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Case profile: Prostatolithiasisprofile
CASE PROFILE: PROSTATOLITHIASIS
PROFILE
A forty-six-year-old man had a three-week history of intermittent fever, severe perineal pain, and urinary symptoms of dysuria, urgeney, and deereased stream. On admission to the hospital, his physical examination revealed severe phimosis with balanitis and an enlarged, tender, gritty prostate with areas of palpable induration. The perineum was edematous and indurated without fluetuanee. His temperature was 103°F; blood sugar was 340 mg/100 ml. Plain film of the pelvis revealed extensive prostatolithiasis (Fig. 1A). There was a large, ealeified stone in the right lateral prostatic lobe.
The patient underwent suprapubic cystotomy and drainage of a prostatoperineal abscess. Both urine and abscess cultures grew Proteus mirabilis and Candida albicans. During the postoperative period, diabetes mellitus was diagnosed and treated with insulin. A voiding eystourethrogram, performed in the oblique position, demonstrated an abscess cavity with peripheral ealeifieation (Fig. 1B). One month later, the patient underwent circumcision and transurethral resection of the prostate. Multiple prostatie calculi were removed endoscopieally via both the suprapubic
FIGURE l. (A) Plain film oJ pelvis shows extensive prostatolithiasis. (B) Voiding cystourethrogram (oblique view) shows abscess cavity with peripheral calcification. 318
UROLOGY / SEPTEMBER1983 / VOLUMEXXII,NUMBER3
and transurethral approach. Residual pus was seen to drain from the dilated prostatic duets. One week after resection, the eystotomy tube was removed, and the patient voided normally. Six months later, urine culture for fungus was negative, and routine eulture and sensitivity revealed less than 5,000 Proteus. E n d o g e n o u s prostatic calculi, o c e u r r i n g mostly in men of age fifty to sixty-five, develop in the acini, duets, and occasionally the stroma of the glandular prostatie tissue. They are most commonly found in the posterior lobe of the prostate, but their size, number, and position within the prostate vary considerably. However, they are rarely found within benign prosratio adenomas. Prostatic calculi usually are associated with chronic inflammation of the acini, and ductal dilatation occurs proximal to stones lodged in the prostatie ducts.l.2 These calculi often cause chronic, recurrent infection, and may be associated with such complications as prostatic and perineal abscess, prostatie induration and fibrosis, bladder outlet obstruction, and intermittent stone passage, a Prostatic calculi result from impregnation of corpora amylaeea, a mueoprotein matrix produet of normal prostatic secretions, with inorganic salts, most commonly calcium phosphate. Analysis of prostatic calculi reveals a eompaet n u c l e u s of c a l c i u m p h o s p h a t e , u s u a l l y whitloekite, surrounded by concentric rings of precipitated apatite and other compounds. These specific organic salts are found fre-
UROLOGY
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SEPTEMBER 1983
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quently in prostatic seeretions, and since they are more c o m m o n to prostatic than renal calculi, stone analysis gives a hint as to the site of stone formation. 4-~ The radiographic picture of prostatic calculi varies considerably with the size of the prostate and the presence of glandular hyperplasia. On physical examination, the prostate may be firm, nodular, and indurated, although usually mobile. Prostatic calculi usually ean be differentiated from tuberculous prostatitis which occurs in a younger age group, but full evaluation requires needle biopsy to exclude concomitant prostatic carcinoma. Robert A. Riehle, Jr., M.D. Department of Urology New York Hospital/Cornell Medical Center 525 E. 68th Street New York, New York 10021 References 1. Drach G: Urinary lithiasis, in Harrison JH, et al (Eds): Campbell's Urology, ed 4, chap 22, Philadelphia, W. B. Saunders Co, 1979. 2. MalekR: Caleulus disease of the genitourinary tract, inWitten DM, et al (Eds): Emmett's Clinical Urology, ed 4, Philadelphia, W. B. Saunders Co, 1977, p 1349. 3. Eykyn S: Prostatic calculi as a source of recurrent baeteriuria in the male, Br J Urol 46:527 (1974). 4. Huggins C, and Bear R: The course of the prostatic duets and the anatomy, chemical and x-ray diffraction analysis of prostatic calculi, J Urol 51:37 (1944). 5. Sutor D, and Wooley S: The crystalline composition of prostatie calculi, Br J Urol 46:533 (1974). 6. Ramirez C, et al: A crystallographic study of prostatic calculi, J Urol 124:840 (1980).
