Case Report
Prostatitis and Acute Urinary Retention as First Manifestations of Wegener's Granulomatosis
Prostatitis y retención aguda de orina como comienzo de granulomatosis de Wegener
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Wegener in 1936, characterized by granulomatous lesions in multiple organs and varying degrees of disseminated vasculitis of arteries and veins of medium and small caliber.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The pathogenesis of the disease remains unknown, although it is believed that an abnormal hypersensitivity response develops against exogenous or endogenous antigens, probably located in the upper respiratory tract, synthesizing antibodies to proteinase 3, an enzyme present in polymorphonuclear cells. These antibodies are associated to a granular cytoplasmic staining pattern in these cells using indirect immunofluorescence, or anti-neutrophil cytoplasmic antibodies (c-ANCA) and may contribute to the pathogenesis of the disease.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It affects men and women, with a 1:1 ratio, and the highest incidence occurs in the fifth decade of life, with an estimated 20 cases per million per year prevalence.</p><p id="par0010" class="elsevierStylePara elsevierViewall">It affects the upper airway (92%) and lungs (85%), with granulomatous lesions, necrotizing vasculitis, as well as the kidneys (77%) in the form of glomerulonephritis.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Urological extrarenal manifestations are very low in frequency and almost always develop in an advanced multisystem disease. We present a case of prostatitis as the first manifestation of Wegener's granulomatosis.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Clinical Case</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 48-year-old male who was admitted with fever, urinary symptoms, suprapubic pain and acute urinary retention. The onset of symptoms had been 10 days before without other accompanying phenomena present. His medical history was unremarkable, except for being an ex-smoker of 15 cigarettes/day. On physical examination, temperature was 39<span class="elsevierStyleHsp" style=""></span>°C, he had a distended bladder (evacuating, after a suprapubic cystostomy, 750<span class="elsevierStyleHsp" style=""></span>ml), with painless renal fist percussion, and normal external genitalia .Rectal examination was very painful, with a grade 2/4 prostate, congestive without suspicious fluctuating abscessed areas.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Other initial tests highlighted leukocytosis (14.4<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>/μl, neutrophils 70.2%), with the rest of the parameters being a normal blood count, a urine sediment with pyuria (410–420<span class="elsevierStyleHsp" style=""></span>cells/field), hematuria (20–25 red blood cells/field) and intense bacteriuria. All other laboratory tests were normal.</p><p id="par0025" class="elsevierStylePara elsevierViewall">With the presumptive diagnosis of acute bacterial prostatitis, treatment was started with ceftriaxone 2<span class="elsevierStyleHsp" style=""></span>g/24<span class="elsevierStyleHsp" style=""></span>h intravenously (iv), IV anti-inflammatory drugs and alpha blockers orally (po). The evolution was torpid, with fever and suprapubic pain yielding partially, but then developing asthenia, anorexia, joint/muscle pain and weight loss 10<span class="elsevierStyleHsp" style=""></span>kg in 1 week. Given the negative results of blood cultures and urine, we started meropenem 1<span class="elsevierStyleHsp" style=""></span>g/8<span class="elsevierStyleHsp" style=""></span>h iv and new laboratory tests were performed: complete blood count with WBC 17,000 (<span class="elsevierStyleItalic">N</span> 93%), hemoglobin 12<span class="elsevierStyleHsp" style=""></span>g/dl, hematocrit 36%, mean corpuscular volume 87<span class="elsevierStyleHsp" style=""></span>fL, ESR: 36<span class="elsevierStyleHsp" style=""></span>mm/h. Biochemistry: alanine aminotransferase 81<span class="elsevierStyleHsp" style=""></span>U/l, gammaglutamil transpeptidase: 159<span class="elsevierStyleHsp" style=""></span>U/l. Rheumatoid factor negative. C-reactive protein: 69. Salmonella and Brucella agglutinations were negative. C3, C4, AAT, copper and ceruloplasmin: normal. Antinuclear antibodies, anti-mitochondrial antibodies, antibodies to extractable nuclear antigens and anti-LKM1: negative. Anti-neutrophil cytoplasmic antibodies (ANCA) were positive at a titer of 1/160 (16<span class="elsevierStyleHsp" style=""></span>U/ml) by indirect immunofluorescence, with a cytoplasmic pattern. Proteinogram: normal. Human chorionic gonadotropin beta and α-fetoprotein: normal. PSA 1.7<span class="elsevierStyleHsp" style=""></span>ng/ml. Syphilis, human immunodeficiency virus, B and C hepatitis virus serology were negative. The Löwenstein–Jensen urine culture was negative.