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CARCINOMA OF PROSTATE 
Carcinoma of the prostate is the common malignant condition in men over the age of 65 years. About 20% of cases of prostatic obstruction prove to be due to carcinoma. It is less common in Japanese while its incidence is higher and its behavior is more aggressive in American Negroes.
Carcinoma of prostate, which is an adeno-carcinoma, starts on the outer zone glands of a normal or hypertrophied prostate and may occur in the false capsule deliberately left behind after prostatectomy for benign hypertrophy. So prostatectomy for benign hypertrophy of gland confers little protection from the subsequent development of carcinoma.

Histological appearance
Prostate is a glandular structure consisting of ducts and acini, there for histological pattern is one of an adeno-carcinoma. A layer of myoepithelial cells surrounds the prostate glands. The first change associated with carcinoma is the loss of this layer with the glands appearing in confluence. As the cell type becomes less differentiated more solid sheets of carcinoma cells are seen.

Local spread
A growth commencing in the posterior zone of the gland is prevented from extending backwards by the strong tunica of Denovilliers. Consequently it tends to grow up wards to involve the seminal vesicle. Further upwards extension obstructs the lower end of one or both ureters— the latter terminating in anuria. Carcinoma commencing in a lateral lobe involves the prostatic urethra early.
In advanced cases the base of the bladder is invaded. The rectum may become stenosed by growth infiltrating round it. But direct involvement is very late.
Spread by blood stream
Occurs particularly to bones .The Prostate is the most common site of origin for skeletal metastasis (being followed in turn by the breasts, the kidney, the bronchial tree and the thyroid gland). The bones most frequently involved are pelvic bones and the lower lumbar vertebrae. Femoral head, rib cage and skull are other favoured sites. The frequent proximity of skeletal metastases to the primary growth has been attributed to reversed flow from the vesical venous plexus to the emissary vein of the pelvic bone during coughing, sneezing etc. Bony metastases appear in x-ray as sclerotic areas.

Lymphatic spread
Through the lymphatic vessels passing along the sides of the rectum to the lymph nodes along the internal iliac vein which lies in the hollow of the sacrum.
Through lymphatic which pass over the seminal vesicles and follow the vas deference for a short distance to drain in to external illiac node.
From both this situation the retroperitoneal lymph node, later the mediastinal lymph node and occasionally the supraclavicular lymph node become affected.
 
CLINICAL FEATURES: 
Carcinoma prostate usually occurs in older man. Symptoms are very similar to benign hypertrophy of prostate. (Frequency, urgency and difficulty of micturition.) But the main difference is that the history is quit short and they get worse rapidly. Incontinence a short history of up to 6 month and pain on micturition are suggestive features of carcinoma in a patient with history of prostatism.

According to the progression of disease; it can be classified in to 5 types.
Type 1: Discovered only on histological examination of tissue removed at prostatectomy.
Type 2: Rectal findings of a hard nodule or extension outside the capsule, investigated by perineal biopsy.
Type 3: The primary may be tiny and occult, the patient presenting with the rheumatism or arthritis with blood acidphosphatase level often very high. Urinary symptoms are absent or slight. The prostate specific antigen (PSA) is high.
Type 4: Pain in the back or sciatica is the main symptoms. Bilateral sciatica in an elderly man is most often due to metastases in the spine from a carcinoma of the prostate. Oedema of one or either legs, paraplegia or a spontaneous fracture is occasionally due to metastases from a carcinoma of the prostate. Anaemia may be the presenting symptoms.
On account of destruction of bone marrow, bone metastases from carcinoma of prostate can give rise to a haernorrhagic diathesis and the patient suffers haernorrhage often severe, not necessarily from the urinary tract.
If the malignant gland obstructs the urethra, the patient complaints of difficulties in micturition, urinary retension, infection, stones or renal failure. (Indistinguishable from those caused by benign hypertrophy of prostate) Because carcinoma begins in outer zone glands, it only obstruct the urethra when it is locally advanced and some patient have no urinary symptoms but they have pain in back or sciatica caused by bony metastases. 

Rectal examination:
Bimanual examinations under anesthesia, together with cystoscopy and needle biopsy are essential in order to assess the local stage of growth. Irregular indurations with stony hardness in part or in the whole of gland with obliteration of the median sulcus suggests carcinoma .

