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Granulomatous prostatitis: A reminder to clinicians

Authors:
Shanggar Kuppusamy at University of Malaya
Shanggar Kuppusamy
M Z Zulkifli
M Z Zulkifli
M Z Zulkifli
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Azad Hassan Razack at University of Malaya
Azad Hassan Razack
Norman Dublin at University of Malaya
Norman Dublin
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Abstract

Granulomatous Prostatitis (GnP) is a heterogenous entity classified into specific infections, non-specific infections, post surgical i.e. post-transurethral resection of prostate (TURP) and rare secondary (systemic) causes. A total of 1388 reports of prostatic biopsy and prostatic chips from TURP were reviewed from 1995 and 2007. The results which showed granulomatous prostatitis were analyzed and retrospective data collected from the patient's records. A total of 9 cases with granulomatous prostatitis were identified. There are 3 types of entities which are the non-specific (NSGnP), post-TURP and the specific type. The incidence of GnP in our center is lower than reported by Stillwell et al. The majority of the patients were Malays.
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Med J Malaysia Vol 65 No 1 March 2010 21
SUMMARY
Granulomatous Prostatitis (GnP) is a heterogenous entity
classified into specific infections, non-specific infections, post
surgical i.e. post-transurethral resection of prostate (TURP)
and rare secondary (systemic) causes. A total of 1388 reports
of prostatic biopsy and prostatic chips from TURP were
reviewed from 1995 and 2007. The results which showed
granulomatous prostatitis were analyzed and retrospective
data collected from the patient’s records. A total of 9 cases
with granulomatous prostatitis were identified. There are 3
types of entities which are the non-specific (NSGnP), post-
TURP and the specific type. The incidence of GnP in our
center is lower than reported by Stillwell
et al
2. The majority
of the patients were Malays.
KEY WORDS:
Granulomatous Prostatitis, Non-specific infection, Specific
infection, Post-TURP
INTRODUCTION
Granulomatous Prostatitis (GnP) is a heterogenous entity
encompassing lesions attributed to specific infections, non-
specific infections, post surgical (i.e. post-transurethral
resection) and rare secondary (systemic) causes1,2 which is
based on the classification system proposed by Epstein and
Hutchins that is widely accepted and generally used1.
Infective causes include BCG instillation for superficial
transitional cell carcinoma of the bladder and less frequently
Mycobacterium tuberculosis infection, various fungi and
other organisms. Post-surgical GnP is usually the result of
transurethral resection of the prostate. Rare secondary causes
include Wegener’s granulomatosis and an allergic reaction
associated with asthma. NSGnP may be clinically and
histologically mistaken for prostate adenocarcinoma3,
occasionally leading to surgical overtreatment. In the data
reported by Stillwell2the incidence of GnP consisted of 69%
NSGnP, 24.5% post-TURP GnP, 3.5% infective (IGnP), and 3%
systemic GnP. The present study was undertaken to look at
the incidence of GnP and its characteristics in our center.
MATERIALS AND METHODS
All data from prostatic biopsy between 1995 and 2007 at our
center were reviewed. A total of 1388 reports of prostate
biopsy and prostatic chips were reviewed. All
histopathological results showing granulomatous prostatitis
were analyzed and retrospective data collected from the
patient’s records. Those who were found to have
granulomatous prostatitis were further subdivided into
Epstein and Hutchin’s classification i.e. specific, non-specific,
post-TURP and allergic granulomatous prostatitis. The
selected patients data were studied and analyzed according to
their age, race, documented urine culture and underlying
medical illnesses as well as any previous TURP surgery
documented.
RESULTS
There were 9 cases with granulomatous prostatitis aged from
16 to 79 years (mean 59.5 years). This constitutes 0.65% from
the total of 1388 cases of prostatic biopsy. Four (4) out of 9
cases were Malays (44%), three (3) were Chinese (30%) and
two (2) more were Indians (22%). The diagnosis were
obtained from TURP specimens in 66.7% (n=6) cases, from
transrectal ultrasound (TRUS) biopsy in 22.2% (n=2) and
11.1% (n=1) from Trucut biopsy of the prostate. NSGnP was
noted in 55.6% (n=5) whereas 22.2% (n=2) post-TURP GnP
and another 22.2% (n=2) had a specific infection causing
GnP. The two patients with spesific granulomatous prostatitis
had coexisting pulmonary tuberculosis, while those with
NSGnP had documented urinary tract infection. None of the
patients were noted to have allergic type of GnP.
DISCUSSION
The pathogenesis of GnP remains unknown but extravasation
of prostatic secretions due to inflammation (i.e. from
infection, surgical diathermy or tissue necrosis), and blockage
and rupture of prostatic ducts appear to be important factors
in the development of granulomas. These processes can
occur in normal, carcinomatous or most commonly in a
nodular hyperplastic prostate gland4. The distribution is
generally periglandular with some glandular destruction5. It
is reported in most cases that the cause of GnP is unknown5,
but GnP can occur after various events, e.g. UTI (73%)2,
TURP/open prostatectomy6, needle biopsy and instillation of
BCG into the bladder7. From our study, we have found that
the incidence of GnP in our center is lower than reported by
Stillwell et al2, (which calculated a 0.8% incidence of GnP in
a series of needle biopsies and transurethral resection). Our
series showed only an incidence of 0.65%. Majority of our
patients with GnP were Malays followed by Chinese and
Indians.
