Saudi Journal of Kidney Diseases and Transplantation

BRIEF COMMUNICATION
Year
: 2011  |  Volume : 22  |  Issue : 2  |  Page : 298--301

Prostatic abscess: Diagnosis and management in the modern antibiotic era


Punit Tiwari1, Dilip K Pal1, Astha Tripathi2, Suresh Kumar1, Mukesh Vijay1, Amit Goel1, Pramod Sharma1, Arindam Dutta1, Anup K Kundu1,  
1 Department of Urology, IPGMER & SSKM, Kolkata, W. B., India
2 Department of Pediatrics, IPGMER & SSKM, Kolkata, W. B., India

Correspondence Address:
Punit Tiwari
Senior Resident, Department of Urology, IPGMER & SSKM Hospital, Kolkata-20, W. B.
India

Abstract

This retrospective study was aimed at analyzing the clinical findings and thera­peutic strategies in 24 patients who were admitted with prostatic abscess, during the period from 1999 to 2008. The diagnosis of prostatic abscesses was made clinically by digital rectal palpation based on the presence of positive fluctuation with tenderness. All cases were confirmed by trans­rectal ultrasound (TRUS), and only positive cases were included in this study. The diagnostic work­up included analysis of midstream urine and abscess fluid culture for pathogens. Therapeutic options included endoscopic trans-urethral incision or trans-perineal aspiration under ultrasound guidance, or conservative therapy. Of the 24 patients studied, 45.83% of the cases had a pre-di­posing factor, and diabetes mellitus (37.50%) was the most common. Digital rectal palpation re­vealed fluctuation in 70.83% of the cases. Trans-abdominal ultrasonography missed the condition in 29.16% of the cases. On TRUS, all the study patients showed hypo-echoic zones, while nine others showed internal septations. In most of the cases, the lesion was peripheral. A causative pathogen could be identified in 70.83% of the cases. Surgical drainage of the abscess by trans­urethral deroofing was performed in 17 cases (including one with failed aspiration), trans-perineal aspiration under TRUS guidance was performed in three cases and conservative therapy was followed in five cases. Our data confirms the importance of predisposing factors in the patho­genesis of prostatic abscess. In most of the cases, the clue to diagnosis is obtained by digital rectal palpation. TRUS gives the definite diagnosis and also helps in follow-up of patients. Trans­urethral deroofing is the ideal therapy where the abscess cavity is more than 1 cm, although in some selected cases, TRUS-guided aspiration or conservative therapy does have a role in treatment.



How to cite this article:
Tiwari P, Pal DK, Tripathi A, Kumar S, Vijay M, Goel A, Sharma P, Dutta A, Kundu AK. Prostatic abscess: Diagnosis and management in the modern antibiotic era.Saudi J Kidney Dis Transpl 2011;22:298-301


How to cite this URL:
Tiwari P, Pal DK, Tripathi A, Kumar S, Vijay M, Goel A, Sharma P, Dutta A, Kundu AK. Prostatic abscess: Diagnosis and management in the modern antibiotic era. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2021 Dec 3 ];22:298-301
Available from: https://www.sjkdt.org/text.asp?2011/22/2/298/77609


Full Text

 Introduction



In modern urology practice, the prevalence of prostatic abscess has decreased markedly due to the widespread use of recent antibiotics. [1],[2],[3] Clinically, the patients present with non-spe­cific symptoms, and the diagnosis is based on digital rectal examination. [4],[5] Although fluctuation is an important diagnostic sign, it may not always be present, [6] creating confusion about the diagnosis. Trans-rectal ultrasonography (TRUS) is the most sensitive investigation to diagnose the condition. [7],[8],[9] Herewith, we present our ex­perience with 24 patients with prostatic abs­cess based on TRUS.

 Subjects and Methods



During the period between 1999 and 2008, 24 patients were admitted for the management of prostatic abscess. The patients presented with clinical symptoms of dysuria, high fever with chills and rigors, perineal pain, urethral dis­charge and severe tenderness with or without fluctuation on digital rectal examination. All the patients were investigated by hematolo­gical tests, including HIV screening and renal biochemical parameters, trans-abdominal and trans-rectal USG, midstream urine or pus for culture as well as CT scan of the pelvis in selected cases. Trans-abdominal USG was per­formed in all cases initially. Trans-rectal USG was performed in all clinically suspected cases, even when no abscess was found on trans­abdominal USG. The patients were treated by trans-urethral incision and deroofing, trans-pe­rineal needle aspiration under TRUS guidance or, conservatively, with a prolonged course of antibiotics. All the patients received parenteral antibiotics (ceftriaxone + amikacin) followed by oral antibiotics as per the culture and sensi­tivity report.

 Results



All the study patients had dysuria, fever and perineal pain with sensation of incomplete voiding at presentation. Five patients (1.2%) had terminal hematuria in addition. Nine of the 24 patients (37.5%) were diabetic, of whom seven were insulin dependent. Two patients had history of prolonged catheterization, one due to neurogenic bladder and the other due to benign hyperplasia of the prostate. The age of the study patients ranged between 26 and 78 years, with a mean age of 43 years. All the study cases were HIV-negative. Digital rectal examination revealed enlarged tender prostate with positive fluctuation in 17 patients (70.83%), and enlarged tender prostate without any fluc­tuation in seven (29.16%), leading to an initial diagnosis of acute bacterial prostatitis in them. One patient aged 26 years had a hugely en­larged prostate with variegated consistency leading to a clinical impression of rhabdomyo­sarcoma.