TNM -Classification (adopted by the international union against cancer) 
This is a detailed clinical staging, which is arrived at simply by the clinician ascertaing the following points during his examination of the patient.
1. What is the extent of the primary turner?
2. Are there any lymph node affected?
3. Are there any metastases?  
TUMOUR 
NODES 
METASTASES  
T.O- Clinically unsuspected 
N. 0- No evidence of involvement of regional lymph node  
M.0- No evidence of distant metastases  
T. 1- Local nodule  
N. 1- Involvement of one regional lymph node. 
M. 1-Distant metastases.  
T.2-Difuse or deforming capsule.  
N.2- Involvement of several regional node. 
T.3-Out side capsule or extension in to vesicle  
N.3- Fixed mass of regional lymph node  
T.4- Fixed to the other tissue. 
N.4- Involvement of common illiac or Para-aortic node  
 
INVESTIGATION
Blood: Hemoglobin percentage (Leucoerythroblastic anaemia secondary to extensive marrow invasion or anaemia may be secondary to renal failure)
Platelet count: Platelet count sometimes reduced when metastases present.
Renal function test: Because hydronephrosis may exists from chronic bladder out flow obstruction or from direct invasion of one or both of the ureters by the carcinoma.
Liver function test: Abnormal when there is extensive metastatic invasion of the liver.
Alkaline phosphatase may be raised from hepatic involvement or from secondaries in the bone.
Acid phosphatase: Prostatic fraction can be measured by an enzyme technique or a radio immuno assay. A raised value is strongly suggestive of prostatic carcinoma. 20 % of patient with metastases will have a normal value. So it is not a good screening test.
Prostatic specific antigen: Measurement of prostatic specific antigen is now thought to have great specificity when looking for a response to treatment.
Radiological: X-ray chest- metastases in the lung fields or the ribs.
Abdominal X-ray - sclerotic metastases too commonly in the lumbar vertebra and pelvic bones.
Ultrasonography: Transrectal ultrasound helpful in staging local disease.
Bone scan: Achieved by the injection of technetium 99 the isotope is then monitered using a gamma camera.
Lymphangiography: Assessment of lymph nodes in the pelvis can be performed by lyraphangiography.
Bone marrow aspiration: Reveal the presence of metastatic carcinoma cells.
Biopsy: Using a Vin Silverman needle transrectally can be done if the diagnosis ii in doubt.
 
TREATMENT
Surgery:
1. Trans urethral resection (TUR)
TUR is done in the presence of out flow obstruction. This will give material for diagnosis and provide symptomatic relief. TUR may not remove all the local cancer. It may be appropriate if the bone scan is normal.
2. Radical prostatectomy
    Radical prostatectomy commonly results in total urinary incontinence and loss of potency.
3. Pelvic lymph node dissection and 1-131 seed implantation
A pelvic lymph node desection with frozen section examination is performed. I 131 seeds are then implanted into the prostate assuming the nodes are free of tumor. This technique delivers a high dose of radiotherapy with low penetration.
4.Orchidectomy
   Bilateral orchidectomy will eliminate the major source of testosterone production
5. Hypophysectomy and adrenalectomy
Not used in now-a days. 
Radio therapy:
Local: Radical radiotherapy to the prostatic bed and pelvic lymph node. Local complication are inevitable- namely irritation of bladder, urinary frequency, urgency and some times urge incontinence. Some upset to rectum with diarrhoea – occasionally late radiation prosatitis.
General: radiotherapy for symptomatic metastases is a excellent form of treatment often producing dramatic pain relief.
 
DRUG TREATMENT (HOMOEOPATHIC)
Carcinocine . Plumb met Sulphur
Conium mac Psorinum Thuja
Crot. hor (pain with) Selenium Silicea
Cop Sence ,  Iodum

   PROSTATITIS 

Acute prostatitis is usually seen in men between the ages of 30 and 50. In both acute and chronic prostatitis the seminal vesicles and the prostatic urethra are also usually involved. Then there is a triad of pathological condition namely posterior urethritis, prostatitis and seminal vesIculitis. Acute prostatitis is a common clinical condition seen in our day today practice.

AETIOLOGY
The usual organism responsible is E. coli. But staphylococcus aureas and albus, streptococcus faecalis and the gonococcus may be responsible.
The infection is haematogenous from a distant focus notably furunculosis, infected tonsils, caries teeth or diverticulitis. In a minority of cases, the infection ascends from the urethra or descends from the bladder or kidney.

CLINICAL FEATURES
Infection usually blood borne. General manifestations are- the patient feels ill, shivers, may have rigor, aching all over, especially the back. The temperature may be up to 39-c. Pain on micturition is usual. Perineal heaviness, rectal irritation and pain on defecation may occur and sitting may be uncomfortable. Frequency occurs when the infection spreads up to the bladder.
Rectal examination-reveals a tender prostate and the seminal vesicle may be involved.

CHRONIC PROSTATITIS
Aetiology:  is a sequel of inadequately treated acute prostatitis. Smears show bacteria in about 40% and cultures are positive in 70% of cases. The predominant organisms are E. coli, Staphylococcus, streptococcus and Diphtheroids in that order. Trichomonas has been found to be a cause of chronic prostatitis (and may be common to both husband and wife) Chlamydia is another causative organism.
PATHOLOGY
Lumen of the ducts becomes blocked with epithelial debris and pus. This causes a soft enlargement of the organ. Later fibrosis occurs, and the prostate becomes smaller and harder.
 
