Prostate

• ______ of all BPH arises in the transition zone, and only 5 % form the _____ _____ or tissue • Since the urethra passes through this zone, these patients typically present with urinary symptoms

95%; periurethral glands

Benign Prostatic Hyperplasia cystic changes Very small and asymptomatic, although the conditions they are seen with causes multiple problems • Cysts may also be seen in association with _____- due to degenerative process

carcinoma

• There is controversy in classification and origination of _____ due to close proximity of the vasa deferentia, seminal vesicles, ejaculatory ducts, and prostate, as well as their complex embryologic development

cysts

The prostatic urethra walls appear ______ at the midline of the gland

echogenic

The _____ ______ are paired sac-like structures that lie posterior to the urinary bladder and superior to the prostate. They join the vas deferens ducts to form the _________ ______

seminal vesicles; ejaculatory ducts

When aspirated, the fluid may be a brownish red and will not contain ________

spermatozoa

seminal vesicles; _____ compared to the prostate They are seen in long axis on ______ plane scans

Hypoechoic; transverse

• Sonography is useful in identifying the location of a cyst and its relationship to the prostate • ____ ______ and_______ _____ cysts are the most common of the pelvic cystic masses

Mullerian duct ; utricle duct

The endorectal approach • The endorectal approach is the method of choice • ______ nerve block is the most common and popular method of anesthesia, as well as the use of lidocaine gel • A cleansing enema is often given before a biopsy • _____ are given to minimize the risk of sepsis • Not appropriate when abscess is suspected because of the risk of infection with fecal material

Periprostatic; Antibiotics

Sonographic Findings of Prostatitis • One of the most common is a ___ _____ in the periurethral area • Heterogeneous echo pattern of the peripheral gland most often seen in ____ cases of prostatitis due to areas of scarring and necrosis caused by previous episodes of inflammation • Must evaluate for ______ -focal hypoechoic or anechoic lesions -a thickened wall -septations

hypoechoic halo; chronic; abscess

TRUS offers an evaluation of the zonal anatomy and sites through which extracapsular extension (ECE) can occur: • Most tumors tend to grow along the prostatic capsule • These tumors can easily extend into subcapsular space • The capsule of the apex can be very thin or absent and provides an excellent escape from the peripheral zone • 75 % of all tumors occur within__ __ _____mm of the apex making this a popular tumor location

3 to 6

Approximately_____ cm long,______ cm wide, and _______ cm AP Normal volume of the prostate gland is 20-30 mL

3.5; 4.0; 2.5

BPH rarely causes symptoms before age___ More than half of men in their ___ have some symptoms of BPH. As many as 90 percent of men in their 70s and 80s have some symptoms of BPH

40.; 60s

Each seminal vesicle measures approximately __ cm in length and less than ___ cm in diameter

5 ; 1

______ of cancers originate in the outer gland and 20 % in the inner gland The _______ zone is the location of origin of 70 % of prostate cancers, the central zone-1 to 5 % and the remaining 20 %- the transitional zone

80 % ; peripheral

Radioactive Seed Implants • The seeds are tiny, and the radiation spreads only a small distance around each seed, so ______ seeds may be implanted in a single case in order to treat the entire prostate. •_____ _____ implantation is a treatment for men with prostate cancer that is contained within the prostate or the area immediately around the prostate.

80-120; Prostate seed

_____ _____ ______ • Patients are acutely ill, with a fever, low back/perineal pain • The disease is associated with BPH • Easily diagnosed by a urine test (large numbers of gram- negative bacteria) • On DRE the prostate will feel hard, swollen, and very tender • Therapy usually consists of a series of bacterial antibiotics

Acute Bacterial Prostatitis

__________ • The most commonly diagnosed prostate cancer with a vast majority arising from the peripheral zone • 85 % are multifocal, as opposed to a solitary discrete mass • On u/s it is not uncommon to appear isoechoic to surrounding prostate tissue

