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Tuberculous prostatitis
TUBERCULOUS MICHAEL
PROSTATITIS
J. O’DEA, M.D.
S. BREANNDAN LAURENCE
MOORE,
F. GREENE,
M.D. M.D.
From the Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT -A study of 5 patients with tuberculous prostatitis revealed that (1) there is a greater chance of striking a noncaseating granuloma than a caseating lesion by needle biopsy when both are present; (2) the absence of caseation on biopsy does not necessarily rule out tuberculosis; and (3) special stains may be negative for tuberculosis because of the small size of the tissue sample. Thus, if the clinical suspicion of tuberculous prostatitis is high and if noncaseating lesions are found, a second biopsy specimen should be taken for culture only.
From 1963 through 1972, 2,599 patients with prostatitis were seen at the Mayo Clinic. Only 5 of the patients had tuberculous prostatitis diagnosed. We reviewed our experience with these 5 patients, placing particular emphasis on the diagnosis. Findings The ages of the 5 patients ranged from thirtysix to sixty-five years (Table I). Chronic fatigue, fever, and loss of weight were common presentations. Two patients had flank tenderness, while 1 patient gave a history of gross hematuria and severe urgency of urination. In all 5 patients the prostate felt abnormal. In only 2 patients was tuberculous prostatitis suspected initially. Four patients had acid pyuria with positive smear or cultures (or both) for acid-fast bacilli. Only 2 patients had radiologic evidence of tuberculosis in the upper urinary tract. The diagnosis was made after transrectal needle biopsy of the prostate in 4 patients and after transurethral resection in 1 patient, when a previous transrectal needle biopsy had demonPresented at the meeting of the Southeastern Section of the American Urologic Association, New Orleans, March 27 to 31, 1977.
UROLOGY
/ MAY 1978 I
VOLUME
XI, NUMBER
5
strated nonspecific granuloma. This last patient also had a focus of grade 1 adenocarcinoma of the prostate. Four patients had the classic appearance of central caseous necrosis with surrounding palisades of chronic inflammatory cells and variable degrees of minimal fibrosis at the periphery. Four of the patients had noncaseating granulomas, and both noncaseating and caseating granulomas were seen in 3 of the 4. Two patients had the Nite blue stain positive for tuberculosis. In all 5 patients, the silver chromate stain for fungi such as cryptococci and blastomyces was negative. All of these findings permitted a satisfactory diagnosis of tuberculous prostatitis to be made. Treatment involved the use of three appropriate antituberculosis drugs for six months, with regular urine cultures being obtained and sensitivity tests being done, followed by a further twelve to eighteen months of a combination of two appropriate antituberculosis drugs. Two patients were followed up for three and eight years, and both responded satisfactorily and had annual negative urine cultures. Refractory tuberculous meningitis developed in 1 patient who did not respond to therapy and who subsequently died. The remaining 2 patients were lost to follow-up.
483
TABLE I. Clinical data on 5 patients with tuberculous prostatitis
Case
Age at Onset (Yr.)
1
36
2
59
3
52
4
56
5
65
Clinical
Presentation
Chronic fatigue, R. flank tenderness, urinary tract infection, nodule of Ft. lobe of prostate Fever, fatigue, L. flank tenderness, nodule of L. lobe of prostate Gross hematuria, large firm prostate Weight loss, back pain, hard L. lobe of prostate Weight loss, anorexia, fever, urinary urgency, irregular R. lobe of prostate
History
of Tuberculosis
Positive
PPD
Tuberculosis childhood
contact
in
Tuberculosis of R. hip, orchiectomy Ear tuberculosis No No
FIGURE 1. (A) Admixture of caseating (dark centers) and noncaseating prostatic granulomus. (B) Incidental microscopic focus of grade 1 adenocarcinoma in patient with tuberculous prostatitis; (hematoxylin and eosin, original mugnijcation x 64 for both A and B).