VOLUME XXII, NUMBER 3
319
PROFILE
A forty-six-year-old man had a three-week history of intermittent fever, severe perineal pain, and urinary symptoms of dysuria, urgeney, and deereased stream. On admission to the hospital, his physical examination revealed severe phimosis with balanitis and an enlarged, tender, gritty prostate with areas of palpable induration. The perineum was edematous and indurated without fluetuanee. His temperature was 103°F; blood sugar was 340 mg/100 ml. Plain film of the pelvis revealed extensive prostatolithiasis (Fig. 1A). There was a large, ealeified stone in the right lateral prostatic lobe.
The patient underwent suprapubic cystotomy and drainage of a prostatoperineal abscess. Both urine and abscess cultures grew Proteus mirabilis and Candida albicans. During the postoperative period, diabetes mellitus was diagnosed and treated with insulin. A voiding eystourethrogram, performed in the oblique position, demonstrated an abscess cavity with peripheral ealeifieation (Fig. 1B). One month later, the patient underwent circumcision and transurethral resection of the prostate. Multiple prostatie calculi were removed endoscopieally via both the suprapubic
FIGURE l. (A) Plain film oJ pelvis shows extensive prostatolithiasis. (B) Voiding cystourethrogram (oblique view) shows abscess cavity with peripheral calcification. 318
UROLOGY / SEPTEMBER1983 / VOLUMEXXII,NUMBER3
and transurethral approach. Residual pus was seen to drain from the dilated prostatic duets. One week after resection, the eystotomy tube was removed, and the patient voided normally. Six months later, urine culture for fungus was negative, and routine eulture and sensitivity revealed less than 5,000 Proteus. E n d o g e n o u s prostatic calculi, o c e u r r i n g mostly in men of age fifty to sixty-five, develop in the acini, duets, and occasionally the stroma of the glandular prostatie tissue. They are most commonly found in the posterior lobe of the prostate, but their size, number, and position within the prostate vary considerably. However, they are rarely found within benign prosratio adenomas. Prostatic calculi usually are associated with chronic inflammation of the acini, and ductal dilatation occurs proximal to stones lodged in the prostatie ducts.l.2 These calculi often cause chronic, recurrent infection, and may be associated with such complications as prostatic and perineal abscess, prostatie induration and fibrosis, bladder outlet obstruction, and intermittent stone passage, a Prostatic calculi result from impregnation of corpora amylaeea, a mueoprotein matrix produet of normal prostatic secretions, with inorganic salts, most commonly calcium phosphate. Analysis of prostatic calculi reveals a eompaet n u c l e u s of c a l c i u m p h o s p h a t e , u s u a l l y whitloekite, surrounded by concentric rings of precipitated apatite and other compounds. These specific organic salts are found fre-
UROLOGY
/
SEPTEMBER 1983
/
quently in prostatic seeretions, and since they are more c o m m o n to prostatic than renal calculi, stone analysis gives a hint as to the site of stone formation. 4-~ The radiographic picture of prostatic calculi varies considerably with the size of the prostate and the presence of glandular hyperplasia. On physical examination, the prostate may be firm, nodular, and indurated, although usually mobile. Prostatic calculi usually ean be differentiated from tuberculous prostatitis which occurs in a younger age group, but full evaluation requires needle biopsy to exclude concomitant prostatic carcinoma. Robert A. Riehle, Jr., M.D. Department of Urology New York Hospital/Cornell Medical Center 525 E. 68th Street New York, New York 10021 References 1. Drach G: Urinary lithiasis, in Harrison JH, et al (Eds): Campbell's Urology, ed 4, chap 22, Philadelphia, W. B. Saunders Co, 1979. 2. MalekR: Caleulus disease of the genitourinary tract, inWitten DM, et al (Eds): Emmett's Clinical Urology, ed 4, Philadelphia, W. B. Saunders Co, 1977, p 1349. 3. Eykyn S: Prostatic calculi as a source of recurrent baeteriuria in the male, Br J Urol 46:527 (1974). 4. Huggins C, and Bear R: The course of the prostatic duets and the anatomy, chemical and x-ray diffraction analysis of prostatic calculi, J Urol 51:37 (1944). 5. Sutor D, and Wooley S: The crystalline composition of prostatie calculi, Br J Urol 46:533 (1974). 6. Ramirez C, et al: A crystallographic study of prostatic calculi, J Urol 124:840 (1980).
VOLUME XXII, NUMBER 3
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