Prostate

 Site & structure:

• It is a fibro-musculo-glandular organ surrounding the

prostatic urethra lying just below the neck of urinary
bladder.

• It lies behind the lower border of symphysis pubis and in front

of lower part of rectum.
 Shape: It is 4 sided pyramidal organ with apex down and a base
up and has four surfaces (anterior, posterior and two infero-
lateral).

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  Relations:

• Above: Its base surrounds the bladder neck.

• Below: Its apex lies on the deep perineal pouch.

• Anteriorly:

➢ Symphysis pubis & it is connected to the back of the pubic

bones by pubo-prostatic ligaments.

➢ The urethra emerges from its anterior surface just above its apex.

• Posteriorly:

➢ rectum, separated from it by fascia of Denonvilliere.

➢ 2 ejaculatory ducts pierce the upper part of its posterior surface.

• Infero–lateral: related to the anterior free border of levator

ani and its fibers forming levator prostate.

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 Sagittal section in Male Pelvis:
*

Rectum

Coils of pelvic
colon
Urinary
bladder
Coils of ileum
Prostate
Recto-vesical pouch
Membranous
urethera Coccyx
Seminal vesicle
Penile Ampulla of vas
urethera

Ano-coccygeal body
Colle's
fascia Anal canal
Recto-vesical fascia (of denonvillier)
Bulb of
penis Perineal body
Superficial perineal Ejaculatory duct
pouch Perineal membrane
Deep perineal pouch

Loops of sigmoid colon

Loops of ileum
Rectum

Uterus

Cervix
Utero- Recto-vaginal pouch
vesical (Douglas pouch)
pouch
Coccyx
Urinary
Ano-coccygeal body
bladder

Vagina
Recto-anal junction
Urethera Anal orifice

Perineal body Anal canal

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 Lobes & zones:

• Benign prostatic hyperplasia (BPH) is characteristically nodular

which produce the endoscopic appearance of 2 lateral lobes and
middle lobe. Therefore, in the past, 5 prostatic lobes were
described in this patient.

1) Median lobe: wedge between prostatic urethra & ejaculatory

ducts.

2) Two lateral lobes: On the sides of urethra and median lobe.

There is a groove separating the 2 lateral lobes in the lower part
of the posterior surface.

3) Anterior lobe: In front of urethra.

4) Posterior lobe: Behind ejaculatory ducts.

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 • Normally, the young prostate is actually not divided into lobes.
• Recently the normal prostate is described as it has 4 histological
zones:
1) Anterior fibromuscular stroma.
2) Periurethral zone: the tissues around urethra (adenomatous
zone).
3) Central zone: It is traversed by ejaculatory ducts.
4) Peripheral zone: It is posterior and lateral to the central zone
(carcinomatous zone).

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h6
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 Prostat
e Urinary bladder
Ureter (Rt.)

Ureter (Lt.)

Prostate (base)
Antero- inf.
border
Ejaculatory ducts
Infero-
lat
surface Post. Surface of
Urether prostate
a
Isthmus Prostatic urethera
Lat.
lobe
Median lobe
ant. inf.
border ejaculatory duct
Lat.
lobe
apex
(lateral ampulla of
view) Pubo- prostatic vas
muscle
Seminal vesicle

Isthmus Urether ampulla of

a rectum
Median lobe Sup. surface
Fascia of
Lat. lobe Denonvillier
Recto- anal
ejaculatory duct junction
Post
. Post. surface Perineal body
View
Pelvic fascia
Deep
2lat. lobes separated by perineal
a groove on the pouch
posterior surface

Media ejaculatory
n lobe ducts

Ant. Post. lobe

lobe
One lat. lobe

Prostatic Pubo prostatic

urethera 2 ligaments
Sagittal Section

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 Body of pubis.

Pubo- prostatic ligaments

Urethera
False capsule
Inner zone
Prostatic venous
plexus Outer zone

Histological section (Transverse

section) of Normal prostate.

True capsule

False capsule
(prostatic fascia) Urethera
True capsule

Senile
Pathological enlargement
capsule (outer
of the inner
compresed zone)
zone
Transverse section of a prostate showing
senile enlargement of the prostate

Vertebral

Venous
plexus

Vesical venous
plexus

Deep dorsal
vein of penis

Valveless veins
of Bateson

Prostatic
venous plexus

Prostatic venous plexus & its

connections

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Structures within the prostate: (3 tubes)
1) Prostatic urethra:
• It enters the base of the prostate and passes downwards and
forwards to emerge from the anterior surface just above the
apex.
2) Two ejaculatory ducts:
• Each duct enters the upper part of the posterior surface of the
prostate, pass downwards and forewords, to open into the
posterior wall of the prostatic urethra.
3) Prostatic utricle: it is an embryological remnant of
paramesonephric duct in the form of a small saccule which
extends upwards and backwards in the median part of the prostate
and opens in the posterior wall of the prostatic urethra between
the two openings of the ejaculatory ducts.

 Capsules of the prostate: 2 capsules with the prostatic venous

plexus in between.

1) Inner true fibromuscular capsule.

