|Year : 2015 | Volume
| Issue : 3 | Page : 189-193
Condyloma acuminata of the bladder in benign prostatic obstruction: Case report and review of literature
Emmanuel Ajibola Jeje1, Moses Adebisi Ogunjimi1, Taiwo Opeyemi Alabi1, Nicholas Awodele Awolola2, Rufus Wale Ojewola1
1 From the Urology Unit, Department of Surgery, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Morbid Anatomy, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria
|Date of Web Publication||30-Nov-2015|
Taiwo Opeyemi Alabi
From the Urology Unit, Department of Surgery, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos
Source of Support: None, Conflict of Interest: None
Condyloma acuminata (CA) is a warty lesion caused by the sexually transmitted human papillomavirus that most commonly affects external genitalia and mucocutaneous junctions. Involvement of the urinary tract (UT) is rare. Anogenital CA is considered a predisposition for urethral and subsequently bladder involvement. Isolated urinary bladder involvement is thought to be due to immunosuppression. A 60-year-old man presented with progressively worsening lower UT symptoms, which culminated in acute urinary retention due to histologically proven benign prostatic obstruction (BPO). He had neither cutaneous nor anogenital CA, and viral markers were unremarkable. He had failed a trial of voiding without catheter and had simple prostatectomy 2 years later. Findings at surgery included an enlarged prostate with prominent median lobe and a sessile, warty lesion of 1.2 cm in the widest diameter found incidentally at the dome of the bladder, which turned out to be CA after histopathological analysis of excisional biopsy specimen. CA of the urethra is uncommon while that of the bladder is rare. CA of the bladder without preceding anorectal CA or immunosuppression is uncommon. There is no report of CA of the bladder in BPO till date. Complete surgical excision is the preferred option of management except when not practicable.
Keywords: Anogenital, condyloma acuminata, obstruction, papilloma, prostatic
|How to cite this article:|
Jeje EA, Ogunjimi MA, Alabi TO, Awolola NA, Ojewola RW. Condyloma acuminata of the bladder in benign prostatic obstruction: Case report and review of literature. Niger Postgrad Med J 2015;22:189-93
|How to cite this URL:|
Jeje EA, Ogunjimi MA, Alabi TO, Awolola NA, Ojewola RW. Condyloma acuminata of the bladder in benign prostatic obstruction: Case report and review of literature. Niger Postgrad Med J [serial online] 2015 [cited 2021 May 6];22:189-93. Available from: https://www.npmj.org/text.asp?2015/22/3/189/170737
| Introduction|| |
Condyloma acuminata (CA) is a warty lesion that most commonly affects external genitalia and mucocutaneous junctions. Involvement of the urinary tract (UT) is rare. The causative organism is the sexually transmitted human papillomavirus (HPV). Our review of literature revealed that 40 cases of CA of the UT have been reported in English literatures till date, 22 (55%) of these had a preceding anogenital CA, while 18 (45%) had isolated UT CA. Anogenital CA is considered a predisposition for urethral and subsequently bladder involvement. Isolated urinary bladder involvement is thought to be due to immunosuppression. Thirteen (32.5%) of the reported cases were immunocompetent, 12 (30.0%) were immunocompromised, while the immune status was not stated in 15 cases. We report a case of an incidentally discovered CA of the urinary bladder in an immunocompetent patient with benign prostatic obstruction (BPO).
| Case Report|| |
A 60-year-old man presented to the urology clinic of Lagos University Teaching Hospital, Lagos with a 2-week history of progressively worsening lower UT symptoms, which culminated into acute urinary retention. There was no history of haematuria. He was a known hypertensive and diabetic, both were well controlled on oral medications. He had no cutaneous or anogenital warts and no other abnormality on general physical examination. Digital rectal examination revealed an enlarged prostate with benign features.
