eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions
Prostatitis, Tuberculous
Updated: Jun 26, 2009
Introduction
Background
Tuberculosis (TB) has plagued humankind since antiquity. The effects of TB have been noted in skeletal remains from 4000 BC, and both Hippocrates and Galen described TB's clinical manifestations; however, prostatic TB was not described until the turn of the 20th century.
The most common site of TB infection is the pulmonary tract; however, the genitourinary tract is the most common extrapulmonary site of TB infection (33% of cases). Only 20% of TB prostatitis cases are accompanied by underlying pulmonary infection.1
Despite optimistic predictions on the eradication of TB in developed nations, the disease continues to pose a major worldwide health problem. In 2006, the World Health Organization reported that more than 2 billion people, roughly one third of the world’s population, are infected with TB and a reported 1.7 million deaths per year are due to TB. Developing nations continue to carry a burden of the disease (83% of total cases), with 9.6 million new cases of TB reported worldwide during 2006. To compound the problem, in both developing and industrialized nations, rates of active TB associated with HIV infection are increasing (8% of total), and the incidence of multidrug-resistant TB is also increasing, with a reported 0.5 million cases during 2006.2
Pathophysiology
The causative agent in tuberculous prostatitis is Mycobacterium tuberculosis, a strictly aerobic nonmotile bacterium. The bacterium grows slowly, dividing only once every 24 hours, and is capable of surviving within immune cells after phagocytosis. Generally, tuberculous prostatitis results from hematogenous dissemination of the mycobacteria from the site of the primary infection. Theories of descending spread via infected urine have been abandoned, largely in light of animal studies demonstrating hematogenous spread and the scarcity of prostatic urethral TB in association with prostatic parenchymal TB.
Frequency
United States
Large autopsy studies from the first half of the 20th century report a 10%-12% incidence of prostatic involvement in men with TB.
International
Direct data are lacking, although extrapolation of the US autopsy data suggests that 10%-12% of men with TB might have prostatic involvement. More recent small series suggest a lower rate of clinically detected prostatic TB.
Mortality/Morbidity
- Mortality directly attributable to prostatic TB has not been reported in the recent literature. A case report described 2 patients with HIV infection who died of disseminated TB during hospitalization. Unsuspected tuberculous prostatic abscesses were noted in both patients during the postmortem examination.
- Male factor infertility, which manifests as decreased ejaculate volume, oligospermia, azoospermia, and leukocytospermia, has been observed in association with tuberculous prostatitis. A perineal urinary fistula may result from tubercular cavern formation within or behind the prostate. Reports note perineal swelling, pain, and discharge preceding the development of the urinary fistula. Prostatic tuberculous abscess formation has been noted, particularly in men with AIDS.
Race
Contemporary studies have not addressed racial distributions of tuberculous prostatitis. Autopsy data published in 1949 evaluated prostatic TB in white and nonwhite patients. Of 169 nonwhite patients with TB, 18 (10.7%) had prostatic involvement during autopsy, compared with 50 of 660 (7.6%) white patients.
Sex
Prostatic TB affects only males.
Age
In 1937, Moore presented the age distribution of 243 cases of prostatic TB. Seventy-nine percent of patients were younger than 50 years. Moore describes this as "a disease of young adults."3 The recent literature is unable to offer as large a view of the age distribution.
Kostakopoulos et al (1998) presented 5 cases of unsuspected prostatic TB, all in patients aged 60-71 years.4 Although this starkly contrasts with Moore's earlier data, all 5 cases were incidental findings at the time of transurethral resection of the prostate (TURP), and they do not necessarily reflect the age at which the disease first developed.
Over the last 15 years, case reports of prostatic TB in immunocompetent men note patient ages of 26-85 years. Reported cases of prostatic TB in men with HIV infection document presentation in men aged 30-47 years. Most recently, Kulchavenya and Khomyakov reported on a series of 58 Siberian men with prostatic TB; their mean age was 49 years.5
Clinical
History
- The often-incidental finding of tuberculosis (TB) in TURP chips suggests that many men may not have symptoms attributable to prostatic TB.
