Incidental Tubercular Prostatitis Diagnosed After TURP in a Patient with BPH: A Case Report

Incidental Tubercular Prostatitis Diagnosed After TURP in a Patient with BPH: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Incidental Tubercular Prostatitis Diagnosed After TURP in a Patient with BPH: A Case Report Dr. Ankush Nayyar, Dr. Romilla Mittal This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7129965/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Benign prostatic hyperplasia (BPH) is common in elderly men, but tubercular involvement of the prostate is rare. This case emphasizes the need for vigilance when encountering atypical intraoperative findings. A 65-year-old male presented with lower urinary tract symptoms attributed to BPH. He underwent transurethral resection of the prostate (TURP). Intraoperatively, purulent pockets were noted. Histopathological evaluation of resected prostate chips revealed granulomatous inflammation. Ziehl-Neelsen stain confirmed the presence of acid-fast bacilli, leading to a diagnosis of tubercular prostatitis. Tubercular prostatitis can present incidentally during routine surgical management of BPH. Histopathological examination is crucial for diagnosis, particularly in endemic areas. Histopathological review of TURP specimens can reveal rare coexisting conditions like tubercular prostatitis in patients with typical BPH. Lower urinary tract symptoms (LUTS) benign prostatic hyperplasia (BPH) Tubercular prostatitis Figures Figure 1 Figure 2 Figure 3 Introduction Benign prostatic hyperplasia is characterized by the proliferation of smooth muscle and epithelial cells within the prostatic transition zone (1), a common occurrence in aging men. Pathological studies indicate that BPH affects a significant proportion, with incidence rates reaching up to 80% in men over 60 (1). Clinically, BPH manifests as lower urinary tract symptoms, encompassing a range of obstructive and irritative voiding difficulties that can substantially reduce the quality of life (1).Granulomatous prostatitis, while less common, can also impact the prostate. Diagnosis often relies on histopathological examination due to its potential to mimic other conditions, including carcinoma and BPH. It's important for pathologists to be aware of this condition to avoid potential misdiagnosis (2). Granulomatous prostatitis, a relatively uncommon inflammatory condition of the prostate gland, presents a diagnostic challenge due to its diverse etiologies and potential for mimicking malignancy. The causes of granulomatous prostatitis vary considerably, encompassing infectious, iatrogenic, systemic, and idiopathic factors (3). Despite its rarity, awareness of this condition is essential to avoid misdiagnosis and ensure appropriate management (4). Case presentation A 65-year-old male presented to the urology clinic with complaints of urinary frequency, urgency, and nocturia. His medical history was significant for benign prostatic hyperplasia, for which he had been receiving conservative management. Patient was diabetic. There was no history of fever, weight loss, or night sweats. Upon examination, the patient exhibited mild suprapubic tenderness. Digital rectal examination revealed an enlarged, non-tender prostate. Laboratory tests, including a complete blood count and urinalysis, showed no significant abnormalities. A prostate-specific antigen (PSA) test was performed, yielding a mildly elevated result. Physical examination revealed a moderately enlarged, smooth, symmetrically enlarged prostate on digital rectal examination with no palpable nodularity. Vital signs were within normal limits and there were no signs of systemic illness. Given the long-standing LUTS and physical findings consistent with BPH, the patient was scheduled for transurethral resection of the prostate (TURP) to manage his obstructive urinary symptoms. Initial laboratory studies, inclusive of a complete blood count (CBC), serum creatinine, blood urea nitrogen (BUN), and prostate-specific antigen (PSA), were within normal limits except for a marginally elevated PSA (4.8 ng/mL), which was attributed to the patient’s BPH. The patient’s chest radiograph was unremarkable. Urinalysis did not reveal pyuria or hematuria. An ultrasound of the kidneys and bladder demonstrated an enlarged prostate measuring approximately 50 grams, with no evidence of hydronephrosis. During the TURP procedure, the patient underwent a standard resection for presumed BPH. Intraoperative findings were largely in keeping with the expected appearance of BPH tissue; however, the surgical team noted the unexpected presence of small pockets of purulent exudate within the prostatic tissue. This purulent material was observed in several resection areas. Due to the primary presumption of benign hyperplasia and the unexpected nature of the intraoperative findings, the purulent material was not sent for bacteriological or mycobacterial cultures. Multiple prostate chips were collected and subsequently submitted for histopathological analysis. Microscopic evaluation of the resected tissue revealed few