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Chest X-ray and CT were normal. Abdominal ultrasound and CT showed a prostate with a volume of 56<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>, without evidence of abscess. Flexible cystoscopy confirmed the enlargement of the prostate.</p><p id="par0035" class="elsevierStylePara elsevierViewall">An evaluation by the Rheumatology Department of our center was requested and, suspecting GPA, a prostate biopsy was performed, the pathologic diagnosis being necrotizing epithelioid granuloma and vasculitis of a Wegener type (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Treatment with methylprednisolone was established 40<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>h iv and cyclophosphamide 100<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h vo, increasing to 150<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h 5 days later, with disappearing symptoms and a reduction of the prostatic volume to 34<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>. The suprapubic cystostomy was removed to recover spontaneous voiding, with postvoid residue less than 50<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>. Analytically, the c-ANCA became negative.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The patient was discharged with prednisone 60<span class="elsevierStyleHsp" style=""></span>mg/day and cyclophosphamide 150<span class="elsevierStyleHsp" style=""></span>vo<span class="elsevierStyleHsp" style=""></span>mg/vo day. He presented systemic recurrence 4 months later, coinciding with the decrease in corticosteroid treatment.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Twelve months into the process, while in remission, we replaced cyclophosphamide for azathioprine due to its better toxicity profile and, 6 months later, for methotrexate, reaching the target of a 20<span class="elsevierStyleHsp" style=""></span>mg/week dose, gradually reducing prednisone to 12.5<span class="elsevierStyleHsp" style=""></span>mg/day, while the patient remained asymptomatic. We made the changed from azathioprine to methotrexate because of the latter's better dosaging profile upon request by the patient, to ensure compliance.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Comments</span><p id="par0050" class="elsevierStylePara elsevierViewall">The urological manifestations of extrarenal GPA are uncommon, especially in isolation, and in most cases are associated with concomitant renal injury, or may precede the clinical manifestation of the disease, making diagnosis difficult. The prostate is the most frequently genitourinary organ involved (2%–7.4%) after the kidney, but onset with urinary symptoms is rare.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> There is also sporadic involvement of the testicles, bladder, seminal vesicles, urethra, penis, ureter, and adrenal glands<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The diagnosis of GPA is performed by a combination of clinical and histological data. The initial and characteristic involvement of the upper and lower airways and the subsequent development of glomerulonephritis of varying severity leads the clinician toward the diagnosis. However, a biopsy of the affected organ, and visualization of lesions of necrotizing granulomatous vasculitis, is essential to confirm the diagnosis.</p><p id="par0060" class="elsevierStylePara elsevierViewall">High titers of c-ANCA were identified in 88% of patients with active disease. The finding of high levels of c-ANCA shows a sensitivity of 41%–96% depending on the degree of activity, and a specificity of 99%, in the diagnosis of GPA.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,7</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">ANCA are a group of autoantibodies, mainly IgG, directed against antigens which are present in the cytoplasm of the neutrophil granulocytes and in the cytoplasm of monocytes, and which are particularly associated with systemic vasculitis. pANCA or perinuclear fluorescence pattern are cytoplasmic autoantibodies against myeloperoxidase (anti-MPO). c-ANCA fluorescence or cytoplasmic pattern autoantibodies are specific against serine proteinase-3 (anti-PR3).