A 72-year-old Indian man with a 3-week history of severe perineal pain, dysuria, and fever (38.5°C) presents to the emergency department. He reports recent urinary retention and has been on intermittent catheterization for 2 days. Digital rectal examination reveals a tender, boggy, swollen prostate. Urinalysis shows pyuria and bacteriuria (E. coli isolated). Serum PSA is 8.2 ng/mL. Transrectal ultrasound shows hypoechoic areas within the prostate with no discrete mass. A needle biopsy is performed. What is the most likely histopathological finding?

Explanation

## Diagnosis: Acute Bacterial Prostatitis ### Clinical Presentation This patient presents with the acute prostatitis triad: 1. **Systemic symptoms:** fever, malaise 2. **Lower urinary tract symptoms:** dysuria, urinary retention 3. **Perineal/rectal pain:** severe, localized 4. **Risk factor:** recent catheterization (instrumentation) 5. **Microbiological evidence:** E. coli in urine and culture ### Histopathological Features of Acute Bacterial Prostatitis | Feature | Acute Prostatitis | BPH | Adenocarcinoma | TB Prostatitis | |---------|-------------------|-----|----------------|----------------| | **Inflammation** | Acute (PMN-rich) | Absent | Minimal/absent | Chronic (lymphocytes, granulomas) | | **Glandular architecture** | Preserved | Hyperplastic nodules | Infiltrative, disrupted | Destroyed, caseation | | **Causative organism** | Bacteria (E. coli, Klebsiella) | None | None | Mycobacterium tuberculosis | | **Cytologic atypia** | Absent | Absent | Present | Absent | | **PSA level** | Elevated (acute phase) | Normal–mildly elevated | Often >4 ng/mL | Elevated | | **Imaging** | Hypoechoic, edematous | Uniform enlargement | Focal lesion/asymmetry | Cavitation, calcification | **Key Point:** Acute bacterial prostatitis is characterized by **acute suppurative inflammation** with a dense infiltrate of **neutrophils (PMNs)**, **preservation of glandular architecture**, and **absence of malignant cells**. The glands remain intact but are surrounded by inflammatory cells. ### Histologic Details - **Acute phase:** edema, congestion, neutrophilic exudate within and around acini - **Glandular epithelium:** intact but may show reactive changes (cytoplasmic swelling, hyperchromasia) - **No atypia:** nuclei remain uniform and normochromatic; no loss of polarity - **Organisms:** may be visible with Gram stain or culture **Clinical Pearl:** Acute prostatitis is a medical emergency. The elevated PSA (8.2 ng/mL) is due to acute inflammation and glandular disruption, not malignancy. PSA typically normalizes within 4–6 weeks after antibiotic therapy. Biopsy is NOT routinely indicated in acute prostatitis; it is performed here to rule out abscess or malignancy if clinical response is poor. **High-Yield:** The key discriminator is the **acute inflammatory infiltrate without atypia**. Adenocarcinoma would show malignant cells with nuclear enlargement and hyperchromasia; TB would show granulomas and caseation; BPH would show hyperplastic glands without inflammation. **Mnemonic: ACUTE PROSTATITIS = A**cute **P**MN infiltrate, **P**reserved glands, **R**eactive epithelium, **O**rganisms present, **S**ystemic symptoms, **T**ender DRE, **A**ntibiotics curative, **T**ransient PSA elevation, **I**nflammation only, **T**ypically E. coli, **I**nstrumentation risk, **S**upurative (not granulomatous) [cite:Robbins 10e Ch 20]