well-circumscribed granulomas composed of epithelioid histiocytes, Langhans-type multinucleated giant cells, and a central zone of caseous necrosis. Figure 1 and 2 show Histopathological images of the granulomas in prostatic tissue. Other tissue bits showed biphasic proliferation of benign prostatic glands and benign stroma of prostate, indicating presence of Benign Prostate Hyperplasia. Special staining with Ziehl-Neelsen stain highlighted the presence of acid-fast bacilli in the areas showing granulomatous inflammation, providing definitive evidence of tuberculous infection. Figure 3 shows presence of Acid Fast Bacilli. In addition to granulomatous inflammation, majority of benign prostatic tissue consistent with BPH was also observed. The dual pathology confirmed the incidental diagnosis of tuberculous prostatitis in a patient primarily treated for BPH. Following the histopathological confirmation of tubercular prostatitis, the patient was initiated on standard anti-tubercular therapy (ATT) as per national guidelines. The patient was monitored during and after completion of therapy. At both 2-month and 6-month follow-ups, he reported resolution of urinary symptoms and no new complaints. Timeline: - Initial presentation with LUTS: Month 0 - TURP performed: Week 3 - Histopathological diagnosis of tubercular prostatitis: Week 4 - ATT initiation: Week 4 - Follow-up at 2 months: Patient showed significant symptomatic improvement - Follow-up at 6 months: Patient remained asymptomatic and stable Patient Perspective: The patient expressed satisfaction and relief upon receiving a diagnosis and effective treatment after months of unresolved urinary symptoms. Discussion The prostate gland is susceptible to various benign and malignant conditions that can present with similar clinical and imaging characteristics. (5). Benign Prostatic Hyperplasia is a common age-related condition characterized by the proliferation of smooth muscle and epithelial cells in the prostate's transition zone (1). Granulomatous prostatitis (GP) is an uncommon inflammatory condition of the prostate, accounting for less than 1% of all prostate specimens examined histopathologically (6). It holds clinical significance as it can mimic prostate cancer or coexist with benign prostatic hyperplasia (BPH), thereby complicating both diagnosis and management (5). BPH is characterized by the benign enlargement of the prostate gland and commonly presents with lower urinary tract symptoms (LUTS) such as urinary retention, hesitancy, and nocturia. Although BPH is a non-malignant condition, its clinical and radiological features can overlap with those of tubercular prostatitis, making differential diagnosis particularly challenging (7). GP is defined histologically by the presence of granulomas within the prostate tissue and may arise from either non-specific or specific etiologies. The most prevalent variant is non-specific granulomatous prostatitis (NSGP), which is typically idiopathic but has been linked to prior infections or autoimmune responses (6). Specific forms of GP include tubercular prostatitis, caused by Mycobacterium tuberculosis, which represents a rare manifestation of extrapulmonary tuberculosis (7). Another subtype is allergic or iatrogenic granulomatous prostatitis, which may result from immune-mediated reactions, particularly following intravesical Bacillus Calmette-Guérin (BCG) therapy used in the treatment of bladder cancer (8). Notably, tubercular prostatitis remains a rare clinical entity, even in areas where tuberculosis is endemic (9). Tubercular prostatitis is a rare form of extrapulmonary TB, which accounts for approximately 10-15% of all TB cases in endemic regions (10). Extrapulmonary TB can affect various organs, including the genitourinary system, including prostate. However, prostate is an uncommon site for tuberculosis (TB) infection, primarily due to a combination of anatomical, physiological, and immunological factors. Hematogenous spread of Mycobacterium tuberculosis to the prostate is rare, largely because the gland has a relatively low blood supply and oxygen tension, both of which are unfavorable for mycobacterial proliferation 7). Additionally, the fibromuscular stroma and glandular architecture of the prostate are less supportive of M. tuberculosis growth compared to other tissues (9). The organ's unique immune microenvironment may also play a role in limiting bacterial colonization and dissemination (10). The diagnosis of tubercular prostatitis is often delayed, as its clinical presentation mimics BPH and prostate cancer. Patients typically present with LUTS, such as urinary retention, dysuria, and hematuria, which are non-specific and can lead to misdiagnosis or missed diagnosis (7). Radiological investigations, such as ultrasound and MRI, often reveal non-specific findings, such as hypoechoic lesions or irregular prostate contours, which are not of much help and can further complicate the diagnosis (5). Even biochemical markers like PSA have limited use because it can be elevated in both BPH and tubercular prostatitis (6). Given the limitations of