Skip to main content

Ulcerative colitis that developed during radiotherapy for prostate cancer, deteriorated rapidly and required emergency surgery



Although there are reports linking ulcerative colitis (UC) to prostate cancer (PC), those reports are of PC patients who were previously diagnosed with UC. There are no reports of the development of UC during radiotherapy. Here we describe the first case of a patient who developed UC during radiotherapy for PC. The UC progressed rapidly and required emergency surgery.

Case presentation

A 61-year-old Japanese man underwent a prostate biopsy at another hospital due to a high prostate-specific antigen level and was diagnosed with PC. Goserelin and bicalutamide treatment was initiated in 2019, and intensity-modulated radiotherapy (total of 60 Gy/20 Fr) was administered in 2020. Diarrhea began during the radiotherapy and bleeding began post-radiotherapy. He was admitted to another hospital 14 days after the end of the radiotherapy, and colonoscopy revealed a deep ulcer in the colon, which led to the suspicion of UC. He was transferred to our hospital, and colonoscopy showed a widespread map-like ulcer, pseudopolyposis, and very easy bleeding in the colon. We diagnosed severe UC, and it worsened rapidly with uncontrollable bleeding, which we considered an indication for surgery. Emergency surgery (a total colectomy and ileostomy creation) was performed. The specimens confirmed an extensively spreading ulcer throughout the colon. The pathological report was UC in the active phase. The postoperative course was good.


When a patient exhibits diarrhea while undergoing radiotherapy for PC, clinicians should be aware of the possibility of UC in addition to radiation colitis, and colonoscopy should be considered.


Ulcerative colitis (UC) is a disease that begins with diarrhea and bleeding and gradually worsens, but it sometimes progresses rapidly to the point of requiring emergency surgery [1]. Although there are clear data linking inflammatory bowel disease (IBD) to colorectal cancer [2, 3], several reports have linked IBD patients and the risk of prostate cancer (PC) [4, 5]. Prostate cancer is the most common cancer in men in the U.S. and UK [5, 6]. The effect of radiation for PC on patients’ ulcerative colitis has been studied [4, 5, 7, 8], but those reports are of PC patients who were previously diagnosed with UC. We have found no reports of a patient who developed UC after the diagnosis of PC. Here, we report the rare case of a patient who developed severe UC during radiotherapy (RT) for his PC. The UC progressed rapidly and required emergency surgery.

Case presentation

A 61-year-old Japanese man had been treated for schizophrenia and showed a high level of prostate-specific antigen (PSA, 11.68 ng/mL) at a clinic. He underwent a prostate biopsy at another hospital and was diagnosed with prostate cancer (Fig. 1). In August 2019, treatment with goserelin (subcutaneous injection) and bicalutamide (oral administration) was initiated at our hospital’s urology department. From January to February in 2020, intensity-modulated radiation therapy (IMRT; total of 60 Gy/20 Fr) was administered (Fig. 2). The patient’s PSA level went down. Diarrhea began during this IMRT period, and bleeding began after the completion of the IMRT.

Fig. 1

Microscopically, the biopsied specimen was composed of eosinophilic tumor cells with oval nuclei, which exhibited fused microacinar gland pattern by hematoxylin–eosin (HE) staining. The Gleason score was 4 + 3 = 7

Fig. 2

Clinical course after the diagnosis of prostate cancer

At 14 days after the end of the RT, the patient was admitted to another hospital. He was hospitalized with a diagnosis of radiation colitis. He continued fasting, and an intravenous drip was given. Three days post-admission, colonoscopy revealed a deep ulcer in the colon, which led to the suspicion of UC. The next day, he was transferred to our Teikyo IBD Center (Fig. 2).

