A 68-year-old male presented to outpatient department of surgery with history of increased frequency of micturition for 17 days associated with urinary dribbling, poor flow which didn't improve while straining, urgency and nocturia. The patient was a known case of Benign Enlargement of Prostate (BEP) and has been under medication with tamsulosin 0.4 mg HS (taken at bed time) and finasteride 5 mg OD (once daily) for last 2 years. There was no history of hematuria, fever, pain abdomen and difficulty breathing. The patient had no history of urethral instrumentation, surgical intervention, past history of tuberculosis among family members or any chronic illness in the past. On clinical examination, vitals were stable. Chest and abdominal examination findings were normal. Per rectal examination revealed a boggy swelling anteriorly, which was cystic in consistency along with massively enlarged prostate that was slightly tender was appreciated. Laboratory examinations were normal with increased level of prostate specific antigen (PSA) level of 5.64 ng/mL. Routine urine examination showed pus cells of 10-12/high power field (HPF). Foleys catheterization was done and patient was admitted. Transrectal ultrasonography being unavailable, transabdominal ultrasonography (USG) revealed massive enlargement of prostate with central avascular necrotic area showing moving internal echoes (Fig. 1A).
Urine culture showed growth of enterococcus species and Vancomycin with Cefoperazone-sulbactum was started in the view of prostatic abscess. Contrast Enhanced Computed Tomography (CECT) abdomen showed massively enlarged prostate measuring about 230 g with central liquefaction of approximately 101 mm3 along with significant adjacent inflammatory changes (Fig. 2A and B). Six days after admission when urine culture was sterile, transurethral drainage of the abscess was planned by the surgical team and prepared for surgery accordingly. Intraoperatively, bi-lobar enlargement of prostate along with high bladder neck was appreciated (Fig. 3A). The prostatic abscess could not easily be delineated whilst resection of the enlarged prostate was carried out. Meanwhile, intraoperative per-rectal manipulation of prostate visualized the pus point and puncture of the prostate was done into it along with gentle transrectal massage of the prostate which provided the counter force to expel the pus from the cavity (Fig. 3B and C). About 60 g of prostatic tissue was removed. Patient was catheterized again, put on intravenous antibiotics. Pus culture sensitivity was sterile. Sixth day post operatively, the patient was discharged for home-based care after removal of catheter on oral antibiotics with linezolid which was sensitive preoperatively for next 7 days. Histopathology examination of prostatic specimen showed well-formed epithelioid granulomas with caseation and Langhan's type of giant cell suggestive of necrotizing granulomatous prostatitis highly suggestive of prostatic tuberculosis (Fig. 4A and B).
Follow up examination after 2 weeks showed the urinary symptoms of the patient improving with no evidence of rectal-urethral fistula as evidenced by micturition cystourethrogram (MCUG) in view of unavailability of Magnetic Resonance Imaging (MRI). (Fig. 5) Repeat transabdominal USG showed 53.5 g of prostate (Fig. 1B). Mantoux tuberculin skin test was normal along with serum adenosine deaminase (ADA). Sputum acid fast bacilli (AFB) was negative. Patient was then started on category 1 antitubercular therapy with Isoniazid, Rifampicin, Pyrazinamide and Ethambutol (HRZE) in the view of extrapulmonary tuberculosis. No evidence of other primaries was found concluding tuberculosis to be prostatic primary. The second follow up after 2 months of initiation therapy of ATT was devoid of side effects and patient compliance was good.