MIND MAP A.

BASIC SCIENCE
1. ANATOMY PROSTATE
A. BASIC SCIENCE
a. Definition
1. ANATOMY PROSTATE
2. HISTOLOGY PROTATE Prostate merupakan accessory gland terbesar dari system reproduksi
3. PHYSIOLOGY pria. Memiliki ukuran sebesar kenari dengan panjang 3 cm, lebar 4 cm,
a. PROSTATE dan ketebalan 2 cm.
b. MICTURITION
4. PATHOLOGY Reference: Keith L. Moore, Clinically Oriented Anatomy 6th edition
a. LUTS
Prostate memiliki berat sekitar 20 gram.
b. HISTOPATHOLOGY
B. CLINICAL SCINCE Reference: Junquiera’s Basic Histology 13th edition
1. URINE RETENTION
2. SUPRAPUBIC MASS b. Topography
3. BENIGN PROSTATIC HYPERPLASIA • Base berhubungan dengan neck of bladder
C. BHP & IIMC • Apex berhubungan dengan fascia pada superior aspect urethral
D. PATHOMECHANISM sphincter
• Posterior surface berhubungan dengan ampulla rectum
• Inferolateral surface berhubungan dengan levator ani

Reference: Keith L. Moore, Clinically Oriented Anatomy 6th edition

c. Structure

Sekitar 2/3 bagian prostate adalah glandular part dan 1/3 bagian
adalah fibromuscular.

Prostate terdiri dari beberapa bagian, yaitu:

• Isthmus
• Right and left lobes
• Inferoposterior ((lower posterior) lobule
• Inferolateral (lower lateral) lobule
• Superomedial lobule
 • Anteromedial lobule
Reference: Keith L. Moore, Clinically Oriented Anatomy 6th edition
d. Vascularization
1. Artery
Prostate diperdarahi oleh cabang dari internal iliac artery, especially
inferior vesical arteries but also the internal pudendal and middle rectal
arteries.
Reference: Keith L. Moore, Clinically Oriented Anatomy 6th edition
2. Vena
Veins bersatu membentuk Prostatic venous plexus kemudian di
drainase ke internal iliac veins.
Reference: Keith L. Moore, Clinically Oriented Anatomy 6th edition
e. Innervation
• Presynaptic sympathetic fibers originate from cell bodies in the
intermediolateral cell column of the T12-L2 (or L3) spinal cord
segments.
• Presynaptic parasympathetic fibers from S2 and S3 spinal cord
segments traverse pelvic splanchnic nerves, which also join the
inferior hypogastric/pelvic plexuses.
Reference: Keith L. Moore, Clinically Oriented Anatomy 6th edition
f. Lymphatic
Berdrainase ke nodus limfoid illiaca interna, nodus limfoid di daerah
Reference: Guyton & Hall: Textbook of Medical Physiology 12th edition
sacrum, dan illiaca externa.
2. HISTOLOGY PROSTATE
- Prostat adalah kumpulan 30-50 kelenjar tubuloalveolar
bercabang yang salurannya bermuara ke dalam uretra pars
prostatika.
- Menghasilkan cairan prostat dan disimpan di bagian dalam
untuk dikeluarkan selama ejakulasi.
- Dikelilingi oleh sebuah jaringan ikat fibroelastis dengan
banyak otot polos di sekelilingnya.
- Jaringan ikat ini masuk diantara kelenjar dan membaginya
menjadi lobus.
- Struktur kelenjar dikelilingi stroma fibromuskular
Zona-zona postat:
o Zona sentralis volume kelenjarnya 25%
o Zona perifer volume kelenjarnya 70%  carcinoma
prostat
o Zona trasnsisional volume kelenjarnya 5%  BPH
o Kelenjar dibatasi 2 lapisan sel ; lapisan basal low cuboidal
epithelium yang ditutupi oleh sel sekretori kolumnar.
3. PHYSIOLOGY
A. PROSTATE
- Kelenjar prostate mensekresikan milky fluid yang mengandung
calcium, citrate ion, phosphate ion, clotting enzyme, dan
profibrinolysin.
- Ciaran prostate bersifat alkaline yang penting untuk fertilisasi ovum
karena vas deferens mensekresikan cairan yang relative asam dan
juga vaginal mensekresikan cairan yang bersifat asam sehingga
motilitas sperma tidak optimal. Oleh karena itu, cairan prostate
yang alkaline dapat membantu menetralkan keasaman dari seminal
fluid selama ejakulasi dan dapat memperkuat motility dan fertility
dari sperma.
 B. MICTURITION Macroscopic
*ada di DS sebelumnya - Nodules thatcontain mostly
glands are yellow-pink and soft
4. PATHOLOGY - Exude a milky white prostatic
fluid
A. LUTS
- Nodular enlargements may
*ada di DS sebelumnya encroach on the lateral walls of
the urethra to compress it to a
B. HISTOPATHOLOGY slitlike orifice.
- Benign prostatic hyperplasia - The cut surface contains many
fairly well-circumscribed
nodules that bulge from the cut
surface.
- The nodules may have a solid
appearance or may contain
cystic spaces.
Reference:
- Robbins and Cotran Pathologic Basic of Disease, 9th edition
- Robbins Basic Pathology, 8th edition
Reference: Ming Zhou, Genitourinary pathology 2nd edition
Microscopic
- hyperplastic nodules are
composed of varying proportions
of proliferating glandular
elements and fibromuscular
stroma.
- The hyperplastic glands are lined
by tall, columnar epithelial cells
and a peripheral layer of flattened
basal cells.
- crowding of the proliferating
epithelium results in the
formation of papillary projections
in some glands
- The glandular lumina often
contain inspissated, proteinaceous
secretory material, termed
corpora amylacea
- The glands are surrounded by
proliferating stromal elements.
- Other nodules are composed
predominantly of spindle-shaped
stromal cells and connective
tissue.
 B. CLINICAL SCIENCE 2. SUPRAPUBIC MASS
1. URINE RETENTION - Most common causes of suprapubic mass is urinary retention
a. Definition due to infravesical obstruction
o in male infants or young boys is thickened
Urinary retention is the inability to urinate and therefore empty the hypertrophied bladder secondary to obstruction caused
bladder. by posterior urethral valves
Reference: Chris Dawson & Janine Nethercliffe, ABC of Urology 3rd o in adults or old men is secondary obstruction caused by
edition BPH.
b. Etiology - Rarer causes include colonic carcinoma, huge bladder tumor or
stone.
The exact cause of acute urinary retention is unclear, however several
different conditions may contribute to it and these can be broadly
divided into four major categories. 3. BENIGN PROSTATIC HYPERPLASIA
a. Definition