radiological imaging and biochemical tests in accurately identifying tubercular prostatitis, histopathological examination remains the definitive diagnostic modality. The presence of hallmark features such as presence of granulomas and Langhans-type giant cells on histology is characteristic of tubercular prostatitis(7). Further, presence of Acid fast bacilli serves to confirm the diagnosis with high specificity.Additionally, molecular tests, such as the cartridge-based nucleic acid amplification test (CBNAAT), can confirm the presence of Mycobacterium tuberculosis in prostate tissue (9). However in our case, this could not be done as the specimen was received in formalin. The diagnosis relied on histopathology and identification of AFB on ZN stain. In Table 1 we have enumerated a comparison of the three conditions of prostate which can be confusing to diagnose and differentiate. Table1 : Comparison of Key Features of Tubercular Prostatitis, BPH, and Prostate Cancer Feature Tubercular Prostatitis Benign Prostatic Hyperplasia (BPH) Prostate Cancer Incidence Rare, even in endemic regions (9,10) Common in aging men, affecting up to 90% by age 80 (6) Varies by population, higher in older men (6) Clinical Presentation LUTS, such as urinary retention, dysuria, and hematuria (7,10) LUTS, such as urinary hesitancy, nocturia, and weak stream (6) LUTS, hematuria, and palpable prostate nodules (6) Radiological Findings Hypoechoic lesions on TRUS, non-specific mpMRI findings (5) Enlarged prostate with heterogeneous echotexture on TRUS (6) Suspicious lesions on MRI, often with high PIRADS scores (5) Histopathological Features Caseating granulomas and Langhans-type giant cells (7,10) Benign prostatic nodular hyperplasia (6) Malignant glandular and stromal changes (6) Diagnostic Challenges Non-specific symptoms and radiological findings, requiring histopathological confirmation (7,1) Overlapping symptoms with other prostate conditions (7) Elevated PSA levels and suspicious imaging findings Conclusion This case underscores the importance of considering rare pathological entities such as tubercular prostatitis, even in patients presenting with typical features of benign prostatic hyperplasia. While BPH remains a common cause of lower urinary tract symptoms in elderly males, the incidental histopathological discovery of granulomatous inflammation with acid-fast bacilli in this case highlights the diagnostic value of routine histopathological examination of TURP specimens. Given the overlapping clinical presentations and non-specific imaging findings, tuberculosis of the prostate may easily go unrecognized. Diagnosis by histopathology is essential for initiating anti-tubercular therapy and avoiding potential complications. Clinicians and pathologists alike should maintain a high index of suspicion for such dual pathologies to ensure comprehensive patient management. Declarations Learning Point: This case underscores the importance of histopathological analysis of TURP specimens to detect rare coexisting pathologies like tubercular prostatitis. Compliance with Ethical Standards: Funding: No Funding was obtained Informed Consent: Informed written consent was obtained from the patient for publication of this case report and accompanying images. Informed Consent/Consent to Participate: Written Informed Consent was taken from patient for participation. Informed Consent/Consent to Publish: Written Informed Consent was taken from patient for publication. Conflict of Interest: All Authors declare that they have no conflict of interest. Ethical approval: All procedures performed in studies involving human participants were in accordance with the research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by Indus Institutional review board for Research and Publication. Clinical trial number: not applicable No conflicts exist for the specified authors No Funding or grants where taken Ethical approval: All procedures performed in studies involving human participants were in accordance with the research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by Indus Institutional review board for Research and Publication. Informed Consent/Consent to Participate: Written Informed Consent was taken from patient for participation. Informed Consent/Consent to Publish: Written Informed Consent was taken from patient for publication. No prior abstract publication/presentation was done Acknowledgment of all authors' contribution(s) to the research and manuscript: Dr. Ankush Nayyar- Preparation of manuscript, Diagnosis of the case Dr. Romilla Mittal- Preparation of manuscript, Diagnosis of the case References Lerner LB, McVary KT, Barry MJ, Bixler BR, Dahm P, Das AK, et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia—AUA guideline part I—initial work-up and medical management. J Urol. 2021;206(4):806–17. doi:10.1097/ju.0000000000002183 Crocetto F, Barone B, De Luca L, Creta M. Granulomatous prostatitis—A challenging differential diagnosis to take into consideration. Future Oncol. 