Candida prostatitis: A rare entity

Abstract

Prostatitis may present with lower urinary tract symptoms (LUTS) attributable to acute and chronic bacterial infections (NIH Category I/II) or as asymptomatic inflammatory prostatitis (NIH Category IV). Patients with chronic prostatitis/chronic pelvic pain syndrome, (CP/CPPS, NIH Category III) may present with a wide range of symptoms resulting from varied etiology, however, seldom caused by fungal infections. Occasional case reports have been published on prostatitis due to Candida sp. We report a case of an elderly diabetic patient who underwent perurethral prostatic resection (TURP) for benign prostatic hyperplasia (BPH) and returned with complaints of LUTS and perineal discomfort one month later. After repeat surgery, the TURP chips on histopathology showed features of prostate hyperplasia and prostatitis with numerous hyphae and yeast forms of Candida admixed with acute and chronic inflammatory exudate. After confirmation by special stains and positive urine culture, a final diagnosis of prostatic candidiasis was made.

Keywords

Fungal infection diagnosis urologic

Introduction

Prostatitis is a commonly encountered condition in urologic practice. Infections due to bacterial causes are well documented in the literature but fungal infection is less commonly seen.^1–8 Candida albicans is the commonly detected species in most cases though infections due to Candida glabrata and Candida krusei have also been reported.^1,4 Aspergillus fumigatus, Cryptococcus neoformans, Coccidioides immitis, and Histoplasma capsulatum are among the other rarer causes.^1–4

Case report

A 60-year-old known diabetic presented with complaints of obstructive LUTS and hematuria for 6 months. A TURP was performed and histology showed BPH. He was relieved of symptoms after surgery and was discharged. He again presented after a month with complaints of urinary retention and perineal discomfort. There was mild tenderness on rectal examination. Urinalysis showed 20–30 erythrocytes and 30–40 leucocytes per HPF and a urine sample after prostate massage was sent for culture and sensitivity. An MRI prostatic scan revealed heterogenous nodular appearance in the residual transition zone on T2WI (T2 weighted Images) with minimal post-contrast enhancement and no restriction of diffusion. A repeat TURP procedure was therefore performed. Resection chips demonstrated features of nodular hyperplasia of prostate along with prostatitis on histology. There were focal areas of necrosis (Figure 1(a)) and dense areas of acute-on-chronic inflammation and numerous hyphae and budding forms of approximately 2–4 μ in diameter; consistent with the morphology of Candida, further confirmed on special stains (Figure 1(b) to (d)). Subsequently, urine culture also grew Candida albicans, concluding a final diagnosis of Candida prostatitis (Figure 1(e)). Our patient never experienced any systemic symptoms at any time. He was treated with antifungals and discharged after subsidence of symptoms.

Figure 1.

(a) Focal areas of necrosis with preserved prostatic tissue, H&E stain, 400×; (b) hyphae and budding yeast forms of candida, H&E stain, 400×; (c) hyphae and budding yeast forms of candida, silver methenamine stain, 1000×; (d) hyphae and budding yeast forms of candida, PAS stain, 400×; (e) budding yeast forms, Gram stain, 1000×.

Discussion

TURP is routinely accompanied by prophylactic antibiotic therapy and post-procedural catheterization. An association of fungal infection with catheterization and use of broad-spectrum antibiotics is well known.^1–4 In addition, immunosuppression and comorbidity in elderly patients favor the growth of fungi. Fungal prostatic infections are, however, relatively uncommon and prostatitis due to Candida sp. is even rarer² (Table 1). Most infections are due to C. albicans.^1–3

Table 1.

Case reports on prostate infections due to Candida sp. in literature.

Cases reported in literature	No. of cases	Comorbid condition	Radiology	Clinical presentation	Diagnosis
Wise et al. (2006)	5
	Case 1	Diabetic ketoacidosis	Ultrasound-emphysematous changes in bladder and prostate	60y/M, suprapubic discomfortMinimally enlarged, nontender prostate	C. albicans
	Case 2	Insulin-dependent diabetes, PVD, antibiotic therapy	CT (computed tomography)—large prostate with multiple fluid-filled densities and dilated seminal vesicles	66y/M, dysuria, frequency, feverSoft, large, nontender prostate	C. tropicalis
	Case 3	Insulin-dependent diabetes, antibiotic therapy	CT—prostatic abscess	72y/M, urinary retention, feverEnlarged prostate	C. albicans
	Case 4	Broad spectrum antibiotics	MRI (magnetic resonance imaging)—enlarged prostate and numerous abscesses	47y/M, perineal pain, fever, purulent urethral discharge, retropubic pain and tendernessEnlarged and painful prostate	C. albicans, C. krusei
	Case 5	Insulin-dependent diabetes	Transrectal ultrasound—well defined hypoechoic area within capsule of prostate	66y/M, feverEnlarged and boggy prostate	C. albicans, C. glabrata
Septimus et al. (2006)	1	Catheterization, broad spectrum antibiotics	-	57y/M, urinary retention, dysuriaBoggy, mildly tender prostate	C. albicans
Demirci et al. (2018)	1	Nil	Ultrasound: enlarged prostate of volume 33cc	51y/M, frequency, perineal and suprapubic pain, weak urine stream, white particles in urine	C. glabrata
Present case (2021)	1	Diabetes, catheterization, broad spectrum antibiotics	MRI: enlarged prostate	60y/M, BOO (bladder outlet obstruction) symptoms, HematuriaMildly tender prostate	C. albicans

Fungal prostatitis may provoke no symptoms, may produce LUTS, or can even mimic and co-exist with prostate cancer. Diagnosis can be established by positive urine, semen, or blood cultures or the presence of yeast or hyphae forms in biopsy specimens.¹ Good response to antifungal regimes is seen, but if left untreated, a prostatic abscess or dissemination, particularly in immunocompromised patients, may occur.

Footnotes

Authors’ contribution

Shabnam Singh was involved in writing paper, literature search, and compilation. Meeta Singh was involved in writing, editing, and reporting histopathology. Lovenish Bains was involved in clinical supervision, surgery, and treatment. Tanu Sagar was involved in urine routine and culture reporting.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article

ORCID iDs

Meeta Singh

Tanu Sagar

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