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CASE REPORT
Year : 2006  |  Volume : 22  |  Issue : 3  |  Page : 264-265
 

Wegener's granulomatosis of urinary tract presenting as bladder outlet obstruction


Departments of Urology, Rheumatology and Pathology, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India

Correspondence Address:
PVLN Murthy
Dept of Urology, Nizam's Institute of Medical Sciences, Hyderabad - 500 080
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-1591.27638

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   Abstract 

We report a rare case of Wegener's granulomatosis involving the prostate gland in a 45-year-old male who presented with acute urinary retention. Treatment was initiated with oral cyclophosphamide and steroids. The prostate size regressed in four weeks and patient voided well after removal of catheter.


Keywords: Wegener′s granulomatosis and urinary tract


How to cite this article:
Suryaprakash V, Murthy P, Liza R, Ch. Ramreddy, Srinivas N, Prayag A. Wegener's granulomatosis of urinary tract presenting as bladder outlet obstruction. Indian J Urol 2006;22:264-5

How to cite this URL:
Suryaprakash V, Murthy P, Liza R, Ch. Ramreddy, Srinivas N, Prayag A. Wegener's granulomatosis of urinary tract presenting as bladder outlet obstruction. Indian J Urol [serial online] 2006 [cited 2019 Jun 18];22:264-5. Available from: http://www.indianjurol.com/text.asp?2006/22/3/264/27638



   Introduction Top


Wegener's granulomatosis (WG) is a systemic granulomatous vasculitis affecting medium and small arteries, arterioles and venules. The disease primarily involves the respiratory tract and kidneys. The other organ systems commonly involved include the skin, joints, heart and nervous system. In rare cases when it involves the genito-urinary tract, it most frequently affects the prostate. The initial treatment of choice for WG of the prostate is medical. Surgical treatment can be indicated and in one published series, transurethral resection of the prostate (TURP) was performed in 15% of cases of WG with prostate involvement.[1]


   Case report Top


A 45-year-old diabetic male presented with breathlessness, streaky hemoptysis of one-month duration. He also complained of obstructive voiding symptoms in the form of poor urinary stream, hesitancy and straining of one-month duration and was catheterized for acute urinary retention two days prior to hospital admission. Patient also had intermittent low-grade fever and significant loss of weight in the past four months. Earlier, he was diagnosed to have chronic maxillary sinusitis and antral washes were done for the same. On examination, bronchial breathing with crepitations was noted in the left infrascapular region. Abdominal examination was normal and digital rectal examination (DRE) showed Grade III hard prostate mimicking malignancy.

Blood picture showed polymorphonuclear leucocytosis. Urine examination showed traces of albumin and 8-10 pus cells. Ultrasound abdomen revealed bilateral Grade I renal parenchymal changes, thickened bladder wall and enlarged prostate (60 gm). Serum PSA was 0.52 ng/ml. Contrast enhanced computerized tomography (CECT) of para-nasal sinuses and chest showed pan-sinusitis with bony erosions, multiple patchy and nodular hyper-attenuated areas involving lung parenchyma. CECT abdomen revealed an infarct in spleen, normal upper urinary tracts and enlarged prostate [Figure - 1] . All these features were suggestive of classic Wegener's granulomatosis. Antineutrophil cytoplasmic antibodies (C-ANCA) were strongly positive.

Bronchoscopy showed diffuse inflammation of tracheo-bronchial tree with white patches and cystourethroscopy showed white patches over the lateral lobes of prostate. The prostatic enlargement was obstructive as the lateral lobes were meeting in the midline for a length of about 3 cm. Bladder interior showed Grade II trabeculations and white patches on lateral walls. Transrectal biopsy of prostate and cold cup biopsies from bladder mucosa revealed necrotizing granulomatous vasculitis consistent with Wegener's granulomatosis [Figure - 2]a and b . Patient was treated with cyclophosphamide 1 mg/kg/day and prednisolone 60 mg/day. His symptoms improved significantly. Foley's catheter was removed after four weeks. Uroflowmetry showed good peak flow (12.4 ml/sec) and DRE revealed marked reduction in the size of prostate. On a subsequent visit, he was found to have subglotic stenosis, sensorineural deafness and later was lost to follow-up. We presume that he died of systemic manifestations of the disease.


   Discussion Top


Wegener's granulomatosis is an uncommon disease characterized by granulomatous vasculitis of the upper and lowers respiratory tract along with glomerulonephritis. The histological hallmarks of WG are necrotizing vasculitis of small arteries and veins along with granuloma formation. Urogenital manifestations of the disease described in the literature include acute urinary retention, hematuria and urinary tract infections related to prostatitis,[2] ureteral stenosis, bladder psuedotumor orchitis and penile ulceration.[3] Prostate involvement is demonstrated histologically in 2-7% of the patients.[4]

While nonspecific granulomatous inflammation is mostly found in these cases, a similar histological picture may also be caused by more specific conditions such as tuberculosis, blastomycosis,  Brucellosis More Details and chronic prostatitis. Such findings have also been reported following bacilli Calmette-Guerin treatment of bladder cancer.[5]

The diagnosis of WG was made after the prostatic biopsy in the present case. Anticytoplasmic antibodies are highly specific for the diagnosis of active WG.

A trial of aggressive medical therapy should be tried before contemplating surgery for prostate as most cases respond to medical treatment. Very few patients require TURP when presented with bladder outlet obstruction (BOO).[1],[6] The most effective therapy is oral cyclophosphamide along with prednisolone. Cyclophosphamide will be given for one year following remission and gradually tapered. Prednisolone is gradually tapered and discontinued after six months.

We present a patient in whom WG was diagnosed primarily because of prostate involvement which is a rare manifestation. Symptoms of BOO may sometimes precede the onset of other organ systemic disease but before contemplating TURP, time should be allowed for the immunosuppressive agents to work.

 
   References Top

1.Khattak AO, Nair M, Haqqani MT, Williamson EP. Wegener's granulomatosis: Prostatic involvement and recurrent urinary tract infections. BJU Int 1999;84:531-2.   Back to cited text no. 1    
2.Gaber KA, Ryley NG, Macdermott JP, Goldman JM. Wegener's granulomatosis involving prostate. Urology 2005;66:195.   Back to cited text no. 2    
3.Huong DL, Papo T, Piette JC, Wechsler B, Bletry O, Richard F, et al . Urogenital manifestations of Wegener's granulomatosis. Medicine (Baltimore) 1995;74:152-61.  Back to cited text no. 3    
4.Mundinger A, Pumpe K, Grosser G, Herbst EW, Grotz W, Kropelin T. Primary manifestation of Wegener's granulomatosis of the prostate. Urologe A 1989;28:234-6.  Back to cited text no. 4    
5.Gunnarsson R, Omdal R, Kjellevold KH, Ellingsen CL. Wegener's granulomatosis of the prostate gland. Rheumatol Int 2004;24:120-2.  Back to cited text no. 5    
6.Stillwell TJ, DeRemme RA, Mc Donald TJ, Weiland LH, Engen DE. Prostatic involvement in Wegener's granulomatosis. J Urol 1987;138:1251-3.   Back to cited text no. 6    


    Figures

  [Figure - 1], [Figure - 2]



 

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