Case Report
GENITOURINARY TUBERCULOSIS MANIFESTING AS ACUTE
EPIDIDYMO-ORCHITIS: A REPORT OF TWO CASES
A b d u r r a h m a n Ö z g ü r , M . D . * / T u fa n T a r c a n , M . D . * L e v e n t T ü r k e r i , M . D . * / Ç iğ d e m A t a i z i Ç e l i k e l , M . D . * *
* D e p a r t m e n t o f U ro lo g y , S c h o o l o f M e d ic in e , M a rm a ra U n iv e rs ity , Is ta n b u l, T u rk e y .
* * D e p a r t m e n t o f P a th o lo g y , S c h o o l o f M e d ic in e , M a r m a ra U n iv e rs ity , Is ta n b u l, T u rk e y .
A B S T R A C T
Like tuberculous infection the overall incidence of genitourinary tuberculosis has increased in many countries during the recent ye a rs.
Two c a s e s of testicular tuberculosis manifesting a s acute epididymo-orchitis are presented.
K e y W o r d s : Tub ercu lo sis, Orchitis
IN T R O D U C T IO N
Isolated tuberculous epididymo-orchitis occurs rarely. Tub ercu lo u s epididym itis occu rs most commonly between the a g es 20 and 50 years and patients usually present with the insidious onset of scrotal pain with no irritative voiding sym pto m s. U n fortu n ately, the definitive diagnosis of tuberculous epididymo-orchitis is often made after pathological exam ination of the orchiectom y sp ecim en.
C a s e 1 :
A 44-year-old man admitted to our out-patient clinic b ecau se of a painful right scrotal swelling of one w e e k’s duration. Th e physical examination
revealed an elastic hard, irregular and painful right-sided scrotal m ass (8.5x8 cm) and a normal left testicle. Tum or m arkers (A F P , beta-hCG. and LDH) and chest X-ray were found to be normal w hereas, erythrocyte sedimentation rate and C- reactive protein level were slightly elevated. The patient had no fever or any co-morbidity. Urine analysis and cultures were normal. Ultrasound revealed a normal upper and lower urinary tract, a normal left testicle and a right epididymo- orchitis with m icro-calcifications. The patient w as started on Ofloxacine (1x400 mg) and Diclofenac (2 x100 mg) treatm ent, but there w a s no sym ptom atic im provem ent during a 2-w eek follow up. A repeat scrotal ultrasound revealed right testicular a b sc e ss. The patient underwent right inguinal orchiectomy and histopathological examination revealed caselflcous granulomatous orchitis (Figs 1, 2). Three early morning urine sam ples for acid resistance bacteria examination and urine Bactec culture test were negative. C a s e 2 :
A 65-year-old man admitted to our out-patient clinic because of left testicular swelling and pain which w as not associated with fever, a month after the transurethral resection of prostate (T U R P ). T h e p hysical exam ination revealed testicular swelling and pain on the left side.
(A c c e p te d 2 7 F ebru ary, 2 0 0 2 ) M arm ara M e d ic a l J o u rn a l 2 0 0 2 ;1 5 (2 ):1 19-121 Correspondance to: Abdurrahman Ozgur, M.D, - Department of Urology,
School of Medicine, Marmara University Hospital, Altunizade, Istanbul, Turkey, e.mail address: aozgur75@hotmail.com
Abdurrahman Ozgür, et al
F i g . l : (x40, Hemotoxylin-Eosin staining) (a granulomatous lesion in which a large area of caséification necrosis is surrounded by palisading epithelioid histiocytes and lymphocytic rim.)
F i g . 2 :(x100 , Hemotoxylin-Eosin staining) (caséification necrosis)
F i g . 3 : (x40. Hemotoxylin-Eosin staining) (Granulomas formed by epithelioid histiocytes and lymphocytes; large area of necrosis in the center)
His past m edical history revealed a 6-week course of intravesical B acillu s Calm ette-Guerin (B C G ) treatment for his superficial transitional cell bladder carcinom a. During his last tumor-free c h e ck -cy sto sco p y the patient had also undergone a T U R P for benign p rostatic h y p e rp lasia (B P H ). H istopathological exam ination of T U R P specim en had revealed nonspecific granulom atous prostatitis.
Scrotal ultrasound revealed a left epididiymo- orchitis with m icro-calcifications. Urine a n a lysis and cultures w ere found norm al. O floxacine (1x400 mg) and Diclofenac (2x100 mg) treatment w as started on an out-patient b asis. Tw o w eeks later, he underwent left inguinal orchiectom y sin c e no im provem ent w a s a ch ie v e d with antim icrobial treatm ent. H istopathological exam ination revealed tuberculous epididymitis and atrophic left testicle (Fig . 3). T h e urinary tract w a s radiologically normal.
Both patients are currently on an antituberculous drug regim en and no other sym pto m s or com plications have developed.
D IS C U S S IO N
It is estim ated that from 8 to 10 million people develop overt tuberculosis annually and 3 million die due to tuberculosis (1). T h e p revalence may be a s high a s 400 in 100,000 in the developing co un tries (1 ). G e n ito u rin a ry tu b e rcu lo sis a cco u n ts for 14% of nonpulm onary m anife statio ns (1 ,2 ). Like the tu b erculou s infection of other syste m s, the overall incidence of genitourinary tuberculosis h as increased in m any countries during the past y e a rs (3).
The predisposing risk factors asso ciated with the developm ent of tuberculosis include prolonged steroid u se , im m u n e su p p re ssiv e th erap y, d ise a se s that impair cell-m ediated immunity and d ise a se s with poor local immune m echanism . A higher incidence of granulom atous prostatitis w a s found in patients who had been treated with in tra ve sica l B C G (4 ,5 ). Extra p u lm o n a ry tuberculosis has been reported to be steadily in creasin g in patients with acq uired im m unodeficiency syndrom e (6 ,7 ).
Tuberculous orchitis
Tuberculous epididymitis occu rs most commonly betw een the a g e s of 20 and 50. Lattim er contends that epididymal tuberculosis is almost a lw a y s se c o n d a ry to a prostatic lesion, presum ably via a retrocanicular descent (8). Gow argues for hem atogenous dissem ination to the epididym is, reporting that only 1 of 20 men with epididymal tuberculosis had results on prostate biopsy positive for acid-fast bacilli (9). Testicular involvem ent is usually via a direct extension from the epididym is, although there is evidence of o c ca sio n a l h em ato g en o us infection (9 ,1 0 ). Com m on presenting problem s are scrotal sw e llin g , pain, d isch a rg e and sin u se s (11). When only the external genitalia are involved pyuria, urinary acid -fast bacilli and irritative voiding sym ptom s are usually absent. Fever is infrequent a s are other constitutional symptoms (11). Patients usually present with the insidious onset of scrotal pain with no irritative voiding sym ptom s. Therefo re, the definitive diagnosis of tuberculous epididymo-orchitis is often made after pathological exam ination of the orchiectomy specim en.
Tuberculous epididymo-orchitis should alw ays be considered in the differential diagnosis of acute testicular swelling and pain, especially when sym ptom s do not resolve after a 2-week antibacterial chem otheraphy and/or if the patient has received a prior intravesical B C G treatment. It must be rem em bered that urine culture tests for tuberculosis m ay be negative in tuberculous epididymo-orchitis and definitive diagnosis may only be made by histopathological exam ination.
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