The common diseases affecting the prostate are benign hypertrophy of the prostate, carcinoma of the prostate and prostatitis. Prostatic calculi and tuberculosis of the prostate are two other diseases rarely affecting the prostate. These conditions usually occur in men over 50 years of age.

Before dealing with the diseases of the prostate, we must have an idea about the structure of prostate gland. Prostate is an accessory gland of male reproductive system, which adds to the bulk of the seminal fluid. (It is purely a genital organ; this is evinced by the fact that in animals manifesting a seasonal sexual life, the organ is rudimentary except during rutting season. The normal adult prostatic epithelium undergoes atrophy after castration)

Prostate resembles an inverted cone and is firm in consistency, which lies below the neck of the urinary bladder and surrounding the commencement of male urethra. It lies behind the lower part of pubis symphysis and in front of rectum. 

Size: About 4 cm across the base (width)
3cm vertically apex to base (length) and
2 cm antero-posteriorly (thickness)
Weight: About 8 gm. 
Apex:  Directed down wards between the medial margins of the levator ani muscle. 
Base: Directed upwards and is structurally continues with the neck of bladder. 
Surface: Four surfaces
Anterior surface lies 2cm behind the pubic symphysis with retro pubic fat intervening. Its upper part is connected to pubic bone by pubo- prostatic ligaments and the lower end is pierced by the urethra.
Posterior surface: Triangle in shape. 4cm from the anus and can be easily palpated on digital examination through the rectum. Near its upper border it is pierced on each side of the median plane by the ejaculatory duct.
Inferio-lateral surfaces: Related to anterior fibers of levator ani. 
Lobes: The urethra and ejaculatory duct traverse the prostate and divide it into 5 lobes. 
Anterior lobe: - is a small isthmus connecting the two lateral lobes in front of urethra. It contain little or no glandular tissues and there for seldom forms an adenoma
Posterior lobe: connects the two lateral lobes behind the urethra. Adenoma never occurs here. But the Primary carcinoma is said to begin in this part. 
Median lobe: lies behind the upper part of the urethra and in front of the ejaculatory duct and just below the neck of the bladder. It contains much glandular tissues and is common site of adenoma. 
Lateral lobe: lie on each side of the urethra. It contains enough of glandular tissues, which may form an adenoma in old age. 
Capsule: Prostate has a thin capsule of fibro muscular tissues (true capsule) but is also enclosed in a loose sheath of visceral pelvic fascia (false capsule), which is separated from the capsule at the front and sides by prostatic venous plexus. 
Histology: shows two well defined concentric zones separated by an ill-defined irregular capsule. The zones are absent anteriorly. Outer larger zone is composed of large branched gland. This is the exclusive zone for carcinoma. Inner smaller zone composed of submucosal glands and a group of short simple mucosal glands surrounding the upper part of the urethra. This zone is typically prone to benign hypertrophy of prostate due to oestrogenic stimulation. 
Blood supply: Branches from inferior vesical, middle rectal and internal pudental artery. (Valve less communication between the prostatic and vertebral venous plexus exists through which the prostatic cancer can spread to vertebral column and the skull.)
Lymphatic drainage: In to the internal illiac and sacral nodes. Partly in to the external illiac nodes. 
Nerve supply: Both sympathetic and Para sympathetic nerve. 
Prostatic secretion: is watery opalescent fluid, which contain acid phosphatase and protein. It is discharged into the urethra by contraction of the muscular stroma at ejaculation. Enzymes that split organic phosphates are present in many human tissues, but their concentration in the adult prostate is several hundred times greater than in any other organ or tissues. (This high level is not achieved until after puberty)

BENIGN ENLARGEMENT OF THE PROSTATE 

             Benign enlargement of the prostate usually occurs in men over 50 years of age, most often between 60 and 70. (After 45- 50 years the prostate is either enlarged (BHP) or reduced in size (Senile atrophy). These changes are progressive till death.]
In Indian, prostatic enlargement is less frequent and occurs more often in a younger age group.  
Theories of causation: 
It is usually attributed to the endocrine changes of aging.
Hormone theory: As age advances the male hormone (androgen) diminishes while the quantity of the oestrogenic hormone is not decreased equally. According to this theory the prostat3e enlarges because of predominance of oestrogenic hormone. The prostatic enlargement can be regarded as involuntary hyperplasia due to disturbance of the ratio and quantity of the circulating androgens and oestrogens.
Neoplastic theory: Postulates that the enlargement is a benign neoplasm “fibromyoadenoma” [as the prostate is composed of fibrous, muscular and glandular tissues]

