Malakoplakia prostate presenting as urinary retention: a report of two cases and review of the literature
- Swaroop Subbaraya ,
- Ajit Sawant ,
- Prakash Pawar and
- Sunil Patil
- Department of Urology, LTMMC & GH, Mumbai, Maharashtra, India
- Correspondence to Dr Swaroop Subbaraya; swaroop0appu@gmail.com
Abstract
Malakoplakia is a rare chronic inflammatory condition, which primarily occurs in genitourinary tract, with prostatic malakoplakia being extremely rare. We present two cases of acute urinary retention, with clinically firm nodular prostate and a raised serum prostate-specific antigen. Transrectal ultrasound-guided prostatic biopsy showed features of malakoplakia. There was a significant reduction of size of prostate on transrectal ultrasonography after 4 weeks of antibiotics. However, one patient had failed trial without catheter and was subjected to transurethral resection of prostate. The biopsy of the prostatic chips also showed features of malakoplakia. Other patient improved symptomatically after antibiotics and was managed conservatively. Both the patients are on regular follow-up and are asymptomatic. Prostatic malakoplakia presenting as urinary retention is very uncommon with around 12 cases in the literature. Recognition of prostatic malakoplakia is important because clinically it can masquerade prostatic malignancy. Treatment with antibiotics is necessary before subjecting the patients for surgery in patients with obstructive symptoms.
Background
Malakoplakia is a rare granulomatous inflammatory condition, which most commonly involves the urinary bladder and it is considered to develop as a result of a defective immune response to bacterial agents. Malakoplakia is a rare disorder worldwide, with less than 1000 patients diagnosed in the USA yearly.1 Prostatic malakoplakia is extremely rare and has been documented in about 50 cases, mostly in individual case reports or small cases series.2 Out of these reported cases, only 12 cases presented with urinary retention. It is important to identify malakoplakia of prostate as it clinically mimics prostatic malignancy and it can be treated conservatively with antibiotics before subjecting patient for surgery.
Case presentation
Case 1
A 75-year-old man with no comorbidities presented with acute painful urinary retention and a history of lower urinary tract symptoms with predominantly voiding symptoms since 1 month. On examination, patient had palpable tender bladder and grade 3 prostatomegaly, which was nodular, firm in consistency and mucosa was free. 14 Fr/urethral catheterisation was done.
Case 2
A 63-year-old man with diabetes mellitus since 10 years on regular treatment with oral hypoglycaemic drugs was referred to us with a history of acute urinary retention and foleys insertion. Patient gives history of lower urinary tract symptoms since 4 months with both voiding and storage symptoms with dysuria. On per rectal examination, patient had grade 2 firm to hard prostate with nodules in left lobe and rectal mucosa was free. Patient had a 14 Fr/urethral catheter in situ.
Investigations
Case 1
Urine culture yielded Escherichia coli growth and was sensitive to ciprofloxacin. Serum prostate-specific antigen (Serum PSA) was 4.6 (done after 1 week of retention). Prostate size was 88cc on transrectal ultrasonography (TRUS) and TRUS biopsy showed features of malakoplakia without any evidence of malignancy. As malakoplakia may be associated with prostatic adenocarcinoma, a multiparametric MRI of prostate was done, which showed thickened peripheral zone with major part showing diffuse T2 hypointensity and ill-defined T2 hypointense nodules with central hyper intensity within, but some of them show restricted diffusion and corresponding low ADC values without any abnormal enhancement on postcontrast scans. Transitional and central zone were bulky with heterogeneously hyperintense on T2. These features were not consistent with prostatic malignancy (figure 1).
MRI prostate showing thickened peripheral zone with major part showing diffuse T2 hypo intensity and ill-defined T2 hypointense nodules with central hyper intensity.
Case 2
Urine culture yielded E. coli growth and was sensitive to ciprofloxacin. Serum PSA was 11.3 and prostate was 57cc on TRUS. TRUS biopsy showed features suggestive of malakoplakia (figure 2) without any evidence of malignancy.
