Tuberculosis of the Prostate with Benign Prostatic Hyperplasia with Prostatitis – A Rare Presentation.
Genitourinary tuberculosis contributes to 10-14% of extrapulmonary tuberculosis and is a major health problem in India. Prostate
tuberculosis is uncommon and is usually found incidentally following transurethral resection. The most common mode of involvement is
haematogenous, though descending infection and direct intracanalicular extension is known. Predisposing factors include prior tubercular
infection, immunocompromised status, previous BCG therapy. Apart from histopathological examination which is confirmatory to
diagnosis, urine PCR with good sensitivity and specificity, may be quite helpful in the diagnosis. Imaging techniques like CT/MRI
also allow good visualization of the lesion and its extension. We report a case of a 35 year old male who presented with complaints of
difficulty in micturition. On digital rectal examination prostate was found to be enlarged with nodularity. TRUS biopsy showed diffuse
caseating epithelioid granulomas. Treatment was given in the form of chemotherapy regimen of 4 anti-tubercular drugs. This case has
emphasised the importance of considering prostatic tuberculosis in the differential diagnosis of carcinoma prostate, both of which may
have the same clinical presentation. With a high index of suspicion, it may be possible to diagnose a larger number of cases of prostatic
tuberculosis, especially in our country where tuberculosis is almost endemic.
Genitourinary, Granulomatous, Hyperplasia, Infection, Prostate, Tuberculosis
Tuberculosis is one of the major health problems with huge cost
implications in India. Genitourinary tuberculosis comprises 20.0%
of all extra pulmonary tuberculosis, with the prostate being involved
in 70.0% of all cases.1 Amazingly, primary prostatic tuberculosis in
the absence of demonstrable disease elsewhere is rare. An autopsy
incidence of primary prostatic tuberculosis is only 1.0%, although
the prostate is contiguous to the bladder and may be bathed in
mycobacteria infested urine for a long time.2 Involvement of the
prostate by tuberculosis occurs rarely and tuberculous prostate
abscess is an even rarer occurrence. The diagnosis of prostatic
tuberculosis can only be confirmed on histopathology. It has varied
presentations and can mimic malignancy.
A 35 year old male presented to the surgical out patients department
with few weeks history of increasing difficulty in micturition and
mild perineal pain. On examination, he was afebrile and the general
physical and abdominal examination was normal. On digital rectal
examination, his prostate was markedly enlarged, nodular, firm to
hard in consistency and mildly tender. His blood counts were normal
but his erythrocyte sedimentation rate (ESR) was raised at 55 mm
in one hour. On urinalysis pyuria and microscopic haematuria was
noted but urine culture was negative. Gram staining of urine did
not show any bacteria. Routine biochemistry was normal. Serum
PSA was 2.5ng/ml. Trans-abdominal ultrasonography showed
normal upper renal tract but his prostate was slightly enlarged with
irregular outline. Chest X-ray was normal. Intravenous urography
showed normal upper tracts.
Mantoux test was positive with intradermal tuberculin. Urine was
negative for acid fast bacilli (AFB) on three consecutive days.
HIV test was negative. At cystoscopy prostate was found to be
markedly enlarged and occlusive with epithelial erythema. Bladder
was mildly inflamed without any trabeculations. He was thought
to have some inflammatory prostatic disorder and TRUP biopsy of the hypoechoic mass was done. On Gross multiple, firm, white
tissue pieces aggregate measuring 0.5cm is seen. Microscopic
examination of the prostatic tissue showed granulomatous
infection with caseous necrosis compatible with tuberculosis. He
was started on anti-tubercular treatment consisting of 4 drugs for
2 months, followed by 2 drugs for 7 months. After 6 months of
follow up, the patient was well with no urinary symptoms.
Tuberculosis of the prostate is a rather rare condition. Cases
of tubercular prostatitis and abscess in relatively young or
middle age patient with HIV infection have been reported.3,4
Tuberculosis of prostate results from the haematogenous spread of
the microorganisms from the lungs or less often from the skeletal
system.5,6 It may also spread from direct invasion from the
urethra, but this route of infection has been questioned.7,8
Tuberculosis of the prostate is usually asymptomatic except in
rare cases when the disease spreads rapidly and cavitation may
lead to perineal sinus.7 Early tubercular lesions in prostate are
seldom detected on palpation, but when the disease is advanced,
enlargement occurs and fluctuant tender zones may be felt
bilaterally.8 The disease may perforate into the urethra and extend
into the urinary bladder.9 With still further spread, sinus track may
perforate into rectum, perineum and the peritoneal cavity.8
Advanced lesions that destroy tissue may cause a reduction in the
volume of semen, a sign that may help in the diagnosis.9 In the
present case, the patient had noticed reduction in the volume of
semen for 5 months, before presenting with difficulty in micturition.