</p><p id="par0070" class="elsevierStylePara elsevierViewall">Plasma levels of c-ANCA can be used as immunological (not biochemical) markers of the disease, although they not always have a parallel course to activity.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> They can be used for: monitoring response to treatment, diagnosis of recurrence, determining disease progression and identification of patients who achieved a complete remission, as this is one area where negativisation of antibody titers occurs, although 43% of patients with a complete clinical remission show some degree of positive c-ANCA.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">It is common to find changes in other laboratory tests: elevated ESR, hypergammaglobulinemia and elevated rheumatoid factor, and laboratory abnormalities features that reflect dysfunction of the organs affected by the disease.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In the patient in our case, c-ANCA positivity was a valuable piece of data for diagnosis because of the limited nature of the disease, with no clinical features present as in most patients with GPA. Ultrasonography was not useful for diagnosis, as it only allowed to visualize the existence of an enlarged prostate, which by its sonographic features was indistinguishable from an infectious process at this level, although it was useful for monitoring<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The differential diagnosis is made with infectious processes such as tuberculosis, atypical mycobacterial infection, brucellosis, fungal infections, syphilis and parasitic infections leading to necrotizing granulomatous lesions similar to Wegener's granulomatosis. In our patient, no infectious agent was identified in cultures. This data, together with high titers of c-ANCA, allowed us to diagnose Wegener's granulomatosis.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Therapy of GPA has two components: induction of remission with initial immunosuppressive treatment and maintenance immunosuppressive therapy for a variable period to prevent relapse. The induction of remission is usually accomplished through the combination of glucocorticoid and cyclophosphamide. Glucocorticoids are often administered for 6 months, while treatment with cyclophosphamide is longer, up to one year after complete remission. Other agents used are azathioprine, trimethoprim-sulfamethoxazole and methotrexate.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Trimethoprim can be useful and beneficial in localized GPA, especially during phases of remission induction and maintenance, and in infections by <span class="elsevierStyleItalic">Staphylococcus aureus</span> or <span class="elsevierStyleItalic">Pneumocystis jirovenci</span> in secretions from the upper respiratory tract. Chemoprophylaxis with cotrimoxazole is used to prevent systemic infections secondary to the use of immunosuppressive drugs.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Current therapeutic regimens allow for remission rates exceeding 90% in larger series, although 25%–30% of these patients experience a recurrence in the long-term.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Our patient was treated by combining glucocorticoids and cyclophosphamide, with rapid resolution of urological symptoms and complete remission 3 months after starting treatment, demonstrated by the disappearance of symptoms and a negative c-ANCA result, showing early extraurological recurrence after reducing corticosteroid treatment.Surgical treatment, such as transurethral resection of the prostate, is reserved for patients with persistent clinical manifestations despite medical treatment, although cases where nephrectomy or radical prostatectomy for suspected carcinoma was performed have been described. In our case, the patient required suprapubic cystostomy for acute urinary retention.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0105" class="elsevierStylePara elsevierViewall">Prostatitis as the initial presentation of GPA is a rare entity. Prostatitis should be suspected in those patients with poor outcomes despite adequate empiric treatment, negative cultures and malaise. Positive c-ANCA titers guide the diagnosis and help monitor treatment and evolution. Immunosuppressive drugs such as glucocorticoids and cyclophosphamide are the treatment of choice for moderate forms.