Classification and treatment of prostate cysts and stones, and early warning signs of prostate cancer.

(1) Etiology: Cystic changes in the prostate gland due to various congenital or acquired causes are called prostatic cysts. Prostatic cysts are relatively rare clinically, but with the development of medical science and the widespread use of urethrography, ultrasound, and CT scans, their detection rate has significantly increased. ① Congenital cysts: These occur in the mesonephric duct or the remnants of the paramesonephric duct system, and are paramesonephric duct cysts or prostatic cysts. Their tissues have a dual origin, including paramesonephric duct epithelium (squamous epithelium) and mesonephric duct epithelium (cuboidal and transitional epithelium). These cysts are mostly located above the prostate, behind the bladder, along the midline, and can be quite large. ② Acquired cysts: Acquired cysts refer to retention cysts. These cysts can be located anywhere within the prostate or protrude from the bladder neck, and are generally 1–2 cm in diameter. The cyst contents are clear mucus, which may be dark brown. The cyst may contain sperm. (1) Cysts are caused by the tough prostatic stroma leading to incomplete or intermittent obstruction of the acini, which gradually thins the acinar epithelium and eventually results in retention cysts. The cyst wall is covered by cuboidal or squamous epithelium. (2) Clinical manifestations: Prostatic cysts can occur at any age, but acquired ones are most common in young adults. Symptoms may include urinary frequency, urgency, difficulty urinating, thin urine stream, dribbling, significant residual urine, and even urinary retention. Hematuria is extremely rare. Congenital cysts may be accompanied by malformations such as hypospadias, cryptorchidism, and renal hypoplasia or agenesis. (3) Treatment: Larger cysts can be surgically removed via the retropubic or perineal approach, but sometimes complete removal is difficult. Some advocate for better exposure and complete removal via the sacral approach, but this is more invasive, and care should be taken to avoid damaging the adjacent seminal vesicles and ureters during the operation. Perineal or rectal aspiration of cysts is prone to infection and recurrence and is rarely used. If the cyst protrudes into the bladder, it can be removed via the bladder or by transurethral resection of the cyst top to allow for adequate drainage, or by vaporization and resection of the enlarged prostate along with the cyst.

Prostate stones can be divided into two types: true stones and false stones. The former refers to stones that occur in the prostate tissue or acini, while the latter refers to stones embedded in the prostatic urethral segment or existing in the abscess cavity communicating with the posterior urethra. The two should not be confused. True prostate stones are not uncommon in clinical practice, and mostly occur in elderly people over 50 years of age. They are usually accompanied by benign prostatic hyperplasia and prostatitis. (1) Etiology of prostate stones: Prostate infection is the primary cause of prostate stones. Diseases such as chronic prostatitis, gonorrhea, and prostatic diverticulum can cause obstruction of the glandular ducts and stagnation of secretions, resulting in stones. When the urethra is strict, the posterior pressure caused by the stricture causes the ducts and acini of the prostate to dilate and stagnate, which is also conducive to the formation of stones. Prostate stones can be located in any part of the gland, and can be scattered or clustered in one or both sides of the gland, or can be limited to a certain lobe. When combined with benign prostatic hyperplasia, the stones are located between the hyperplastic gland and the external cyst. Single stones are rare, and there are often many, even more than 1,000 stones. Generally, the diameter is less than 1 cm, but there are also reports of stones exceeding 4 cm or completely replacing the entire prostate tissue. The stones are round or oval, with a smooth surface, brown or black, and a few with scattered white or silvery-white inclusions. (2) Clinical manifestations: Most patients have no specific symptoms and are therefore often overlooked, only to be discovered during examinations for other diseases. Common coexisting diseases include benign prostatic hyperplasia, chronic prostatitis, and urethral stricture. Clinically, symptoms may include urinary frequency, urgency, dysuria, hematuria, difficulty urinating, dribbling, urinary retention, burning dysuria, or radiating pain in the lower back, perineum, and penis. Sexual dysfunction may also occur, such as erectile dysfunction, premature ejaculation, painful ejaculation, or hematospermia. The presence of stones will eventually aggravate the infection of the gland, and the symptoms will gradually worsen. Some cases develop into abscesses. If left untreated, they may rupture into the urethra, rectum, or perineum, or even above the pubic bone, forming a urinary fistula. (3) Treatment of prostatic calculi: Small prostatic calculi discovered incidentally without any clinical symptoms may not require treatment, as surgical removal is sometimes not easy. For patients with severe symptoms who require surgical treatment, the appropriate surgical method can be selected based on the number, size, and location of the calculi, the patient's age and overall condition, and any related complications. ① Transurethral resection of the prostate (TURP) and calculi removal. Calculi can often be removed by rinsing and aspirating the TURP sheath. This method is simple and minimally invasive, and is particularly suitable for young patients who need to preserve their sexual function and for elderly and frail patients with severe complications. In cases with benign prostatic hyperplasia, the prostate and calculi can be removed simultaneously. ② Perineal or retropubic prostatectomy for calculi removal. Since the cavity within the gland remains after removing the calculi alone, and calculi are prone to recurrence, it is advisable to remove the prostate and calculi together. If secondary infection is severe and acute urinary retention occurs, a suprapubic cystostomy should be performed first, and further treatment should be considered after the acute inflammation is controlled. ③ Total prostatectomy. Sometimes stones are located between the hyperplastic gland and the external cyst. Simple prostatectomy cannot remove all stones. In some cases, due to complications such as infection or fibrous tissue hyperplasia, the prostate gland and its surrounding tissue are tightly adhered and difficult to separate. In such cases, total prostatectomy excluding the seminal vesicle can be performed.