Pathology:
 The pathological changes are confined to the inner zone glands of lateral or middle lobe or of both. This pathological changes consists of an increase in number of glands [adenosis] and in their cellularity [epitheliosis] and increase also in the amount of fibrous tissue in the stroma
[Stromal proliferation] between the glands, and there is formation of small cysts if the ducts of the glands are blocked. [The histological changes are closely resembles those of fibro adenosis in the female breast.]
If adenosis and cyst formation predominate, the inner zone enlarges (sometimes to a remarkable extent) and this hypertrophied inner zone compress the outer zone of glands that forms a false capsule. This false capsule compresses, distorts and elongates the prostatic urethra, so that the out flow of urine from the bladder is obstructed.
With the prostatic hypertrophy, which obstructs the flow of urine from the bladder, secondary pathological changes may occur in the bladder, ureters and kidneys.
In bladder these changes consists of
1.TrabeculatIon- hypertrophied bands of muscle fibers are formed inside the bladder
2.Infection
3.Stone and
4.diverticula formation-there is shallow depression [known as sacculation] in between the hypertrophied muscle fibers of the bladder. Some times one of the saccules (rarely two or more) continues to enlarge and forms a diverticulum.
Upper urinary tract -
1. Dilatation of ureters and pelvis -caused by back pressure.
2. Infection and
3. Stone.
Kidney-
1.Chronic renal failure. 

Clinical features
Clinical features of benign hypertrophy of prostate are those of obstruction to the out flow of urine from the bladder and these are variable according to the lobes affected.
Frequency is the earliest symptoms especially at night. [Usually commencing at 2 or 3 a.m.] Increase frequency of micturition is due to inadequate emptying of the bladder and due to presence of sensitive prostatic mucus membrane of the intravesical enlargement of the prostate. The frequency becomes progressive and is then present both by night and by day.
Urgency due to the fact that urine escapes through the stretched vesical sphincter in to sensitive prostatic mucosa [empty prostatic urethra], which causes reflex for intense desires to void.
Difficulty in micturition -- Difficulty in starting micturition. He must wait patiently for urination to start. Strains hinder the flow rather than increasing the flow. The stream is weak and dribbles down instead of being projected. Patient should be asked weather strains improve the streams (as in urethral stricture) or retard the stream- (enlarged prostate.)
Enlargement of median lobe not only projects in to the bladder but also forms a sort of valve over the internal urethral orifice. So that the more the patient strain the more does it obstruct the passage. Urine passes when the patient relaxes.
Acute retention of urine-- Patient has an urgent desire to micturate but is unable to do so and the bladder is distended, tense and tender. Acute retension of the urine may be the first symptoms compel the patient to seek releaf because of the intense pain it produces.
Postponement of micturation, indulgence in alcoholic liquors particularly when he goes out of doors on a cold night and confinement to bed on account of some intercurrent illness or operation are common precipitating causes of acute retension of urine.
Chronic retention with over flow-- Each time the patient micturates the evacuation is incomplete and the bladder gradually but progressively distends. The patient may be unaware that his bladder is distended but usually complains that he has little control over the small quantities of urine, which overflow down the urethra at frequent intervals. Nocturnal enuresis should be a warning sign. Chronic retension indicates severe and prolonged obstruction and is often associated with dilatation of upper urinary tract, vesico- uriteric reflux, infection and chronic renal failure.
Stream is variable, often weak, tending to stop and start and dribbles towards the end of micturition.
Pain occurs with cystitis or acute retension of urine.
When hydronephrosis commences there may be a dull pain in the loins. A feeling of weight in the perineum, or fullness in the rectum is occasional complaints.
Recurrent or persistent infections and stones in the bladder and sometimes in the kidneys.
Haematuria or urethral bleeding may occur when the prostate gland is congested and sometimes is the only symptoms of prostatic hypertrophy. Occasionally alarming haematuria occurs from a ruptured prostatic vein or from erosion on the enlarged prostate itself.
Chronic renal failure-- The patient present himself with signs of chronic renal failure.
 