His haemogram as well as electrolytes, urea and creatinine were essentially normal. However, the prostate-specific antigen (PSA) was found to be elevated (14.86 ng/ml). He was not reactive to HIV 1 and 2 as at the time of the test. Hepatitis and venereal disease research laboratory screenings were negative. Abdominopelvic ultrasound scan showed an enlarged prostate with volume of 50 ml and prominent median lobe with homogenous peripheral zone and heterogeneous transition zone. The bladder was grossly distended with 1.5 L of urine and had a thickened wall. There was hydroureter and hydrocalycosis with grade I renal parenchymal disease. He had suprapubic cystostomy on account of failed urethral catheterization. He was subsequently discharged on oral antibiotics and tamsulosin to the urological outpatient care. Retrograde urethrogram showed a patent urethra with an elevated bladder base. Prostate biopsy done on account of the elevated PSA revealed benign prostatic hyperplasia with prostatitis.
The diagnosis of BPO was made. He had failed medical therapy and had unsuccessful urethral catheterization necessitating suprapubic cystostomy. He was on monthly suprapubic catheter change due to inability to afford surgery. He finally had transvesical prostatectomy 2 years after presentation. Intra-operative findings included prominent median lobe of the prostate with a sessile, warty lesion of 1.2 cm in the widest diameter located at the dome of the bladder. The lesion was excised with 2 cm margin and the defect closely primarily. Histology report of the enucleated prostatic tissue revealed fibromuscular and glandular hyperplasia, whereas that of the excised warty lesion revealed papillary fronds lined by hyperplastic and metaplastic squamous epithelium with koilocytosis (perinuclear halos), wrinkled nuclei and binucleated cells [Figure 1]. There was variable atypia, but no anaplasia seen. This was consistent with CA [Figure 2] and [Figure 3].
|Figure 1: Low power photomicrograph showing normal transitional epithelial mucosa of the bladder (upper fragment) and condyloma (lower fragment) (H and E, ×40)|
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|Figure 2: Medium power photomicrograph of the lower tissue fragment in Figure 1 showing mucosal papillary fronds lined by hyperplastic and metaplastic squamous epithelium|
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|Figure 3: High power photomicrograph showing squamous epithelial koilocytosis (with perinuclear halo and nuclear atypia), wrinkled nuclei and binucleated cells (H and E, ×400)|
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| Literature Review and Discussion|| |
CA of the external genitalia, perineum and anal region is a common disease but its involvement of the UT is considered to be rare. Forty cases of UT involvement have been reported in English literature till date. The clinical data on these reported cases obtained from our literature search are as depicted in [Table 1] and [Table 2]. Male to female ratio was 1.6:2.4, while the age range was 4–96 years. Female preponderance was also reported by Batta et al. Preceding anogenital lesion is thought to be an important predisposition for distal urethral involvement. However, posterior urethra and bladder are believed to be involved by retrograde inoculation of the organism during procedures such as urethral catheterization or cystoscopy. Of the 24 females with UT CA, 16 had preceding anogenital CA, whereas only 5 out of 16 male patients had preceding anogenital CA. This shows that preceding anogenital CA might be a more important predisposition in females than males due to shorter urethra in females.
|Table 2: CA involvement of other parts of UT with or without urinary bladder|
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The lower UT is most commonly involved; this occurred in 39 out of 40 cases. The only reported ureteric involvement had concomitant bladder involvement. No isolated ureteric involvement has been reported till date, which further reinforces the theory of retrograde spread. The urinary bladder was involved in 38 (95%) out of 40 reported cases. There could be an isolated bladder involvement or in association with other part(s) of the UT. Isolated bladder involvement was seen in 27 (69.2%) out of 39 cases of lower UT involvement [Table 1] and also constitutes 67.5% of all (40) cases of CA involving the UT. Fourteen (51.9%) out of these 27 with isolated bladder involvement had preceding anogenital CA. Isolated bladder involvement was more common in females; 20 (74.1%) out of 27 cases. Thirteen (65%) out of these 20 cases in females had preceding anogenital CA. Only 7 males had isolated bladder involvement, of these, just two had anogenital CA. Concomitant bladder and urethral involvement occurred in only 11 (28.9%) out of 38 cases of bladder involvement. Of these, 4 (36.4%) occurred in females, while 7 (63.6%) occurred in males. All the four females had preceding anogenital CA. This shows that anogenital CA might be less important as a predisposing factor in males compared to females due to a longer urethra and less contiguity of the external urethral meatus with the perineum and anogenital region in males.
