Abstract  

Tubercular prostatitis and tuberculous orchitis are uncommon mani-festations of genitourinary tuberculosis. Recto prostatic urethral fis-tula  is  also  an  extremely  rare  condition  with  less than  10  cases  of tubercular  recto-urethral  fistula  reported  in  literature.  We present  a case of  post-tubercular  recto-prostatic  urethral  fistula,  which  was diagnosed   by    history,   clinical   examination,    micturating   cystourethrogram,  cystourethroscopy and  MRI  abdomen pelvis.  The patient  was  treated  by  simple  prostatectomy  with  rectal  repair  with omental interposition along with a diversion ileostomy, followed by a course of Anti tubercular drugs following histopathological confirmation.  

KEYWORDS  Tubercular recto prostatic urethral fistula, Genito urinary tuberculosis, Tuberculous orchitis 
 

Introduction  

Genitourinary Tuberculosis is seen as an extra pulmonary manifestation in 10-14% of  tuberculosis.1    Prostatic  involvement  occurs  via  descending  infection, hematogenous spread or as a direct extension from a neighbouring focus. Usually manifests  as  granulomatous  prostatitis  with  a  low  incidence.  Tubercular  Recto-urethral fistulas are a rare entity with only 10 cases reported worldwide.2 Recto-urethral  fistulas  may  present  with  fecaluria,  pneumaturia  and/or  urine  in  stools. Patients  of  tubercular  recto-prostatic  urethral  fistulas  present  with  lower  urinary tract  symptoms  along  with  the  aforementioned  features.  Even  though  the prevalence of urogenital tuberculosis in the non-industrialised world is common, but tubercular recto-urethral 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  recto-urethral fistulas.    

Case Description  

A 70 year old diabetic and hypertensive presented with complaints of passage of urine per rectum since 1 year with recurrent right testicular pain and 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 epididymo-orchitis 3 years back. Clinical  examination  revealed  right  testicular  tenderness  with  induration  of  the epididymis  and  a  sinus  discharging  pus  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 the prostate. Retrograde  urethrogram  was  suggestive  of  prostatic urethral  diverticulum. Micturating cystourethrogram showed opacification of large bowel loops suggestive of  vesico  rectal  fistula.  MRI  revealed  a  fistulous tract  between  the  prostate  and rectum. 

Fig. 1. RGU, MCU and MRI films revealing the recto prostatic urethral fistula.

 Cystoscopy  showed  proximal  bulbar  urethral  stricture  with  a  rent  in  prostatic urethra  just  proximal  and  adjacent  to  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.

Fig. 2. Cystoscopy and sigmoidoscopy images revealing site of Fistula.

Patient  underwent  simple  prostatectomy  with  fistulous  tract  excision  and  rectal repair with omental interposition and diversion ileostomy. Right orchidectomy was also done. Histopathological  examination  of  prostate  and  testes  showed  granulomatous inflammation with Langhans type of giant cells.

Fig. 3. Microscopic examination revealing the granulomatous inflammation with Langhans giant cells.

Postoperatively the patient was started on Anti-Tubercular medications.  

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. Testicular tuberculosis is an uncommon form, seen in only 3% cases of genitourinary tuberculosis.3 Recto-urethral fistula is an uncommon but distressing condition for both the patient and the operating surgeon. Optimal strategies for management need to be devised in  order  to  reduce  the  morbidity  associated  with  the  disease.  Most  studies  for benign  recto-urethral  fistulas  have  advocated  fecal  and  urinary  diversion  as  the initial treatment. After diversion, spontaneous closure has been reported to be 14%-46.5%.4 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 dartos pedicled flap, posterior sagittal approach, transanal approach, posterior trans-sphincteric  approach  or  modified  York-Mason  method,  use  of  rectal advancement flaps, gracilis flaps or omental transposition.5  In view of the large size of the recto urethral fistula in this patient he underwent simple prostatectomy with rectal repair and omental interposition. This case is being reported as Tuberculosis causing a recto-urethral fistula is extremely rare.      

Conclusion  

Spontaneous tubercular recto-prostatic urethral 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 Acid  Fast  Bacilli  may  be  negative  and  only  prostatic  and  testicular  biopsies  may prove the diagnosis. Hence in recto-urethral fistulas there should be a high index of suspicion of Tuberculosis especially in countries where it is endemic.

Meet The Experts: 

Dr Mohan Keshavamurthy 

Dr Shakir Tabrez

Dr Prem Kumar

Dr Sreeharsha H

Dr Karthik Rao

Dr Mohan BA

Learn More - https://www.sciencedirect.com/science/article/pii/S2214442020302448

Specialities

Neurology

Urology

Gastroenterology

Orthopaedic

Hematology

Transplant programme