2020;16(13):805–6. doi:10.2217/fon-2020-0185 Kumbar R, Dravid N, Nikumbh D, Patil A, Nagappa KG. Clinicopathological overview of granulomatous prostatitis—An appraisal. J Clin Diagn Res. 2016;10(1):EC20–EC23. doi:10.7860/jcdr/2016/15365.7146 Al-Naimi A, Karzoun MZ, Abdelfattah O, Ibrahim T. Granulomatous and xanthogranulomatous prostatitis—A case report. Urol Case Rep. 2021;40:101887. doi:10.1016/j.eucr.2021.101887 Bertelli E, Zantonelli G, Cinelli A, Pastacaldi S, Agostini S, Neri E, et al. Granulomatous prostatitis, the great mimicker of prostate cancer—Can multiparametric MRI features help in this challenging differential diagnosis? Diagnostics (Basel). 2022;12(10):2302. doi:10.3390/diagnostics12102302 Gunawardene WDMC, Abeygunasekera A, Sosai C. Granulomatous prostatitis—Clinicopathological overview and review of the literature. Sri Lanka J Urol. 2024;15(1):14–25. doi:10.4038/slju.v15i1.4108 Sysoev PG, Khrabrov IS, Kiryanov NA, Mukhametova NT, Burdikina SA. Features of prostate tuberculosis in a 60-year-old male patient. Bull Contemp Clin Med. 2024;17(5):125–9. doi:10.20969/vskm.2024.17(5).125-129 Gaudiano C, Corcioni B, Ciccarese F, Bianchi L, Schiavina R, Droghetti S, et al. Multiparametric magnetic resonance imaging for the differential diagnosis between granulomatous prostatitis and prostate cancer—A literature review to an intriguing diagnostic challenge. Front Oncol. 2023;13:1178430. doi:10.3389/fonc.2023.1178430 Rawat S, Singh AK, Singh A, Verma A, Sagar M. Prostate tuberculosis masquerading as prostate carcinoma—A rare case report. Cureus. 2022;14(11):e30978. doi:10.7759/cureus.30978 Mishra KG, Ahmad A, Singh G, Tiwari RK. Tuberculosis of the prostate gland masquerading prostate cancer—Five cases experience at IGIMS. Urol Ann. 2019;11(4):389–92. doi:10.4103/UA.UA_119_18 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7129965","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":501777610,"identity":"7bb5737a-afda-4138-9349-7655047271a6","order_by":0,"name":"Dr. Ankush Nayyar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIiWNgGAWjYFACNgYGxgYYpwKImZkbcCrGouUMSAuCS4QWxjYwiV8L/+y2NMmfOxjy+GfkGH6unFcbzd8O1PKjYhtOLRJ3jh2T5j3DUCxxI8dY8uy247kzDjM2MPacuY3bmhvpbdJA9yQ23MgxkGzcdiy3AaiFmbENtxZ5oBbJn0At84G2/Gyccyx3PiEtBjfSjknwArVsuJFjJtnYUJO7gZAWwxtpyda8bRKJG888K7NsOHYgdyNQy0F8fpG7kWZ482ebTeK848mbbzbU1OXOO3/44IMfFXi8DwESDAwCGQZAxmEw9wAh9RDAf/wBkKwjTvEoGAWjYBSMKAAAx8tf/D8VnBsAAAAASUVORK5CYII=","orcid":"","institution":"Consultant Pathology Atulaya Labs and Research \u0026 Publications Officer, Indus International Hospital Mohali","correspondingAuthor":true,"prefix":"Dr.","firstName":"Ankush","middleName":"","lastName":"Nayyar","suffix":""},{"id":501777612,"identity":"9865b3a8-31fc-4bd6-944c-8ad24f974603","order_by":1,"name":"Dr. Romilla Mittal","email":"","orcid":"","institution":"Atulaya LabsMohali","correspondingAuthor":false,"prefix":"Dr.","firstName":"Romilla","middleName":"","lastName":"Mittal","suffix":""}],"badges":[],"createdAt":"2025-07-15 11:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7129965/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7129965/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89654534,"identity":"2894abd7-57ce-4fd3-88f4-eac41c255bd4","added_by":"auto","created_at":"2025-08-22 10:19:20","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":944703,"visible":true,"origin":"","legend":"\u003cp\u003eLow power View of many well formed granulomas in prostate\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7129965/v1/4bf2652f1f8d54ed2c27d3ac.jpeg"},{"id":89654536,"identity":"631a19fe-6a39-4628-8532-a3b267691f05","added_by":"auto","created_at":"2025-08-22 10:19:20","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":553749,"visible":true,"origin":"","legend":"\u003cp\u003eHigh power view of the granulomas composed of lymphocytes, Epithelioid cells, Langhans type of Giant cell\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7129965/v1/8a5cd528346a90f137c5ff7c.jpeg"},{"id":89654539,"identity":"6128bf9d-6be9-44d2-bdee-3dde3159600f","added_by":"auto","created_at":"2025-08-22 10:19:20","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":231036,"visible":true,"origin":"","legend":"\u003cp\u003eAFB stain showing presence of acid fast bacilli\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7129965/v1/fc265b0445394e449c06f511.jpeg"},{"id":92091339,"identity":"f6da377b-0802-4339-add0-7b8b54ffc93a","added_by":"auto","created_at":"2025-09-24 13:39:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2214247,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7129965/v1/f11c5fa3-077a-4888-8bba-f7e4c6dc64af.