Disseminated genitourinary tuberculosis (GUTB) with emphysematous prostatitis

Disseminated genitourinary tuberculosis (GUTB) with emphysematous prostatitis represents a rare, severe form of extrapulmonary tuberculosis with gas-forming secondary infection, typically in immunocompromised individuals. This condition requires multidisciplinary insight, involving infectious disease, radiology, urology, and pathology.

1. Cause and Etiology

Causative Agent:

Mycobacterium tuberculosis, an obligate aerobic acid-fast bacillus, is the etiological agent.
Emphysematous prostatitis is often caused by gas-forming uropathogens, primarily:

Escherichia coli
Klebsiella pneumoniae
Pseudomonas aeruginosa
Proteus spp.

Pathogenic Association:

Disseminated TB may involve hematogenous spread to multiple organs, including the prostate.
Secondary superinfection with gas-producing organisms can result in emphysematous changes.

Risk Factors:

Immunocompromised state (HIV/AIDS, diabetes mellitus, chronic kidney disease)
Prior TB infection (especially pulmonary TB)
Indwelling catheters
Recent instrumentation of the urinary tract
Poorly controlled diabetes (promotes emphysematous infections)

2. Pathophysiology

Genitourinary TB (GUTB):

Hematogenous dissemination from a primary pulmonary or miliary TB focus.
TB bacilli lodge in the renal cortex, then descend via the urinary tract to the ureters, bladder, prostate, epididymis, and seminal vesicles.
In the prostate, TB induces chronic granulomatous inflammation with caseating necrosis.

Emphysematous Prostatitis:

Superinfection of a compromised prostatic tissue (already necrotic or inflamed from TB) by gas-forming bacteria.
These bacteria ferment glucose to produce hydrogen, nitrogen, and carbon dioxide.
Result: Gas accumulates within the prostatic parenchyma and surrounding tissues.

Combined Pathogenesis:

TB-induced immune suppression and granulomatous necrosis in the genitourinary tract create an environment conducive to anaerobic bacterial overgrowth and gas production.

3. Epidemiology

Genitourinary TB is the second most common form of extrapulmonary TB after lymphatic TB.
Incidence varies by region:

High in TB-endemic areas (India, sub-Saharan Africa, Southeast Asia).
More common in males aged 30–60 years.

Emphysematous prostatitis is extremely rare.

Accounts for a subset of emphysematous urinary tract infections, which themselves are rare.
More prevalent in elderly diabetic men.

4. Clinical Presentation

Symptoms of disseminated GUTB with emphysematous prostatitis include a combination of:

Systemic TB Symptoms:

Fever, weight loss, night sweats
Fatigue, anorexia

Urogenital TB Symptoms:

Dysuria
Hematuria
Sterile pyuria
Perineal discomfort
Urinary frequency and urgency
Possible scrotal swelling or epididymo-orchitis

Prostatic Involvement Symptoms:

Severe perineal pain
Urinary retention
Prostatomegaly
Rectal pain or tenesmus
Possible septic shock if emphysematous prostatitis progresses

Signs:

Tender, boggy prostate on digital rectal exam (DRE)
Signs of sepsis: hypotension, tachycardia, confusion

5. Imaging Features

A. Ultrasound (TRUS or abdominal):

doi: 1259/bjrcr.20220101.

Enlarged, heterogeneous prostate
Hyperechoic foci with dirty shadowing indicating gas
May show prostatic abscess formation

B. CT Scan (Preferred Modality):

doi:10.1148/rg.2021200154

Gas within the prostate—pathognomonic of emphysematous prostatitis
Prostatic enlargement with hypodense necrotic areas (suggesting TB abscess)
Possible extension of gas into the periprostatic tissues or the seminal vesicles
Additional findings in GUTB:

Hydronephrosis, ureteral strictures, moth-eaten calyces, calcifications
Cavitary renal lesions
Bladder wall thickening or a small capacity bladder

C. MRI:

doi:10.1148/rg.2021200154

Used for soft tissue detail
T2 hypointense granulomas, central necrosis
Can help in surgical planning

D. CXR or Chest CT (for systemic TB):

Evidence of active or healed pulmonary TB (e.g., upper lobe cavitations, miliary pattern)

