Urology Journal

UNRC/IUA

Vol. 1, No. 4, 276-277 Autumn 2004

Printed in IRAN

276

Case Reports

Huge Benign Prostatic Hyperplasia

HOSSEINI SY1, SAFARINEJAD MR2*

1Department of Urology, Shaheed Modarress Hospital, Shaheed Beheshti University of

Medical Sciences, Tehran, Iran
2Department of Urology, Military University of Medical Sciences, Tehran, Iran

KEY WORDS: benign prostate hyperplasia, large prostate, diagnosis

Introduction

When prostate gland grows massively in an

intravesical direction, diagnosis, both radiograph-

ically and clinically may be difficult. Although

modern imaging techniques have increased the

diagnostic yield, it may mimic other lower uri-

nary tract and pelvic diseases. We report a huge

filling defect in the bladder caused by intravesical

enlargement of the prostate and discuss differen-

tial diagnosis.

Case report

A 47-year-old male was admitted with lower uri-

nary tract symptoms (LUTS). The patient com-

plained of straining, nocturia, dysuria, hesitancy,

and severe constipation. On rectal examination, a

firm, small, and smooth prostate thought to

weight approximately 20 gr with a large pelvic

mass above the prostate were palpated. Blood

chemistry and urinalysis were normal, but serum

prostatic specific antigen (PSA) level was 69

ng/ml. Ultrasound revealed a pelvic solid mass.

Additional transrectal ultrasound did not confirm

intraprostatic location of a solid structure. CT

scan and magnetic resonance imaging (MRI) only

depicted a solid pelvic mass measured 9 ×10 cm

(fig. 1).

On urethrocystoscopy, prostatic urethra was

normal, but bladder outlet was completely

obstructed. Histopathological examination of nee-

dle biopsies from the mass, demonstrated benign

prostatic hyperplasia.

A suprapubic surgical approach to the bladder

was performed. A pedunculated lesion arising

from the bladder neck was noted. The mass was

enucleated. It weighed 508 gr and consisted of

stromal and glandular hyperplasia. The postoper-

ative course was uneventful. Serum PSA level,

three months after surgery, was 2.6 ng/ml.

Discussion

Median lobe enlargements tend to push intrav-

esically and produce marked filling defects in the

floor of the bladder. 

Clinical diagnosis of solitary subcervical or

median lobe hypertrophy can be quite difficult.

Rectal examination is not only unsatisfactory, but

may even be misleading for, if the lobe grows

intravesically, it cannot be felt through the rec-

tum. Symptomatology may not be proportional to

the degree of hyperplasia. Huge enlargement of

the gland in an intravesical direction may give

minimal symptoms. The radiographic differential

diagnostic possibilities, considered for filling

Received November 2003

Accepted April 2004

*Corresponding author: P.O. Box: 19395-1849,

Tel: +98 912 109 5200,  E-mail: safarinejad@unrc.ir

FIG.1. CT scan demonstrated a huge intravesical mass,

occupying most of the bladder.



Hosseini, Safarinejad 277

defect within the bladder, include defects caused

by blood clot, solitary vesical calculus, bladder

tumor, or an extravesical mass arising posterior

to the bladder. Retrovesical masses include pro-

static utricle cyst, prostatic abscess, seminal vesi-

cle hydrops, seminal vesicle cyst, seminal vesicle

empyema, large ectopic ureterocele, and connec-

tive tissue tumors such as myxoid liposarcoma

and malignant fibrous histiocytoma.(1)

Occasionally, radiological differentiation of these

conditions may be impossible. Ultrasonography

may be especially helpful in confirming the cystic

nature of a mass, even if it contains high-density

hemorrhagic fluid, and localization of large cysts

close to the bladder. Transrectal ultrasound has

been increasingly popular as a diagnostic tool to

evaluate the prostate and seminal vesicles. It is

essential to minimize the possibility of missing

important clues and achieve accurate diagnostic

imaging studies, such as CT scan and/or MRI.(2)

CT scan accurately demonstrates the anatomical

relationship of associated internal pelvic organs.

In our patient CT scan and MRI only disclosed a

solid pelvic mass without localization of it into

the prostate. Others have stressed the usefulness

of endorectal MRI, which may provide further

diagnostic information of the pelvic mass.(3)

Occasionally, preoperative or intraoperative

biopsy and histopathological examination

remains the key for diagnosis.

References

1. Dahms SE, Hohenfellner M, Linn JF, Eggersmann C,

Haupt G, Thuroff JW. Retrovesical mass in men: pitfalls

of differential diagnosis. J Urol. 1999;161:1244-1248.

2. Genevois PA, Van Sinoy ML, Sintzoff SA Jr, et al. Cysts

of the prostate and seminal vesicle: MR imaging findings

in 11 cases. AJR Am J Roentgenol. 1990;155:1021-1025.

3. Parsons RB, Fisher AM, Bar-Chama N, Mitty HA.

MR imaging in male infertility. Radiographics.

1997;17:627-631.