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eIncidental Tubercular Prostatitis Diagnosed After TURP in a Patient with BPH: A Case Report\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBenign prostatic hyperplasia is characterized by the proliferation of smooth muscle and epithelial cells within the prostatic transition zone (1), a common occurrence in aging men. Pathological studies indicate that BPH affects a significant proportion, with incidence rates reaching up to 80% in men over 60 (1). Clinically, BPH manifests as lower urinary tract symptoms, encompassing a range of obstructive and irritative voiding difficulties that can substantially reduce the quality of life (1).Granulomatous prostatitis, while less common, can also impact the prostate. Diagnosis often relies on histopathological examination due to its potential to mimic other conditions, including carcinoma and BPH. It\u0026apos;s important for pathologists to be aware of this condition to avoid potential misdiagnosis (2). Granulomatous prostatitis, a relatively uncommon inflammatory condition of the prostate gland, presents a diagnostic challenge due to its diverse etiologies and potential for mimicking malignancy. The causes of granulomatous prostatitis vary considerably, encompassing infectious, iatrogenic, systemic, and idiopathic factors (3). Despite its rarity, awareness of this condition is essential to avoid misdiagnosis and ensure appropriate management (4).\u0026nbsp;\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 65-year-old male presented to the urology clinic with complaints of urinary frequency, urgency, and nocturia. His medical history was significant for benign prostatic hyperplasia, for which he had been receiving conservative management. Patient was diabetic. There was no history of fever, weight loss, or night sweats.\u003c/p\u003e\n\u003cp\u003eUpon examination, the patient exhibited mild suprapubic tenderness. Digital rectal examination revealed an enlarged, non-tender prostate. Laboratory tests, including a complete blood count and urinalysis, showed no significant abnormalities. A prostate-specific antigen (PSA) test was performed, yielding a mildly elevated result.\u003c/p\u003e\n\u003cp\u003ePhysical examination revealed a moderately enlarged, smooth, symmetrically enlarged prostate on digital rectal examination with no palpable nodularity. Vital signs were within normal limits and there were no signs of systemic illness. Given the long-standing LUTS and physical findings consistent with BPH, the patient was scheduled for transurethral resection of the prostate (TURP) to manage his obstructive urinary symptoms.\u003c/p\u003e\n\u003cp\u003eInitial laboratory studies, inclusive of a complete blood count (CBC), serum creatinine, blood urea nitrogen (BUN), and prostate-specific antigen (PSA), were within normal limits except for a marginally elevated PSA (4.8 ng/mL), which was attributed to the patient\u0026rsquo;s BPH. The patient\u0026rsquo;s chest radiograph was unremarkable. Urinalysis did not reveal pyuria or hematuria. An ultrasound of the kidneys and bladder demonstrated an enlarged prostate measuring approximately 50 grams, with no evidence of hydronephrosis.\u003c/p\u003e\n\u003cp\u003eDuring the TURP procedure, the patient underwent a standard resection for presumed BPH. Intraoperative findings were largely in keeping with the expected appearance of BPH tissue; however, the surgical team noted the unexpected presence of small pockets of purulent exudate within the prostatic tissue. This purulent material was observed in several resection areas. Due to the primary presumption of benign hyperplasia and the unexpected nature of the intraoperative findings, the purulent material was not sent for bacteriological or mycobacterial cultures.\u003c/p\u003e\n\u003cp\u003eMultiple prostate chips were collected and subsequently submitted for histopathological analysis.\u003c/p\u003e\n\u003cp\u003eMicroscopic evaluation of the resected tissue revealed few well-circumscribed granulomas composed of epithelioid histiocytes, Langhans-type multinucleated giant cells, and a central zone of caseous necrosis. Figure 1 and 2 show Histopathological images of the granulomas in prostatic tissue. Other tissue bits showed biphasic proliferation of benign prostatic glands and benign stroma of prostate, indicating presence of Benign Prostate Hyperplasia. Special staining with Ziehl-Neelsen stain highlighted the presence of acid-fast bacilli in the areas showing granulomatous inflammation, providing definitive evidence of tuberculous infection. Figure 3 shows presence of Acid Fast Bacilli. In addition to granulomatous inflammation, majority of benign prostatic tissue consistent with BPH was also observed. The dual pathology confirmed the incidental diagnosis of tuberculous prostatitis in a patient primarily treated for BPH.\u003c/p\u003e\n\u003cp\u003eFollowing the histopathological confirmation of tubercular prostatitis, the patient was initiated on standard anti-tubercular therapy (ATT) as per national guidelines.\u003c/p\u003e\n\u003cp\u003eThe patient was monitored during and after completion of therapy. At both 2-month and 6-month follow-ups, he reported resolution of urinary symptoms and no new complaints.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTimeline:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;- Initial presentation with LUTS: Month 0\u003cbr\u003e\u0026nbsp;- TURP performed: Week 3\u003cbr\u003e\u0026nbsp;- Histopathological diagnosis of tubercular prostatitis: Week 4\u003cbr\u003e\u0026nbsp;- ATT initiation: Week 4\u003cbr\u003e\u0026nbsp;- Follow-up at 2 months: Patient showed significant symptomatic improvement\u003cbr\u003e\u0026nbsp;- Follow-up at 6 months: Patient remained asymptomatic and stable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Perspective:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient expressed satisfaction and relief upon receiving a diagnosis and effective treatment after months of unresolved urinary symptoms.