A Rare Case Of Tubercular Recto-Prostatic Urethral Fistula With Tuberculous Orchitis

Tubercular prostatitis and tuberculous orchitis are uncommon manifestations of genitourinary tuberculosis. Rectourethral fistula is also an uncommon condition. The most common site of occurrence is the prostaticurethra, in which a communication develops with the rectum. The common causes are surgery or radiotherapy for prostate cancer. Inflammatory causes are uncommon, and amongst them, tuberculosis is the least. There are less than 15 cases of tubercular rectourethral fistula reported in literature. In this case report, we present a case of post-tubercular recto-prostatic urethra fistula, which was diagnosed by history, clinical examination, micturating cystourethrogram, cystourethroscopy and MRI abdomen pelvis. The patient was treated by prostatectomy, urinary diversion along with fecal diversion in the form of a colostomy, followed by a course of Anti tubercular drugs on histopathological confirmation by biopsy.

Introduction

Prostate gland tuberculosis presents as granulomatous prostatitis with a low incidence. Rectourethral fistulas are a rare entity. Culp and Calhoon classification, groups rectourethral fistulas into five types which are congenital, iatrogenic, traumatic, neoplastic and inflammatory. Iatrogenic fistulas are usually after surgery or radiotherapy for prostate cancer, with an incidence of 0.1%-3%. Inflammatory fistulas are even rarer, with inflammatory bowel disease, malakoplakia and tuberculosis being some of the known etiologies. Approximate incidence of rectourethral fistulas from Crohn’s disease is 0.3%. Till date only 10 cases of tubercular rectourethral fistulas are reported and none with tuberculous orchitis. Rectourethral fistulas may present with fecaluria, pneumaturia and/or urorrhoea. Patients of tubercular recto-prostatic urethral fistulas present with symptoms of storage lower urinary tract symptoms along with the aforementioned features. Direct communication between the rectum and prostatic urethra has been confined to males due to anatomical reasons. Eventhough the prevalence of urogenital tuberculosis in the non-industrialised world is common, but tubercular rectourethral fistula is extremely rare; probably due to the fact that the fascia between the prostate and the rectum acts as a barrier for its spread. Apart from suggestive history, digital rectal examination and certain investigations like cystourethroscopy, proctoscopy, Micturating Cystourethrogram (MCU) and cross-sectional imaging like CT/MRI can be useful aids in diagnosing rectourethral fistulas. Testicular tuberculosis is also an uncommon manifestation of genitourinary tuberculosis.

Case report

A 70 years old male patient presented with complains of passage of urine per rectum since 1 year, increased since 1 month, he also had symptoms of recurrent right testicular pain, recent onset of pus discharge from right scrotum, urinary frequency, occasional dysuria and previous history of recurrent UTI. There was no history of pneumaturia, fecaluria, alteration in bowel habits or bleeding per rectum. He had a past history of left orchidectomy for recurrent epididymoorchitis 3 years back, cholecystectomy for calculous cholecystitis 5 years back and had undergone coronary artery bypass grafting for coronary artery disease 11 years back. He is a known case of diabetes and hypertension since 15 years. On clinical examination, there was right testicular tenderness with induration suggestive of epididymoorchitis with a pus discharging sinus in the right scrotal wall. On digital rectal examination, grade 1 firm prostate with variegated surface was noted, and an indurated area in the anterior wall of rectum just adjacent to prostate.Patient underwent retrograde urethrogram which was suggestive of prostatic urethral diverticulum and micturating cystourethrogram which showed opacification of large bowel loops suggestive of vesico rectal fistula.

Patient underwent MRI abdomen and pelvis, for exact anatomical localization of fistulous tract with plain and contrast films showing recto urethral fistula at the distal prostatic urethra and common bile duct calculi. he patient underwent cystoscopy and sigmoidoscopy. Cystoscopy showed proximal bulbar urethral stricture with a rent in prostatic urethra just proximal and adjacent to verumontanum along with few small openings containing calculi near the verumontanum. Sigmoidoscopy showed a sessile polyp in sigmoid colon which was biopsied and turned out to be benign and showed a suspicious fistulous opening in lower rectum 3 cm from anal verge. Patient also underwent endoscopic retrograde cholangiopancreaticography and stenting for common bile duct calculi.

Patient was then preoperatively evaluated and prepared and underwent simple prostatectomy and fistulous tract excision and rectal repair and omental transposition and vesicourethral anastomosis and bilateral double j stenting and diversion ileostomy and right orchidectomy and specimens sent for Histopathological examination

Discussion

Tubercular involvement of the prostate gland is known to present as granulomatous prostatitis. The exact incidence is unknown at present, but is reportedly low. It is less common than renal, urinary bladder-seminal vesicle and epididymal tuberculosis. In India, a survey of 126 patients who underwent fine needle aspiration cytology for suspicion of prostate malignancy revealed tuberculosisin 3%. Testicular tuberculosis is an uncommon form, seen in only 3% cases of genitourinary tuberculosis. Rectourethral fistula is an uncommon but distressing condition for both the patient who is suffering from it and the operating surgeon. Optimal strategies for management need to be devised in order to reduce the morbidity associated with the disease. Most studies have advocated fecal and urinary diversion as the initial treatment. After diversion, spontaneous closure has been reported to be 14%-46.5%. Fecaluria is known to be a poor prognostic sign, indicating that the fistula may be large in size and difficult to heal. Different methods of treatment are described in literature, like diversion, surgical procedures like perineal approach with dartospedicled flap, posterior sagittal approach, transanal approach, posterior transsphincteric approach or modified York-Mason method, use of rectal advancement flaps, gracilis flaps or omental transposition. In case of tubercular rectourethral fistulas, the majority of reported cases have resolved with diversion and anti-tubercular drug treatment. In our case, the patient was diagnosed to have tubercular prostatitis with recto-urethral fistula with tuberculous orchitis with a discharging sinus. On cystoscopic examination, the fistulous opening was found, alongwith other multiple small openings of sinus near the verumontanum, which is characteristic of prostatic TB, as described by Veenema and Lattimer. The patient had a negative urine study for AFB, which emphasizes on the fact that even if urine for acid fast bacilli is negative, patient can have prostatic tuberculosis(as suggested in this case by prostatic biopsy), and antitubercular treatment should be promptly given.

Conclusion

Spontaneous tubercular rectoprostatic fistulae are a rare complication of prostatic tuberculosis. There is no renal, ureteric or bladder involvement. The fistulae open adjacent to the verumontanum in the prostatic urethra. Tuberculous orchitis is also an uncommon manifestation of genitourinary tuberculosis. Urine for acidfast bacilli may be negative and prostatic and testicular biopsy proves the diagnosis. A proper knowledge of this distressing condition, its presentation and diagnosis will help in ideal treatment and improve the patient’s quality of life.