eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions
Prostatitis, Tuberculous: Treatment & Medication
Updated: Jun 26, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Once the diagnosis of tuberculous prostatitis is confirmed, the treatment is similar to that of other tuberculous infections. Tuberculous prostatitis must be viewed as a systemic disease, and the treatment is primarily medical. Hospitalization is usually unnecessary but may be required to treat noncompliant patients. Patients should be isolated in a negative-pressure room, if available. In addition, the local health department should be notified to aid in identifying patient contacts. Drug susceptibility testing should be performed on the isolates obtained from the prostate.
Surgical Care
Some urologists advocate resection of the prostate, although only medical therapy is usually needed. In patients with obstructive symptomatology, resecting the prostate is reasonable. In addition, in resistant tuberculosis (TB), prostate resection can theoretically lessen the infected tissue burden. Surgical treatment should be undertaken only once antituberculous therapy has been initiated to reduce the risk of exposure to the surgical team.
In persons infected with HIV, prostatic TB can present as an abscess. Surgical drainage of an abscess collection is required. Wolf (1996) and Moreno (1988) have described TRUS-guided needle drainage.7,8 Trauzzi et al (1994) successfully treated one such patient with transurethral unroofing of the collection.9 The surgeon should obtain intraoperative samples of any abscess fluid for AFB staining, culture, and PCR, if available.
Consultations
A consultation with an infectious disease specialist is indicated.
Activity
Advise patients to use condoms during intercourse. Sexual transmission of TB via infected semen has been reported to result in a vaginal tuberculous ulcer.
Medication
To prevent the emergence of resistant organisms, a multidrug regimen is the primary treatment. Resistance to primary antituberculous agents is increased in immigrants from Southeast Asia, China, the Indian subcontinent, and Central America. This has led to more complex empiric regimens. Compliance is difficult because of the length of therapy and the adverse effects; therefore, directly observed therapy is often recommended.
Isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and either ethambutol (EMB) or streptomycin (STP) should be the initial regimen. If the isolate is susceptible to INH and RIF, EMB or STP can be stopped and the 3-drug regimen of INH, RIF, and PZA can be continued for 8 weeks followed by 16 weeks of INH and RIF. Pyridoxine (vitamin B-6) at 25-50 mg/d should be considered in all patients to prevent neuropathy associated with INH use.
If INH resistance is documented, a 3-drug regimen of RIF, PZA, and either EMB or STP should be continued for at least 6 months. Multidrug-resistant tuberculosis (TB) has been isolated, and, if this is the case, patients should be referred to an expert in the treatment of TB disorders. In these cases, therapy usually consists of 3 drugs to which the organism is susceptible.
Initial therapy is similar to that used to treat pulmonary disease. Four drugs are used unless a drug resistance is improbable (eg, INH resistance in the community of <4%, no prior therapy for TB, no exposure to contacts with drug-resistant TB, patient is not from an area of increased resistance). Treatment is usually administered daily or, if a supervised regimen is used, twice weekly.
Successful treatment, documented with negative prostatic biopsy results upon follow-up following a triple-drug regimen of RIF, EMB, and INH for a duration of 6 months, has been reported.
In complicated cases, including recurrent genitourinary TB, prolonged therapy for a total of 9-12 months may be required.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Isoniazid (Laniazid)
Best combination of effectiveness, low cost, and minor adverse effects. First-line drug unless known resistance or another contraindication exists. Note that 50-70% of dose is excreted in urine in 24 h.
Adult
5 mg/kg/day PO; not to exceed 300 mg
Alternatively, 15 mg/kg PO 2 times/wk; not to exceed 900 mg
Pediatric
Not established
Higher incidence of INH-related hepatitis can occur with daily alcohol ingestion; aluminum salts may decrease INH serum levels (administer 1-2 h before taking aluminum salts); may increase anticoagulant effects with coadministration; may inhibit metabolic clearance of benzodiazepines; carbamazepine toxicity or INH hepatotoxicity may result from concurrent use (monitor carbamazepine concentrations and liver function); coadministration with cycloserine may increase CNS adverse effects (eg, dizziness); acute behavioral and coordination changes may occur with coadministration of disulfiram; coadministration with RIF after halothane anesthesia may result in hepatotoxicity and hepatic encephalopathy; may inhibit hepatic microsomal enzymes and increase toxicity of hydantoin
Documented hypersensitivity; previous INH-associated hepatic injury or other severe adverse reactions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor patients with active chronic liver disease or severe renal dysfunction; periodic ophthalmologic examinations during INH therapy are recommended, even when visual symptoms do not occur; peripheral neuropathy, especially in persons predisposed to neuritis (eg, persons who are malnourished, have alcoholism, or have diabetes); pyridoxine deficiency is sometimes observed
Rifampin (Rifadin, Rimactane)
For use in combination with at least 1 other antituberculous drug. Inhibits DNA-dependent bacterial, but not mammalian, RNA polymerase. Cross-resistance may occur. Treat for 6-9 mo or until 6 mo have elapsed from conversion to sputum culture negativity. Eliminated mostly through bile.
