|Year : 2013 | Volume
| Issue : 1 | Page : 84-86
Primary prostatic tuberculosis: A rare entity
Sandeep Gupta, Somarendra Khumukcham, Bijit Lodh, Akoijam Kaku Singh
Department of Urology, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Web Publication||17-Aug-2013|
Department of Urology, Regional Institute of Medical Sciences, Imphal - 795 004, Manipur
Source of Support: None, Conflict of Interest: None
Genitourinary tuberculosis is caused by metastatic spread of the organism through the bloodstream during the initial infection. The kidney is usually the primary organ infected in urinary disease, and other parts of the urinary tract become involved by direct extension. Primary prostatic TB is a very rare form of presentation of the tuberculous infection, which is generally caused by the M. tuberculosis, and which has shown an increase in incidence and prevalence, due to an increase of immunocompromised patients and the pandemic of the Syndrome of Acquired Immune Deficiency. However, it can exceptionally be found as an isolated lesion in immunocompetent patients as in this case. Hence we wish to report an unusual case encountered and successfully managed in our department in which primary TB of the prostate produced obstructive urinary symptoms and eventually many months later, the patient presented with anuria and deranged renal function.
Keywords: Anuria, Primary prostatic tuberculosis, Ureteric stricture
|How to cite this article:|
Gupta S, Khumukcham S, Lodh B, Singh AK. Primary prostatic tuberculosis: A rare entity. J Med Soc 2013;27:84-6
| Introduction|| |
Genitourinary tuberculosis (TB) accounts for 30-40% of all extra-pulmonary TB, second only to lymph nodal affection. Primary prostatic lesion in the truest sense is probably very rare.  The prostate commitment by TB is the least frequent at genitourinary level, which can be developed more frequently secondary to primary pulmonary TB or more rarely by the settling product of the sexual transmission of the Mycobacterium., In cases where progression occurs, caseous destruction of prostatic tissue ensues; that may be significant enough to cause a noticeable reduction in semen volume. The lesions are often incidentally found on trans-urethral resection specimens. Densely fibrotic nodules may form and are indistinguishable from cancer. The possible routes of TB involvement of the prostate are: Descending infection from the urinary tract, lymphatic and hematogenous spread, direct extension from neighbouring organs, and rarely ascending infection through the urethra. It has been known to occur following intravesical Bacillus Calmette-Guérin therapy for bladder carcinoma.  The frequency of prostatic TB is not reflected in clinical practice as we have poor access to the organ as well as lack of awareness about this pathology.  The prevalence of prostatic TB is on the rise due to an increase of immunocompromised patients. However, it can exceptionally be found as an isolated lesion in immunocompetent patients as in this case. We wish to present this rare case of primary prostatic TB encountered in our department who later on presented with anuria.
| Case Report|| |
This 70 year old gentleman presented to us with chief complaints of lower urinary tract symptoms, especially nocturia since last few months, burning micturition on and off, and unexplained weight loss of around 10 kg in the last 3 months. He did not have any other complaints like fever and cough. He neither had any known co-morbid conditions, nor have any form of immunodeficiency. On digital rectal examination, it was a Grade 2, firm prostate with few hard areas. It was non-tender and non-nodular. Other systemic examination was essentially normal. Ultrasonography of the abdomen revealed a 66 g prostate without any malignant features. The post-void residue was insignificant. X-ray chest was also normal. Enzyme-linked immunosorbent assay test for HIV was negative. In view of the digital rectal examination findings, the total serum prostate-specific antigen was sent which came as 3.4 ng/mL.
His renal function test was within normal range and urinalysis showed pus cells 5-6/hpf and 7-10 erythrocytes/hpf.