Comment The presence of systemic signs of tuberculous prostatitis in 4 of our patients was considered unusual because of the absence of active tuberculosis in other areas of the body. The
importance of obtaining an accurate past history is evidenced by the finding of previous contact or actual documentation of previous tuberculosis at other sites in 3 of our 5 patients. Acid pyuria should always lead one to suspect tuberculosis and should be pursued by
. 484
UROLOGY
/ MAY1978
I VOLUMEXI,
NUMBER5
Not surprisingly, 2 of further investigations. our patients had radiologic evidence of previous involvement of the upper urinary tract. It is important to note the frequent presence of noncaseating lesions with caseating lesions (Fig. 1A).Needle biopsy provides only a small core of prostatic tissue, and changes seen in a single biopsy specimen may not be representative of changes present but undetected elsewhere. Special stains for mycobacteria are notoriously unreliable for tissue diagnosis except in fairly recent, active lesions, and the absence of positive tissue stains for mycobacteria in no way rules out the diagnosis. In one of our patients the finding of a small focus of grade 1 adenocarcinoma probably was serendipitous (Fig. 1B). There is no welldocumented association between the two entities. Controversy exists concerning the pathogenesis of tuberculosis of the prostate. l-4 We are unable to add any data to this controversy. Although much has been written on the type and length of therapy, disagreement persists.5-8 However, we are impressed by the documentation of recurrences many years after
UROLOGY
/
MAY 1978
/
VOLUME
XI, NUMBER
5
therapy6sg and therefore term follow-up.
would
advocate
long-
200First Street, S.W. Rochester, Minnesota 55901 (DR. O’DEA) References 1. Winblad B: Male genital tuberculosis: the possibility of lymphatic spread; a case report, Acta Pathol. Microbial. Stand. [A] 83: 425 (1975). 2. Duchek M, and Winblad B: Experimental male genital tuberculosis, the possibility of lymphatic spread, Ural. Res. 1: 170 (1973). 3. IDEM: Spread of tuberculosis from the urinary bladder to the male genital organs: an experimental study, ibid. 1: 141 (1973). 4. Mazurek LJ: The importance of the urethro-seminal reflux in the pathogenesis of the genital tuberculosis in the male, Urologia 30: 220 (1963). 5. G’Boyle P, and Gow JG: Genitourinary tuberculosis: study of 20 patients, Br. Med. J. 1: 141 (1976). 6. Butler MR, and O’Flynn JD: Reactivation of genitourinary tuberculosis: a retrospective review of 838 cases, Eur. Urol. 1: 14 (1975). 7. Edwards CO: Follow-up in tuberculosis, Lancet 2: 1453 (1974). 8. Gow JG: Results of treatment in a large series of cases of genito-urinary tuberculosis and the changing pattern of the disease, Br. J. Urol. 42: 647 (1970). 9. Wechsler H: Recurrence of renal tuberculosis 29 years after therapy, J. Urol. 118: 102 (1977).
485
PROSTATITIS
J. O’DEA, M.D.
S. BREANNDAN LAURENCE
MOORE,
F. GREENE,
M.D. M.D.
From the Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT -A study of 5 patients with tuberculous prostatitis revealed that (1) there is a greater chance of striking a noncaseating granuloma than a caseating lesion by needle biopsy when both are present; (2) the absence of caseation on biopsy does not necessarily rule out tuberculosis; and (3) special stains may be negative for tuberculosis because of the small size of the tissue sample. Thus, if the clinical suspicion of tuberculous prostatitis is high and if noncaseating lesions are found, a second biopsy specimen should be taken for culture only.
From 1963 through 1972, 2,599 patients with prostatitis were seen at the Mayo Clinic. Only 5 of the patients had tuberculous prostatitis diagnosed. We reviewed our experience with these 5 patients, placing particular emphasis on the diagnosis. Findings The ages of the 5 patients ranged from thirtysix to sixty-five years (Table I). Chronic fatigue, fever, and loss of weight were common presentations. Two patients had flank tenderness, while 1 patient gave a history of gross hematuria and severe urgency of urination. In all 5 patients the prostate felt abnormal. In only 2 patients was tuberculous prostatitis suspected initially. Four patients had acid pyuria with positive smear or cultures (or both) for acid-fast bacilli. Only 2 patients had radiologic evidence of tuberculosis in the upper urinary tract. The diagnosis was made after transrectal needle biopsy of the prostate in 4 patients and after transurethral resection in 1 patient, when a previous transrectal needle biopsy had demonPresented at the meeting of the Southeastern Section of the American Urologic Association, New Orleans, March 27 to 31, 1977.