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe prostate gland is susceptible to various benign and malignant conditions that can present with similar clinical and imaging characteristics. (5). Benign Prostatic Hyperplasia is a common age-related condition characterized by the proliferation of smooth muscle and epithelial cells in the prostate\u0026apos;s transition zone (1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGranulomatous prostatitis (GP) is an uncommon inflammatory condition of the prostate, accounting for less than 1% of all prostate specimens examined histopathologically (6). It holds clinical significance as it can mimic prostate cancer or coexist with benign prostatic hyperplasia (BPH), thereby complicating both diagnosis and management (5). BPH is characterized by the benign enlargement of the prostate gland and commonly presents with lower urinary tract symptoms (LUTS) such as urinary retention, hesitancy, and nocturia. Although BPH is a non-malignant condition, its clinical and radiological features can overlap with those of tubercular prostatitis, making differential diagnosis particularly challenging (7).\u003c/p\u003e\n\u003cp\u003eGP is defined histologically by the presence of granulomas within the prostate tissue and may arise from either non-specific or specific etiologies. The most prevalent variant is non-specific granulomatous prostatitis (NSGP), which is typically idiopathic but has been linked to prior infections or autoimmune responses (6). Specific forms of GP include tubercular prostatitis, caused by Mycobacterium tuberculosis, which represents a rare manifestation of extrapulmonary tuberculosis (7). Another subtype is allergic or iatrogenic granulomatous prostatitis, which may result from immune-mediated reactions, particularly following intravesical Bacillus Calmette-Gu\u0026eacute;rin (BCG) therapy used in the treatment of bladder cancer (8). Notably, tubercular prostatitis remains a rare clinical entity, even in areas where tuberculosis is endemic (9).\u003c/p\u003e\n\u003cp\u003eTubercular prostatitis is a rare form of extrapulmonary TB, which accounts for approximately 10-15% of all TB cases in endemic regions (10). Extrapulmonary TB can affect various organs, including the genitourinary system, including prostate. However, prostate is an uncommon site for tuberculosis (TB) infection, primarily due to a combination of anatomical, physiological, and immunological factors. Hematogenous spread of Mycobacterium tuberculosis to the prostate is rare, largely because the gland has a relatively low blood supply and oxygen tension, both of which are unfavorable for mycobacterial proliferation 7). Additionally, the fibromuscular stroma and glandular architecture of the prostate are less supportive of M. tuberculosis growth compared to other tissues (9). The organ\u0026apos;s unique immune microenvironment may also play a role in limiting bacterial colonization and dissemination (10).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe diagnosis of tubercular prostatitis is often delayed, as its clinical presentation mimics BPH and prostate cancer. Patients typically present with LUTS, such as urinary retention, dysuria, and hematuria, which are non-specific and can lead to misdiagnosis or missed diagnosis (7). Radiological investigations, such as ultrasound and MRI, often reveal non-specific findings, such as hypoechoic lesions or irregular prostate contours, which are not of much help and can further complicate the diagnosis (5). Even biochemical markers like PSA have limited use because it can be elevated in both BPH and tubercular prostatitis (6). Given the limitations of radiological imaging and biochemical tests in accurately identifying tubercular prostatitis, histopathological examination remains the definitive diagnostic modality. The presence of hallmark features such as presence of granulomas and Langhans-type giant cells on histology is characteristic of tubercular prostatitis(7). Further, presence of Acid fast bacilli serves to confirm the diagnosis with high specificity.Additionally, molecular tests, such as the cartridge-based nucleic acid amplification test (CBNAAT), can confirm the presence of Mycobacterium tuberculosis in prostate tissue (9). However in our case, this could not be done as the specimen was received in formalin. The diagnosis relied on histopathology and identification of AFB on ZN stain.