Our study also revealed that the non-specific granulomatous
prostatitis (NSGnP) is the most common granulomatous
lesions of the prostate, followed by the post-TURP type and
specific GnP type. None of the patients in our series had an
allergic GnP. NSGnP is usually reported as an incidental
finding, with an incidence of 3.4% in an unselected series of
patients8; it is detected in 0.44% of routine prostatectomy
Granulomatous Prostatitis: A Reminder to Clinicians
K Shanggar, FRCS Urol, M Z Zulkifli, MBBS, A H Razack, FRCS, N Dublin, FRCS Urol
Fakulti Perubatan, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
ORIGINAL ARTICLE
This article was accepted: 27 February 2010
Corresponding Author: Shanggar Kuppusamy, Lecturer in Surgery, Fakulti Perubatan, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
Email: drshanggar@um.edu.my
001519 NV-6-GRANULOMATOUS:3-PRIMARY.qxd 4/12/10 1:28 PM Page 21
Original Article
22 Med J Malaysia Vol 65 No 1 March 2010
specimens6and in 0.29%6to 3.3%12 of needle prostate
biopsies. It has been hypothesized that this can result from a
foreign body response to a colloidal substance, bacterial
products or refluxed urine3,10. It can also be a result of an
immunologic response to extraductal prostatic secretions9,11
arising from ducts obstructed by hypertrophy or
inflammation. The distinction of NSGnP from specific forms
of GnP is important because of the former’s benign and
resolving clinical course3.
Specific GnP generally occurs in 1.3% of patients after
intravesical BCG treatment13. It was reported that
Mycobacterial prostatitis is more common in patients with
BCG immunotherapy for superficial bladder carcinoma. The
incidence of prostatic involvement in systemic tuberculosis
ranges from 3% to 12%. In over 90% of these cases, there is
coexisting pulmonary tuberculosis. In patients with
urogenital tuberculosis, the prostate is involved in 75-95% of
the cases14,15. However, in only 7-13% of cases of urogenital
tuberculosis is the prostate the sole organ involved. Most
cases of tuberculous prostatitis appear to arise from
haematogenous dissemination rather than contact with
infected urine. In our study, the patients with tuberculous
prostatitis were found to have coexisting pulmonary TB. The
two patients in this group were diagnosed to have GnP at a
young age. However, our series revealed that none of the
patients had intravesical BCG treatment.
Prostatic granulomas are frequently a sequelae after a
transurethral resection1,16. Our study showed that two
patients (22.2%) had GnP post-transurethral resection/post-
biopsy which is slightly lower than reported by Stillwell et al.
It is noted that the interval between post-transurethral
resection granuloma formation ranges from 9 days to 52
months. Although it is much more common to have a
granulomatous reaction following transurethral resection,
similar linear granulomas may occasionally develop following
needle biopsy.
Eventhough carcinoma co-exist in 10-14% of patient with
clinically diagnosed GnP17,18, we did not find any record
reporting this. This may be due to the pathologists awareness
in usage of special staining technique for clarification. GnP
can also cause a significant but transient increase in serum
Prostate Specific Antigen (PSA) levels19. The correlation of
granulomatous prostatitis with PSA levels could not be
analyzed in our study as PSA level testing was not carried out
in most of the cases.
CONCLUSION
The incidence of GnP in our center is lower than reported in
literature but still is an entity to be considered when dealing
with prostatic diseases. The majority of our patients were
Malay. Non-specific granulomatous prostatitis (NSGnP) is the
most common granulomatous lesions of the prostate,
followed by the post-TURP type and specific granulomatous
prostatitis type.
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prostatitis; a report of 200 cases. J Urol. 1987, 138: 320-23.