Healing with calcification may supervene and large calcifications
in the prostate should suggest tuberculous involvement.10 In the
late stage, the prostate becomes shrunken, fibrotic and hard to the
point that it may simulate carcinoma on palpation.8,10
Microscopically the initial lesion is in the stroma but it quickly
spreads to the acini. Initial lesion show confluent foci of caseous
necrosis with epithelioid granulomas. Use of intravesical BCG
for bladder carcinoma may result in caseating or non caseating
tuberculous granulomas in prostate and may be located along the
periurethral or transition zone or involve the gland diffusely.11,12
Urinalysis and routine urine cultures are normal. Tuberculin test
is almost always positive in most of the cases.13 In the present
case report, mantoux test was positive with intradermal tuberculin.
Prostate specific antigen (PSA) may be normal or increased.13
In our case, both PSA and prostate acid phosphatase were within
Transrectal ultrasonography (TRUS) of the prostate may reveal
enlargement and hypoechoic areas in the prostatic tissue.9,10
Using transrectal ultrasonography, guided biopsies for histological
diagnosis can be taken and abscess drainage can be accomplished.10
Wang et al8 have demonstrated the clinical usefulness of contrast
enhanced CT for the diagnosis of tuberculosis of prostate, in which
low density multiple and bilateral lesions with irregular borders
are seen. Magnetic resonance imaging (MRI) for the diagnosis of
the tuberculous prostate has been described.8,9 MRI has certain
advantages over CT including better resolution and multiplanner
imaging capabilities. In prostatic tuberculosis, diffuse radiating
streaky low signal intensity lesions are seen in the prostate
(watermelon skin sign), which are quite different from MRI findings
of carcinoma of prostate.8,9 Although imaging examinations
may be helpful in the diagnosis, a definite diagnosis is made by
histologic examination of the prostatic biopsy specimen.
Two important points for the clinicians regarding tuberculosis
of prostate are firstly, viable organisms frequently persist long
after other parts of the genitourinary system have been sterilized
and secondly tuberculosis can be transmitted by means of
infected semen in such patients. 14,15 Sometimes the diagnosis
of the husband’s disease may be made only after the lesion has
appeared in the wife. A painful swelling of the inguinal glands
in female that proves to be tuberculous should alert the clinician
to the possible diagnosis of genital tract tuberculosis in the male
partner.15 Treatment of prostatic tuberculosis, once the diagnosis
is confirmed, is complete course of anti-tubercular drugs.9 Surgery
is usually reserved for cases where chemotherapy fails and is done
after 4-6 weeks of anti-tubercular therapy.
Although most cases of tuberculosis of prostate are diagnosed after
prostatectomy, but it can occur in healthy young males with no
respiratory symptoms or immune deficiency as a primary prostatic
tuberculosis.15,16 Prostatic tuberculosis has a varied clinical
presentation and is an important cause of granulomatous prostatitis
especially in developing countries.14,16 The presentation may
range from asymptomatic prostatic abscess (due to spread of
abdominal tuberculosis to genitourinary tract) or may be associated
with testicular swelling and rectal sinus in rare case.9,13 Probably
several cases of tuberculosis of prostate remains undiagnosed.
This condition must be considered in cases of tuberculosis of
genitourinary tract and appropriate investigations should be
carried out to diagnose it.
The differential diagnosis of tuberculosis of the prostate are
prostatic carcinoma, benign prostatic hyperplasia, malakoplakia
and pyelonephritis. Our patient was 35 years old. Prostatic cancer
was easily ruled out, as it is a disease of old age (above 50 years),
seen in peripheral zone of glands with high serum PSA level
(>10ng/ml) and show perineural and angio-lymphatic invasion,
with closely packed infiltrating small to medium sized crowded
glands with atypical glandular cells on microscopy. Benign
prostatic hyperplasia is seen in middle aged males of more than
40 years and is associated with obstructive symptoms of urination,
such as urgency, dribbling of urine, nocturia and dysuria and on
microscopy shows diffuse hyperplasia of glandular and stromal
elements. Our case had a foci of benign prostatic hyperplasia.
Malakoplakia is a nonspecific tissue reaction of the prostate gland
to gram negative bacteria, usually E coli. It is more common
after 45 years of age, easily diagnosed by von kossa stain and on
microscopy show michaelis gutmann body along with iron and
calcium deposition in tissue. Pyelonephritis can be ruled out easily,
as it shows dilated and distorted calyces and pelvis on IVP.
Tuberculosis of the prostate is relatively rare. Prostatic tubercular
lesions are most commonly secondary to a primary foci. A thorough
examination to rule out other primary sites should be attempted.
With the recent increase in the incidence of tuberculosis, clinicians
need to be aware of this possibility, consider tuberculosis of
prostate in the differential diagnosis of prostatic carcinoma and
thus, play a role in the early detection of this disease.
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