Secondary effects of prostatic enlargement 
Urethra: - The portion of urethra lying above the erumontanum becomes elongated, sometimes to as much as twice its normal length. The canal is compressed laterally so that it tends to become an antro-posterior slit.
(Verurnontanum - a median longitudinal ridge of mucus membrane present on the posterior wall of prostatic urethra - also known as urethral crest]
Bladder: - The musculature of the bladder hypertrophies to overcome the obstruction. When the middle lobe projects upwards in to the bladder it acts as a dam to the last ounce of urine, which remains in the prostatic pouch. Calculi are prone to form in this stagnant pool of urine.
Trabiculations, sacculations and diverticulum formation are also may found in the bladder.
The enlarged prostate may compress the prostatic venous plexus; the resulting congested veins (vesical piles) at the base of bladder are apto cause haematuria.
Unless the obstruction is relieved a time is reached when bladder hypertrophy gives place to atony. The tired muscle making no attempt to overcome the obstruction.
Ureters and Kidneys: - Increasing intravesical pressure or in some cases direct pressure of the intravesical portion of the prostate on the ureteric orifices causes gradual dilatation of ureters, followed by some degree of bilateral hydronephrosis. When bladder hypertrophy wanes the sphincter mechanism around the ureteric orifices ceases to function permitting reflux of urine from the bladder in to the dilated ureters with increasing damage to the renal parenchyma. As a result of ascending infection acute or chronic pyelonephritis supervenes.
Sexual organs: - In the early stages of prostatic enlargement there is increased libido. Later impotence is the rule. 

Examinations 
1. Examination of the abdomen- Obstruction to the out flow of urine from the bladder will be found on palpation, percussion and sometimes on inspection with loss of the transverse supra-pubic skin crease.
The renal areas should be palpated for tenderness and possible enlargement of the kidneys.
2. Examination of the tongue- Dry brown tongue and urine of low specific gravity indicate renal insufficiency.
3. Examination of urinary meatus- to exclude stenosis.
4. Rectal examination- Findings on rectal examination vary depending on which lobe or lobes of the prostate are involved. If the lateral lobes are involved the prostate feel large and smooth, is elastic and uniform in consistence and mobile
If the middle lobe alone is affected, the prostate feels normal on examination because an enlarged middle lobe projects forwards into the rectum and can be recognized only by cystoscopy.
Residual urine may be felt as a fluctuating swelling above the prostate. It should be noted that if there is considerable amount of residual urine present, it pushes the prostate downwards making it appear larger than it is.
5. When possible, the act of micturition should be watched. Loss of projectile power is significant.
6. A mid stream specimen of urine sent for bacteriological examination.
7. Nervous system examination- to eliminate neurological lesion.  
Diabetes mellitus
Tabes
Disseminated sclerosis
Cervical spondylosis may give symptoms that mimic prostatic
Parkinson’s disease and obstruction
Other neurological states  
8. The micturograph—A graphic recording of patients stream rate and volume of the urine can be obtained and is most helpful in determining the degree of outflow obstruction.
9. Examination of blood
a] Blood urea        
b] Blood count being essential.
c] Serological test for syphilis.
10. Examination of urine-
a] For evidence of infection
b] Culture
c] Test for the presence of glucose.
 
11. Intravenous urography- it has been the tradition to perform an intravenous urograph when investigating patients with bladder out flow obstruction. The plaine film may show the presence of a calculus whether in the kidney or in the bladder. It will also show if there is degenerative disease of the lumbar spine and sometimes the characteristics feature of a sclerotic bony metastasis from carcinoma of the prostate. It will show the contour of the bladder and whether trabiculation, sacculation or a diverticulum is present. A film after micturition reveals significant residual urine.
12. Ultra sound examination
13.Urodynamics- when a clear diagnosis has not been reached or if neuropathy is suspected an urodynamic investigation can usually established whether bladder out flow obstruction is present. [The principle is artificially simulate bladder filling and emptying whilst obtaining scientific measurement of the various functions involved] Recording of the residual volume, the intravesical pressure, the bladder capacity and the sensation of fullness can all be obtained quite simply.
14. Cysto urethroscopy- inspection of the urethra, the prostate and urothelium of the bladder should always be made before prostatectomy. It beeing important to exclude the presence of urethral stricture, a bladder carcinoma and the occasional non-radio opaque vesical calculus.
15. Catheterization and residual urine- Introduction of a catheter may determine the type of obstruction in urethra. With an enlarged prostate obstruction is encountered after the catheter has gone beyond the apex of the prostate due to kinking of prostatic urethra.
Residual urine [amount of urine collected by means of a catheter after the patient has voided urine] is a good indication of the capacity of the retro- prostatic pouch particularly in case of prostatic enlargement.
 
