Lower urinary tract symptoms are the common reason for presentation to the urologist of men from their middle ages and beyond. This is common as a result of prostatic diseases such as benign prostate enlargement or prostate cancer. Other conditions that could cause LUTS in this age group include, but less often, urethral stricture, lumbar spondylosis, and neurogenic bladder. Prostate schistosomiasis is often not considered as a possible differential diagnosis of LUTS or even BOO due to its rarity. Thus, it underscores the need for a high index of suspicion. In the two index cases, this was not considered until the histology finding confirmed the diagnosis. The ages of the index cases at presentation are well in keeping with the time of manifestations of LUTS as seen in the patients. However, to determine what the concurrent presence of BPE and prostate schistosomiasis contribute to LUTS and its severity may be difficult. In any case, LUTS in these patients may be due to BPH or prostate schistosomiasis, or both. Prostate schistosomiasis will better explain the severity of LUTS in the younger patient. This can also be a subject of debate. But it is worthy of note that patients who had childhood exposure to acute urinary schistosomiasis may be presenting in adulthood with sequelae of the chronic or fibrotic type which occur late in the disease progression (Barsoum 2013). The effects of prostate fibrosis with involvement of bladder neck will cause bladder neck stenosis and subsequent BOO. This pathologic process can also explain the LUTS in the patients (Bushman and Jerde 2016).
In addition, this pathology may even be the underlying reason why benign prostatic hyperplasia (BPH) patients who ought to have benefited from medical therapy often fail as seen in the index patients. Fibrotic prostate is a recognized cause of failed medical therapy. Failed medical therapy as shown by the development of recurrent urinary retention was one of the reasons the patients were prepared for the bipolar transurethral resection of the prostate (TURP). This choice of treatment has the advantage of addressing the static component of the BPH, at the same time widening the bladder neck, thus minimizing the LUTS due to bladder neck stenosis from prostate schistosomiasis. One can argue that the known treatment options of bladder neck stenosis depend on whether the stenosis is a primary or secondary type. The common treatment options include urethral dilation, endoscopic bladder neck incisions, stenting, or abdominoperineal reconstruction of the bladder neck (Nicholson et al. 2017). These treatments are suitable for isolated causes of bladder neck stenosis. In combined bladder neck stenosis with BPH as may be the case here, we considered bipolar TURP a suitable option in their management due to the resolution of LUTS during the follow-up visit. Although one of the index cases was lost to follow-up, he could have also benefited from bipolar transurethral resection of the prostate, since he also had urinary retention due to failed medical therapy for his lower urinary tract symptoms. The reason for the loss to follow-up in the index case was not clear. However, financial constraints to the planned surgery may be likely because many patients still rely on out-of-pocket spending for their treatment.
Also, the fibrotic prostate may clinically feel hard. The digital rectal examination in one of the patients revealed enlarged, hard, and nodular prostate with obliterated median groove as well as restricted mobility of overlying rectal mucosa. Although this patient’s PSA was 1.2 ng/ml, we had a high index of suspicion of prostate cancer due to abnormal DRE until the histology result proved otherwise. Abnormal DRE and normal or low serum level of PSA can also be seen in patients on medical treatment with 5 α reductase inhibitors such as dutasteride for BPH and patients with neuroendocrine prostate cancers. The recurrent prostate inflammation from schistosomal induced prostatitis can cause elevation of PSA as seen in one of the patients. This could explain the drop in the PSA from the initial value of 31.0 ng/ml to 7.5 ng/ml after antibiotic treatment observed in one of the patients. The elevated PSA which is a useful diagnostic tool of prostatic disease patient evaluation can pose a diagnostic challenge. This creates the wrong impression of a sinister condition of the prostate such as prostate cancer at presentation. It may unnecessarily expose patients to prostate biopsy with its attendant complications.
Prostate schistosomiasis can have a varied presentation. Since one of the index cases had clinical findings while the other biochemical finding suggestive of prostate cancer. Hence, prostate schistosomiasis is a diagnosis of exclusion. The significance of unrecognized prostate schistosomiasis is the attendant pathological changes caused in the prostate leading to bladder neck stenosis, BOO, and eventually obstructive nephropathy. We advocate for early decision and surgical treatment particularly minimally invasive like TURP, especially where facilities are available. The open surgical intervention in these patients may be fraught with difficulties due to background myofibrous prostate stroma as demonstrated in Figs. 1 and 2.
Sokoto is endemic for urinary schistosomiasis (Singh et al. 2016). It may explain the high burden of urological conditions associated with schistosomal endemicity here, such as upper tract calculi, lower ureteric obstruction post-schistosomal lower ureteral fibrosis, and bladder cancer of squamous histologic preponderance (Mungadi and Malami 2007; Aminu et al. 2014; Mungadi and Khalid 2021). Probably, a good number of these cases of prostate schistosomiasis may go undiagnosed since not all patients treated for LUTS due to BPE medically or at times surgically have the benefit of the histologic diagnosis. Also, in chronic stage schistosomiasis, Schistosoma ova may not be seen. Therefore, a high index of suspicion is required by the urologist practicing in a schistosomal endemic environment to exclude schistosomiasis of the prostate as a differential diagnosis of patients presenting with LUTS or BOO.