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethical Responsibilities</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protection of human and animal subjects</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Confidentiality of data</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Right to privacy and informed consent</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of Interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres376330" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objectives" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec355391" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres376329" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivos" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec355390" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical Case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Comments" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical Responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of Interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec355391" "palabras" => array:3 [ 0 => "Wegener's granulomatosis" 1 => "Prostatitis" 2 => "Cytoplasmic antineutrophil cytoplasmic antibody" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec355390" "palabras" => array:3 [ 0 => "Granulomatosis de Wegener" 1 => "Prostatitis" 2 => "Anticuerpos citoplasmáticos contra los neutrófilos con patrón citoplasmático" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We present a case of prostatitis with acute urinary retention as a rare initial manifestation of Wegener's granulomatosis.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The case was a 48-year-old male with symptoms of prostatitis over 10 days. The patient presented urinary retention, with partial response to antibiotic treatment. High levels of cytoplasmic antineutrophil cytoplasmic antibody and a prostatic biopsy were compatible with Wegener's granulomatosis.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">After starting treatment with glucocorticoids and cyclophosphamide, a significant improvement to the point of disappearance of symptoms was observed. At 3 months pulmonary and upper airway symptoms began, requiring higher doses of cyclophosphamide to control symptoms.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Wegener's granulomatosis is a multisystem entity whose presentation as prostatitis with urinary retention is rare.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Presentar un caso de prostatitis con retención aguda de orina como manifestación inicial poco frecuente de granulomatosis de Wegener.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se presenta el caso de un varón de 48 años con un cuadro de prostatitis de 10 días de evolución, que presentó retención de orina, con respuesta parcial al tratamiento antibiótico, y con niveles elevados de anticuerpos citoplasmáticos contra los neutrófilos con patrón citoplasmático y estudio anátomo-patológico de la biopsia prostática compatible con granulomatosis de Wegener.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Tras el inicio de tratamiento mediante glucocorticoides y ciclofosfamida se observa mejoría notable de los síntomas hasta su desaparición. A los 3 meses inicia clínica pulmonar y de vías aéreas superiores, precisando para el control de sus síntomas dosis mayores de ciclofosfamida.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La granulomatosis de Wegener es una entidad multisistémica cuya forma de presentación como prostatitis con retención de orina es poco frecuente.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pereira Beceiro J, Rodríguez Alonso A, Bonelli Martín C, Pérez Valcárcel J, Mosquera Seoane T, Cuerpo Pérez MÁ. Prostatitis y retención aguda de orina como comienzo de granulomatosis de Wegener. Reumatol Clin. 2014;10:409–412.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 753 "Ancho" => 1003 "Tamanyo" => 300096 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Detail of necrotizing granulomatous epithelioid cells surrounded organized as a palisade.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 742 "Ancho" => 1003 "Tamanyo" => 100018 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Transrectal ultrasound prostate image, with diffuse hypoechoic areas displayed.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Ref no. