Diagnostic Ultrasound - Abdomen and Pelvis

Prostatic Hyperplasia
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Diagnoses: Urinary Tract
○ Sonographic appearance of BPH is variable, depending
on histopathologic changes
– Diffusely enlarged TZ; heterogeneous, nodular
– ± calcification of corpora amylacea → prostatic calculi
– ± cystic degeneration of BPH nodules
○ Potential secondary changes of bladder and upper
urinary tracts are best seen transabdominally
– Possible bladder findings: Wall
thickening/trabeculation, diverticula, stones,
abnormal postvoid residual (PVR)
– Possible upper tract changes: Ureteral dilation,
hydronephrosis
• Color Doppler
○ Normal prostate is moderately vascular
○ Vascularity is usually higher in malignancy and prostatitis
than in BPH
• Power Doppler
○ Cannot reliably differentiate BPH from prostatic cancer
Imaging Recommendations
• Best imaging tool
○ Ultrasound is typically not needed in BPH management
but may be obtained to investigate BPH as cause of renal
insufficiency → measure prostate size and PVR, evaluate
for upper tract obstruction
DIFFERENTIAL DIAGNOSIS
Prostate Carcinoma
• Commonly originates in PZ (70%)
• Classically described as hypervascular hypoechoic PZ nodule
but is difficult to differentiate cancer from BPH, prostatitis
and other nonmalignant entities
Prostatitis
• Variable, may be normal
○ Main role of US is to exclude prostatic abscess
• Acute: Enlarged gland; diffuse or focal hypoechogenicity
with focal or global hypervascularity; may mimic carcinoma
• Chronic: Abnormalities may be diffuse or only in the
periurethral or peripheral areas
○ Scattered hypoechoic areas in PZ; hyperechoic regions
with hypoechoic halos; focal or diffuse hypervascularity;
ejaculatory duct calcifications; thick/irregular capsule
Bladder Carcinoma
• Enlarged median lobe in BPH simulates bladder mass
PATHOLOGY
General Features
• Etiology
○ Nodular periurethral stromal and epithelial hyperplasia
○ BOO from BPH may occur from urethral constriction
from increased smooth muscle tone and resistance
(dynamic) &/or urethral compression from gland
enlargement (static)
○ All BPH nodules develop in TZ or periurethral region
Gross Pathologic & Surgical Features
• Enlarged, rubbery gland at prostatectomy
Microscopic Features
• Hyperplastic nodules due to glandular &/or fibrous or
muscular stromal proliferation
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Asymptomatic or LUTS
○ Size of prostate does not correlate with severity of
symptoms or urodynamic changes
• Other signs/symptoms
○ Urinary incontinence: Overflow or urge
○ Hematuria
○ UTI
○ Acute urinary retention
• Clinical profile
○ Enlarged prostate on rectal exam
○ May have elevated prostate-specific antigen (PSA)
○ Possible bladder sequelae: Trabeculation, diverticula,
calculi, detrusor muscle failure
○ Possible upper tract changes: Ureterectasis,
hydronephrosis
– Can be from secondary vesicoureteral reflux,
obstruction from muscular hypertrophy or angulation
at ureterovesical junction, sustained high pressure
bladder storage
Demographics
• Epidemiology
○ Affects 70% of men by age 60-69 years; 80% of those
aged 70-80 years; 90% men aged 80-90 years
Natural History & Prognosis
• May lead to detrusor muscle failure, renal insufficiency
Treatment
• Options, risks, complications
○ Noninvasive: No therapy if asymptomatic or no
bothersome symptoms
– If bothersome symptoms, then drug therapy is first
line
○ Minimal invasive & surgical options if drug therapy fails
– Transurethral: Resection of the prostate (TURP),
incision of the prostate (TUIP), microwave
thermotherapy (TUMT), needle ablation (TUNA), laser
– Embolization
– Simple prostatectomy, open or robot-assisted
DIAGNOSTIC CHECKLIST
Consider
• Prostate carcinoma or prostatitis
Image Interpretation Pearls
• Median lobe hyperplasia may simulate bladder mass
SELECTED REFERENCES
1. Trabulsi E, Halpern E, Gomella L. (2012). Ultrasonography and Biopsy of the
Prostate. In Campbell-Walsh Urology (10th ed., pp. 2735-2747). Philadelphia:
Saunders.
2. Roehrborn, C. (2012). Benign Prostatic Hyperplasia. In Wein AJ, et al (Ed),
Campbell-Walsh Urology (10th edition, pp 2570-2610). Philadelphia:
Saunders.