Benign prostatic hyperplasia (juga dikenal sebagai nodular

hyperplasia) Merupakan pembesaran prostate yang disebabkan oleh
peningkatan jumlah sel.

Reference: Ming Zhou, Genitourinary pathology 2nd edition

Benign Prostatic Hyperplasia merupakan proses hyperplastic hasil dari

peningkatan jumlah sel. BPH terjadi di transition zone.

Reference: Smith & Tanaghos’s General Urology 18th edition

b. Epidemiology
• BPH merupakan benign tumor yang paling sering terjadi pada
laki-laki
• Prevalensi
o 20% pada laki-laki usia 41-50
o 50% pada laki-laki usia 51-60
o >90% pada laki-laki usai >80 tahun
Reference: Chris Dawson & Janine Nethercliffe, ABC of Urology 3rd
Reference: Smith & Tanaghos’s General Urology 18th edition
edition
 c. Risk factor g. Clinical Manifestation

• Risk factors for the development of BPH are poorly understood. Pada umumnya, pasien BPH dating dengan gejala traktus urinarius
• Some studies have suggested a genetic predisposition, and some bawah/ lower urinary tract symptoms (LUTS) yang terdiri atas:
have noted racial differences.
1. Gejala Obstruksi (storage)
th
Reference: Smith & Tanaghos’s General Urology 18 edition o Miksi terputus
• Age o Hesitancy
• Genetic and familial factor o Harus mengedan saat mulai miksi
• Obesity o Berkurangnya kekuatan dan pancaran urin
• Hormonal o Sensasi tidak selesai berkemih
• Smoking o Menetes pada saat akhir miksi
2. Gejala Iritasi (voiding)
Reference: Campbell-Walsh’s Urology 11th edition
o Frekuensi (sering miksi)
d. Etiology o Urgensi (tidak dapat menahan saat ingin miksi)
• The etiology of BPH is not completely understood o Nokturia (terbangun saat malam hari untuk miksi)
• but it seems to be multifactorial and endocrine controlled o Inkontinensia (urin keluar diluar kehendak)

Reference: Smith & Tanaghos’s General Urology 18th edition Reference: Kapita Selekta Kedokteran, UI Edisi 4
• Androgens, estrogens, and growth factors, may play a role,
either singly or in combination, in the etiology of the
hyperplastic process.

Reference: Campbell-Walsh’s Urology 11th edition

e. Pathogenesis
*terlampir di halaman terakhir

f. Pathophysiology
*terlampir di halaman terakhir
 h. Diagnosis Skala keluhan 0-5. Total skor 35. Keluhan sedang : skor 0-7, moderat :
- Anamnesis 8-19, berat : 20-35.

- Physical Examnination
o Digital Rectal Examination

ukuran, konsistensi. (akan teraba prostat yang membesar, halus,

elastis, padat). Jika ada indurasi, ada kecurigaan kanker dan butuh
pemeriksaan lebih lanjut.