Adenocarcinoma

_______ • Inferior portion of the prostate, which is located superior to the urogenital diaphragm

Apex

____ _____ _____ • Patients are asymptomatic • There is no evidence of bacterial infection or leukocytes in the EPS (Expressed Prostatic Secretion) and DRE is normal • Infection is usually found in cells from a prostate biopsy

Asymptomatic Inflammatory Prostatitis

A combination of two types, resulting in stromal and glandular hyperplasia. This form is the most common and is heterogeneous in appearance will most likely lead to the diagnosis of _______

BPH

Glandular hyperplasia, which may look hypoechoic or hyperechoic, depending on the cystic changes and gland size will most likely lead to the diagnosis of _______

BPH

Homogeneous stromal hyperplasia, which is sonographically hypoechoic will most likely lead to the diagnosis of _______

BPH

• _____ is commonly found when performing TRUS on men over the age of 40

BPH

______ • Superior portion of the prostate, which is located below the inferior margin of the urinary bladder

Base

_______ is the enlargement of the inner gland, which is hypoechoic relative to the peripheral zone • The most common symptomatic tumor-like condition • The cause is not well understood

Benign Prostatic Hyperplasia

• _____ acts as an obstructive process to the flow of urine • On rectal examination, the prostate feels soft, boggy, and nodular • On u/s: the prostate appears more rounded and can be up to four times its original size

Benign Prostatic Hyperplasia

Contour-smooth and the margins well defined ______ may be seen throughout gland in older patients

Calcifications

Sonographic Findings of Prostatitis • _____ may be visualized within the gland of a patient with a chronic prostatitis • The ______ may harbor the bacteria that cause prostatitis, making it impossible for antibiotic therapy to be effective • Color or Power Doppler may be useful in detecting a hyperemic flow pattern often associated with infection and abscess • ______ may be diffuse or focal

Calculi; Hyperemia

_______ Zone • Extends from the base of the prostate to the _______ and surrounds the _______ _____ • Located between the peripheral and transition zone

Central; verumontanum; ejaculatory ducts

____ _____ _____ • May be difficult to diagnose and treat due to the wide variety of clinical presentation • The same organisms cause the acute form, yet these patients have not necessarily had an episode of acute bacterial prostatitis Symptoms: discomfort in penis, scrotum, and perineum; dysuria, urgency and frequency This disease is characterized by relapsing UTIs Quite often, DRE will disclose no findings

Chronic Bacterial Prostatitis

____ ____ ____ ____ • Is the inflammation of the prostate of unknown etiology • This infectious process is not easily detected and there is usually no h/o UTIs • Noninflammatory CPPS seen in young to middle-age men • Spasms and narrowing of the prostatic urethra due to neuromuscular dysfunction cause irritative urinary flow, lower back/perineum pain. • Stress can also lead to noninflammatory ___ __ _____ _____

Chronic Pelvic Pain Syndrome (CPPS)

______ of the Male Pelvis • Extremely rare • Patients can present with various clinical symptoms ranging from urinary retention to perineal pain

Cysts

_______ of the ejaculatory duct of vas deferens • Seen between the base of the prostate and the seminal vesicles, and can occur along the ejaculatory duct course

Diverticulum

_____ stones • Causes: any pathologic process, such as BPH or prostatitis • On u/s easily seen within the parenchyma of the gland

Endogeneous

_____ stones • True prostatic stones (corpora amylacea), normally occur with age • If large enough, they may be felt on DRE and may be mistaken for a tumor because of their firmness

Endogeneous

______ _____ • Range in size from very small to very large (3 cm or bigger) • May appear in clusters or alone • These stones are different from those that occur within the ejaculatory ducts or urethra

Endogeneous stones

• Prostate calculi can be classified into two groups: 1. _____ (found within the substance of the prostate and form from the prostatic fluid) 2. ____- (found in the urethra and are derived primarily from urine)

Endogeneous; Exogeneous

Prostate Biopsy Approaches Two approaches: • ____ • ______

Endorectal; Transperineal

_____ _____ Outline the course of the urethra and are particularly well seen on midline images They can produce an " Eiffel Tower" appearance if located at the level of the verumontanum, which is best appreciated in a transverse view