On physical examination, the patient's abdomen was flat and soft without tenderness or distension. The laboratory data were as follows: RBCs 356 × 104/μL (low), hemoglobin 9.9 g/dL (low), WBCs 9100/μL, platelets: 32.5 × 104/μL, total protein 4.7 g/dL (low), albumin 1.5 g/dL (low), and CRP 14.41 mg/dL (high). He passed bloody diarrhea and the number of stools was > 10/day. Contrast CT showed diffuse edema and wall thickening throughout the colon (Fig. 3a, b). Colonoscopy showed a widespread map-like ulcer, pseudopolyposis, and very easy bleeding in the colon but edematous inflammation with no ulcer in the rectum (Fig. 4a–c). The patient’s Disease Activity Index [9] was 11. We diagnosed with severe UC that worsened rapidly with uncontrollable massive bleeding, which was considered an indication for surgery. Emergency surgery was performed on the day of the patient's transfer to our Center.

Fig. 3

CT showed edematous and thickening of the colon [a ascending colon (yellow arrow) and descending colon (blue arrow), and b sigmoid colon (red arrow)]

Fig. 4

Colonoscopy performed on the day of transfer. A circumferential ulcer was found in the transverse colon (a). A deep ulcer was found in the sigmoid colon (b). Edematous inflammation with no ulcer was found in the rectum (c)

The surgery (total colectomy and creation of an ileostomy) was performed as follows. The abdomen was opened by a midline incision of the entire abdomen. Edema, redness, hyperemia, and thickening in the colon were observed. Intraoperative endoscopy revealed a deep ulcer in the sigmoid colon, but the rectum was slightly inflamed with no ulcer (Fig. 5a–c). A cut-off between the sigmoid colon and the rectum was selected. After transection of blood vessels, the ileocolic artery and vein were preserved and the ileum was cut-off at the terminal ileum. An ileostomy was created in the lower right abdomen.

Fig. 5

Intraoperative colonoscopy. A deep ulcer was observed in the sigmoid colon (a). The light from the endoscope could be seen through the ulcer area (b). Residual rectum showed no deep ulcer (c)

The specimens showed an ulcer spreading extensively throughout the colon (Fig. 6). The pathological report was UC in the active phase (Fig. 7a, b). The patient’s postoperative course was good, and he was discharged 26 days after the operation.

Fig. 6

Excised specimen. Ulcers were spreading throughout the colon

Fig. 7

Histological findings of the transverse colon. Residual mucosal islands were located between ulcerated areas (a HE staining, 10×). Crypt branching and irregularity of size and shape with chronic inflammatory cells were observed in some areas (b HE staining, 100×)


This patient suffered from diarrhea during the radiotherapy for his prostate cancer, and he was thought to have radiation colitis when he was admitted to the previous hospital; however, UC developed and worsened during and after his radiotherapy. To investigate the issue of whether the radiation or the patient's PC caused his ulcerative colitis, we searched the Medline (using PubMed) for studies reporting cases of UC patients undergoing radiotherapy for PC. The search terms included (ulcerative colitis) (prostate cancer) (radiation therapy) in all fields. Our search identified 20 publications by all three search terms, 226 documents by UC and RT, and 83 documents by UC and PC. The studies that have evaluated radiotherapy for PC in UC patients are summarized in Table 1 [5, 7, 8, 10,11,12,13,14,15]. In all of these cases, the patient's UC had already been diagnosed prior to the occurrence of PC.

Table 1 Summary of studies assessing radiotherapy for prostate cancer in IBD patients

Several reports have described a correlation between IBD and the risk of PC. Men with IBD had a significantly higher incidence of PC (4.4% at 10 years) compared to controls (0.65% at 10 years) [16]. In other studies, IBD patients had significantly elevated risks for PC (relative risk: 1.70; standardized incidence ratio: 2.47) [17, 18]. A meta-analysis indicated that the presence of IBD posed a 78% increase in the risk of developing PC [19]. The underlying pathophysiology of how IBD might increase one’s risk of prostate cancer has been discussed [4]; one possibility is that the local or systemic inflammation associated with IBD may lead to prostatic inflammation, predisposing patients with IBD to the development of prostate cancer [16]. Another possibility is the translocation of pro-inflammatory bacteria from the gastrointestinal tract to the prostate by either the blood stream or the urinary tract, leading to chronic inflammation of the prostate, which, in turn, increases the risk of PC [4, 20]. Shared genetic susceptibility for prostate cancer and IBD has also been raised as a possible explanation [16].