- Ancillary Examination
a. Prostate Specific Antigen (PSA)

PSA is an extremely important prostate cancer marker. PSA is prostate

specific but not cancer specific. Serum elevation greater than 4.0 ng/ml
is correlated with prostatic cancer, however, serum level vary with
prostatic volume, inflammation, and amount of cancer within the
gland.

b. Biopsy

Indication: elevated PSA, nodule in DRE, and PSA density more than
0,15.

i. Differential Diagnosis
- Urethral Stricture
- Bladder Neck Contracture
- Bladder Stone
- Prostate Cancer
- Decrease Bladder Contractility

Reference: Kapita Selekta Kedokteran, UI Edisi 4

 j. Management
1. Watchful Waiting
Observasi waspada dapat dilakukan pada pasien gejala ringan
dengan skor IPSS 0-7. Evaluasi dilakukan secara berkala, yaitu
3,6, dan 12 bulan kemudian, serta dianjurkan 1 kali per tahun.
 This drug affects the epithelial component of the
prostate, resulting in a reduction in the size of the gland
and improvement in symptoms.
c. Combination Therapy

Reference: Kapita Selekta Kedokteran, UI Edisi 4 Combination α-blocker and 5α-reductase inhibitor therapy
o Finasteride and terazosin
o Finasteride and doxazosin
2. Medical Therapy
a. α- Blocker d. Phytotherapy
 blok alpha-1 adrenoreceptor di prostate dan bladder Phytotherapy refers to the use of plants or plant extracts for
sehingga menurunkan resistensi otot polos. medicinal purposes.
o saw palmetto berry (Serenoa repens)
o bark of Pygeum africanum
o roots of Echinacea purpurea and Hypoxis rooperi

b. 5α- Reductase Inhibitor
 Blocks the conversion
dihydrotestosterone (DHT).
 E.g., Finasteride, Dutasteride
3. Surgical Therapy
a. Transurethral Resection of the Prostate (TURP)
- Prosedur pembuangan bagian dalam prostate untuk mengurangi
pembesaran
- Resectoscope dimasukan ke dalam ujung penis  urethra
(prostatic part)  buang jaringan prostate yang memblok
aliran urin
- Risiko dan komplikasi
o Retrograde ejaculation
o Impotensi
o Incontinence
o Perforasi kapsul prostate
o TURP syndrome
of testosterone to b. Transurethral Incision of the Prostate (TUIP)
c. Simple (subtotal) Protatectomy
4. Minimal Invasive Therapy b. IIMC
- Laser therapy (visual contact ablative atau interstitial laser
therapy) Aku pernah berada di samping Rasulullah Saw lalu datanglah
- Transurethral electrovaporization of prostate serombongan arab dusun.
- Hyperthermia Microwave
- Mereka bertanya , “ Wahai Rasulullah, bolehkah kami
- Transurethral needle ablation of prostate
- High intensity focused ultrasound berobat?”
- Intraurethral Stent - Beliau menjawab : “Iya, wahai para hamba Allah, berobatlah.

k. Complication Sebab Allah SWT tidaklah meletakkansebuah penyakit

- Chronic urinary retention melainkan meletakkan pula obatnya, kecuali satu penyakit.”
- Urinary stone formation - Mereka bertanya, “ Penyakit apa itu ?
- Prostate Cancer
- Urinary tract Infection - beliau menjawab “Penyakit tua”
- Damage to the kidneys
- Hydronephrosis
(HR Ahmad, Al Bukhari dalam Al-Adabul mufrad, Abu Dawud, Ibnu
Masa, At tirmidzi)
l. Prognosis

C. BHP & IIMC D. PATHOMECHANISM

a. BHP
- Menjelaskan bahwa ini adalah resikosetiap laki-laki yang telah
memiliki usia lanjut.
- Menjelaskan terapi dan efek samping terapi.
- Menjelaskan risiko yang berkaitan dengan komplikasi,
komplikasi pasca operatif, dan kecenderungan keganasan.
*Pathogenesis

Metabolic Syndrome Penuaan Inflamasi

Hyperinsulinemia Prostatitis
Visceral Fat ↑ Ketidakseimbangan Signaling Pathway dan
Stromal Epithelial Interaction
Jaringan Fibromuscular ↑
Aktivitas Menghasilkan Estrogen Conversion
Sympathetic
Modifikasi Sel Basal
Nerve ↑
Estrogen ↑
Perubahan Metabolisme Intra cell
Sympathetic
Tone ↑ Induksi Androgen reseptor

Tissue Remodeling ↑

Jumlah reseptor ↑ Sensitivitas reseptor ↑

Testosteron → DHT

DHT ↑

Adanya ikatan DHT dengan Androgen reseptor

Stimulasi Transkripsi Androgen Dependent Genes

FGF TGF β

Reawekaning Prostatic Apoptosis ↓

Ketidakseimbangan pertumbuhan Epitel dan Stroma

Pertumbuhan Sel Prostat ↑

Benign Prostate Hyperplasia

*Pathophysiology

Benign Prostate Hyperplasia

Menyumbat saluran uretra

Obstruksi Bladder Outlet

Retensi Urine di Bladder

Gejala LUTS Hypertrophy dan Hyperplasia dari Bladder Distension

Detruso m.

Obstruksi Iritatif Perubahan Kontraksi Merangsang Nociceptor Suprapubic mass

 Hesitancy  Urgency
 Dribbling  Frequency ↑
 Straining  Nocturia Dihantarkan oleh Saraf
 Weak stream  Dysuria Aferen dari CN
 Incomplete emptying

Melaui traktus Medulla Spinalis

Menuju ke Cerebrum (Somato Sensory Cortex)

Pain di Suprapubic