Immunodeficiency has long been implicated as a predisposing factor for UT CA most especially in the setting of isolated bladder involvement without a preceding anogenital CA. Out of the 27 patients with urinary bladder CA presented in the [Table 1], 9 (33.3%) were immunocompetent, 8 (29.6%) immunocompromised, whereas the immune status was not stated in 10 (37.0%) patients. Our case report was one of the few immunocompetent patients with condyloma of the bladder without any associated anogenital CA. He had monthly suprapubic catheter change for about 2 years and one would think of inoculation of the bladder epithelium with the organism carried by the urethral catheter. Our patient never had successful urethral catheterization possibly because of the very prominent median lobe of the prostate. Nevertheless, there was neither mucocutaneous nor anogenital CA lesion seen in him which could be regarded as the source of this organism. There may probably be another mechanism of spread of this sexually transmitted infection to the UT, which is yet to be understood.
Grossly, CA of the UT commonly appears as papillary to polypoid lesion. This appearance was found in 37.5% (15 cases). Nevertheless, patchy/flat (3 cases) as well as sessile (3 cases) appearances representing 7.5% each have also been reported. Others did not describe the gross appearance in their reports. The index case, however, showed a sessile wart at the dome of the bladder.
More than 70 HPV strains have been identified. They are classified into high (16, 18, 45, 46), intermediate (30, 31, 33, 34, 35, 39, 40, 49, 51, 52, 53, 57, 58, 63, 64) and low (6, 11, 42, 43, 44, 59, 66, 68, 70) risk HPV DNA types based on their oncogenic potentials. Eleven (27.5%) out of the 40 cases reported in the literature had HPV DNA analysis done and majority (81.8%) of these eleven cases had HPV 6/11 DNA. The remaining two cases reported 16/18 and 56/58 HPV DNA. Some workers have reported the presence of HPV DNA in bladder tumours. Nonetheless, no cause-effect relationship has been established between HPV and bladder cancer as it has been with HPV and cervical cancer.
Various therapeutic options have been explored. Surgery is most commonly used; 15 (37.5%) of the reported cases had transurethral resection, 10 (25.0%) cystectomies, 2 (5.0%) cystectomies plus urethrectomy and 4 (10.0%) had pelvic exenteration. Other modalities of treatment reported include chemo-radiation (1 case), immunotherapy (1 case), electrocautery (1 case) and palliation (3 cases).
CA is generally considered to be prone to recurrence. This is why, except when not practicable, complete surgical excision is the treatment of choice. Eight (20%) cases reported recurrence, 4 (50%) out of these were females who all had concomitant anogenital CA. Whereas of the four males with disease recurrence, only one (25%) had concomitant anogenital CA. Our patient also had complete resolution of his bladder CA after complete surgical excision.
| Conclusion|| |
CA of the UT is a rare condition with greater female preponderance. The lower UT is most commonly affected, with the urinary bladder involvement being the most common. No single case of isolated upper UT involvement has been reported till date. Anogenital CA is considered an important predisposing factor for CA of the UT. The infection is believed to spread retrogradely from these anogenital foci to involve the UT. Nevertheless, many cases of isolated bladder involvement without a concomitant anogenital CA clearly indicates that there must be another mechanism of involvement of the UT apart from this retrograde spread theory, especially in men. Immunodeficiency has been implicated as another predisposing factor. Complete surgical excision is the most favoured treatment modality. CA of the UT is prone to recurrence hence follow-up of the patient is highly essential.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]
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