Symptom Finder - Prostatic Mass or Enlargement
PROSTATIC MASS OR ENLARGEMENT
Generally, when the physician examines the prostate in a routine physical, there are only two conditions that he or she is looking for—benign prostatic hypertrophy and prostate carcinoma. The former presents a diffuse enlargement, soft in consistency, and the prostate varies in size from a plum to an orange. Prostate carcinomas, in contrast, present as a stony, hard nodule in the lateral superior or inferior areas in the early stages or as a diffuse, hard, nodular enlargement in the more advanced stages. The approach is different for the patient presenting with a urethral discharge or difficulty voiding, because then one must include acute and chronic prostatitis and prostatic abscess in the differential.
In brief, that is the differential diagnosis of an enlarged prostate. The only trick that might be useful in remembering it is to keep in mind the ages 20, 40, 60, and 80. In general, 20-year-old men usually have acute prostatitis from gonorrhea or other bacteria. The 40-year-old men usually have chronic prostatitis from previous gonorrhea or from nonspecific prostatitis. The 60-year-old men generally have prostatic hypertrophy, and the 80-year-old men most likely have prostatic carcinoma. However, it is important to remember that any one of these diseases may appear at the ages of 40, 60, and 80.
Approach to the Diagnosis
The main consideration in diagnosing a prostatic mass is to rule out carcinoma. It is therefore wise to draw blood for prostate-specific antigen (PSA) before proceeding in anyone who is suspected of having prostate cancer. If the mass is located in the posterior lobes, there is further support for the diagnosis. Ultrasonography can be done for further localization before proceeding with a biopsy. Obviously, if the PSA test is positive, referral to an urologist is mandatory, although false positives can occur in
this test.
Bear in mind that the PSA is elevated in BPH and acute prostatitis. A large, boggy prostate suggests a prostatic abscess or prostatitis. If there is no urethral discharge, one can elicit a discharge by prostatic massage. However, this should not be done if the patient has fever and significant tenderness of the prostate. It is better to proceed with antibiotic therapy and reexamine the patient after the fever has subsided. A smear and culture of the discharge is made. If upon examining the discharge under high-power microscopy, four or more white blood cells (WBCs) per high-power field are found, the diagnosis of prostatitis can be made. If benign prostatic hypertrophy is suspected, cystoscopy and retrograde pyelography can be done.
Other Useful Tests
1. CBC
2. Sedimentation rate (infection)
3. Chemistry panel (uremia)
4. Urinalysis (cystitis, UTI)
5. Cystogram (prostatic hypertrophy)
6. Skeletal survey (metastatic carcinoma)
7. Bone scan (metastatic carcinoma)
8. Acid phosphatase level (metastatic carcinoma)
9. CT scan of pelvic lymph nodes (metastasis)
10. Lymphoscintigraphy (node metastasis)
11. Cystoscopy (bladder neck obstruction)
PROSTATIC MASS OR ENLARGEMENT
Generally, when the physician examines the prostate in a routine physical, there are only two conditions that he or she is looking for—benign prostatic hypertrophy and prostate carcinoma. The former presents a diffuse enlargement, soft in consistency, and the prostate varies in size from a plum to an orange. Prostate carcinomas, in contrast, present as a stony, hard nodule in the lateral superior or inferior areas in the early stages or as a diffuse, hard, nodular enlargement in the more advanced stages. The approach is different for the patient presenting with a urethral discharge or difficulty voiding, because then one must include acute and chronic prostatitis and prostatic abscess in the differential.
In brief, that is the differential diagnosis of an enlarged prostate. The only trick that might be useful in remembering it is to keep in mind the ages 20, 40, 60, and 80. In general, 20-year-old men usually have acute prostatitis from gonorrhea or other bacteria. The 40-year-old men usually have chronic prostatitis from previous gonorrhea or from nonspecific prostatitis. The 60-year-old men generally have prostatic hypertrophy, and the 80-year-old men most likely have prostatic carcinoma. However, it is important to remember that any one of these diseases may appear at the ages of 40, 60, and 80.
Approach to the Diagnosis
The main consideration in diagnosing a prostatic mass is to rule out carcinoma. It is therefore wise to draw blood for prostate-specific antigen (PSA) before proceeding in anyone who is suspected of having prostate cancer. If the mass is located in the posterior lobes, there is further support for the diagnosis. Ultrasonography can be done for further localization before proceeding with a biopsy. Obviously, if the PSA test is positive, referral to an urologist is mandatory, although false positives can occur in
this test.
Bear in mind that the PSA is elevated in BPH and acute prostatitis. A large, boggy prostate suggests a prostatic abscess or prostatitis. If there is no urethral discharge, one can elicit a discharge by prostatic massage. However, this should not be done if the patient has fever and significant tenderness of the prostate. It is better to proceed with antibiotic therapy and reexamine the patient after the fever has subsided. A smear and culture of the discharge is made. If upon examining the discharge under high-power microscopy, four or more white blood cells (WBCs) per high-power field are found, the diagnosis of prostatitis can be made. If benign prostatic hypertrophy is suspected, cystoscopy and retrograde pyelography can be done.
Other Useful Tests
1. CBC
2. Sedimentation rate (infection)
3. Chemistry panel (uremia)
4. Urinalysis (cystitis, UTI)
5. Cystogram (prostatic hypertrophy)
6. Skeletal survey (metastatic carcinoma)
7. Bone scan (metastatic carcinoma)
8. Acid phosphatase level (metastatic carcinoma)
9. CT scan of pelvic lymph nodes (metastasis)
10. Lymphoscintigraphy (node metastasis)
11. Cystoscopy (bladder neck obstruction)