Treatment
Benign hypertrophy of prostate is treated not because the gland is large but because it is causing obstruction. There is no correlation between the size of the prostate assessed by rectal examination and the degree of obstruction.
Medical treatment may reduce the congestion in the gland, control infection and improve renal function and patient’s general condition. Acute urinary retention is distressing and painful. It requires decompression of the bladder by the passage of a urethral catheter.
Chronic urinary retension, which is painless, and having no symptoms suggestive of coexistent infection and with the normal serum creatinie level do not necessarily require a catheter.
Uraemic patient with chronic retension are often dehydrated at the time of admission. Due to the chronic back pressure on the distal tubules within the kidney, loss of their ability to reabsorb salt and water. Then there is enormous out flow of salt and water, which has become known as a post obstructive diuresis. Intravenous fluid replacement is required if the patient is unable to keep up with this fluid loss.
 
Operative treatment
Indication for operation:
1. Prostatism- [frequency, urgency and difficulty of micturition] prostatectomy is advised.
2 .Acute retension- which is unrelieved by passing a catheter.
3. Chronic retension— a residual urine of 200 ml or more.
4. Complication- stone, infection and diverticulum formation.
5. Haemorrhage— venous bleeding from a ruptured vein overlying the prostate will not stop with catheter drainage. So prostectomy must be performed.
Prostactomy or more correctly the removal of the adenomatous hyperplasla, by one of the four routes is practicable in the great majority of cases.

The prostate can be approached
1.Through the bladder [transvesical]
2 Retro pubically
3.Frorn the perineum
4.Trans urethrally [TURP, PURP— Trans urethral or pre urethral resection of prostate.] Transurethral resection of prostate has largely replaced other methods unless diverticulectomy or the removal of large stones necessitates open operation.

Complication of operation: -
1 Local and
2 General
Local complication
Haemorrhage is the most tiresome complication following prostatectomy whatever surgical approach. Secondary haemorrhage tends to occur around the tenth postoperative day and is usually associated with the patient overexerting himself or the presence of urinary infection.
Perforation of the bladder or the prostatic capsule can occur.
Infection in the bladder, epididymis or kidney.
Incontinence is inevitable if the external sphincter mechanism is damaged.
Retrograde ejaculation and impotence-- All patients having a prostatectomy should be warned that they are likely to suffer from retrograde ejaculation.
[This occurs once the bladder neck is rendered incompetent.]
Stricture may occur secondary to prolonged catheterization.
Bladder neck contracture due to the over use of the coagulating diathermy.
 
General complication: -
Cardio vascular system- pulmonary atelectasis, pneumonia, myocardial- infarction congestive cardiac failure and deep vein thrombosis.
Water intoxication- the absorption of water in to the circulation at the time of a trans-urethral resection can give rise to congestive cardiac failure, hypo- natraemia and haemolysis.
 
