Theprostate is anaccessory gland of themale reproductive system and a muscle-driven mechanical switch betweenurination andejaculation. It is found in all male mammals.[1] It differs between species anatomically, chemically, and physiologically. Anatomically, the prostate is found below thebladder, with theurethra passing through it. It is described ingross anatomy as consisting of lobes and inmicroanatomy by zone. It is surrounded by an elastic, fibromuscular capsule and contains glandular and connective tissue.
The prostate produces and contains fluid that forms part ofsemen, the substance emitted duringejaculation as part of the malesexual response. This prostatic fluid is slightlyalkaline, and milky or white in appearance. The alkalinity of semen helps neutralize the acidity of thevaginal tract, prolonging the lifespan ofsperm. The prostatic fluid is expelled in the first part of ejaculate, together with most of the sperm, because of the action ofsmooth muscle tissue within the prostate. In comparison with the few spermatozoa expelled together with mainly seminal vesicular fluid, those in prostatic fluid have bettermotility, longer survival, and better protection of genetic material.
Disorders of the prostate includeenlargement,inflammation,infection, andcancer. The wordprostate is derived fromAncient Greekprostátēs (προστάτης), meaning "one who stands before", "protector", "guardian", with the term originally used to describe theseminal vesicles.
The prostate is aexocrine gland of themale reproductive system. In adults, it is about the size of awalnut,[2] and has an average weight of about 11 grams (0.39 oz), usually ranging between 7 and 16 grams (0.25–0.56 oz).[3] The prostate is located in the pelvis. It sits below theurinary bladder and surrounds theurethra. The part of the urethra passing through it is called theprostatic urethra, which joins with the twoejaculatory ducts.[2] The prostate is covered in a surface called theprostatic capsule orprostatic fascia.[4]
The internal structure of the prostate has been described using both lobes and zones.[5][2] Because of the variation in descriptions and definitions of lobes, the zone classification is used more predominantly.[2]
The back of the gland that surrounds the distal urethra and lies beneath the capsule. About 70–80% ofprostatic cancers originate from this zone of the gland.[6][7]
Central zone (CZ)
20%
This zone surrounds the ejaculatory ducts.[2] The central zone accounts for roughly 2.5% of prostate cancers; these cancers tend to be more aggressive and more likely to invade the seminal vesicles.[8]
Transition zone (TZ)
5%
The transition zone surrounds the proximal urethra.[2] ~10–20% of prostate cancers originate in this zone. It is the region of the prostate gland that grows throughout life and causes the disease ofbenign prostatic enlargement.[6][7]
This area, not always considered a zone,[4] is usually devoid of glandular components and composed only, as its name suggests, ofmuscle andfibrous tissue.[2]
The "lobe" classification describes lobes that, while originally defined in the fetus, are also visible in gross anatomy, including dissection and when viewed endoscopically.[5][4] The five lobes are the anterior lobe or isthmus, the posterior lobe, the right and left lateral lobes, and the middle or median lobe.
Lobes of prostate
Zones of prostate
Inside of the prostate, adjacent and parallel to the prostatic urethra, there are two longitudinal muscle systems. On the front side (ventrally) runs the urethraldilator (musculus dilatator urethrae), on the backside (dorsally) runs the muscle switching the urethra into the ejaculatory state (musculus ejaculatorius).[9]
The prostate receives blood through theinferior vesical artery,internal pudendal artery, andmiddle rectal arteries. These vessels enter the prostate on its outerposterior surface where it meets the bladder, and travel forward to the apex of the prostate.[4] Both the inferior vesical and the middle rectal arteries often arise together directly from theinternal iliac arteries. On entering the bladder, the inferior vesical artery splits into a urethral branch, supplying the urethral prostate; and a capsular branch, which travels around the capsule and has smaller branches, which perforate into the prostate.[4]
The lymphatic drainage of the prostate depends on the positioning of the area. Vessels surrounding thevas deferens, some of the vessels in the seminal vesicle, and a vessel from the posterior surface of the prostate drain into theexternal iliac lymph nodes.[4] Some of the seminal vesicle vessels, prostatic vessels, and vessels from the anterior prostate drain intointernal iliac lymph nodes.[4] Vessels of the prostate itself also drain into theobturator andsacral lymph nodes.[4]
The prostate consists of glandular andconnective tissue.[2] Tallcolumn-shaped cells form the lining (theepithelium) of the glands.[2] These form one layer or may bepseudostratified.[4] The epithelium is highly variable and areas of lowcuboidal orflat cells can also be present, with transitional epithelium in the outer regions of the longer ducts.[10]Basal cells surround the luminal epithelial cells in benign glands. The glands are formed as many follicles, which drain into canals and subsequently 12–20 main ducts, These in turn drain into the urethra as it passes through the prostate.[4] There are also a small amount of flat cells, which sit next to the basement membranes of glands, and act as stem cells.[2]
The connective tissue of the prostate is made up of fibrous tissue andsmooth muscle.[2] The fibrous tissue separates the gland into lobules.[2] It also sits between the glands and is composed of randomly orientated smooth-muscle bundles that are continuous with the bladder.[11]
Over time, thickened secretions calledcorpora amylacea accumulate in the gland.[2]
Microscopic glands of the prostate
Microanatomy of a prostatic gland, showing both luminal cells and surrounding basal cells. H&E stain.