2) Prostatic sheath:

➢ False outer capsule, it is condensed of pelvic fascia.

➢ It is connected to the back of body of pubis by 2 pubo-

prostatic ligaments.

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 Posterior wall of prostatic urethra

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 Uretheral
Coronal section to show crest
features of post. wall of
prostatic urethera from inside.

Prostatic
sinus Seminal
colliculus (veru
montanum)

Opening of
ejaculatory
Openings of duct
prostatic
glands Opening of
prostatic
utricle

Prostat
ic
urether
Opening of
a prostatic
Seminal
colliculus utricle
Uretheral Opening of
crest ejaculatory
duct
Prostatic
sinus

Prostatic
glands

Ejaculatory
Transverse section in the duct
prostate & the prostatic Prostatic
urethera at the level of the utricle
seminal colliculus

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 Ligaments of the prostate:

• Medial and lateral puboprostatic ligaments, are condensation

of pelvic fascia, extend from the lower part of the body of the pubic
bone to the upper part of anterior surface the prostate enclosing
the retropubic space (cave of Retzius).

 Nerve supply:

• Parasympathetic: Pelvic splanchnic nerve (S 2,3,4) is secretory to

the glandular element. alkaline
• Sympathetic: Inferior hypogastric plexus is motor to the
muscular element of the gland during ejaculation.

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 Arterial supply: inferior vesical & middle rectal arteries.

and lower of rectum

❖ N.B: The base of the bladder, prostate, seminal vesicles and vas
deferens are supplied by inferior vesical & middle rectal arteries.

 Venous drainage:

• Prostatic venous plexus which receives also deep dorsal vein of

penis, veins from the bladder base and veins from surrounding
bones. It is connected also with vertebral plexus by valveless veins.

• Prostatic venous plexus drains into inferior vesical veins to

internal iliac vein.

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 Lymphatic drainage: to internal & external iliac L.Ns → common
iliac L.Ns.

 Applied anatomy:

1) Benign prostatic hyperplasia (BPH) affects about 50% of males

after the age of 50 years as ageing sign.

2) Carcinoma of the prostate is the commonest carcinoma in

males.

3) Benign prostatic hyperplasia arises from the periurethral zone

while carcinoma of prostate arises from the peripheral zone of the
prostate.

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 4) Because the prostate surrounds the bladder neck and prostatic
urethra → diseases of prostate lead to lower U.T obstruction →
difficulty of micturation.

5) On straining, benign prostatic hyperplasia enlarges → acting like a

valve blocks the urethra → arrest of micturation, therefore, the
patient has to wait and relax to pass urine (hesitancy).

6) Minor degrees of hypertrophy without urethral obstruction

produce a small swelling called the uvula, at the apex of the
trigone of the bladder.

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 7) Compression of prostatic venous plexus (receives deep dorsal
vein of penis) due to BPH → congestion of penis → sexual
symptoms in the form of continuous erection.

8) Compression of prostatic venous plexus (drain lower part of bladder

base) → bladder varices → haematuria.

9) Prostate is closely related to the anterior wall of the rectum → P-R

examination allows palpation of the size and shape of the
prostate and to differentiate between BPH and carcinoma .

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 10) P-R exam. the groove between the 2 lateral lobes is preserved in
BPH and obliterated in cancer prostate.

Posterior surface of bladder & prostate

11) Transrectal ultrasound and transrectal biopsy are important

investigations to any prostatic disease.

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 12) In prostatitis, P-R shows enlarged, tender, hot prostate and
prostatic massage is performed to obtain prostatic fluid for
microscopic and bacteriological examination.

13) Partial or complete surgical removal of the prostate is called

prostatectomy. Prostatectomy in BPH is actually adenectomy.

14) Prostatectomy is usually done nowadays by endoscopic

transurethral resection or rarely by open surgery through
trans-vesical approach or retropubic approach through midline
suprapubic incision.

15) Total prostatectomy is only done for prostatic cancer.

16) Preservation of nerves and blood vessels to the penis that pass
beside the prostate allows the patient to retain erection and
sexual function after surgery.

Endoscopic trans-urethral prostatectomy

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 Suprapubic transvesical prostatectomy

17) Direct spread of carcinoma of the prostate, posteriorly to the

rectum is delayed due to the presence of Denonvillier's fascia.

18) Carcinoma of prostate spread Directly to the surrounding

structures eg. urinary bladder, seminal vesicles, pelvic wall, pubic
bone, rectum….. etc

19) Lymphatic spread of carcinoma of prostate to internal &

external iliac LNs.

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 20) Blood spread of carcinoma of prostate: 90% to bones, 10%
to lung, brain or liver.

21) The prostate is the commonest origin for skeletal

metastases (usually involve surrounding bones as hip bones,
femur, lumbar vertebrae and sacrum).

22) Bones are affected by reverse of blood flow from the prostatic
venous plexus to veins of these bones during coughing or
sneezing.

23) Prostatic skeletal metastases are usually osteoselerotic.

24) Prostatic Artery Embolization:

• An image-guided arterial catheter is used to inject small
particles to occlude the blood flow to the prostate →
shrinkage of benign prostate hyperplasia within few days .

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