Exogenous calculi

T or F:PSA decreases with:• Patient age• Prostate volume• Benign prostatic hyperplasia • Prostate cancer • Prostate cancer will elevate the PSA level approximately 10 times that of benign prostatic hyperplasia

F it increases

________ _________-is the non-glandular, anterior portion of the prostate. Therefore, it is not affected by cancer, prostatitis, or hyperplasia

Fibromuscular stroma

BPH symptoms may lead to one or more of the following: • Incontinence• ____ damage• Bladder damage• Urinary tract infections• _____ stones• Inability to pass urine at all

Kidney; Bladder

_____ _____ ______ • Occur because of failure of regression of the mullerian duct • They are attached to the prostate by a stalk-like structure extending into the prostate

Mullerian duct cyst

BPH can raise ______ levels two to three times higher than the normal level. An increased PSA level does not indicate ______, but the higher the PSA level, the higher the chance of having _____.

PSA (prostate-specific antigen); cancer; cancer

Diagnosis _____ has become the primary test for identifying patients at increased risk of prostate cancer However it can be elevated in _______ and prostatitis as well Therefore, definitive diagnosis relies on u/s-guided biopsy TRUS + clinical findings can be a valuable tool and help in management of ______ cancer

PSA; BPH ; prostate

_________ Zone • Located posterior and lateral to the distal prostatic urethra • Normally, it is the largest zone• The location for approximately 70% of all prostate cancers • The classic appearance of prostate cancer on ultrasound is a hypoechoic, peripherally-oriented lesion

Peripheral

Periurethral Zone • This region runs along most of the prostatic urethral segment • The ducts of this tissue open directly into the urethral lumen • _______ often appear in this area and are thought to be secondary to reflux of urine into these ducts

Periurethral; Calculi

_____ Cancer • Is the most common cancer in American men, and is the second most deadly male cancer • More than 70% of prostate cancers are diagnosed in men over the age of 65 • African American men have a 60 % greater risk than Caucasians • Most patients referred for TRUS for prostate cancer present with either a bladder outlet obstruction, an abnormal PSA level, or an abnormal DRE

Prostate

______ ______ • Extremely common, but usually reported as incidental finding • Most are small and asymptomatic

Prostate Calcifications

what is the most common blood test to identify men at increased risk of prostate cancer?

Prostate-Specific Antigen (PSA)

Surgery • Patients in good health are usually offered surgery as treatment for prostate cancer. • ___________ -a surgical procedure to remove the prostate, surrounding tissue, and seminal vesicles.

Prostatectomy

_____ Cyst • May occur in any of the glandular zones • On u/s: simple, smooth walled, appear completely anechoic• Do not contain spermatozoa when aspirated

Prostatic

___ ____ • May be congenital or acquired (e.g. retention cysts)• Retention cyst results from occlusion of a prostatic duct• These cysts are small in size (1 to 2 cm ) and not clinically significant

Prostatic Cyst

_____ _______ • On u/s: focal or diffuse complex areas occurring in any part of the prostate gland • Color or Power Doppler may show hyperemic blood flow • Diagnosis is confirmed by aspiration and microscopic evaluation of the fluid • Treated with antibiotics

Prostatic abscess

_____ • This term refers to an inflammation of the prostate as demonstrated by an increased number of leukocytes in prostatic fluid

Prostatitis

_____ ______ _____ • Prostate seed implantation, or brachytherapy, is a type of radiation treatment for prostate cancer. • Small metal tubes, or "seeds", which contain radioactive material are placed into the prostate using small needles and ultrasound guidance. • In order for seed implantation to be effective the prostate volume must be less than 45 to 50 cubic centimeters.