UROLOGY
/ MAY 1978 I
VOLUME
XI, NUMBER
5
strated nonspecific granuloma. This last patient also had a focus of grade 1 adenocarcinoma of the prostate. Four patients had the classic appearance of central caseous necrosis with surrounding palisades of chronic inflammatory cells and variable degrees of minimal fibrosis at the periphery. Four of the patients had noncaseating granulomas, and both noncaseating and caseating granulomas were seen in 3 of the 4. Two patients had the Nite blue stain positive for tuberculosis. In all 5 patients, the silver chromate stain for fungi such as cryptococci and blastomyces was negative. All of these findings permitted a satisfactory diagnosis of tuberculous prostatitis to be made. Treatment involved the use of three appropriate antituberculosis drugs for six months, with regular urine cultures being obtained and sensitivity tests being done, followed by a further twelve to eighteen months of a combination of two appropriate antituberculosis drugs. Two patients were followed up for three and eight years, and both responded satisfactorily and had annual negative urine cultures. Refractory tuberculous meningitis developed in 1 patient who did not respond to therapy and who subsequently died. The remaining 2 patients were lost to follow-up.
483
TABLE I. Clinical data on 5 patients with tuberculous prostatitis
Case
Age at Onset (Yr.)
1
36
2
59
3
52
4
56
5
65
Clinical
Presentation
Chronic fatigue, R. flank tenderness, urinary tract infection, nodule of Ft. lobe of prostate Fever, fatigue, L. flank tenderness, nodule of L. lobe of prostate Gross hematuria, large firm prostate Weight loss, back pain, hard L. lobe of prostate Weight loss, anorexia, fever, urinary urgency, irregular R. lobe of prostate
History
of Tuberculosis
Positive
PPD
Tuberculosis childhood
contact
in
Tuberculosis of R. hip, orchiectomy Ear tuberculosis No No
FIGURE 1. (A) Admixture of caseating (dark centers) and noncaseating prostatic granulomus. (B) Incidental microscopic focus of grade 1 adenocarcinoma in patient with tuberculous prostatitis; (hematoxylin and eosin, original mugnijcation x 64 for both A and B).
Comment The presence of systemic signs of tuberculous prostatitis in 4 of our patients was considered unusual because of the absence of active tuberculosis in other areas of the body. The
importance of obtaining an accurate past history is evidenced by the finding of previous contact or actual documentation of previous tuberculosis at other sites in 3 of our 5 patients. Acid pyuria should always lead one to suspect tuberculosis and should be pursued by
. 484
UROLOGY
/ MAY1978
I VOLUMEXI,
NUMBER5
Not surprisingly, 2 of further investigations. our patients had radiologic evidence of previous involvement of the upper urinary tract. It is important to note the frequent presence of noncaseating lesions with caseating lesions (Fig. 1A).Needle biopsy provides only a small core of prostatic tissue, and changes seen in a single biopsy specimen may not be representative of changes present but undetected elsewhere. Special stains for mycobacteria are notoriously unreliable for tissue diagnosis except in fairly recent, active lesions, and the absence of positive tissue stains for mycobacteria in no way rules out the diagnosis. In one of our patients the finding of a small focus of grade 1 adenocarcinoma probably was serendipitous (Fig. 1B). There is no welldocumented association between the two entities. Controversy exists concerning the pathogenesis of tuberculosis of the prostate. l-4 We are unable to add any data to this controversy. Although much has been written on the type and length of therapy, disagreement persists.5-8 However, we are impressed by the documentation of recurrences many years after
UROLOGY
/
MAY 1978
/
VOLUME
XI, NUMBER
5
therapy6sg and therefore term follow-up.
would
advocate
long-
200First Street, S.W. Rochester, Minnesota 55901 (DR. O’DEA) References 1. Winblad B: Male genital tuberculosis: the possibility of lymphatic spread; a case report, Acta Pathol. Microbial. Stand. [A] 83: 425 (1975). 2. Duchek M, and Winblad B: Experimental male genital tuberculosis, the possibility of lymphatic spread, Ural. Res. 1: 170 (1973). 3. IDEM: Spread of tuberculosis from the urinary bladder to the male genital organs: an experimental study, ibid. 1: 141 (1973). 4. Mazurek LJ: The importance of the urethro-seminal reflux in the pathogenesis of the genital tuberculosis in the male, Urologia 30: 220 (1963). 5. G’Boyle P, and Gow JG: Genitourinary tuberculosis: study of 20 patients, Br. Med. J. 1: 141 (1976). 6. Butler MR, and O’Flynn JD: Reactivation of genitourinary tuberculosis: a retrospective review of 838 cases, Eur. Urol. 1: 14 (1975). 7. Edwards CO: Follow-up in tuberculosis, Lancet 2: 1453 (1974). 8. Gow JG: Results of treatment in a large series of cases of genito-urinary tuberculosis and the changing pattern of the disease, Br. J. Urol. 42: 647 (1970). 9. Wechsler H: Recurrence of renal tuberculosis 29 years after therapy, J. Urol. 118: 102 (1977).
485