A Case Report

Robelle Joan A.  Peralta, MD.

Edgardo Penserga, M.D., FPCS, FPSGS

Reynaldo Joson, M.D., MHPEd, MS Surg

Department of Surgery

Ospital ng Maynila Medical Center

Key word:  Epididymal Tuberculosis

Reprint request:  Robelle Joan A.  Peralta, M.D.

Department of Surgery, Ospital ng Maynila Medical Center

ommcsurgery@yahoogroups.com

Abstract:

A 37-year-old male Filipino patient presented with a right painless scrotal mass with one month duration with associated undocumented fever at night, chills, night sweats, anorexia, weight loss and dysuria. Male genital tuberculosis was diagnosed using positive acid fast bacilli culture of urine and sputum. He underwent radical orchiectomy; surgical pathology revealed granulomas containing acid-fast bacilli in the testis and epididymis. Treatment using a standard four-drug regimen is started postoperatively and patient was discharged, improved.

Introduction:

Genital disease is an unusual extrapulmonary manifestation of tuberculosis, often seen in middle-aged men with renal or pulmonary tuberculosis. Clinical findings are variable, but commonly include dysuria with sterile pyuria or a painless testicular mass. Initial diagnosis is often incidentally made on pathological specimens and confirmed with nucleic acid amplification and cultures.

This case is used to raise awareness of, and formulate a minimally invasive diagnostic approach to, this unusual but important entity.

 Case Report:

We are presented with a 37-year-old Filipino male presented with a right painless scrotal mass with one month duration and dysuria for 2 days.  He also complained of undocumented fever at night, chills, night sweats, anorexia, weight loss. He did not report cough or haemoptysis. BCG vaccination had been administered in childhood. On physical examination, the patient appeared thin (body-mass index 20 kg/m²) with a temperature of 36·4°C, a blood pressure of  100/60 mm Hg, a heart rate of 72 beats per min, and a respiratory rate of 20 breaths per min. Lungs were clear to auscultation bilaterally. A large, firm, irregular mass was palpable on the superior pole of the right testis; several small right inguinal lymph nodes were noted. No other lymphadenopathy was present and the remainder of his physical examination was unremarkable.

Laboratory data (normal ranges in parentheses) revealed a white blood cell count of 9000 cells per μL (4·0–8·5 cells per μL), haemoglobin concentration of 13·9 g/dL (13·5–17·5 g/dL), a platelet count of 734 000 per μL (140–440 per μL).  Urinalysis revealed greater than 50 leucocytes (normal less than five) and no erythrocytes (normal less than three) per high-powered field.

A chest radiograph was normal. Scrotal ultrasound showed a heterogeneous left testicular mass concerning for malignancy He was referred to the urology service and subsequently admitted for a radical right orchiectomy for suspected testicular carcinoma. The surgical pathology showed granulomatous inflammation of the right testis and epididymis without evidence of malignancy. A modified Ziehl-Neelsen stain was positive for numerous acid-fast bacilli (AFB); since infection was not suspected initially, no operative cultures were obtained.

Sputum and urine specimens were both positive for AFB on smear examination.  The patient was started with anti-Koch’s regimen. After recovering from surgery, he was discharged home with advised follow up one week with take  home medications of Cloxacillin 500 mg tablet QID for days, Mefenamic acid 500 mg tablet 1 tablet TID prn for pain on full stomach, anti Koch’s and Vitamin B complex.  No follow up information was available.

Discussion:

Male genital tuberculosis usually occurs in men aged 30–50 years.   In the past, prostatic tuberculosis affected mainly younger men; however, the disease is being increasingly reported in men older than 60 years, usually as an incidental pathological finding on biopsy to rule out malignancy. Between 34% and 76% of patients with male genital tuberculosis had some form of tuberculosis previously. The incubation period between primary infection and reactivation ranges from less than 1 year to 30 years, which may explain the rarity of genitourinary tuberculosis in children.

 Isolated male genital tuberculosis is unusual; most patients have either concomitant renal (49–88%) or pulmonary (56–87%)  disease, or both. The epididymis and prostate are most commonly involved; disease of the testes, seminal vesicles, and vas deferens typically only occurs in association with disease in other sites, is often asymptomatic and discovered only on autopsy.

The lungs are the most common primary portal of entry for M tuberculosis. Bacillaemia then occurs with seeding of distal sites, including any part of the genitourinary tract, such as the highly vascular kidney and epididymis. Some controversy exists regarding the exact sequence of events leading to the initial infection in other areas. Older pathology series suggest that the majority of disease in the prostate, seminal vesicles, and vas deferens originates from infected urine possibly through microscopic renal foci that open into the urine and spontaneously heal. However, 11% of men with male genital tuberculosis in this study did not have any renal lesions, suggesting that a haematogenous route may also be important.

Other experts, reflecting a more contemporary understanding of tuberculosis pathogenesis in other organs, suggest that direct haematogenous spread is the most common method of initial infection in male genital tuberculosis.  Primary lesions, regardless of their source, usually heal and form granulomas where M tuberculosis can remain viable for decades. Most male genital tuberculosis is the result of reactivation from granuloma(s) in one or more sites, often after a long quiescent period.