Radioactive Seed Implants

_______ ____ ___ • Uncommon (<0.005 % of the male population) • Over 2/3 associated with ipsilateral renal agenesis

Seminal vesicle cyst

____ _____ _____ _____ • Small cell prostate cancer is made up of small round cells • It's a type of neuroendocrine cancer • Very aggressive and does not induce a change in PSA levels • Less than 1% of all prostate cancers • Prognosis is very poor

Small Cell Prostate Carcinoma

_____ _____ ______ • These cancers develop from flat cells that cover the prostate • Incredibly rare • Fast growing • Aggressive

Squamos Cell Carcinoma

• _____ ______ is a demarcation between the inner gland (central and transitional zones) and the outer gland (peripheral gland), which normally appears hypoechoic but may be echogenic if corpora amylacea or calcifications occur along the line

Surgical capsule

T OR F: Explain the examination to the patient Verbal or written consent is required• The exam should be witnessed by another health care professional

T

T or F: If a male transabdominal study is ordered then patient prep, patient position, and transducer choices are the same as those for the TA for the female pelvis

T

T or F: Preparing the transducer includes providing a water path: • Cover the probe with a disposable sheath or condom and secure it with a rubber band • Lubricate the outside • Then insert the probe into the rectum • Fill the sheath or condom with 30 to 50 ml of an unionized water for a water path

T

______ Zone • Located on both sides of the proximal urethra • Normally, it is the ______ zone • 95 % of all BPH (Benign Prostatic Hyperplasia) arises in the transition zone, and only 5 % form the periurethral glands or tissue.

Transition; smallest

______ ______ ______ Starts in the cells that line the tube carrying urine to the outside of the body (the urethra) This type of cancer usually starts in the bladder and spreads into the prostate But rarely it can start in the prostate and may spread into the bladder entrance and nearby tissues. • Usually presents with blood in the urine or difficulty urinating

Transitional Cell Carcinoma

The prostate gland is best evaluated by _______

Transrectal Ultrasound (TRUS)

___ ____ ____ ___ is done to relieve the symptoms caused by compression of the prostatic urethra • Using a cystoscope, a surgeon removes the excess tissue, creating a large defect

Transurethral resection of the prostate (TURP)

What are symptoms of BPH? Symptoms may include:• Leaking or dribbling of urine• More frequent urination, especially at night• Urgency to urinate• _________ _______• A hesitant, interrupted, weak stream of urine

Urine retention (inability to urinate)

___ _____ • Usually associated with hypospadias, undescended testicles, and renal anomalies • Occur when a prostatic utricle is dilated • They are located directly midline and close to the verumontanum

Utricle cyst

Prostatic abscess • Associated with_____ _____ ______, but can be also seen in diabetic male patients • Symptoms: fever, chills, urinary frequency, perineal/low back pain, dysuria, and hematuria

acute bacterial prostatitis

The prostate is bordered: • ________ by the pubic bone • posteriorly by the rectum • ___________ by the bladder • inferiorly by the urogenital diaphragm(also called the ______ _______)

anteriorly; superiorly; triangular ligament

• Large ______ are associated with perineal pain, dysuria, hematospermia, and ejaculatory pain • Can contain calculi • The seminal vesicle on the affected side may be dilated due to the obstruction • Aspiration of these cysts will yield ____

diverticula; spermatozoa

• A _______ or cyst can occur due to a distal obstruction of the spermatic ductal system by a congenital abnormality or inflammation

diverticulum

It consists of fibromuscular and ______ ______ that surrounds the neck of the bladder and urethra

fibromuscular; glandular tissue

It is about the size of a chestnut and funnel shaped, surrounded by a _______ capsule

fibrous

Mullerian duct cyst Symptoms and signs: partial urinary obstruction, ________, low ejaculate volume, ________, painful ejaculation, and rectal discomfort

hematospermia; infertility

The ___ frequency endorectal transducer can be placed closer to the area of interest and produce highly detailed images.

