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Tuberculous Prostatic Urethritis: A Suggestive Diagnostic Sign
TUBERCULOUS PROSTATIC URETHRITIS: A S.UGGESTIVE DIAGNOSTIC SIGN JOHN KINGSLEY LATTIMER From the Department of Urology of the Kingsbridge Veterans Administration Hospital, Bronx, New York, and The Columbia University College of Physicians and Surgeons, New York, N. Y.
"\Vhen the prostate gland becomes tuberculous, certain well defined changes take place in the appearance of the prostatic urethra. These changes can be seen clearly with the usual indirect vision cystoscope during routine cystoscopy by merely withdrawing the instrument a short distance into the posterior urethra. Examination with a urethroscope is unnecessary. Early cases exhibit a beefy redness of the urethral epithelium with occasional superficial ulcerations. When infection has been present longer, however, pathological changes are greater and the floor of the urethra may be drawn into thick longitudinal folds with a dark-red, velvety surface.
Fm. 1. Prostatic urethra in chronic tuberculous prostatitis
Chronic cases, which are much more common, show the changes illustrated in figure l. Three principal features appear characteristic: 1) Dilatation of the prostatic urethra, just proximal to the verumontanum; 2) "golf-hole" dilatation of the prostatic ducts, on the floor of the urethra; 3) trabeculation of the prostatic urethra, with longitudinal ridges intertwining among the dilated prostatic ducts. 326
TUBERCULOUS PROSTATIC URETHRITIS
327
In some cases only one or two prostatic ducts are dilated. In other cases enlargement of the ducts may become so great as to suggest multiple diverticula of the urethra. The underlying disease is a scarring and contracture of the prostate in the area of the prostatic ducts, with subsequent shrinkage of the tissue around the infected, dilated ducts. Due to fibrous contraction there appears to be a pull on the ducts toward the fixed prostatic capsule. This leads to dilatation, "golfhole" formation and trabeculation of the prostatic urethra. The "golf-hole" prostatic ducts seem to be analagous in their formation to the "golf-hole" ureteral orifices seen with tuberculosis. They do not have the ragged margins which would be expected if they represented caseous cavities whose contents haq. liguefied and sloughed out. The changes in the prostatic urethra described above are not caused by tuberculosis exclusively. Other infections of sufficient intensity and chronicity may produce them. They are present with few exceptions, however, in patients with tuberculous prostatitis, and for this reason, whenever they are seen, tuberculosis should be suspected and demonstrated if possible, by guinea pig inoculation, smear and culture. These conditions have been found with considerable regularity in a large group of patients with proved tuberculosis of the genito-urinary tract, now under treatment with streptomycin in the Kingsbridge Veterans Hospital Research Project. Systematic cystoscopic studies of these patients have been most revealing, and in several instances unsuspected prostatic tuberculosis has been foµnd by following up this suggestive sign. SUMMARY
When the prostatic urethra is seen to be slightly dilated, with a trabeculated floor and "golf-hole" prostatic ducts, tuberculosis of the prostate gland should be suspected.
180 Fort Washington Ave., New York 32, N. Y.
"\Vhen the prostate gland becomes tuberculous, certain well defined changes take place in the appearance of the prostatic urethra. These changes can be seen clearly with the usual indirect vision cystoscope during routine cystoscopy by merely withdrawing the instrument a short distance into the posterior urethra. Examination with a urethroscope is unnecessary. Early cases exhibit a beefy redness of the urethral epithelium with occasional superficial ulcerations. When infection has been present longer, however, pathological changes are greater and the floor of the urethra may be drawn into thick longitudinal folds with a dark-red, velvety surface.
Fm. 1. Prostatic urethra in chronic tuberculous prostatitis
Chronic cases, which are much more common, show the changes illustrated in figure l. Three principal features appear characteristic: 1) Dilatation of the prostatic urethra, just proximal to the verumontanum; 2) "golf-hole" dilatation of the prostatic ducts, on the floor of the urethra; 3) trabeculation of the prostatic urethra, with longitudinal ridges intertwining among the dilated prostatic ducts. 326
TUBERCULOUS PROSTATIC URETHRITIS
327
In some cases only one or two prostatic ducts are dilated. In other cases enlargement of the ducts may become so great as to suggest multiple diverticula of the urethra. The underlying disease is a scarring and contracture of the prostate in the area of the prostatic ducts, with subsequent shrinkage of the tissue around the infected, dilated ducts. Due to fibrous contraction there appears to be a pull on the ducts toward the fixed prostatic capsule. This leads to dilatation, "golfhole" formation and trabeculation of the prostatic urethra. The "golf-hole" prostatic ducts seem to be analagous in their formation to the "golf-hole" ureteral orifices seen with tuberculosis. They do not have the ragged margins which would be expected if they represented caseous cavities whose contents haq. liguefied and sloughed out. The changes in the prostatic urethra described above are not caused by tuberculosis exclusively. Other infections of sufficient intensity and chronicity may produce them. They are present with few exceptions, however, in patients with tuberculous prostatitis, and for this reason, whenever they are seen, tuberculosis should be suspected and demonstrated if possible, by guinea pig inoculation, smear and culture. These conditions have been found with considerable regularity in a large group of patients with proved tuberculosis of the genito-urinary tract, now under treatment with streptomycin in the Kingsbridge Veterans Hospital Research Project. Systematic cystoscopic studies of these patients have been most revealing, and in several instances unsuspected prostatic tuberculosis has been foµnd by following up this suggestive sign. SUMMARY
When the prostatic urethra is seen to be slightly dilated, with a trabeculated floor and "golf-hole" prostatic ducts, tuberculosis of the prostate gland should be suspected.
180 Fort Washington Ave., New York 32, N. Y.