating. Sufferers may experience a weak urinary stream, difficulty in starting to urinate and a frequent need to pass urine, which often wakes them during the night. Also, blockage of the urethra can cause repeated bladder infections and even anuria. The aetiology of this condition, in which multiple fibroadenomatous nodules develop in the region of the prostate around the urethra, is unknown, although it may involve hormonal changes associated with ageing. Histologically the nodular tissue is glandular, with varying proportions of fibrous stroma – note the large number of complex, folded glands on this microscope slide.

Rectal examination in such a patient generally reveals an enlarged prostate with a rubbery consistency, although an apparently small gland may be sufficiently large to cause obstruction. In 30 to 50% of BPH sufferers the serum level of prostate-specific antigen (PSA) is moderately elevated, depending upon the extent of enlargement and degree of obstruction. Initial treatment is generally medical, directed at stabilising renal function and eradicating infection, but the definitive therapy is surgical. Compared to open surgery, fewer patients experience postoperative problems such as impotence and incontinence after transurethral resection of the prostate (TURP). During this procedure a thin tube bearing a light and camera is inserted into the urethra from its opening at the tip of the penis. The tube is passed towards the bladder until it reaches the obstruction, which is then removed by electrocautery.

The causes of prostate cancer are not understood, but environmental factors are believed to be extremely important; the prevalence of active disease ranges from 0.5 per 100,000 men in parts of China to 102.1 per 100,000 men in the USA. Moreover, studies indicate that the global differences are not genetic, because when individuals with the same genetic background are reared in different environments, their risk of developing prostate cancer depends upon the country in which they reside.

Known risk factors include increasing age, a family history of the disease, race (it is much more common in African Americans than white men) and diet (foods high in animal fat may increase the risk). In the early stages the condition may be symptomless, but a digital rectal examination or elevated serum PSA level may indicate its presence. Definitive diagnosis is by biopsy. Treatment options include watchful waiting, surgery, radiotherapy and hormone therapy, sometimes in combination. The present site covers the various alternatives at some length, including the possible side effects, while the Prostate Outcomes Study has evaluated the impact of various treatments on the quality of life of patients.

To end on an encouraging note, although prostate cancer is responsible for about 10% of cancer-related deaths in American men, about 99% of those diagnosed with the condition survive for more than 5 years, and 92% survive at least 10 years (click here for more key statistics). By anyone's standards those are very good odds indeed!

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