6. Treatment

A. Anti-Tuberculous Therapy (ATT):

Standard 4-drug regimen:

Isoniazid, Rifampin, Pyrazinamide, Ethambutol (2 months)
Followed by Isoniazid + Rifampin (4–7 months)

Duration: 6–9 months for uncomplicated cases; 9–12 months if disseminated or abscess present
Monitor liver enzymes and adjust for renal insufficiency

B. Antibiotics for Emphysematous Prostatitis:

Empiric broad-spectrum antibiotics initially:

Carbapenems (e.g., meropenem)
3rd-gen cephalosporins + metronidazole
Tailor based on culture/sensitivity

Duration: 2–4 weeks IV, followed by oral agents

C. Supportive Care:

Intravenous fluids
Glycemic control in diabetics
Management of sepsis if present

D. Interventions:

Drainage of prostatic abscess if large or unresponsive

TRUS-guided aspiration
Transurethral resection of the prostate (TURP)

Nephrostomy or stenting in case of obstructive uropathy
Surgical debridement if necrotizing infection or fistula formation

7. Prognosis

Prognosis depends on:

Timeliness of diagnosis and initiation of treatment
Patient’s immune status (worse in HIV or advanced diabetes)
Presence of septic shock or multi-organ involvement

A favorable outcome is expected with early ATT and appropriate drainage
High mortality (up to 20–40%) reported in emphysematous prostatitis with sepsis or delayed treatment
Long-term sequelae:

Infertility
Bladder dysfunction
Ureteric strictures
Chronic prostatitis

Summary Table

Aspect	Description
Cause	Mycobacterium tuberculosis; gas-forming bacteria (e.g., E. coli)
Pathophysiology	Hematogenous TB spread + necrotizing granulomas + secondary gas-forming infection
Risk Factors	Diabetes, HIV, prior TB, catheterization
Symptoms	Perineal pain, dysuria, fever, systemic TB signs
Imaging	CT: gas in prostate; renal cavitations; ureteric strictures
Treatment	ATT + antibiotics + drainage
Prognosis	Good with early treatment; poor if septic or immunocompromised

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Case Study: A 31-Year-Old Male with Iliac Pain, Testicular Swelling, and Dysuria-Disseminated Genitourinary Tuberculosis with Emphysematous Prostatitis

DOI: 10.1259/bjrcr.20220101

Abstract

Genitourinary tuberculosis (UGTB) can involve the entire urinary tract, including the kidneys, ureters (leading to strictures), bladder, and prostate, and may also affect the reproductive organs. In modern medicine, ultrasound and cross-sectional imaging play a crucial role in the radiologic diagnosis of UGTB. If left untreated, UGTB may result in devastating sequelae such as end-stage renal disease, infertility, and life-threatening systemic infection.

UGTB is rare in developed countries and may mimic other pathologies, including malignancies. Therefore, radiologists must consider it in the differential diagnosis, particularly in patients with risk factors such as travel to endemic areas, to ensure timely treatment and optimal outcomes. UGTB is generally managed by infectious disease specialists using multi-drug chemotherapy.

In this report, we present a microbiologically confirmed case of extrapulmonary tuberculosis, predominantly involving the genitourinary tract. The absence of co-infection with other pathogens and the specific response to anti-tuberculous therapy suggest that this may be the first reported case of emphysematous tuberculous prostatitis.

Emphysematous prostatitis refers to a gas-forming infection of the prostate, commonly associated with abscess formation and readily identified on CT imaging. It is not a well-recognized manifestation of tuberculosis infection, underscoring the need for microbiologic confirmation in such atypical cases.

History and Imaging Findings

A 31-year-old male presented with iliac region pain and dysuria, which had developed over the past several days.
He reported testicular swelling that had begun approximately one month before presentation.
Laboratory results showed mild eosinophilia (up to 1.03 × 10⁸/L) and slightly elevated inflammatory markers, while the complete blood count remained within normal limits.
Scrotal ultrasound identified an isolated lesion within the epididymis, which was confirmed to have progressed on follow-up ultrasound.
Serum levels of tumor markers, including alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and testosterone, were within normal limits.
The case was discussed by the multidisciplinary germ cell tumor team, who reached a broad consensus supporting a presumptive diagnosis of tuberculosis (TB) infection as the most likely etiology.
CT imaging revealed several significant findings, most notably emphysematous prostatitis, ultimately leading to a diagnosis of urogenital tuberculosis (UGTB).