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn Table 1 we have enumerated a comparison of the three conditions of prostate which can be confusing to diagnose and differentiate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable1 : Comparison of Key Features of Tubercular Prostatitis, BPH, and Prostate Cancer\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFeature\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTubercular Prostatitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eBenign Prostatic Hyperplasia (BPH)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eProstate Cancer\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eIncidence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRare, even in endemic regions (9,10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCommon in aging men, affecting up to 90% by age 80 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eVaries by population, higher in older men (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Presentation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLUTS, such as urinary retention, dysuria, and hematuria (7,10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLUTS, such as urinary hesitancy, nocturia, and weak stream (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLUTS, hematuria, and palpable prostate nodules (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRadiological Findings\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHypoechoic lesions on TRUS, non-specific mpMRI findings (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEnlarged prostate with heterogeneous echotexture on TRUS (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSuspicious lesions on MRI, often with high PIRADS scores (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHistopathological Features\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCaseating granulomas and Langhans-type giant cells (7,10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBenign prostatic nodular hyperplasia (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMalignant glandular and stromal changes (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnostic Challenges\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNon-specific symptoms and radiological findings, requiring histopathological confirmation (7,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOverlapping symptoms with other prostate conditions (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eElevated PSA levels and suspicious imaging findings\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case underscores the importance of considering rare pathological entities such as tubercular prostatitis, even in patients presenting with typical features of benign prostatic hyperplasia. While BPH remains a common cause of lower urinary tract symptoms in elderly males, the incidental histopathological discovery of granulomatous inflammation with acid-fast bacilli in this case highlights the diagnostic value of routine histopathological examination of TURP specimens. Given the overlapping clinical presentations and non-specific imaging findings, tuberculosis of the prostate may easily go unrecognized. Diagnosis by histopathology is essential for initiating anti-tubercular therapy and avoiding potential complications. Clinicians and pathologists alike should maintain a high index of suspicion for such dual pathologies to ensure comprehensive patient management.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eLearning Point:\u003c/strong\u003eThis case underscores the importance of histopathological analysis of TURP specimens to detect rare coexisting pathologies like tubercular prostatitis.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eCompliance with Ethical Standards: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding: \u003c/strong\u003eNo Funding was obtained\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent: \u003c/strong\u003eInformed written consent was obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent/Consent to Participate:\u003c/strong\u003e Written Informed\u0026nbsp;Consent was taken from patient for participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent/Consent to Publish:\u003c/strong\u003e Written Informed\u0026nbsp;Consent was taken from patient for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e All Authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval: \u003c/strong\u003eAll procedures performed in studies involving human participants were in accordance with the research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003eThe study was approved by \u003cstrong\u003eIndus Institutional review board for Research and Publication.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e not applicable\u003c/p\u003e\n\u003cp\u003eNo conflicts exist for the specified authors\u003cbr\u003e\u0026nbsp;\u003cbr\u003eNo Funding or grants where taken\u003c/p\u003e\n\u003cp\u003eEthical approval: All procedures performed in studies involving human participants were in accordance with the research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003eThe study was approved by \u003cstrong\u003eIndus Institutional review board for Research and Publication.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed Consent/Consent to Participate: Written Informed\u0026nbsp;Consent was taken from patient for participation.