Reproductive Pathology I Case Studies


CASE 8: Nodular prostatic hyperplasia


Clinical History:

A 71-year-old man had increasing hesitancy and frequency on urination over several years' time. He noted difficulty in starting the stream of urine. His physician found that the prostate appeared enlarged to twice normal size and was firm with palpable nodules on physical examination. A urinalysis showed no RBC's but did show 10-15 WBC's/hpf, and the urine was nitrite positive. He was referred to a urologist who performed transrectal biopsies. This was followed by prostatectomy (usually this is a transurethral resection).
  1. What is the diagnosis?

    This is nodular prostatic hyperplasia.

  2. What are the consequences of his disease if left untreated?

    3. Untreated prostatic hyperplasia can result in urinary tract infections, including pyelonephritis. Pyelonephritis may destroy enough kidney to cause renal failure. Such obstruction may explain the urinalysis findings in this patient (suggestive of urinary tract infection). Obstructive uropathy from prostatic hyperplasia may lead to hydronephrosis and renal failure.

  3. Who gets this disease and why?

    Older men get prostatic hyperplasia, which may have something to do with hormone levels. Studies have identified transforming growth factor beta, fibroblast growth factor and insulin-like growth factor family members as key regulators of cell proliferation and extracellular matrix turnover with interrelated activities. Estrogens, adrenergic signalling, sensitivity to dihydrotestosterone, and inflammatory processes can alter the balance of the factors controlling growth.

  4. Is prostatic hyperplasia a "pre-malignant" condition?

    5. No. The hyperplasia of the prostate is not like endometrial hyperplasia in that there is not a progression to carcinoma.

  5. What therapies are available for this condition?

    6. Medical therapy for prostatic hyperplasia includes two main types of drugs. The adrenergic blockers relax the smooth muscle of the bladder neck and improve urine flow. The functional adrenoceptor in the human prostate is predominantly the alpha IA subtype. Adrenoreceptor antagonists such as tamsulosin and terazosin appear to have a greater, earlier effect on symptoms, but do not reduce prostate size. The 5-alpha-reductase inhibitors block the conversion of testosterone to dihydrotestosterone and reduce androgenic stimulation of the prostate, such as finasteride. For the relatively small number of men who develop progressive symptoms, finasteride has beneficial effects. It will diminish the size of the prostate, but not prevent the need for surgery in most cases with progressive symptoms.

    Surgical therapy includes transurethral resection of the prostate (TURP), which removes most of the prostate and relieves the mechanical obstruction. However, some prostatic tissue is left behind following TURP, and this can continue to grow and cause obstruction. A carcinoma could also arise in the remaining tissue.