Homoeopathic medicine
Argentum nitricum - Emission of a few drops after having finished. Divided stream. Profuse urine and terrible cutting pain. Bloody urine. Urine passes unconsciously day and night. Impotence. Erection fails when coition is attempted.
Aloes soc- urinary incontinence in aged. Bearing down sensation and enlarged prostate. Scanty high coloured urine.
Baryta carb- Diseases of the old man when degenerative changes begin who have hypertrophied prostate or indurated testis. Very sensitive to cold, offensive foot sweats, very weak and weary must sit or lie down or lean on something.
Chimaphila umbellata- Acts principally on kidneys and genitourinary tract. Prostatic enlargement- must strain before flow comes. Scanty urine. Acute prostatis, retension and feeling of a ball in perineum. Unable to urinate without standing with feet wide apart and body inclined forward. Urine turbid, offensive containing ropy or bloody mucus and depositing a copious sediment.
Ferrum picricum— is considered a great remedy to complete the action of other medicine. Senile hypertrophy of the prostate. Pain along entire urethra. Frequent micturition at night with full feeling and pressure in rectum. Smarting at neck of bladder and penis. Retonsion of urine.
Hydrangea— A remedy for gravel, profuse deposit of white amorphous salts in urine. Burning in urethra and frequent desire. Urine hard to start. Great thirst with abdominal symptoms and enlarged prostate.
Populus tremuloides- Catarrh of the bladder especially in old people. Good remedy in vesical troubles after operations. Severe tenesmus. Painful scalding. Prostate enlarged. Pain behind pubis at end of urination.
Sabal aerrulata— Has unquestioned value in prostatic enlargement, epididymitis and urinary difficulties. Acts on membrano-prostatic portion of urethra. Iritis with prostatic trouble. Fear of going to sleep. Desire for milk. Constant desire to pass water at night. Cystitis with prostatic hypertrophy. Discharge of prostatic fluid. Coitus painful at the time of emission.
Senecio aureus- Has marked action over the urinary organs. Scanty high coloured urine with much mucus and tenusmus. Great heat and constant urging. Dull heavy pain in spermatic cord extending to testicles.
Solidago virga — Urine scanty, reddish brown, thick sediment, dysurea, gravel. Difficult and scanty. Clear and offensive urine. Some times make the use of catheter unnecessary
Sulphur- Frequent micturition especially at night. Burning in urethra during micturition lasts long after. Parts sore over which urine passes. Must hurry, sudden call to urinate. Great quantities of colourless urine.
Thiosinaminum— Enlarged glands.
Thuia- Urinary stream split and small. Frequent micturition accompanying pains. Sensation of trickling after urinating. Severe cutting after. Desire sudden and urgent but can not be controlled .Pain and burning felt near neck of bladder with frequent and urgent desire to urinate.
Thyroidinum— Increased flow of urine. Poly urea. Desire for sweets and thirst for cold water. Worse riding in car.
Beuzoicum acidum-- Highly colured and very offensive urine.
Calcarea flurica-- For hard stony glands.
Calcarea iodata— Scrofulous affections, especially enlarged glands.
Conium mac— Acts on glandular system—engorging and indurating it. Altering its structure like scrofulous and cancerous conditions. Much difficulty in voiding urine. It flows and stops again. Dribbling in old men.
Iodum — Frequent and copious dark yellow green.
Lycopodium – Urine slow in coming, must strain. Retension. Polyurea during the night.
Pareira brava—useful in renal colic, prostatic affections and catarrh of bladder. Constant urging, great straining can emit urine only when he goes on his knees pressing head firmly against the floor. Dribbling after rnicturition. Urethritis with prostatic trouble.
Picricum acidum - Prostatic hypertrophy, especially in cases not too for advanced. Dribbling micturition. Nightly urging.
Pulsatilla— Increased desire worse when lying down. Involuntary urination at night while coughing. Acute prostatitis. Pain and tenesmus in urinating worse lying on back.
Sarasaprilla— Severe pain at conclusion of urination. Urine dribbles while sitting.
Staphysagria- Prostatic troubles. Frequent urination, burning in urethra when not urinating up on bladder, feels as if it did not empty as if a drop of urine were rolling continuously along the channel.
Gelsemium—
Graphitis—
Hepar sulph- Urine voided slowly with out force- drops vertically seems as if some always remained. Bladder difficulties of old men.
Kali bich- After urinating a drop seems to remain, which cannot be expelled.
Chromium sulphate—
Eupatorium purpureum- Albuminuria, diabetes mellitus, strangury, irritable bladder, and enlarged prostate are a special feud for this remedy. Constant desire - bladder feels dull.
Ikshuganda (Tribulus terrestris)- Useful in urinary affection, especially dysurea, prostatitis and calculus affection.
Oleum santali (Oil of sandal wood)-- Stream small and slow. Sensation of a ball pressing against the urethra. Worse standing.
Oxydendrn— Prostatic enlargement, vesical calculi. Irritation of neck of bladder.
Piper methysticum (kava kava)-- Urinary and skin symptoms have been verified. Cystitis.
Rhus aromatica— Renal and urinary affection. Senile incontinence. Severe pain before or at beginning of urination. Constant dribbling.
Triticum (Agropyron repens)-- Frequent, difficult and painful urination, incontinence and constant desire.
Medorrhinum—painful tenesmus when urinating. Urine flows very slowly. Enlarged and painful prostate with frequent urging and painful urination. 

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