Histology of normal prostate, H&E stain, with benign features: Glands are rounded to irregularly branching, with an inner layer of epithelial cells surrounded by an outer layer of basal cells. They are surrounded by ample stroma.
Histology of prostate with gradually increasing simple atrophy from left to right, H&E stain. Crowding and angulation may mimic that of adenocarcinoma, but there is nuclear basophilia rather than atypia, and occasional basal cells can still be seen.
About 20,000protein-coding genes are expressed in human cells and almost 75% of these genes are expressed in the normal prostate.[12][13] About 150 of these genes are more specifically expressed in the prostate, with about 20 genes being highly prostate specific.[14] The corresponding specific proteins are expressed in the glandular and secretory cells of the prostatic gland and have functions that are important for the characteristics ofsemen, including prostate-specificproteins, such as theprostate specific antigen (PSA), and theprostatic acid phosphatase.[15]
In the developingembryo, at the hind end lies an inpouching called thecloaca. This, over the fourth to the seventh week, divides into aurogenital sinus and the beginnings of theanal canal, with a wall forming between these two inpouchings called theurorectal septum.[16] The urogenital sinus divides into three parts, with the middle part forming the urethra; the upper part is largest and becomes theurinary bladder, and the lower part then changes depending on the biological sex of the embryo.[16]
The prostatic part of the urethra develops from the middle, pelvic, part of the urogenital sinus, which is ofendodermal origin.[17] Around the end of the third month of embryonic life, outgrowths arise from the prostatic part of the urethra and grow into the surroundingmesenchyme.[17] The cells lining this part of the urethra differentiate into the glandular epithelium of the prostate.[17] The associated mesenchyme differentiates into the dense connective tissue and thesmooth muscle of the prostate.[18]
Condensation ofmesenchyme,urethra, andWolffian ducts gives rise to the adult prostate gland, a composite organ made up of several tightly fused glandular and non-glandular components. To function properly, the prostate needs malehormones (androgens), which are responsible for malesex characteristics. The main male hormone istestosterone, which is produced mainly by thetesticles. It isdihydrotestosterone (DHT), a metabolite of testosterone, that predominantly regulates the prostate. The prostate gland enlarges over time, until the fourth decade of life.[4]
The prostate secretes fluid, which becomes part of thesemen. Its secretion forms up to 30% of the semen. Semen is the fluid emitted (ejaculated) through the maleurethra during thesexual response.[19] Sperm are emitted from thevas deferens into the male urethra via theejaculatory duct, which lies within the prostate gland.[19] Semen is moved into the urethra following contractions of the smooth muscle of the vas deferens and seminal vesicles, following stimulation, primarily of theglans penis. Stimulation sends nerve signals via theinternal pudendal nerves to the upperlumbar spine; the nerve signals causing contraction act via thehypogastric nerves.[19] After traveling into the urethra, the seminal fluid is ejaculated by contraction of thebulbocavernosus muscle.[19] The secretions of the prostate includeproteolytic enzymes,prostatic acid phosphatase,fibrinolysin,zinc, andprostate-specific antigen.[4] Together with the secretions from the seminal vesicles, these form the major fluid part of semen.[4] The prostate contains various metals, including zinc,[20] and is known to be the primary source of most metals found in semen, which are released during ejaculation.[21]
The prostate's changes of shape, which facilitate the mechanical switch between urination and ejaculation, are mainly driven by the two longitudinal muscle systems running along the prostatic urethra. These are theurethraldilator (musculus dilatator urethrae) on the urethra's front side, which contracts during urination and thereby shortens and tilts the prostate in its vertical dimension thus widening the prostatic section of the urethral tube,[22][23] and the muscle switching the urethra into the ejaculatory state (musculus ejaculatorius) on its backside.[9]
In case of an operation, e.g. because of benign prostatic hyperplasia (BPH), damaging or sparing of these two muscle systems varies considerably depending on the choice of operation type and details of the procedure of the chosen technique. The effects on postoperational urination and ejaculation vary correspondingly.[24]
It is possible for some men to achieveorgasm solely through stimulation of the prostate gland, such as viaprostate massage oranal intercourse.[25][26] This has led to the area of therectal wall adjacent to the prostate to be popularly referred to as the "maleG-spot".[27]
