Most cases of male genital tuberculosis are secondary to renal tuberculosis, with a smaller proportion resulting from hematogenous dissemination. The initial lesions often occur in the prostate and seminal vesicles, eventually spreading to the epididymis and testicles via the vas deferens. Isolated tuberculosis of the prostate or seminal vesicles frequently lacks obvious clinical symptoms due to the concealed nature of these structures, making detection difficult. However, epididymal tuberculosis is more clinically apparent and is often recognized by patients and physicians.
Pathology
The pathological changes in male genital tuberculosis are similar to those of general tuberculosis, characterized by tuberculous granulomas, caseous necrosis, cavitation, and fibrosis, while calcification is rare. Tuberculous abscesses of the prostate may rupture into the urethra, resulting in cavitation of the posterior urethra with irregular edges. Fibrosis of the prostate and seminal vesicles may form hard nodules. Tuberculosis of the vas deferens can lead to lumen obstruction, with thickening and hardening of the vas deferens. In epididymal tuberculosis, the lesion often starts at the tail of the epididymis, presenting with caseous necrosis, abscess formation, and fibrosis that may involve the entire epididymis. In cases of hematogenous infection, about 70% of patients with epididymal tuberculosis have a history of pulmonary tuberculosis. Epididymal tuberculosis often affects the tunica vaginalis and scrotal wall, with abscess rupture leading to the formation of long-lasting fistulas. Testicular tuberculosis is usually a direct extension of epididymal tuberculosis.
Clinical Manifestations
The age of onset for male genital tuberculosis is similar to that for renal tuberculosis, with most cases occurring between 20 and 40 years of age. Tuberculous epididymitis may be the initial or sole clinical manifestation of genitourinary tuberculosis. Symptoms of tuberculosis involving the prostate and seminal vesicles are typically inconspicuous, with occasional discomfort in the rectum or perineal region. In severe cases, hematospermia, reduced semen volume, sexual dysfunction, infertility, and perianal fistulas may occur. Digital rectal examination may reveal hard nodules in the prostate or seminal vesicles, typically without tenderness. Epididymal tuberculosis usually has a slow onset, presenting with scrotal swelling, discomfort, or a sense of heaviness. When the vas deferens is involved, it becomes thickened, with painless nodules or a "beaded" appearance. In cases of cold abscesses with secondary infection, redness, swelling, and pain of the scrotum may develop. Rupture of the abscess may lead to chronic non-healing fistulas. Bilateral lesions can result in infertility.
Diagnosis
In cases with the above clinical manifestations, digital rectal examination revealing hard nodules in the prostate or seminal vesicles, or palpable indurations in the epididymis, male genital tuberculosis should be considered. Comprehensive evaluation of the urinary system for tuberculosis lesions is essential. Diagnostic tests include urinalysis, acid-fast bacilli tests in urine, Mycobacterium tuberculosis cultures, and intravenous urography to rule out renal tuberculosis. Mycobacterium tuberculosis may occasionally be detected in prostatic fluid or semen. Urethrography may reveal deformity or dilation of the prostatic urethra, with contrast medium entering cavitary lesions in the prostate.
Differential Diagnosis
Epididymal tuberculosis should be distinguished from nonspecific chronic epididymitis and tumors. Epididymal tuberculosis often presents with irregular hard masses, a slow progression, and a thickened, "beaded" vas deferens. Adhesion of the affected epididymis to the skin or the presence of scrotal fistulas makes diagnosing epididymal tuberculosis less difficult. Nonspecific chronic epididymitis rarely causes localized hard masses, does not typically involve adhesion to the scrotal skin, and often has a history of acute inflammation or concurrent chronic prostatitis. Ultrasound is helpful in differentiating epididymal tuberculosis from testicular tumors. Prostate tuberculosis should be differentiated from nonspecific prostatitis and prostate cancer.
Treatment
Early-stage epididymal tuberculosis can often be cured with anti-tuberculosis pharmacological therapy. In cases with severe lesions, poor treatment outcomes, abscess formation, or scrotal fistulas, epididymectomy or orchiectomy may be necessary alongside drug therapy. Maximum efforts are made to preserve as much epididymal and testicular tissue as possible. Tuberculosis of the prostate and seminal vesicles is generally managed with anti-tuberculosis medication and does not typically require surgical intervention. Any other tuberculous lesions in the genitourinary system, such as renal tuberculosis or epididymal tuberculosis, should also be addressed.