Manifestations are less commonly systemic and more likely to localise to the level of disease; constitutional symptoms suggest extragenital disease.  Symptoms are often mild, intermittent, and insidious. The most common symptoms with prostatic involvement are urinary frequency and nocturia.  Other urinary symptoms such as dysuria, haematuria, and haematospermia also occur with prostatic involvement; urgency is usually not present unless the bladder is affected.   With orchitis or epididymitis, a painless scrotal mass is the most frequent presenting complaint although 7–19% of patients present with pain that may radiate to the groin, thigh, or testicle. Many patients with male genital tuberculosis are asymptomatic and present with an incidental abnormal urinalysis.

On physical examination, several features may be suggestive for genital tuberculosis: an enlarged, hard, and non-tender epididymis; a thickened or beaded vas deferens; an indurated or nodular prostate; or a non-tender testicular mass.   Scrotal oedema may also be present. Digital rectal examination is not sufficiently sensitive to detect early prostatic tuberculosis, but as the disease progresses, soft areas may be palpable as a result of caseous necrosis. Rupture of these areas may occur into the urethra or the perineum, causing fistulae with late disease; scrotal fistulae may also be seen in 11–50% of patients. Inguinal lymphadenopathy may be present. Clinical findings can be unilateral or bilateral.

Since isolated male genital tuberculosis is often not suspected clinically, most laboratory findings have been evaluated in patients with concomitant renal tuberculosis. Urinalysis is abnormal in 77–90% of patients with genitourinary tuberculosis; the classic finding is sterile pyuria, although up to 31% of men have coliform bacteria in their urine, typically Escherichia coli.

Typically, three sequential early morning urine samples are collected for AFB culture; fluid obtained using prostatic massage can also be used.  In genitourinary tuberculosis, urine AFB smears have a 52% higher sensitivity than urine AFB cultures.

The most common findings with tuberculous epididymitis and orchitis have non-specific imaging findings, though tuberculosis abscesses are usually larger and have lower blood flow than pyogenic abscesses. Scrotal ultrasound can reveal focal or diffuse areas of decreased testicular echogenicity or extratesticular calcifications; epididymal involvement suggests a non-specific infectious process. However, ultrasound or CT may show a testicular mass with lymphadenopathy that is radiographically indistinguishable from malignancy.

Plain chest films demonstrate either active or inactive disease in more than 50% of patients. The purified protein derivative (Mantoux) test is positive in more than 90% of patients.

Male genital tuberculosis can present as a testicular mass that is difficult to differentiate from malignancy. Other diagnostic considerations for a testicular mass include infectious (typically epididymitis or epididymo-orchitis) or non-infectious causes (testicular torsion, haematocoele, spermatocoele, varicocele, and indirect inguinal hernia). In our patient's case, the systemic symptoms, clinical findings, and imaging excluded most of these possibilities except for tuberculosis, chronic epdidymitis, and malignancy. Malignancy is often the primary consideration in the diagnostic work-up, but tuberculosis should also be considered, especially in individuals from endemic areas.

Tuberculosis is often only suspected after granulomas are found on genitourinary pathology

Diagnosis requires the combination of compatible clinical, pathological, and microbiological findings; since urine AFB cultures are insensitive, empiric treatment is often used once the more common causes have been ruled out, especially in areas endemic for tuberculosis.  Clinicians still rely heavily on urine AFB cultures, especially when the NAA assay is not easily available, since obtaining tissue for culture can be problematic. NAA analysis of the urine has a reported specificity and sensitivity of 95·6% and 98·1%, respectively, for renal tuberculosis.

With the advent of effective antituberculous drugs, chemotherapy has become the mainstay of treatment of all forms of male genital tuberculosis. Most patients should initially be treated, using DOT, with a four-drug regimen of rifampicin, isoniazid with pyridoxine supplementation, pyrazinamide, and ethambutol. After the first 2 months, treatment can usually be simplified to rifampicin and isoniazid alone to complete 6 months. Treatment may need to be adjusted based on individual clinical response and drug susceptibility.

Surgery should only be considered for established male genital tuberculosis when symptoms do not promptly respond to chemotherapy and for non-resolving caseating abscesses; even extensive disease and abscesses have been successfully treated with chemotherapy alone.

With appropriate diagnosis and therapy, mortality from male genital tuberculosis is low. Morbidity may occur from development of fistulae, and infertility can result from obstruction of the sperm outflow tract or destruction of testicular tissue. With current treatment and good adherence, relapses are rare and histological improvement has been documented with a full course of therapy.

References:

Andre A. Figueiredo, et al.   Urogenital Tuberculosis:  Patient Classification  in seven different groups according to clinical and radiological presentation.. Division of Urology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.

Jesse T Jacob, et al. Male genital tuberculosis.The Lancet Infectious Diseases - Volume 8, Issue 5 (May 2008)  

Wise GJ, Shteynshlyuger A.  An update on lower urinary tract tuberculosis. Division of Urology, Maimonides Medical Center, 48-02 Tenth Avenue, Brooklyn, NY 11219, USA. 2008 Jul;9(4):305-13.

Yu-Hung Lai A, Lu SH, Yu HJ, Kuo YC, Huang CY.  Tuberculous Epididymitis Presenting as huge scrotal tumor. Division of Urology, Department of Surgery, Taipei City Hospital, Taipei, Taiwan; Department of Urology, National Taiwan University Hospital, Taipei, Taiwan; National Yang Ming University School of Medicine, Taipei, Taiwan.2008 Jul 9.