Prostatitis isinflammation of the prostate gland. It can be caused by infection with bacteria, or other noninfective causes. Inflammation of the prostate can causepainful urination or ejaculation, groin pain, difficulty passing urine, orconstitutional symptoms such asfever ortiredness.[28] When inflamed, the prostate becomes enlarged and is tender when touched duringdigital rectal examination. The bacteria responsible for the infection may be detected by aurine culture.[28]
An enlarged prostate is called prostatomegaly, with benign prostatic hyperplasia (BPH) being the most common cause. BPH refers to an enlargement of the prostate due to an increase in the number of cells that make up the prostate (hyperplasia) from a cause that is not a malignancy. It is very common in older men.[28] It is often diagnosed when the prostate has enlarged to the point where urination becomes difficult. Symptoms include needing to urinate often (urinary frequency) or taking a while to get started (urinary hesitancy). If the prostate grows too large, it may constrict the urethra and impede the flow of urine, making urination painful and difficult, or in extreme cases completely impossible, causingurinary retention.[28] Over time, chronic retention may cause the bladder to become larger and cause a backflow of urine into the kidneys (hydronephrosis).[28]
BPH can be treated with medication, aminimally invasive procedure or, in extreme cases, surgery that removes the prostate. In general, treatment often begins with analpha-1 adrenergic receptorantagonist medication such astamsulosin, which reduces the tone of thesmooth muscle found in theurethra that passes through the prostate, making it easier for urine to pass through.[28] For people with persistent symptoms, procedures may be considered. The surgery most often used in such cases istransurethral resection of the prostate,[28] in which an instrument is inserted through the urethra to remove prostate tissue that is pressing against the upper part of the urethra and restricting the flow ofurine. Minimally invasive procedures includetransurethral needle ablation of the prostate andtransurethral microwave thermotherapy.[31] These outpatient procedures may be followed by the insertion of a temporarystent, to allow normal voluntary urination, without exacerbating irritative symptoms.[32]
Prostate cancer is one of the most commoncancers affecting older men in the UK, US, Northern Europe and Australia, and a significantcause of death for elderly men worldwide.[33] Often, a person does not have symptoms; when they do occur, symptoms may include urinary frequency, urgency, hesitation and other symptoms associated with BPH. Uncommonly, such cancers may cause weight loss, retention of urine, or symptoms such asback pain due tometastatic lesions that have spread outside of the prostate.[28]
Adigital rectal examination and the measurement of aprostate-specific antigen (PSA) level are usually the first investigations done to check for prostate cancer. PSA values are difficult to interpret, because a high value might be present in a person without cancer, and a low value can be present in someone with cancer.[28] The next form of testing is often the taking of aprostate biopsy to assess fortumour activity and invasiveness.[28] Because of the significant risk ofoverdiagnosis with widespread screening in the general population,prostate cancer screening is controversial.[34] If a tumour is confirmed,medical imaging such as anMRI orbone scan may be done to check for the presence of tumourmetastases in other parts of the body.[28]
Prostate cancer that is only present in the prostate is often treated with either surgicalremoval of the prostate or withradiotherapy or by the insertion of small radioactive particles ofiodine-125 orpalladium-103, calledbrachytherapy.[35][28] Cancer that has spread to other parts of the body is usually treated also with hormone therapy, to deprive a tumour of sex hormones (androgens) that stimulate proliferation. This is often done through the use ofGnRH analogues or agents (such asbicalutamide) that block the receptors that androgens act on; occasionally,surgical removal of the testes may be done instead.[28] Cancer that does not respond to hormonal treatment, or that progresses after treatment, might be treated withchemotherapy such asdocetaxel.Radiotherapy may also be used to help with pain associated with bony lesions.[28]
Sometimes, the decision may be made not to treat prostate cancer. If a cancer is small and localised, the decision may be made to monitor for cancer activity at intervals ("active surveillance") and defer treatment.[28] If a person, because offrailty or other medical conditions or reasons, has alife expectancy less than ten years, then the impacts of treatment may outweigh any perceived benefits.[28]