With these physical and laboratory findings and in view of the big size of the prostate, retro pubic prostatectomy (Millins) was done and the excised tissue was sent for histopathological examination which revealed prostatic TB [Figure 1]. Patient was put on anti-tubercular therapy of the category 1 regimen for 6 months and the course was completed.
|Figure 1: Histopathological examination of excised prostatic tissue showing caseating granulomas and Langhan's' giant cells|
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After a few months, he presented again with anuria for the last 24 h and a deranged renal function test (serum creatinine-: 3.2%/mg). Bilateral double-J stenting was attempted but the left side stenting failed due to a stricture in the lower ureter. After normalizing his renal function, contrast-enhanced computer tomography-scan was done, which revealed left non-excreting kidney with gross hydronephrosis and thinned out cortex with stricture left lower ureter. Right kidney had a 10 mm lower calyceal calculus and a simple cortical cyst without any features of obstruction. Right ureter was normal [Figure 2].
|Figure 2: Contrast-enhanced computer tomography scan showing grossly hydronephrotic non-excreting left kidney|
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The patient was thoroughly investigated for any foci of TB anywhere in the body, including the genito-urinary tract but all the reports were negative. After a thorough work-up, the patient underwent left nephroureterectomy and the excised specimen was sent for histopathology. The report came suggestive of TB in the left lower ureter without any foci of TB in the excised kidney specimen. Hence, our diagnosis of primary prostatic TB became even more conclusive and the involvement of the left lower ureter was postulated to be due to direct extension from the prostatic foci. After consultation with the concerned specialities, the patient was again put on 4-drug anti-tubercular therapy. On follow-up, the patient is doing well. His right double-J stent was also removed after 3 months and his renal function is within normal limits.
| Discussion|| |
TB is one of the most common infectious diseases. It is estimated that one-third of the world's population are infected with M. TB. It causes nearly 1.6 million annual deaths, which places TB as the second cause of death for infectious diseases in the world, after AIDS.  Koch discovered M. TB in the year 1882. Meanwhile, he succeeded in transmitting the disease to other animals, which was found to be susceptible hosts. Kostakopoulos et al.,  in their study concluded that M. TB can be detected in prostatic fluid. They further stated that the prostate-specific antigen level may be normal or increased in such cases. Prostatic TB has mainly been described in immunocompromised patients.  It is thought that TB involvement of the prostate is usually the result of hematogenous spread, though it can also occur as a result of descent of the organism from the kidneys or from local spread from the genital tract.  Sexual transmission of M. TB has been reported, but it is extremely rare.  TB of the prostate is usually secondary to tuberculous infection of the upper urinary tract.  Primary prostatic TB without initial involvement of the upper urinary tract is very uncommon. However, involvement of the upper tract after prostatic involvement as in our case is possible by direct extension from a prostatic focus. Most of the patients are asymptomatic and are diagnosed incidentally as in this case. The prostate gland can become distorted and indurate because of fibrotic change.  Therefore, it is sometimes difficult to differentiate this entity from carcinoma of the prostate when the prostate is hard and nodular on digital rectal examination and the urine is negative for TB bacilli. , Recently, a new technique for a M. TB diagnosis of specimens from needle biopsies has been developed using polymerase chain reaction (PCR). However, PCR is not positive in all specimens. It depends upon not only the sensitivity and specificity of the technique but also upon the specimens.  The primary treatment for TB of the prostate is antituberculous drugs. Surgical excision is carried out when indicated or in cases with medical failure, but chemotherapy alone was found to be effective in our case.Most clinical specialists agree that a 6-9 months treatment with combination of triple antituberculous drugs is needed. However, it can recur even after successful completion of the course due to activation of any dormant foci. It should be borne in mind that tuberculous prostatitis is not the only inflammatory granulomatous disease that affects the prostate.  The presentation of prostatic TB usually presents with a good prognosis, however, cause significant morbidity in affected patients. The most frequently seen complication is the development of infertility due to the many obstructions in the ejaculatory duct. Another of the complications, but less frequent, is the prostatic abscess, which is more commonly seen in patients with conditions of immunosuppression. , As a concluding remark, we would like to state that whenever a patient comes with history of unexplained weight loss, vague constitutional symptoms and his urine shows sterile acidic pyuria, especially in this part of the world, he/she should be thoroughly evaluated for any evidence of TB. Primary prostatic TB with no history or evidence of compromise of the immune system is a disease which despite being uncommon, is of particular importance due to the progressive increase in its presentation and the possibility of a curative treatment to the affected patients.
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[Figure 1], [Figure 2]