- Nonspecific symptoms, including irritative voiding, may be the only complaints. Of men with prostatic TB, 50% have dysuria and 40% have perineal pain. Renal TB, which is a common comorbidity, may manifest as flank pain. Significant differential diagnostic overlap requires maintaining a high index of suspicion for prostatic TB, particularly in men with a history of exposure to or infection with TB.
- Patients may present with male factor infertility, a well-described complication of prostatic TB.
- Sterile urethral discharge and terminal hematuria may herald tuberculous prostatitis.
- Perineal pain, swelling, and drainage can account for a less common but more overt presentation. Perineal urinary fistula has been reported.
- The most dramatic presentations of prostatic TB may be those in men with AIDS. To date, 6 cases of tuberculous prostatic abscesses have been reported in men with HIV infection. Unlike the more insidious presentations noted in immunocompetent men, these patients presented with fever, perineal pain, and urinary hesitancy; 2 of the patients also presented with mental status changes.
Physical
- Most patients with prostatic TB in contemporary series have a prostate that may be hard, irregular, nodular, or granular.
- In patients with a prostatic tuberculous abscess, a soft fluctuant mass has been noted.
- Tenderness varies with the acuity of the process.
- Prostatic TB should be suspected in patients who have a draining perineal fistula.
Causes
- Prior infection with TB is the most important risk factor. Historically, 10%-12% of men with TB had pathologic evidence of prostatic involvement during autopsy.
- HIV infection increases the risk for active TB and has been suggested to increase the risk for reactivation of dormant foci.
- Prolonged steroid use and immunosuppressive therapy may increase the risk of reactivation of dormant foci.
- Case reports have described prostatic TB as a complication of intravesical bacillus Calmette-Guérin immunotherapy.6
More on Prostatitis, Tuberculous |
 Overview: Prostatitis, Tuberculous |
| Differential Diagnoses & Workup: Prostatitis, Tuberculous |
| Treatment & Medication: Prostatitis, Tuberculous |
| Follow-up: Prostatitis, Tuberculous |
| References |
| Next Page » |
References
Wise GJ, Shteynshlyuger A. An update on lower urinary tract tuberculosis. Curr Urol Rep. Jul 2008;9(4):305-13. [Medline].
Tuberculosis facts 2008. 2008. World Health Organization; 2008.
Moore R. Tuberculosis of the prostate gland. J Urol. 1937;37:372-384.
Kostakopoulos A, Economou G, Picramenos D, et al. Tuberculosis of the prostate. Int Urol Nephrol. 1998;30(2):153-7. [Medline].
Kulchavenya E, Khomyakov V. Male genital tuberculosis in Siberians. World J Urol. Feb 2006;24(1):74-8. [Medline].
Aust TR, Massey JA. Tubercular prostatic abscess as a complication of intravesical bacillus Calmette-Guérin immunotherapy. Int J Urol. Oct 2005;12(10):920-1. [Medline].
Wolf LE. Tuberculous abscess of the prostate in AIDS. Ann Intern Med. Jul 15 1996;125(2):156. [Medline].
Moreno S, Pacho E, Lopez-Herce JA, et al. Mycobacterium tuberculosis visceral abscesses in the acquired immunodeficiency syndrome (AIDS). Ann Intern Med. Sep 1 1988;109(5):437. [Medline].
Trauzzi SJ, Kay CJ, Kaufman DG, Lowe FC. Management of prostatic abscess in patients with human immunodeficiency syndrome. Urology. May 1994;43(5):629-33. [Medline].
Angulo JC, Ramirez JC, Esteban M, et al. Perineal fistulization of genital tuberculosis. J Urol. May 1999;161(5):1576-7. [Medline].
Cek M, Lenk S, Naber KG, Bishop MC, Johansen TE, Botto H. EAU guidelines for the management of genitourinary tuberculosis. Eur Urol. Sep 2005;48(3):353-62. [Medline].