Surgery to remove the prostate is called prostatectomy, and is usually done as a treatment for cancer limited to the prostate, or for prostatic enlargement.[36] When it is done, it may be done asopen surgery or aslaparoscopic (keyhole) surgery.[36] These are done undergeneral anaesthetic.[37] Usually the procedure for cancer is aradical prostatectomy, which means that the seminal vesicles are removed and the vasa deferentia are also tied off.[36] Part of the prostate can also be removed from within the urethra, calledtransurethral resection of the prostate (TURP).[36] Open surgery may involve a cut that is made in theperineum, or via an approach that involves a cut down the midline from the belly button to thepubic bone.[36] Open surgery may be preferred if there is a suspicion that lymph nodes are involved and they need to be removed or biopsied during a procedure.[36] A perineal approach will not involve lymph node removal and may result in less pain and a faster recovery following an operation.[36] A TURP procedure uses a tube inserted into the urethra via the penis and some form of heat, electricity or laser to remove prostate tissue.[36]
The whole prostate can be removed. Complications that might develop because of surgery includeurinary incontinence anderectile dysfunction because of damage to nerves during the operation, particularly if a cancer is very close to nerves.[36][37]Ejaculation ofsemen will not occur duringorgasm if the vasa deferentia are tied off and seminal vesicles removed, such as during a radical prosatectomy.[36] This will mean a man becomesinfertile.[36] Sometimes, orgasm may not be able to occur or may be painful. The penis length may shorten slightly if the part of the urethra within the prostate is also removed.[36] General complications due to surgery can also develop, such asinfections,bleeding, inadvertent damage to nearby organs or within the abdomen, and the formation ofblood clots.[36]
Numerous studies have recorded the proliferation of prostate tissue intransmasculine individuals undergoingtestosterone therapy. A 2022 study concluded that "one hundred percent ofvaginal specimens obtained from transmasculine individuals on testosterone therapy (21/21 cases) demonstrated prostaticmetaplasia" and notes, congruously with similar studies, that further research in this area is warranted so as to contribute to higher standards of care for transgender patients, and so that the presence of this tissue does not register to healthcare providers as an abnormality.[38][39][40][41]
The prostate was first formally identified byVenetian anatomistNiccolò Massa inAnatomiae libri introductorius (Introduction to Anatomy) in 1536 and illustrated byFlemish anatomistAndreas Vesalius inTabulae anatomicae sex (six anatomical tables) in 1538.[42][5] Massa described it as a "glandular flesh upon which rests the neck of the bladder," and Vesalius as a "glandular body".[43] The first time a word similar toprostate was used to describe the gland is credited toAndré du Laurens in 1600, who described it as a term already in use by anatomists at the time.[43][5] The term was however used at least as early as 1549 by French surgeonAmbroise Pare.[5]
At the time, Du Laurens was describing what was considered to be a pair of organs (not the single two-lobed organ), and theLatin termprostatae that was used was a mistranslation of the term for theAncient Greek word used to describe theseminal vesicles,parastatai;[43] although it has been argued that surgeons in Ancient Greece and Rome must have at least seen the prostate as an anatomical entity.[5] The termprostatae was taken rather than the grammatically correctprostator (singular) andprostatores (plural) because thegender of the Ancient Greek term was taken as female, when it was in fact male.[43]
The fact that the prostate was one and not two organs was an idea popularised throughout the early 18th century, as was the English language term used to describe the organ,prostate,[43] attributed toWilliam Cheselden.[44] Amonograph, "Practical observations on the treatment of the diseases of the prostate gland" byEverard Home in 1811, was important in the history of the prostate by describing and naming anatomical parts of the prostate, including the median lobe.[43] The idea of the five lobes of the prostate was popularized following anatomical studies conducted by American urologistOswald Lowsley in 1912.[5][44] John E. McNeal first proposed the idea of "zones" in 1968; McNeal found that the relatively homogeneous cut surface of an adult prostate in no way resembled "lobes" and thus led to the description of "zones".[45]