\u003c/p\u003e\n\u003cp\u003eInformed Consent/Consent to Publish: Written Informed\u0026nbsp;Consent was taken from patient for publication.\u003c/p\u003e\n\u003cp\u003eNo prior abstract publication/presentation was done\u003cbr\u003e\u0026nbsp;\u003cbr\u003eAcknowledgment of all authors\u0026apos; contribution(s) to the research and manuscript:\u003c/p\u003e\n\u003cp\u003eDr. Ankush Nayyar- Preparation of manuscript, Diagnosis of the case\u003c/p\u003e\n\u003cp\u003eDr. Romilla Mittal- Preparation of manuscript, Diagnosis of the case\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLerner LB, McVary KT, Barry MJ, Bixler BR, Dahm P, Das AK, et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia\u0026mdash;AUA guideline part I\u0026mdash;initial work-up and medical management. J Urol. 2021;206(4):806\u0026ndash;17. doi:10.1097/ju.0000000000002183\u003c/li\u003e\n\u003cli\u003eCrocetto F, Barone B, De Luca L, Creta M. Granulomatous prostatitis\u0026mdash;A challenging differential diagnosis to take into consideration. Future Oncol. 2020;16(13):805\u0026ndash;6. doi:10.2217/fon-2020-0185\u003c/li\u003e\n\u003cli\u003eKumbar R, Dravid N, Nikumbh D, Patil A, Nagappa KG. Clinicopathological overview of granulomatous prostatitis\u0026mdash;An appraisal. J Clin Diagn Res. 2016;10(1):EC20\u0026ndash;EC23. doi:10.7860/jcdr/2016/15365.7146\u003c/li\u003e\n\u003cli\u003eAl-Naimi A, Karzoun MZ, Abdelfattah O, Ibrahim T. Granulomatous and xanthogranulomatous prostatitis\u0026mdash;A case report. Urol Case Rep. 2021;40:101887. doi:10.1016/j.eucr.2021.101887\u003c/li\u003e\n\u003cli\u003eBertelli E, Zantonelli G, Cinelli A, Pastacaldi S, Agostini S, Neri E, et al. Granulomatous prostatitis, the great mimicker of prostate cancer\u0026mdash;Can multiparametric MRI features help in this challenging differential diagnosis? Diagnostics (Basel). 2022;12(10):2302. doi:10.3390/diagnostics12102302\u003c/li\u003e\n\u003cli\u003eGunawardene WDMC, Abeygunasekera A, Sosai C. Granulomatous prostatitis\u0026mdash;Clinicopathological overview and review of the literature. Sri Lanka J Urol. 2024;15(1):14\u0026ndash;25. doi:10.4038/slju.v15i1.4108\u003c/li\u003e\n\u003cli\u003eSysoev PG, Khrabrov IS, Kiryanov NA, Mukhametova NT, Burdikina SA. Features of prostate tuberculosis in a 60-year-old male patient. Bull Contemp Clin Med. 2024;17(5):125\u0026ndash;9. doi:10.20969/vskm.2024.17(5).125-129\u003c/li\u003e\n\u003cli\u003eGaudiano C, Corcioni B, Ciccarese F, Bianchi L, Schiavina R, Droghetti S, et al. Multiparametric magnetic resonance imaging for the differential diagnosis between granulomatous prostatitis and prostate cancer\u0026mdash;A literature review to an intriguing diagnostic challenge. Front Oncol. 2023;13:1178430. doi:10.3389/fonc.2023.1178430\u003c/li\u003e\n\u003cli\u003eRawat S, Singh AK, Singh A, Verma A, Sagar M. Prostate tuberculosis masquerading as prostate carcinoma\u0026mdash;A rare case report. Cureus. 2022;14(11):e30978. doi:10.7759/cureus.30978\u003c/li\u003e\n\u003cli\u003eMishra KG, Ahmad A, Singh G, Tiwari RK. Tuberculosis of the prostate gland masquerading prostate cancer\u0026mdash;Five cases experience at IGIMS. Urol Ann. 2019;11(4):389\u0026ndash;92. doi:10.4103/UA.UA_119_18\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Lower urinary tract symptoms (LUTS), benign prostatic hyperplasia (BPH), Tubercular prostatitis","lastPublishedDoi":"10.21203/rs.3.rs-7129965/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7129965/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Benign prostatic hyperplasia (BPH) is common in elderly men, but tubercular involvement of the prostate is rare. This case emphasizes the need for vigilance when encountering atypical intraoperative findings. A 65-year-old male presented with lower urinary tract symptoms attributed to BPH. He underwent transurethral resection of the prostate (TURP). Intraoperatively, purulent pockets were noted. Histopathological evaluation of resected prostate chips revealed granulomatous inflammation. Ziehl-Neelsen stain confirmed the presence of acid-fast bacilli, leading to a diagnosis of tubercular prostatitis. Tubercular prostatitis can present incidentally during routine surgical management of BPH. Histopathological examination is crucial for diagnosis, particularly in endemic areas. Histopathological review of TURP specimens can reveal rare coexisting conditions like tubercular prostatitis in patients with typical BPH.","manuscriptTitle":"Incidental Tubercular Prostatitis Diagnosed After TURP in a Patient with BPH: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-22 10:19:15","doi":"10.21203/rs.3.rs-7129965/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"51ed58b7-b67e-40b8-bdab-031068ceb1fd","owner":[],"postedDate":"August 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-24T13:38:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-22 10:19:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7129965","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7129965","identity":"rs-7129965","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}