Trans-abdominal USG aided in the diagnosis of prostatic abscess in 12 cases (50%), in whom the abscess cavity was more than one cm in diameter [Figure 1]. In all the suspected cases, TRUS confirmed the diagnosis [Figure 2]; in 19 cases (79.16%), hypo-echoic zones with ragged walls were found and in nine, there were internal septations in addition. Intraglan­dular calcifications were observed in seven pa­tients (29.66%). One patient had a large abs­cess (2.44 cm diameter) in the central part, with multiple daughter abscesses <1 cm in dia­meter scattered throughout the gland; this was drained by trans-urethral incision. A CT scan of the pelvis was performed in five cases, in whom TRUS could not be performed due to severe pain. In 14 cases (58.33%), the abscess was located in the right lobe, in seven cases (29.16%) it was in the left lobe and in two other cases it was in the central location. In the youngest patient of our series, the abscess diffusely involved the entire prostate gland. Urine for culture and sensitivity showed growth of E. coli in 10 cases (41.66%), Klebsiella in three cases (12.50%), Pseudomonas in two (8.33%), Staphylococcus in two (8.33%) and no organism was in seven cases (29.16%).{Figure 1}{Figure 2}

We treated 16 patients by trans-urethral inci­sion with deroofing of the cavity when the abs­cess cavities were more than one cm in size, while three patients were treated by trans-pe­rineal needle aspiration (18 gauge Chiba needle) under USG guidance. One patient treated with needle aspiration had recurrence within one month, necessitating trans-urethral deroofing of the abscess cavity. After treatment, the peri­neal pain and fever subsided in all the cases. Five patients in whom the abscess cavies were <1 cm in diameter were treated conservatively with a prolonged course of antibiotics for one month, with serial USG to note the progress of the treatment. The overall follow-up period ranged from six months to seven years.

 Discussion



Prostatic abscess is now an uncommon di­sease due to the widespread use of modern antibiotics as well as decreased incidence of gonococcal urethritis. Before the advent of modern antibiotic therapy, 75% of the prosta­tic abscesses were due to Gonococcus, and the mortality rate was between six and 30%. [1] The third or fourth decade of life was the most common period. Diabetes or prolonged cathe­terization were the most common predisposing factors in these cases. [2],[3],[4] The condition should be suspected when there are recurrent or per­sistent symptoms of fever, dysuria, urethral discharge or frequency associated with urinary tract infection, despite adequate antibiotic treat­ment. [3] Other clinical features include supra­pubic or subpubic pain, severe perineal pain, rectal tenesmus or sudden fever with chills and rigors. [5],[6] More recently, the incidence of pros­tatic abscess is increasing among patients with AIDS. [7] Midstream urinary culture usually de­tects the causative organism in patients with prostatic abscess. Digital rectal examination is the mainstay of diagnosing the condition, al­though fluctuation may not always be posi­tive. [6] In our series, fluctuation was negative in seven cases; of these patients, three were ini­tially diagnosed as acute prostatitis. Trans-rectal USG usually gives a clear idea regarding the extent of the abscess cavity, and demonstrates predominantly echo-poor zones containing ho­mogeneous or heterogeneous fluid and linear stranding, suggesting septate cystic mass. [8],[9] On Doppler studies, most abscess walls are highly vascular, more so than can be expected in tu­mor walls. [10] Sometimes, they may appear com­pletely cystic and thin walled, or with internal echoes, which makes an abscess almost indis­tinguishable from carcinoma on TRUS alone. [11]

Prostate abscess can be drained under TRUS guidance and also helps in monitoring the res­ ponse to treatment. [10],[11] Some surgeons advo­ cate that trans-perineal aspiration of abscess is usually sufficient for treatment, [9],[10] but due to the possibility of recurrence, trans-urethral deroofing is a more rational option for draining the multi-loculated abscesses, leading to better drainage of the abscess cavity with early re­covery. Although there is a theoretical possi­ bility of hematogenous dissemination of the causative organism during trans-urethral deroofing, the use of pre-operative broad-spec­trum antibiotics helps in preventing the occur­rence of septicemia.

References

1B Barozzi L, Pavlica P, Menchi I, De Matteis M, Canepari M. Prostatic abscess: Diagnosis and treatment. AJR Am J Roentgenol 1998; 170:753-7.
2Pai MG, Bhat HS. Prostatic abscess. J Urol 1972;108:599-601.
3Ludwig M, Schroeder-Printzen I, Schiefer HC, Weidner W. Diagnosis and therapeutic manage­ment of 18 patients with prostatic abscess. Urology 1999;53:340-5.
4Marini AJ, Jacobs LD, Clapp PR, Hariharan A, Stams UK, Hodges CV. Emphysematous pros­tatic abscess: Diagnosis and treatment. J Urol 1983;129:385-6.
5Vaccaro JA, Belville WD, Victor J Kiesling JR, Davis R. Prostatic abscess: Computerised tomography scanning as an aid to diagnosis and treatment. J Urol 1986;136:1318-9.
6Sugao H, Hidekazu T, Sakurai T. Transrectal longitudinal ultrasonography of prostatic abs­cess. J Urol 1986;136:1316-7.
7Trauzzi SJ, Kay CJ, Kaufman DG, Lowe FC. Management of prostatic abscess in patients with human immunodeficiency syndrome. Urology 1994;43:629-33.
8Rabii R, Rais H, Joual A, el Mrini M, Benjel­loun S. Prostatic abscess. A review. Ann Urol 1999;33:271-3.
9Lim JW, Ko YT, Lee DH, et al. Treatment of prostatic abscess: Value of transrectal ultra­sonographically needle aspiration. J Ultrasound Med 2000;19:609-17.
10Franco A, Menendez V, Luque MP, et al. Prostatic abscess: diagnosis and treatment. Actas Urol Esp 1996;20:189-92.
11Meire HB, Cosgrove DO, Dewbury KC, Farrant P. Abdominal and general ultrasound, London, Churchill Livingstone, [2]nd edn. Vol. 2, 2001; 603.