Quiz:

1. What is the most common causative organism of emphysematous prostatitis?
(1) Mycobacterium tuberculosis
(2) Klebsiella pneumoniae
(3) Proteus mirabilis
(4) Pseudomonas aeruginosa
(5) Staphylococcus aureus

Explanation: Klebsiella pneumoniae is the most frequently reported pathogen in emphysematous prostatitis, often associated with diabetes mellitus. This facultative anaerobic gram-negative bacillus is known for its gas-forming capability.

2. In which age group is emphysematous prostatitis most commonly observed in men?
(1) Under 10 years
(2) 10–30 years
(3) 30–50 years
(4) 50–70 years
(5) 70–90 years

Explanation: Emphysematous prostatitis predominantly affects older men, particularly those in their sixth to seventh decades, often due to underlying comorbidities such as diabetes and urinary tract obstruction.

3. What is the most common risk factor for emphysematous prostatitis?
(1) An immunocompromised state
(2) Diabetes mellitus
(3) Indwelling urinary catheter
(4) Urinary retention
(5) Recent cystoscopy

Explanation: Diabetes mellitus is the most significant risk factor, as elevated blood glucose levels provide a favorable environment for gas-forming organisms and impair host immune responses, increasing susceptibility to infections.

4. Which of the following conditions is associated with the highest mortality rate?
(1) Emphysematous pyelonephritis
(2) Emphysematous cystitis
(3) Emphysematous prostatitis
(4) Non-emphysematous pyelonephritis
(5) Non-emphysematous prostatitis

Explanation: Among emphysematous infections of the genitourinary tract, emphysematous pyelonephritis has the highest mortality rate, with reports ranging from 20% to 40%. It is a urologic emergency requiring immediate intervention.

5. Through which route is tuberculosis most commonly transmitted?
(1) Via coughing and respiratory droplets, and potentially through sexual contact
(2) Sharing food or drinks
(3) Kissing, hugging, or shaking hands
(4) Blood transfusion
Explanation: Tuberculosis is primarily transmitted through airborne droplets. However, in rare cases, urogenital tuberculosis (UGTB) can be sexually transmitted through infected semen, particularly in male genitourinary TB.

6. Which MRI findings are most suggestive of a prostatic abscess?
(1) A prostatic lesion showing low signal intensity on T1-weighted and T2-weighted images with peripheral contrast enhancement
(2) A prostatic lesion showing low T1 and high T2 signal intensity with central contrast enhancement
(3) A prostatic lesion showing low T1 and high T2 signal intensity with peripheral contrast enhancement
(4) A prostatic lesion showing high signal intensity on diffusion-weighted imaging (DWI) and a high apparent diffusion coefficient (ADC) on MRI
(5) A prostatic lesion showing low signal intensity on DWI and high ADC values on MRI

Explanation: This MRI pattern is characteristic of abscesses: central liquefactive necrosis appears hyperintense on T2-weighted images, hypointense on T1, with rim (peripheral) enhancement due to inflamed capsule after contrast administration.

7. What is the standard treatment option for a prostatic abscess?
(1) Broad-spectrum antibiotics alone; or image-guided (CT or ultrasound) transperineal or transrectal drainage combined with broad-spectrum antibiotics; or transurethral resection with adjunctive antibiotic therapy
(2) Image-guided (CT or ultrasound) transperineal or transrectal drainage alone
(3) Radical prostatectomy

Explanation: Management depends on the abscess size and severity. Broad-spectrum antibiotics may suffice for small abscesses. For larger or unresponsive abscesses, image-guided drainage or transurethral resection is the standard approach. Radical prostatectomy is rarely indicated.

Findings and Diagnosis

Findings
Serial scrotal ultrasound examinations revealed multiple hypoechoic lesions, initially confined to the left epididymis, which progressed to involve the left testis by week three (confirmed by CT).
Subsequent ultrasound images demonstrated contralateral testicular involvement, with associated increased vascularity and scrotal wall thickening.

