Prostate

The prostate gland is part of the male reproductive system and is the largest male accessory gland. It typically weighs between 20-40 grams with an average size of 3 x 4 x 2 cm. The prostate is comprised of 70% glandular tissue and 30% fibromuscular or stromal tissue ^1-3 and provides ~30% of the volume of seminal fluid.

Gross anatomy

The prostate gland is an inverted pyramid that surrounds the proximal urethra, which traverses the prostate close to its anterior surface. The base of the prostate is in continuity with the bladder. It ends inferiorly at the apex at the urogenital diaphragm ^1-3.

The anterior surface forms the posterior wall of the retropubic space. The prostate is connected to the pubic bone by the puboprostatic ligaments ¹. Its inferolateral surface rests on the levator ani fascia ³. Its triangular and flat posterior surface is anterior to the rectum and has a vertical median groove. It is separated from the rectum by the rectovesical fascia (Denonvilliers’ fascia). This is palpable via a digital rectal exam (DRE).

The seminal vesicles are superior and posterior to the prostate gland. Their ejaculatory ducts pierce the posterior surface of the prostate below the bladder ^1-3.

The prostate is comprised of three distinct zones with different embryologic origins:

• peripheral zone
• central zone
• transition zone

The peripheral zone accounts for approximately 70% of the total prostate volume in a young adult. The peripheral zone surrounds the distal urethra at the apex of the prostate and extends posterolaterally to the base. The peripheral zone is deficient anteriorly. This area is filled by the anterior fibromuscular stroma. The central zone takes up 25% of the prostate volume and contains the ejaculatory ducts. The transition zone takes up the remaining 5%. It is predominantly anterolateral to proximal urethra ^2-4. Transition zone is occasionally written incorrectly as the transitional zone'.

The prostate gland lacks a true capsule and the so-called prostate capsule (often confusingly called the true capsule, especially in older texts) is a pseudocapsule formed from fibromuscular tissue surrounding 3 distinct layers of fascia; the anterior, lateral, and posterior fasciae. Anteriorly and apically this pseudocapsule is deficient. Laterally the fascia fuses with the levator fascia. The prostatic venous plexus (Santorini's plexus) lies between, and passes through, the pseudocapsule and fascia ^1-3,9-11.

Neurovascular bundles travel posterolaterally at 5 and 7 o'clock and give off branches into the prostate at the apex and base ⁵.

Relations

• anteriorly: pubic symphysis
• posteriorly: rectum
• superiorly: bladder
• inferiorly: urogenital membrane
• laterally: prostatic venous plexus and levator ani

Arterial supply

• prostatic branch of inferior vesical artery, a branch of the internal iliac artery
• sometimes supplied by the middle rectal arteries

Venous drainage

• prostatic venous plexus in communication with the pudendal plexus to the deep dorsal vein (to the internal iliac vein) with some communication to the Batson vertebral venous plexus ^2,3,5

Lymphatic drainage

• drainage mainly to obturator and internal iliac nodes
• some drainage to external iliac, presacral and para-aortic nodes ^1-4

Innervation

• parasympathetic (S2-S4) and sympathetic (L1-L2) pelvic nerve plexus

Radiographic features

Ultrasound

• best assessed with transrectal ultrasound
• some zonal anatomy distinguishable
• outer gland (central and peripheral zones) - uniform low echogenicity but usually more echogenic than the inner gland ^6,7
• 30cc is a commonly used upper limit for normal volume

CT

•  poor for assessment of prostate zonal anatomy and pathology
•  with adjusted window settings
  • central zone appears hyperdense between 40-60 HU
  • peripheral zone appears hypodense between 10-25 HU
  • useful for nodal and metastatic staging ^4,6,8

MRI

• preferred imaging modality
• T1: homogenous intermediate signal intensity
• T2
  • anterior fibromuscular stroma is low T1W and T2W signal
  • peripheral zone is high T2W signal, similar to or greater than adjacent fat
    • there are age-related decreases in T2W signal
  • central and transition zones are lower T2W signal than peripheral zone
  • "capsule" is a thin rim of low signal intensity
  • distal urethra is a low intensity ring ^4,5

Development

• central zone: Wolffian duct
• transition zone: urogenital sinus
• peripheral zone: urogenital sinus ³

Related pathology

• prostate calcification
• benign prostatic hypertrophy (BPH)
• prostate cancer
• prostatitis
• prostatic abscess
• emphysematous prostatitis
• prostate cystic disease
• prostate sarcoma
• prostatic utricle cyst