Adult
10 mg/kg/day PO/IV; not to exceed 600 mg/day
Pediatric
Not established
Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with INH may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFT results occur)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Obtain CBC counts and baseline clinical chemistries before and throughout therapy; in liver disease, weigh benefits against risk of further liver damage (monitor transaminases q4wk); interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur; doses >600 mg are not well tolerated; occasional GI, CNS, and cutaneous side effects occur; harmless orange discoloration of bodily secretions can occur
Pyrazinamide (Pyrazinamide)
Pyrazine analog of nicotinamide that may be bacteriostatic or bactericidal against M tuberculosis depending on concentration of drug attained at site of infection. Mechanism of action is unknown. Well absorbed from GI tract and hydrolyzed to active metabolite in liver. Note that 70% is excreted in urine within 24 h. Treat patients with drug-resistant disease with individualized regimens.
Adult
15-30 mg/kg/day PO; not to exceed 2 g
Alternatively, 50-70 mg/kg PO 2 times/wk; not to exceed 4 g
Pediatric
Not established
None reported
Documented hypersensitivity; severe hepatic damage; acute gout
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use only in combination with other effective antituberculous agents; inhibits renal excretion of urates; may result in hyperuricemia (usually asymptomatic); perform baseline serum uric acid determinations; discontinue drug if signs of hyperuricemia with acute gouty arthritis occur; perform baseline LFTs (closely monitor in liver disease); discontinue PZA if signs of hepatocellular damage appear; caution in history of diabetes mellitus
Ethambutol (Myambutol)
Diffuses into actively growing mycobacterial cells, such as tubercle bacilli. Impairs cell metabolism by inhibiting synthesis of 1 or more metabolites, in turn causing cell death. No cross-resistance is demonstrated.
Mycobacterial resistance is common with previous therapy. Use in patients who were previously treated in combination with second-line drugs that have not been previously administered.
Absorption is not altered significantly by food. Excreted in urine and feces.
Adult
15 mg/kg/day PO
Alternatively, 50 mg/kg PO 2 times/wk
Pediatric
Not established
Aluminum salts may delay and reduce absorption (administer several hours before or after EMB dose)
Documented hypersensitivity; optic neuritis (unless clinically indicated)
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Decreased color perception and/or decreased visual acuity; a monthly eye examination should be performed; reduce dose in impaired renal function
Streptomycin
Aminoglycoside that interferes with protein synthesis. For treatment of susceptible mycobacterial infections. Use in combination with other antituberculous drugs (eg, INH, EMB, RIF).
Recommended when less potentially hazardous therapeutic agents are ineffective or contraindicated. Excreted in urine.
Adult
15 mg/kg/day IM; not to exceed 1.5 g
Alternatively, 25-30 mg/kg IM 2 times/wk; not to exceed 1.5 g
Pediatric
Not established
Nephrotoxicity may be increased with aminoglycosides, cephalosporins, penicillins, amphotericin B, ethacrynic acid, furosemide, and mannitol
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index; not intended for long-term therapy; caution in patients with renal failure who are not on dialysis; caution with myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; vestibular ototoxicity, rash, fever, and urticaria may occur; baseline audiometric tests are advisable with extended therapy
More on Prostatitis, Tuberculous |
| Overview: Prostatitis, Tuberculous |
| Differential Diagnoses & Workup: Prostatitis, Tuberculous |
 Treatment & Medication: Prostatitis, Tuberculous |
| Follow-up: Prostatitis, Tuberculous |
| References |
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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
