Granulomatous prostatitis

Clinical Notes : Urology

105. Granulomatous Prostatitis

Definition

Definition

Granulomatous prostatitis is a distinct clinical and pathological entity,

apparently a reaction to extravasated prostatic secretions into the surrounding tissues secondary to obstruction and infection within the prostate (1)

It is subclassified as (2) :

infectious granulomas
nonspecific granulomatous prostatitis
postbiopsy granulomas
systemic granulomatous prostatitis

Etiology (3):

Granulomatous prostatitis accounts for fewer than 1% of benign inflammatory conditions of the prostate.

Nonspecific granulomatous prostatitis accounts for most cases of granulomatous prostatitis - up to 70% (4)

Age range from 18 to 86 years; with mean and median age of 62 years.

Causative agents include :

infectious granulomas
- bacteria
  - Mycobacterium tuberculosis is the most common
    - may occur as a result of systemic/genitourinary tuberculosis or
    - more commonly, as a complication of bacillus Calmette-Guérin (BCG) immunotherapy for superficial bladder carcinoma
- fungi
  - Blastomycosis, coccidioidomycosis, and cryptococcosis are the most common
- parasites
- viruses
nonspecific granulomatous prostatitis
- blockage of prostatic ducts and stasis of secretions
postbiopsy granulomas
- reaction to cautery and thermal alterations to prostatic epithelium and stroma
systemic granulomatous prostatitis
- allergic granulomatous prostatitis
- sarcoidosis
- rheumatoid nodules
- Churg-Strauss syndrome
- Wegener granulomatosis

Presentation

In about 80% of the patients, there was a triad of

high fever followed by
symptoms of nonspecific prostatitis and
suggestion of a malignant prostate on rectal palpation.

Diagnosis

The prostate may feel hard and nodular on digital rectal examination, and cancer is usually suspected clinically.
The serum prostate-specific antigen (PSA) level may be elevated.
Hematuria and pyuria may be demonstrated on urine analysis.

Biopsy histopathology is required for final differentiation between granulomatous prostatitis and cancer.

Granulomas are localized collections of activated macrophages (epithelioid histiocytes), usually surrounded by a collar of lymphocytes.
The activated macrophages may fuse to form multinucleated giant cells.

Treatment

Treat symptomatically in the OOH setting, and refer to urologist for biopsy.

Empirical nonsurgical treatment will suffice in most cases if sufficient time is allowed for the inflammatory reaction to resolve.
This seldom requires more than three months