1. Introduction
Tuberculosis remains a priority public health issue for the World Health Organization (WHO). It is a real public health problem in our country and all in developing countries. Globally, no country has ever been able to eradicate TB. Urogenital tuberculosis accounts for 30% - 40% of extra-pulmonary localisations [1]. Prostate involvement is still rare and is usually diagnosed by histopathological analysis of prostate resection or biopsy specimens [2]. Few studies have been found in the literature with 5 cases as the longest series. The aim of our study was to clarify the clinical, histological and therapeutic features of isolated prostatic tuberculosis in 13 cases diagnosed and treated in our department.
2. Patients and Methods
We conducted a single-centre retrospective descriptive study of all patients with prostatic tuberculosis managed in our institution: Urology department of Rabta Hospital, Tunis, Tunisia, between January 2002 and December 2020. To be included, patients should be at least 14 years old at the time of diagnosis. Patients who were lost to follow-up, could not be reached by telephone or whose records were not usable were excluded from this study. All data were collected from the clinical records using a standardised data collection form. This included data on the history, clinical examination, routine biological examinations, necessary radiological investigations, treatment modalities as well as the evolution. The clinical and para-clinical data were entered into an Excel table (Microsoft Excel® 2008). The means used for continuous variables and the percentage for qualitative variables were determined using the calculation functions of Excel® 2008.
3. Results
Two hundred and forty patients were treated for urogenital tuberculosis, including 13 for isolated prostatic tuberculosis. The average age of the patients was 75 years (57 - 86 years). None of our patients had a history of tuberculosis. The vaccination status of our patients was considered correct in all patients. The average of IPSS was 27. Lower urinary tract symptoms were present in all patients, with a predominance of irritative signs. The digital rectal examination was suspicious in only one patient with a nodular consistency. Renal and vesicoprostatic ultrasound revealed an enlarged prostate with significant post-void residual in 61.54% of cases (Figure 1).
The mean prostate size was 52 mL (40 - 80 mL). The mean preoperative PSA was 9.24 ng/mL (0.78 - 50 ng/mL). 6 patients (46.15%) underwent transurethral resection of the prostate for failure of medical treatment of benign prostatic hypertrophy and 7 (53.85%) underwent ultrasound-guided prostate biopsy for
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Figure 1. Homogeneous prostate hypertrophy with significant post-void residual.
suspected prostate cancer. The histological examination showed epithelioid gigantocellular granuloma with isolated caseous necrosis in 61.53% of patients and associated adenomyomatous hyperplasia in 38.47% of patients (Figure 2 and Figure 3).
All patients tested negative for Koch’s bacillus (BK) in urine and sputum. Intravenous urography (IVU), performed in all patients, found no evidence of urinary TB lesions. Antituberculosis treatment was indicated in all cases combining two major (rifampicin, isoniazid) and two minor(pyrazinamide and ethambutol) antituberculosis drugs taken once daily for 2 months, followed by a combination of two major antituberculosis drugs (rifampicin, isoniazid) for 4 months with good clinical and biological tolerance. (Table 1 summarises all patients.)
The average follow-up time was 15 months. All patients reported improvement in lower urinary tract signs. The mean postoperative IPSS s was 17. Three patients still had urinary urgency treated with anticholinergics with good clinical response. The PSA level normalized after 4 months of treatment.
4. Discussion
Urogenital tuberculosis accounts for 10% - 14% of all extra-pulmonary localisations of tuberculosis [3]. Isolated prostate tuberculosis is still rare. It was first described in 1882 by Jasmin [4]. The incidence of isolated prostatic localization has been estimated at 6.6% [3]. Primary prostatic involvement remains exceptional, particularly in immunocompetent subjects [5], and is often discovered incidentally following trans-urethral resection of the prostate or following prostate biopsies [6]. The routes of transmission are downward following an upper urinary tract infection, the haematogenous route, the lymphatic route and more rarely following endo-vesical instillation of Bacillus Calmette-Guerin or by sexual transmission [7]. Clinically, patients are often asymptomatic or present with a non-specific symptomatology consisting of urinary disorders during the filling or emptying phase. However, persistent haemospermia should alert the clinician [8]. In advanced cases, destruction of the prostatic parenchyma leads to a reduction
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Figure 2. Epithelioid and gigantocellular granuloma centred by caseous necrosis. (HE ×40).
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Figure 3. Granulomatous inflammatory changes in the prostatic parenchyma (HE ×10).
PSA: Prostate-specific antigen, AFB: Acid-fast bacilli, PTB: Prostatic Tuberculosis, LUTS: Lower urinary tract symptom, ATT: Antituberculosis treatment, NAD: Not associated with disease, IPSS: international prostate symptom score, RPM: post void residue, BPH: Benign Prostatic Hypertrophy.
in semen volume [9]. Perineal fistulisation may also be observed. On rectal examination the prostate is often firm or nodular [9]. The search for BK in urine and sputum with Ziehl-Neelsen staining can help in the diagnosis but their contribution remains low with a sensitivity of 52.7% [10]. Several molecular biology techniques on urine, based on PCR, are available with excellent sensitivity (95.59%) and specificity (98.12%), depending on the bacillary richness of the sample and the presence of amplification inhibitors (present in about 10% of samples) [10]. Diagnosis is confirmed by pathological examination of the resection shavings or prostate biopsy specimens. The lesion found is epithelioid and gigantocellular granuloma with or without central breakage necrosis. These lesions are not confined to the periductal area as can be seen in non-specific granulomatous prostatitis [7]. Endorectal ultrasound can show hypoechoic lesions or calcifications mainly in the peripheral part of the gland [10]. Computer tomography scan can also show these lesions more specifically. Magnetic resonance imaging is also helpful in the diagnosis, showing nodular or diffuse lesions mainly in the peripheral zone [11]. The first-line treatment is medical, identical to that for pulmonary tuberculosis. It consists of an initial four-drug regimen of isoniazid (4 - 5 mg/kg/d), rifampicin (10 mg/kg/d), ethambutol (15 - 20 mg/kg/d) and pyrazinamide (20 - 25 mg/kg/d) for two months, followed by dual therapy with rifampicin and isoniazid for four months [12]. Surgical treatment is only indicated for cases that do not respond to well-managed medical treatment [13]. It consists of removal of the lesions, with or without endoscopic or open drainage. Medical treatment usually results in a favourable outcome. Our study being retrospective and only based on the clinical records of the patients could taint the added value of the study.
5. Conclusion
Isolated prostatic tuberculosis is rare. It may simulate prostate cancer or be associated with benign prostatic hypertrophy. Histological examination is essential for diagnostic confirmation. The simple and classic anti-tuberculosis treatment is very effective. More than the treatment, it is the early diagnosis of the infection that remains to be improved. Clinicians must have a high index of suspicion of tuberculosis, in particular in patients with lower urinary tract symptoms from endemic zones.
Consent
Written informed consent was obtained from the patients for publication of this series and accompanying images.
Funding Source
This research did not receive any specific grant from funding agencies in the public, commercial, or not.
Registration of Research Studies
None.
Author Contribution for-Profit Sectors
All authors have contributed to this work and have read and approved the final version of the manuscript.