Many studies have attempted to assess the safety of RT in patients with IBD [5, 7, 8, 11]. An examination of the correlation between pelvic RT and IBD patients showed that only the patients with a rectal IBD location or a low body mass index had experienced more severe IBD activity within or after 6 months following the RT [11]. A study assessing IBD-specific outcomes in 100 veterans with IBD revealed that the rates of IBD-associated hospitalizations and IBD-related surgeries were not significantly different between those treated with or without radiation, and there was no effect of radiation on longer-term outcomes [7]. IBD was not considered as an absolute contraindication to RT, and brachytherapy and IMRT might have less bowel toxicity compared to conventional methods of external beam RT [4]. In addition, we searched the Medline (using PubMed) for studies reporting cases of (UC and goserelin) or (UC and bicalutamide), which revealed no papers on them had been published.

We found no reports of patients who were diagnosed with UC after they developed PC or patients who developed UC during their radiation therapy. In our patient’s case, his UC symptoms began after the beginning of the radiation therapy for his PC, and the inflammation was more severe in the colon than the rectum. The following two hypotheses can be inferred for the course of this case. (1) IMRT caused an immune abnormality in the rectum, which triggered UC, and inflammation rapidly spread to the entire large intestine in a short period of time. (2) IMRT happened to coincide with the onset of UC at the same time, and IMRT was not involved in the onset of UC. This is the first report of a case of ulcerative colitis that developed during radiotherapy for prostate cancer.


We report a case of UC that developed during radiation therapy for PC, which deteriorated rapidly and needed emergency surgery. When a patient with PC exhibits diarrhea, while he is undergoing radiation therapy, it is necessary to be aware of the possibility of UC in addition to radiation colitis, and colonoscopy should be considered.

Availability of data and materials

The authors declare that all the data in this article are available within the article.



Inflammatory bowel disease


Intensity-modulated radiation therapy


Prostate cancer


Prostate-specific antigen




Ulcerative colitis


  1. 1.

    Mowat C, Cole A, Windsor A, Ahmad T, Arnott I, Driscoll R, et al. Guidelines for the management of inflammatory bowel disease in adults. Gut. 2011;60(5):571–607.

    Article  Google Scholar 

  2. 2.

    Eaden JA, Abrams KR, Mayberry JF. The risk of colorectal cancer in ulcerative colitis: a meta-analysis. Gut. 2001;48(4):526–35.

    CAS  Article  Google Scholar 

  3. 3.

    Choi CH, Rutter MD, Askari A, Lee GH, Warusavitarne J, Moorghen M, et al. Forty-year analysis of colonoscopic surveillance program for neoplasia in ulcerative colitis: an updated overview. Am J Gastroenterol. 2015;110(7):1022–34.

    Article  Google Scholar 

  4. 4.

    Kim J, Feagins LA. Managing patients with inflammatory bowel disease who develop prostate cancer. Digest Dis Sci. 2020;65(1):22–30.

    CAS  Article  Google Scholar 

  5. 5.

    Mohammed W, Hoskin P, Henry A, Gomez-Iturriaga A, Robinson A, Nikapota A. Short-term toxicity of high dose rate brachytherapy in prostate cancer patients with inflammatory bowel disease. Clin Oncol. 2018;30(9):534–8.

    CAS  Article  Google Scholar 

  6. 6.

    Key Statistics for Prostate Cancer. Accessed 19 Apr 2020.

  7. 7.

    Feagins LA, Kim J, Chandrakumaran A, Gandle C, Naik KH, Cipher DJ, et al. Rates of adverse IBD-related outcomes for patients with IBD and concomitant prostate cancer treated with radiation therapy. Inflamm Bowel Dis. 2019.

    Article  PubMed  Google Scholar 

  8. 8.

    Gestaut MM, Swanson GP. Long term clinical toxicity of radiation therapy in prostate cancer patients with Inflammatory Bowel Disease. Rep Pract Oncol Radiother. 2017;22(1):77–82.

    Article  Google Scholar 

  9. 9.

    Schroeder KW, Tremaine WJ, Ilstrup DM. Coated oral 5-aminosalicylic acid therapy for mildly to moderately active ulcerative colitis. A randomized study. N Engl J Med. 1987;317(26):1625–9.