Fujikawa K, Matsui Y, Fukuzawa S, et al. A case of tuberculosis of the prostate. Scand J Urol Nephrol. Aug 1999;33(4):268-9. [Medline].
Gonzalez Tuero J, Alonso de la Campa J, Perez Lacort L, et al. Granulomatous prostatitis. Urol Int. 1988;43(2):97-101. [Medline].
Gow JG. Genitourinary tuberculosis. In: Walsh PC, Retik AB, Stamey TA, Vaughan ED, eds. Campbell's Urology. 1998. 7th ed. Philadelphia, Pa: WB Saunders; 1998:807-836.
Hemal AK, Aron M, Nair M, Wadhwa SN. 'Autoprostatectomy': an unusual manifestation in genitourinary tuberculosis. Br J Urol. Jul 1998;82(1):140-1. [Medline].
Kochi A. The global tuberculosis situation and the new control strategy of the World Health Organization. Tubercle. Mar 1991;72(1):1-6. [Medline].
Lanjewar DN, Maheshwari MB. Prostatic tuberculosis and AIDS. Natl Med J India. Jul-Aug 1994;7(4):166-7. [Medline].
Lee Y, Huang W, Huang J, et al. Efficacy of chemotherapy for prostatic tuberculosis-a clinical and histologic follow-up study. Urology. May 2001;57(5):872-7. [Medline].
Lubbe J, Ruef C, Spirig W, et al. Infertility as the first symptom of male genitourinary tuberculosis. Urol Int. 1996;56(3):204-6. [Medline].
Medical Economics Staff. Physicians' Desk Reference. 55th ed. Montvale, NJ: Medical Economics Co; 2001.
Medlar EM, Spain DM, Holliday RW. Post-mortem compared with clinical diagnosis of genito-urinary tuberculosis in adult males. J Urol. 1949;61:6.
Moussa OM, Eraky I, El-Far MA, et al. Rapid diagnosis of genitourinary tuberculosis by polymerase chain reaction and non-radioactive DNA hybridization. J Urol. Aug 2000;164(2):584-8. [Medline].
Mundy LM, L'Ecuyer PB. Treatment of infectious diseases. In: The Washington Manual of Medical Therapeutics. 29th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1998:279-81.
Orakwe JC, Okafor PI. Genitourinary tuberculosis in Nigeria; a review of thirty-one cases. Niger J Clin Pract. Dec 2005;8(2):69-73. [Medline].
Saw KC, Hartfall WG, Rowe RC. Tuberculous prostatitis: nodularity may simulate malignancy. Br J Urol. Aug 1993;72(2):249. [Medline].
Selwyn PA, Hartel D, Lewis VA, et al. A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection. N Engl J Med. Mar 2 1989;320(9):545-50. [Medline].
Sporer A, Auerbach O. Tuberculosis of prostate. Urology. Apr 1978;11(4):362-5. [Medline].
Tanagho EA. Specific infections of the genitourinary tract. In: Tanagho EA, McAnich JW, eds. Smith's General Urology. 15th ed. New York, NY: McGraw-Hill Professional Publishing; 2000:265-81.
Veenema RJ, Lattimer JK. Genital tuberculosis in the male: clinical pathology and effect on fertility. J Urol. Jul 1957;78(1):65-77. [Medline].
Wang LJ, Wong YC, Chen CJ, Lim KE. CT features of genitourinary tuberculosis. J Comput Assist Tomogr. Mar-Apr 1997;21(2):254-8. [Medline].
Further Reading
Keywords
tuberculous prostatitis, tuberculosis, TB, prostatic TB, prostatic tuberculosis, consumption, phthisis, Mycobacterium tuberculosis, M tuberculosis, prostatic urethral tuberculosis, prostatic urethral TB, prostatic parenchymal tuberculosis, prostatic parenchymal TB, tuberculous prostatic abscess, genitourinary tuberculosis, GU tuberculosis, genitourinary TB