CLINICAL FEATURES
1. Causing chronic posterior urethritis- specimen shows 50 or more pus cells/ HPF.
2. Causing epididymitis
3. Pain- Local pain (dull ache) in the perineum and rectum. Aggravated by sitting on a hard chair.
   Referred pain- Low back ache, lumbago, some times extending down the leg.
4. Silent prostatitis— Pus has been obtained from the prostate. No other symptoms. (But patient may have arthritis, myositis, neuritis and sometimes iritis   and conjunctivitis.)
5. Recurring attacks of mild pyrexia.
6. Sexual dysfunction— Premature ejaculations, prostatorrhoea and impotence.
 
DIAGNOSIS
1. A 3-glass urine test- If the first glass shows urine containing prostatic threads, prostatitis is present.
2. Rectal examination- May or may not confirm the diagnosis.
3.Examination of the prostatic fluid- Obtained by prostatic massage. (Normal prostatic fluid is slightly opalescent and viscid.) May show many pus cells and sometimes bacteria.
4. Urethroscopy— Reveals inflammation of prostatic urethra.
 
TREATMENT  
Acute prostatitis: Avoidance of alcohol and sexual intercourse for six week is wise.
 
HOMOEOPATH1C MEDICINE
Aconite
Aesculus— Discharge of prostatic fluid at stool. Frequent, scanty, dark and hot urine.
Apis mel
Belladonna
Bryonia
Cantharis-- Intolerable urging & tenesrnus, urine scald him &is passed drop by drop. Constant desire to urinate.
Chimaphilla
Colchicum-- Urine contain clots of putrid decomposed blood, albumin & sugar.
Copaiva — Act powerfully on mucus membrane especially that of urinary tract turbid color. Peculiar pungent odor.
Cubeba-- _ Mucus membrane generally especially that of the urinary tract. Prostatis with thick yellow discharge.
Digitalis — Continued urging in drops dark, hot burnings with sharp cutting pain at the neck of bladder as if a straw was being thrust back & forth, ammoniacal & turbid urine.
Ferrum Phos
Gelsemium
Hepar sulph
Iodum
Kali iod
Merc cor
Merc dul
Nitric acid—Scanty dark offensive smells like horse urine. Cold on passing. Alternation of cloudy phosphatic urine with profuse urinary secretions in old prostatic cases.
Nitrum
Olium santele
Pichi (Fabiana imbricta)--Vesclcal cattarah with suppurative prostatic condition.
Picric acid
Pulsatilla
Sabadilla
Sabal .Ser
Salix nigra_ Has a positive action on the generative organs of both sexes.
Selenium
Silicea
Solidago
Staphysagria
Thuja
Triticum
Verat .v
Vesicaria 

CHRONIC PROSTATIS
Aurm me 
Baryta carb 
Brachyglottis 
Caladium 
Carbonium sulph 
Causticum 
Clematis 
Conium mac 
Ferrum Picricum 
Graphitis 
Hepar sulph 
Hydrocotyl 
Iodum 
Lycopodium  
Merc cor 
Merc sol 
Nitric acid 
Nux vomica 
Phytolacca 
Pulsatilla 
Sabadilla 
Sabina 
Sepia 
Selenium  
Silicea 
Solidago 
Staphysagria 
Sulphur 
Thuja 
Tribulus 

  PROSTATIC CALCULI 

Two types
 1.Endogenous: Common — are usally composed of calcium phospahte plus 20% of organic material
2. Exogenous: Rare-- is a urinary (ureteric) calculus that become arrested in prostatic urethra.
 
CLINICAL FEATURES
Often symptomless, being discovered on X- ray of pelvis for any other cause. Symptoms are at first those of chronic prostatis or prostatic obstruction.
Treatment
Small calculi; Symptoms mild - Treatment of c/c prostatitis
Trans urethral resection
Retropubic prostato lithotomy

  TUBERCULOSIS OF THE PROSTATE 

Tuberculosis of prostate and seminal vesicles associated with renal tuberculosis in at least 60%. In 30% there is history of pulmonary tuberculosis.
Rectal examination reveals one or more well defined nodules most often near the upper or lower border of one or both lateral lobe. 

CLINICAL FEATURES
Urethral discharge is the first symptoms. Painful sometimes bloodstained ejaculation (20 %). Mild ache in the perineum. Infertility (fertility very much reduced). 80% are sterile.
Urinary symptoms— When the posterior urethra becomes involved from extension of tuberculosis from the prostate- there is painful, frequent micturition and sometimes terminal haematuria.
Abscess formation- Cold abscess formation in the prostate. (Slightly tender soft swelling) It usually ruptured in to the urethra, rarely through the perineum or in to the rectum. If a recto— prostatic fistula develops it is extremely difficult to heal even when the tuberculous infection has been eliminated. (If a prostatic abscess forms it is better to evacuate it by the perineal route than to permit it to rupture spontaneously.)

INVESTIGATION
Radiography— large scattered area of calcification
Bacteriological examination of fluid- gives positive culture of tubercle bacilli.
Posterior urethroscopy- reveals one or more dilated prostatic duct plus tubercle bacilli in the ejaculate- establishes an absolute diagnosis.

TREATMENT
General and treatment for tuberculosis.

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