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">1st author. Year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No. patients in the series \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Urogenital and GPA initial manifestation (no. patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Urogenital manifestation in the course of the GPA (no. patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Urogenital recurrence in GPA (no. patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Urogenital symptoms (no. patients) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">This work \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pereira J. 2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prostatitis (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dufour JF. 2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prostatitis (4)Orchitis (4)Epididymitis (1)Renal pseudotumor (1)Urethral stricture (1)Penile ulcers (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Charlier C. 2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">113 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prostatitis (4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Awadh B. 2006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prostatitis (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Helmann F. 2006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prostatitis (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0075"><span 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 4 | 16 |
| 2024 October | 82 | 30 | 112 |
| 2024 September | 100 | 13 | 113 |
| 2024 August | 103 | 37 | 140 |
| 2024 July | 93 | 40 | 133 |
| 2024 June | 93 | 30 | 123 |
| 2024 May | 113 | 45 | 158 |
| 2024 April | 100 | 20 | 120 |
| 2024 March | 111 | 37 | 148 |
| 2024 February | 65 | 27 | 92 |
| 2024 January | 84 | 24 | 108 |
| 2023 December | 81 | 37 | 118 |
| 2023 November | 78 | 24 | 102 |
| 2023 October | 103 | 30 | 133 |
| 2023 September | 107 | 44 | 151 |
| 2023 August | 62 | 32 | 94 |
| 2023 July | 66 | 29 | 95 |
| 2023 June | 72 | 23 | 95 |
| 2023 May | 73 | 24 | 97 |
| 2023 April | 92 | 13 | 105 |
| 2023 March | 115 | 24 | 139 |
| 2023 February | 82 | 31 | 113 |
| 2023 January | 64 | 13 | 77 |
| 2022 December | 80 | 21 | 101 |
| 2022 November | 100 | 26 | 126 |
| 2022 October | 75 | 36 | 111 |
| 2022 September | 83 | 36 | 119 |
| 2022 August | 81 | 53 | 134 |
| 2022 July | 81 | 52 | 133 |
| 2022 June | 94 | 33 | 127 |
| 2022 May | 95 | 35 | 130 |
| 2022 April | 68 | 63 | 131 |
| 2022 March | 90 | 58 | 148 |
| 2022 February | 93 | 38 | 131 |
| 2022 January | 112 | 37 | 149 |
| 2021 December | 57 | 50 | 107 |
| 2021 November | 67 | 39 | 106 |
| 2021 October | 101 | 44 | 145 |
| 2021 September | 85 | 48 | 133 |
| 2021 August | 82 | 36 | 118 |
| 2021 July | 70 | 33 | 103 |
| 2021 June | 69 | 34 | 103 |
| 2021 May | 84 | 38 | 122 |
| 2021 April | 213 | 96 | 309 |
| 2021 March | 121 | 34 | 155 |
| 2021 February | 64 | 24 | 88 |
| 2021 January | 78 | 31 | 109 |
| 2020 December | 61 | 20 | 81 |
| 2020 November | 74 | 18 | 92 |
| 2020 October | 44 | 10 | 54 |
| 2020 September | 45 | 21 | 66 |
| 2020 August | 48 | 21 | 69 |
| 2020 July | 45 | 13 | 58 |
| 2020 June | 68 | 10 | 78 |
| 2020 May | 48 | 21 | 69 |
| 2020 April | 53 | 15 | 68 |
| 2020 March | 25 | 7 | 32 |
| 2018 May | 2 | 1 | 3 |
| 2018 April | 106 | 8 | 114 |
| 2018 March | 132 | 5 | 137 |
| 2018 February | 50 | 3 | 53 |
| 2018 January | 38 | 6 | 44 |
| 2017 December | 62 | 10 | 72 |
| 2017 November | 83 | 13 | 96 |
| 2017 October | 57 | 7 | 64 |
| 2017 September | 64 | 12 | 76 |
| 2017 August | 73 | 11 | 84 |
| 2017 July | 52 | 16 | 68 |
| 2017 June | 93 | 12 | 105 |
| 2017 May | 79 | 6 | 85 |
| 2017 April | 72 | 10 | 82 |
| 2017 March | 71 | 7 | 78 |
| 2017 February | 39 | 10 | 49 |
| 2017 January | 42 | 8 | 50 |
| 2016 December | 81 | 19 | 100 |
| 2016 November | 68 | 9 | 77 |
| 2016 October | 103 | 17 | 120 |
| 2016 September | 196 | 5 | 201 |
| 2016 August | 73 | 3 | 76 |
| 2016 July | 34 | 9 | 43 |
| 2016 May | 1 | 0 | 1 |
| 2015 December | 1 | 0 | 1 |
| 2015 November | 1 | 0 | 1 |
| 2015 September | 2 | 0 | 2 |
| 2015 August | 2 | 0 | 2 |
| 2015 July | 33 | 6 | 39 |
| 2015 June | 37 | 9 | 46 |
| 2015 May | 69 | 20 | 89 |
| 2015 April | 80 | 16 | 96 |
| 2015 March | 232 | 9 | 241 |
| 2015 February | 75 | 12 | 87 |
| 2015 January | 77 | 20 | 97 |
| 2014 December | 81 | 12 | 93 |
| 2014 November | 68 | 16 | 84 |
| 2014 October | 32 | 15 | 47 |
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