Prostate cancer is one of the most common malignant tumors in Europe and America, second only to lung cancer in incidence. Although the incidence and mortality rates of prostate cancer in my country are relatively low, with the improvement of people's living standards and increased fat intake, the incidence of prostate cancer in my country is also increasing, showing a significant upward trend. Prostate cancer is a common disease among elderly men, mostly occurring after the age of 60. According to relevant data analysis, the age of onset of prostate cancer is as follows: under 50 years old accounts for 1%, 50-59 years old accounts for 9%, 60-69 years old accounts for 32%, and 70-79 years old accounts for 43%. The anatomical relationship between the prostate and urethra is very special; the prostate is like a mountain, and the urethra is like a river flowing through it. If silt accumulates in the mountain, the flow of water in the river becomes obstructed. The main early symptoms of prostate cancer include: frequent urination, difficulty urinating, weak urine stream, prolonged urination, painful urination, and urinary retention. In addition, patients may also experience painless hematuria and painful ejaculation, which are also among the early signs of prostate cancer. Prostate cancer develops slowly, and if the cancer progresses to an advanced stage, treatment becomes more difficult. Patients may experience weight loss, fatigue, anemia, and even death. Therefore, early detection and treatment of prostate cancer are of paramount importance. The key to early detection of prostate cancer lies in regularly observing changes in one's health and undergoing regular health checkups. Men over 50 years of age, if able, should have a health checkup every six months to one year. In particular, if one experiences any abnormalities in urination, a timely medical examination is crucial. There are three methods for detecting prostate cancer: (1) Digital rectal examination, where a finger is inserted into the rectum through the anus to palpate the prostate for enlargement or signs of hardening. (2) Blood tests to check the prostate-specific antigen (PSA) level; this method can confirm whether the tumor is malignant. (3) Examination of the prostate fluid for cancer cell detection; if necessary, further prostate biopsy can be performed to obtain tissue for pathological examination. It is worth noting that prostate cancer symptoms are similar to those of prostatitis and benign prostatic hyperplasia (BPH), and careful differentiation is necessary. Both prostate cancer and prostatitis patients can feel hard nodules in the prostate. To clearly distinguish between them, a pathological examination is necessary, which can achieve an accuracy rate of up to 96%. The main difference between prostate cancer and benign prostatic hyperplasia (BPH) lies in their location: BPH occurs in the transitional zone surrounding the urethra, while prostate cancer occurs in the peripheral zone of the prostate.