What are the common causes of prostatic enlargement in an adolescent male with no sexual history?

Prostatic Enlargement in Adolescents: Common Causes

In an adolescent male with no sexual history, prostatic enlargement is exceedingly rare and should prompt immediate investigation for malignancy (particularly rhabdomyosarcoma), followed by consideration of benign prostatic hyperplasia if malignancy is excluded, and evaluation for exogenous androgen exposure. 1, 2

Primary Diagnostic Imperative: Exclude Malignancy

• Rhabdomyosarcoma must be ruled out first in any adolescent presenting with a prostatic mass, as this is the most expected malignancy for this age group. 2
• Transrectal ultrasound-guided biopsy (TRUS-Bx) is essential to document benign tissue before proceeding with any other diagnostic considerations. 1, 2
• The American Academy of Pediatrics and urological guidelines specifically recommend this approach given the rarity of benign prostatic enlargement in this population. 1

Benign Causes After Malignancy Exclusion

1. Benign Prostatic Hyperplasia (BPH)

• While BPH is common in men over 50 years, it is extremely rare in childhood and adolescence, with fewer than five cases reported in patients under 18 years of age. 2, 3
• The pathophysiology mirrors adult BPH, involving proliferation of glandular epithelial tissue, smooth muscle, and connective tissue within the prostatic transition zone. 1
• Unlike adult BPH where age and hormonal factors are well-established, the mechanism in adolescents remains unclear. 1

2. Exogenous Androgen Exposure

• Hormonal factors such as exogenous androgen exposure should be thoroughly investigated in the history. 1
• Documented cases in the literature have identified potential etiologic factors including:
  • Gonadotropin supplement therapy for undescended testes 2
  • Maternal use of human chorionic gonadotropin-containing agents during pregnancy 2
• However, some adolescent cases have no identifiable hormonal exposure or endocrinologic abnormality. 2

Clinical Presentation Patterns

• Adolescents with prostatic enlargement typically present with acute urinary retention as the initial manifestation. 2, 3
• Other presenting symptoms include:
  • Intermittent hematuria 2, 3
  • Voiding symptoms and difficulty 3
  • General weakness and fever (in complicated cases) 3
• Digital rectal examination reveals increased prostate size, and imaging typically shows a large mass arising from the prostate and filling the bladder lumen. 2

Critical Pitfalls to Avoid

• Do not assume BPH based on adult diagnostic criteria in this age group—the standard AUA guidelines explicitly state they pertain only to men over age 50 without significant risk of non-BPH causes of lower urinary tract symptoms. 4
• Younger men with voiding dysfunction require more extensive evaluation than the standard BPH workup. 4
• Do not delay biopsy if there is any suspicion of malignancy—the consequences of missing rhabdomyosarcoma far outweigh the risks of tissue sampling. 2

Management Considerations

• Once benign tissue is confirmed histopathologically, endoscopic transurethral resection of the prostate (TUR-P) is the treatment of choice for symptomatic adolescent BPH. 2
• Owing to the limited number of cases, there is no consensus on treatment of BPH in adolescents, so experiences from adult cases guide pediatric treatment modalities. 2
• Suprapubic prostatectomy may be necessary in cases with significant prostatic enlargement and complications such as hydroureteronephrosis. 3