high

Majority of the parenchyma- ________, midgray, medium-level echoes

homogeneous

The peripheral zone appears homogeneous and slightly _____ relative to adjacent parenchyma

hyperechoic

• Although cancer of a prostate may have a variety of appearances, classically it presents as a ______ lesion • Large, diffuse tumors can go undetected because of the total replacement of the gland and no normal tissue for comparison

hypoechoic

• The venous drainage consists of _____ ______ channels

irregular venous

Mullerian duct cyst The cyst appears slightly _____ from midline and superior to the base of the prostate gland

lateral

Patient position should be ________ with knees bent toward the chest while the sonographer or physician inserts the transducer

left lateral decub. LLD

• Sarcomas comprise less than 0.1% of all primary prostate cancer cases, and develops in soft tissue • The two most common prostate sarcomas include _________ and _______ • Can affect younger men between ages 35 and 60, however, extremely rare cases have been found in children • Prostate sarcomas are hard to detect and usually do not change PSA levels

leiomyosarcomas; rhabdomyosarcomas

seminal vesicles; Ovoid structures with ______ _______ , just superior to the prostate gland

low-level echoes

Utricle cyst • These cysts are typically smaller in size than ____ ______ ______ • May contain calcifications • White or brown fluid is usually aspirated and rarely contains ______

mullerian duct cysts; spermatozoa

Biopsy Guidance Procedures • U/s guidance offers a safe and accurate placement of the biopsy needle to obtain a tissue sample from the prostate • Can be utilized to localize a _____, sonographically suspicious lesion or as guidance for random biopsies of known sites of anatomical weakness

nonpalpable

Normally, the central and transition zones of the prostate are______ ______ ______

not sonographically distinctive

• Both kidneys should be imaged • On u/s appear as a ___ _____structure • The functioning contralateral seminal vesicle may be enlarged • When cyst is aspirated spermatozoa are typically found

paramedian anechoic

Prostatitis • The greater incidence of disease is within the _____ zone • The clinical diagnosis of prostatitis is made by an evaluation of expressed prostatic secretion (EPS) for either positive bacterial cultures or inflammatory cells • The are four categories of prostatitis

peripheral

• The prostate is a gland in the male reproductive system. • The main purpose of the prostate is to_______ ______ ______ _______, which transports sperm during the male orgasm

produce fluid for semen

A • 6-10 MHz phased array is used for the _________

prostate

Prostate-Specific Antigen (PSA) is • Produced exclusively by ____ ______ _____, and rises in relationship to the amount of benign and/or malignant tissue

prostatic acinar cells

• The prostate is supplied from the internal iliac arteries by the ______ arteries

prostaticovesical

• The prostate gland is __________, anterior to the rectum, and inferior to the urinary bladder

retroperitoneal

Pt prep; The patient requires no anesthetic or sedation The patient should have a _______ ______ enema about two hours prior to the exam

self-administrated

When seen the vas deferens is medial to, and has an echo texture similar to, the ____ ______ The ejaculatory duct will appear as bright double lines

seminal vesicles

seminal vesicles; Should be _____ in size, shape, and echogenicity Easier to visualize when the urinary bladder is partially ______

symmetric; filled

Normal gland should appear ______ The periurethral glandular stroma that surrounds the urethra is slightly ______ relative to surrounding tissue

symmetrical; hypoechoic

BPH cystic changes • Cystic changes can be seen in the ______ zone due to BPH • The most common cysts since BPH is a common disorder in the older male population

transition

The ______ approach • Does not require a cleansing enema or antibiotic coverage • Extensive use of local anesthetic directly into perineum • The removal of tissue from the prostate by inserting a thin needle through the skin between the scrotum and rectum and into the prostate.

transperineal

The artery on either side bifurcates into the prostatic artery and inferior vesicle artery, which further branch into the ________ and capsular arteries

urethral

The _____ ______ and ejaculatory ducts may be difficult to distinguish from surrounding structures

vas deferens

These lead to the veins of the _____ _______ and ultimately to the vesicle and internal iliac veins.

vasa deferentia

The glandular portion of the prostate is divided into zones: ___________ Zone •______ Zone •_______ Zone •_____ Zone

•Peripheral ; Central; Transition; Periurethral