Contrast-enhanced CT of the chest, abdomen, and pelvis revealed several acute findings:

Multiple small intraprostatic gas locules were observed in the deep pelvis, consistent with emphysematous prostatitis. There was no radiological evidence of a rectal fistula.
Hypoperfusion was noted in the upper pole of the left kidney without hydronephrosis, consistent with direct parenchymal involvement by tuberculosis.
A peripherally enhancing hypodense lesion was identified in the mid-pelvis, suggesting a tuberculous abscess of the right seminal vesicle.
Additional chronic features indicative of prior tuberculosis were observed on CT, including:
- Isolated, peripherally calcified retroperitoneal lymph nodes within the pelvis.

Differential Diagnosis

Based on initial ultrasound findings:

Infectious epididymo-orchitis with left testicular abscess, with high suspicion of tuberculosis
Paratesticular tumor

Based on initial ultrasound and baseline CT findings:

Renal tuberculosis with disseminated genitourinary involvement
Pyelonephritis
Renal cell carcinoma

Definitive Diagnosis:
Disseminated genitourinary tuberculosis with emphysematous prostatitis

Treatment

The patient was initially treated empirically for atypical epididymo-orchitis with a two-week course of broad-spectrum antibiotics (ciprofloxacin and doxycycline), which may exhibit partial anti-tuberculous activity.

Upon radiologic diagnosis of tuberculosis, the patient was referred to an infectious disease specialist for ongoing management.

Concomitant eosinophilia was identified as a co-infection with Strongyloides and was successfully treated with ivermectin.

The patient was started on first-line quadruple anti-tuberculosis therapy (rifampicin, isoniazid, pyrazinamide, and ethambutol), with significant clinical improvement noted.

Although the patient remained in East Timor for eight months without clinical follow-up, a subsequent CT scan performed after his return to the UK confirmed complete radiologic resolution of acute genitourinary pathology.

Discussion

Emphysematous Prostatitis
Emphysematous prostatitis is a radiologically distinct entity easily identified on CT imaging, characterized by gas-forming infection within the prostate, frequently associated with abscess formation.

It is not a well-recognized manifestation of Mycobacterium tuberculosis infection, and thus, microbiological confirmation is required for definitive diagnosis in such cases.
The absence of evidence for other pathogens and the positive response to anti-tuberculous treatment support the interpretation that this case represents the first documented instance of emphysematous prostatitis caused by tuberculosis.

Learning Points

Urogenital tuberculosis (UGTB) is rare in developed countries.
UGTB often presents with non-specific symptoms and may mimic other pathologies such as renal malignancy.
Early radiological recognition of UGTB is critical for prompt diagnosis and improved outcomes.
In patients from endemic areas, a high index of suspicion for UGTB should be maintained.
UGTB is typically managed by infectious disease specialists using multi-drug chemotherapy.
Complex cases may require a multidisciplinary approach, including urological and interventional radiological procedures.
Systemic tuberculosis can often be clinically silent, and therefore, strict post-treatment follow-up is essential.
Tuberculous prostatitis is a rare entity, and prostatic abscess as a complication is exceedingly uncommon.

References

Muttarak M, Peh WC. Case 120: Tuberculous prostatitis with prostatic abscess formation. Radiology. 2007;242(3):985-988.
Figueiredo AA, Lucon AM. Urogenital tuberculosis: update and review of 8961 cases from the world literature. Rev Urol. 2008;10(3):207–217.
Kapoor R, Ansari MS, Mandhani A, Gulia A. Clinical presentation and diagnostic approach in cases of genitourinary tuberculosis. Indian J Urol. 2008;24(3):401–405.
Wise GJ, Shteynshlyuger A. An update on lower urinary tract tuberculosis. Curr Urol Rep. 2008;9(4):305–313.
Lenk S, Schroeder J. Diagnosis and management of genitourinary tuberculosis. Eur Urol. 2001;40(3):252–259.
Kulchavenya E. Urogenital tuberculosis: definition and classification. Ther Adv Infect Dis. 2014;2(5–6):117–122.
Mert A, Ozaras R, Tabak F, et al. Tuberculous prostatic abscess: a case report and review of the literature. Scand J Infect Dis. 2003;35(12):891–893.

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A 31-Year-Old Male with Iliac Pain, Testicular Swelling, and Dysuria, Disseminated Genitourinary Tuberculosis with Emphysematous Prostatitis