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001519 NV-6-GRANULOMATOUS:3-PRIMARY.qxd 4/12/10 1:28 PM Page 22
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Background: Granulomatous prostatitis is an uncommon entity that is diagnosed incidentally on histopathology and is broadly classified as nonspecific, specific, postsurgical (post-transurethral resection), or secondary to other rare systemic granulomatous diseases. Only very few studies are available in the literature that describe the clinical and histomorphological spectrum of the disease. Methods: A retrospective analysis of histopathological records of 1,181 prostatic specimens received in the pathology department was done over a period of 13 years (January 2003 to January 2016). All histologically proven cases of granulomatous prostatitis were retrieved, and relevant clinical data were collected from patients’ records. Epstein and Hutchins classification was used to categorize these cases. Results: Twenty-two cases of granulomatous prostatitis were identified, accounting for an incidence of 1.86%. Among these, nonspecific granulomatous prostatitis (n=10) was the most common followed by tubercular prostatitis (n=5), posttransurethral resection of the prostate (n=3), allergic (n=2), and xanthogranulomatous prostatitis (n=2). The age range of these patients was between 41 and 75 years, with the majority of patients in their 7th decade. Serum prostate-specific antigen levels ranged between 0.88 ng/mL and 19.22 ng/mL. Hard and fixed nodules were observed on digital rectal examination in 14 cases. Transrectal ultrasound revealed hypoechoic shadows in five cases. Conclusion: Despite present-day advances in imaging modalities and serological investigations, it is virtually impossible to identify granulomatous prostatitis clinically. Histopathology remains the gold standard in diagnosing the disease. However, assigning an etiologic cause to the wide spectrum of granulomas in granulomatous prostatitis requires a pathologist’s expertise and proper clinical correlation for appropriate patient management.
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We have reassessed the fine-needle aspirates of ten cases previously diagnosed as granulomatous prostatitis (GP). Presence of unequivocal epithelioid granulomas (EG) or typical caseous necrosis was required for a smear to be diagnosed as nonspecific granulomatous prostatitis (NGP) or tuberculous prostatitis (TP), respectively. As a consequence only six cases met the criteria set up for the diagnosis of NGP and two for TP. The purpose of this revision was fourfold: to find out if there are other prostatic conditions which may be confused with GP cytologically, to investigate if there is a single cytologic finding that permits a confident diagnosis of GP, to find out if the etiology can be suggested on cytologic grounds alone, and, finally, to assess if carcinoma can be ruled out safely. We conclude the following: 1) There are various prostatic conditions which share some cytologic findings with GP; 2) the presence of distinct EG is the hallmark criterion of GP; 3) NGP and TP can be safely diagnosed cytologically but other forms of GP would require additional clinical data and ancillary techniques; and 4) carcinoma can be safely distinguished from GP cytologically. To succeed in this task the cytopathologist must diagnose carcinoma only if clear-cut carcinoma cells are present and must be aware of the reactive changes induced by the inflammatory infiltrate both in duct/acinar and metaplastic cells.
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The fine needle aspiration (FNA) cytologic findings are presented for 18 cases of granulomatous prostatitis (12 nonspecific, 5 tuberculous and 1 eosinophilic cases). These cases represented 19% of all prostatitis cases and 2% of all prostatic aspirates examined from January 1986 to December 1987. The cytomorphologic differences between the three types of granulomatous prostatitis are described, with emphasis on the differentiation between the nonspecific and specific varieties. The differential diagnostic features between reactive changes and well-differentiated adenocarcinomas of the prostate are also presented. The findings in these cases indicate that FNA cytology is a reliable procedure for the morphologic diagnosis of granulomatous prostatitis, which can clinically mimic prostatic carcinoma when it presents as a diffuse or nodular enlargement with increased consistency.
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Nonspecific granulomatous prostatitis. Histopathological study of 53 cases with a review of the literature
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[Non-specific granulomatous prostatitis]
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  • Feb 1989
  • Ugeskr Laeger
Non-specific granulomatous prostatitis (NGP) is histologically defined and reported with an incidence below 3.4% in unselected series of patients. A survey of the literature concerning NGP is given on the basis of a retrospective investigation of 14 case-histories. Microscopically, NGP is characterized by focal or diffuse occurrence of granulomas in the prostate. The etiological significance has been attributed to acute non-specific prostatitis and local hypersensitivity and/or simple foreign-body reactions are considered to be pathogenetic factors. The mean age of patients suffering from NGP is stated to be 54-65 years. Clinically, NGP is poorly defined. Complaints of cystitis/urethritis within the last month and subsequently rapid development or aggravation of urinary obstruction are frequently reported on admission. On digital rectal examination the gland is enlarged, and carcinoma is often suspected. Fine-needle aspiration biopsy may be of some guidance. However, the diagnosis is settled postoperatively by histologic investigation, where prostatic cancer, iatrogenic granulomas and specific granulomatous inflammations must be considered as differential diagnoses. Irrespective the choice of treatment, conservative or surgery, the prognosis of NGP is excellent.
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The Clinical Spectrum of Granulomatous Prostatitis: A Report of 200 Cases
Article
  • Sep 1987
Granulomatous prostatitis, reviewed in 200 tissue-diagnosed cases, occurred in 0.8 per cent of the benign inflammatory prostatic specimens. Often the disease followed a recent urinary tract infection (71 per cent) and was suspicious clinically for prostatic cancer (59 per cent). The diagnosis usually was made by needle biopsy or at transurethral prostatectomy (94 per cent). Most cases of granulomatous prostatitis were classified as nonspecific. The recently identified entity of post-transurethral resection granulomatous prostatitis was found in 49 patients. A proposed new category of granulomatous prostatitis that is secondary to systemic granulomatous diseases was documented in 6 patients. Most cases of granulomatous prostatitis resolved spontaneously and required no specific therapy.
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