Prostate cancer was first described in a speech to theMedical and Chiurgical Society of London in 1853 by surgeonJohn Adams[46][42] and increasingly described by the late 19th century.[47] Prostate cancer was initially considered a rare disease, probably because of shorterlife expectancies and poorer detection methods in the 19th century. The first treatments of prostate cancer were surgeries to relieve urinary obstruction.[48]Samuel David Gross has been credited with the first mention of a prostatectomy, as "too absurd to be seriously entertained"[49][47] The first removal for prostate cancer (radical perinealprostatectomy) was first performed in 1904 byHugh H. Young atJohns Hopkins Hospital;[50][47] partial removal of the gland was conducted byTheodore Billroth in 1867.[44]
Transurethral resection of the prostate (TURP) replaced radical prostatectomy for symptomatic relief of obstruction in the middle of the 20th century because it could better preserve penile erectile function. Radical retropubic prostatectomy was developed in 1983 by Patrick Walsh.[51] In 1941,Charles B. Huggins published studies in which he usedestrogen to oppose testosterone production in men with metastatic prostate cancer. This discovery of "chemicalcastration" won Huggins the 1966Nobel Prize in Physiology or Medicine.[52]
The role of thegonadotropin-releasing hormone (GnRH) in reproduction was determined byAndrzej W. Schally andRoger Guillemin, who both won the 1977 Nobel Prize in Physiology or Medicine for this work. GnRH receptor agonists, such asleuprorelin andgoserelin, were subsequently developed and used to treat prostate cancer.[53][54]Radiation therapy for prostate cancer was first developed in the early 20th century and initially consisted of intraprostaticradium implants.External beam radiotherapy became more popular as strongerX-ray radiation sources became available in the middle of the 20th century.Brachytherapy with implanted seeds (for prostate cancer) was first described in 1983.[55] Systemicchemotherapy for prostate cancer was first studied in the 1970s. The initial regimen ofcyclophosphamide and5-fluorouracil was quickly joined by multiple regimens using a host of other systemic chemotherapy drugs.[56]
The prostate is found only in mammals.[57] The prostate glands of malemarsupials are proportionally larger than those ofplacental mammals.[58] The presence of a functional prostate inmonotremes is controversial, and if monotremes do possess functional prostates, they may not make the same contribution to semen as in other mammals.[59]
The structure of the prostate varies, ranging fromtubuloalveolar (as in humans) tobranched tubular. The gland is particularly well developed incarnivorans[60] and boars, though in other mammals, such as bulls, it can be small and inconspicuous.[61][62][63] In other animals, such as marsupials[64][65] and smallruminants, the prostate is disseminate, meaning not specifically localisable as a distinct tissue, but present throughout the relevant part of the urethra; in other animals, such asred deer and Americanelk, it may be present as a specific organ and in a disseminate form.[66] In some marsupial species, the size of the prostate gland changes seasonally.[67] The prostate is the only accessory gland that occurs in male dogs.[68] Dogs can produce in one hour as much prostatic fluid as a human can in a day. They excrete this fluid along with their urine tomark their territory.[69] Additionally, dogs are the only species apart from humans seen to have a significant incidence of prostate cancer.[70] The prostate is the only male accessory gland that occurs incetaceans,[71] consisting of diffuse urethral glands[72] surrounded by a very powerful compressor muscle.[73]
The prostate gland originates with tissues in the urethral wall.[citation needed] This means theurethra, a compressible tube used for urination, runs through the middle of the prostate; enlargement of the prostate can constrict the urethra so that urinating becomes slow and painful.[74]
Prostatic secretions vary among species. They are generally composed of simple sugars and are often slightly alkaline.[75] Ineutherian mammals, these secretions usually containfructose. The prostatic secretions ofmarsupials usually containN-Acetylglucosamine orglycogen instead of fructose.[76]
Because theSkene's gland and the male prostate act similarly by secretingprostate-specific antigen (PSA), which is anejaculate protein produced in males, and of prostate-specificacid phosphatase, the Skene's gland is sometimes referred to as the "female prostate".[77][78] Althoughhomologous to the male prostate (developed from the sameembryological tissues),[79][80] various aspects of its development in relation to the male prostate are widely unknown and a matter of research.[81]
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Portions of the text of this article originate from NIH Publication No. 02-4806, a public domain resource."What I need to know about Prostate Problems". National Institutes of Health. 2002-06-01. No. 02-4806. Archived fromthe original on 2002-06-01. Retrieved2011-01-24.