    CAS  Article  Google Scholar 

  10. 10.

    Kirk PS, Govani S, Borza T, Hollenbeck BK, Davis J, Shumway D, et al. Implications of prostate cancer treatment in men with inflammatory bowel disease. Urology. 2017;104:131–6.

    Article  Google Scholar 

  11. 11.

    Annede P, Seisen T, Klotz C, Mazeron R, Maroun P, Petit C, et al. Inflammatory bowel diseases activity in patients undergoing pelvic radiation therapy. J Gastrointest Oncol. 2017;8(1):173–9.

    Article  Google Scholar 

  12. 12.

    Peters CA, Cesaretti JA, Stone NN, Stock RG. Low-dose rate prostate brachytherapy is well tolerated in patients with a history of inflammatory bowel disease. Int J Radiat Oncol Biol Phys. 2006;66(2):424–9.

    Article  Google Scholar 

  13. 13.

    Chen AB, D'Amico AV, Neville BA, Earle CC. Patient and treatment factors associated with complications after prostate brachytherapy. J Clin Oncol. 2006;24(33):5298–304.

    Article  Google Scholar 

  14. 14.

    Willett CG, Ooi CJ, Zietman AL, Menon V, Goldberg S, Sands BE, et al. Acute and late toxicity of patients with inflammatory bowel disease undergoing irradiation for abdominal and pelvic neoplasms. Int J Radiat Oncol Biol Phys. 2000;46(4):995–8.

    CAS  Article  Google Scholar 

  15. 15.

    Grann A, Wallner K. Prostate brachytherapy in patients with inflammatory bowel disease. Int J Radiat Oncol Biol Phys. 1998;40(1):135–8.

    CAS  Article  Google Scholar 

  16. 16.

    Burns JA, Weiner AB, Catalona WJ, Li EV, Schaeffer EM, Hanauer SB, et al. Inflammatory bowel disease and the risk of prostate cancer. Eur Urol. 2019;75(5):846–52.

    Article  Google Scholar 

  17. 17.

    Mosher CA, Brown GR, Weideman RA, Crook TW, Cipher DJ, Spechler SJ, et al. Incidence of colorectal cancer and extracolonic cancers in veteran patients with inflammatory bowel disease. Inflamm Bowel Dis. 2018;24(3):617–23.

    Article  Google Scholar 

  18. 18.

    So J, Tang W, Leung WK, Li M, Lo FH, Wong MTL, et al. Cancer risk in 2621 chinese patients with inflammatory bowel disease: a population-based cohort study. Inflamm Bowel Dis. 2017;23(11):2061–8.

    Article  Google Scholar 

  19. 19.

    Chen M, Yuan C, Xu T. An increase in prostate cancer diagnosis during inflammatory bowel disease: a systematic review and meta-analysis. Clin Res Hepatol Gastroenterol. 2019.

    Article  PubMed  Google Scholar 

  20. 20.

    Sfanos KS, Yegnasubramanian S, Nelson WG, De Marzo AM. The inflammatory microenvironment and microbiome in prostate cancer development. Nat Rev Urol. 2018;15(1):11–24.

    Article  Google Scholar 

Download references


We thank the doctors and nurses working in the Department of Surgery and the IBD Center for their help at the clinical site.


None of the authors received any funding for this study.

Author information




KM and YO designed and conducted the research and wrote this paper. YH drafted the article, revised it critically for important intellectual content, and gave final approval for the content. KA, KO, MT, YF, RS, TO, TH, KN, and TF contributed to the daily medical treatment of the patient. YS contributed to the pathological diagnoses. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Keiji Matsuda.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Informed consent was obtained from the patient to publish the details of the case.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Matsuda, K., Okada, Y., Hashiguchi, Y. et al. Ulcerative colitis that developed during radiotherapy for prostate cancer, deteriorated rapidly and required emergency surgery. surg case rep 6, 250 (2020).

Download citation


  • Ulcerative colitis
  • Prostate cancer
  • Radiotherapy
  • PSA
  • Surgery