(A) Von Hansemann cells in PAS stain (iron). B) Michaelis Gutmann bodies stained with Von kossa stain (calcium).
Treatment
Case 1
Patient was started with ciprofloxacin 500 mg two times a day and Tab.Tamsulosin 0.4 mg. After a period of 4 weeks, per rectal examination revealed grade 1 prostate, and patient’s TRUS (figure 3) revealed a decrease in size of prostate (35cc). Patient voided after catheter removal but with low flow rates and severe LUTS. Patient was managed with transurethral resection of prostate. On cystoscopy, there was one and half field obstructing lateral lobes and trabeculated bladder. Prostatic chips sent for HPE showed features suggestive of malakoplakia (figure 4) without any evidence of malignancy. Foley’s catheter was removed after 3 days of surgery, patient voided without any reports.
Transrectal ultrasonography of prostate showed reduction in size of prostate (35cc).
Michaelis Gutmann bodies with H&E stain showing typical owl eye appearance.
Case 2
Patient was treated with ciprofloxacin and tamsulosin for 4 weeks. After which patient had grade 1 prostate on per-rectal examination and 28cc prostate on TRUS. There was a significant decrease in the size. Patient was given trial voiding without catheter and he voided with good flow rates and with a postvoid residue of 15cc.
Outcome and follow-up
Case 1
Foley’s catheter was removed after 3 days of surgery and patient voided without any reports. Urine culture was done after 4 weeks during follow-up, which was negative. Patient is on regular follow-up since 6 months and is asymptomatic.
Case 2
Patient is on regular follow-up and is on Tamsulosin 0.4 mg. Culture done at 1 month was negative and serum PSA was 2.8 after 1 year. Patient is asymptomatic for past 1.5 years.
Discussion
The initial description of malakoplakia was done in a bladder specimen by Michaelis and Gutmann.1 3However, the term ‘malakoplakia’ was coined by Von Hansemann in 1903, which means ‘soft plaque’. On gross examination a soft, yellow plaque in the bladder was noted. On microscopic examination, they identified small cytoplasmic basophilic inclusions resulting in a targetoid appearance. These targetoid cells are named after Von Hansemann and the inclusions are called Michaelis-Gutmann bodies.1 4 Malakoplakia is a very rare disease. The genitourinary tract is the most commonly affected system and bladder being the most commonly affected organ.1 5 It can affect other organs like lung, skin, uterus, liver, bone, colon and stomach. Carruthers et al described the first case of prostatic malakoplakia in 1959. This location is extremely rare and has been documented in about 50 cases, mostly in individual case reports or small case series.1 2 6 7 Only 12 of these cases have presented with urinary retention (table 1) .
Cases of malakoplakia prostate in literature presenting with urinary retention
| Cases in literature | Age | Culture | Management | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| TURP, Transurethral Resection of Prostate. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Hoffman et al12 | 74 | Sterile | Open prostatectomy | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Coup13 | 72 | Sterile | Septran + stilboestrol | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Kawamura et al14 | 53 | E. coli | Sulfamethoxazole-trimethoprim. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 55 | E. coli | Antibiotics | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Liu et al15 | 78 | E. coli | TURP + b/l orchiectomy | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Sarma et al16 | 60 | – | Open prostatectomy | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Gorgel et al8 | – | E. coli | TURP | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Guner et al17 | 72 | – | Radical prostatectomy | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Medlicott et al2 | 60 | – | Radical prostatectomy | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Pablo et al7 | 60 | – | TURP | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 67 | – | Open prostatectomy | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 70 | E. coli | TURP | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ethics statements
Footnotes
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Contributors SS: Did extensive research of literature, planning and management of the cases and follow up of the cases. AS and PP: Planning and management of the case. SP: Planning and management of the case and inputs in writing manuscript.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.
References
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