|Year : 2009 | Volume
| Issue : 2 | Page : 56-60
Minimally-invasive management of prostatic abscess: The role of transrectal ultrasound
Punit Bansal, Aman Gupta, Ritesh Mongha, Maloy Bera, K Ranjit, Anup K Kundu
Department of Urology, Institute of Post Graduate Medical Education and Research, Kolkata, India
|Date of Submission||12-Mar-2009|
|Date of Acceptance||22-Apr-2009|
|Date of Web Publication||26-Sep-2009|
Department of Urology, Institute of Post Graduate Medical Education and Research, Kolkata
| Abstract|| |
Context and Aim: Prostatic abscess is an unusual condition. The prevalence of prostatic abscess is about 0.5% of all prostatic diseases. The purpose of the study is to present and discuss the role of transrectal ultrasound (TRUS) in the management of prostatic abscess.
Settings and Design: Retrospective study.
Materials and Methods: We retrospectively reviewed the medical records of all eight patients diagnosed and treated for prostatic abscess in the last threeyears. TRUS was used for diagnosis in all cases. Four patients had TRUS guided aspiration for management of prostatic abscess. Data collected regarding etiology, clinical features, investigations and treatment was compared with the available literature.
Results: The age of patients ranged from 18-65 yrs (mean 47.12 yrs). Out of the eight patients, six were diabetics. TRUS revealed one or more hypoechoic areas within the prostate in all the patients. Successful treatment of prostatic abscess with TRUS guided needle aspiration was done in all fourpatients in whom it was used. Mean hospitalization time was 9.4 days, and most frequent bacterial agent was S. aureus.
Conclusions: TRUS is useful in diagnosis as well as in guidance for aspiration of such abscesses. TRUS guided needle aspiration is an effective method for treating prostatic abscess. Most of the patients are diabetics and usually grow Staphaureus. So an antibiotic with staphylococcal coverage should be used empirically.
Keywords: Abscess, prostatic, transrectal ultrasound
|How to cite this article:|
Bansal P, Gupta A, Mongha R, Bera M, Ranjit K, Kundu AK. Minimally-invasive management of prostatic abscess: The role of transrectal ultrasound. Urol Ann 2009;1:56-60
|How to cite this URL:|
Bansal P, Gupta A, Mongha R, Bera M, Ranjit K, Kundu AK. Minimally-invasive management of prostatic abscess: The role of transrectal ultrasound. Urol Ann [serial online] 2009 [cited 2017 Mar 27];1:56-60. Available from: http://www.urologyannals.com/text.asp?2009/1/2/56/56047
| Introduction|| |
Prostatic abscess results from focal accumulation of pus within the prostate gland. Untreated abscess may resolve or bursts pontaneously. The incidence of prostatic abscess has decreased markedly because of the widespread use of antibiotics and decrease in the incidence of gonococcal urethritis.  The prostatic abscess is difficult to diagnose because it mimics several other diseases of the lower urinary tract. Before the advent of modern antibiotic therapy, 75% of prostatic abscess were due to Gonococcus and the mortality rate was between 6 and 30%.  Since the advent of antibiotic therapy the bacteriology has changed. Now E. coli and staphylococcal species are the most common causative organisms. 
In this paper we present data about eight patients diagnosed with prostatic abscess discussing etiology, clinical findings, diagnostic features and treatment results.
| Materials and Methods|| |
The records of all the eight patients who were treated from August 2005 to August 2007 with a primary diagnosis of prostatic abscess were reviewed. These patients were admitted in a tertiary carereferral centre forthe whole of eastern India. The age of the patients ranged from 18-65 yrs (mean 47.12 yrs). Out of the eight patients, six were diabetic, one developed prostatic abscess after prostaticbiopsy and one young patient presented with acute retention of urine. In all the patients abdominal and transrectal sonography (TRUS) was done. All patients received intravenous antibiotics (Ciprofloxacin + Gentamicin) and Tab. Metronidazole empirically on admission. Two patients with micro abscesses were treated exclusively with antibiotics. The presence of pus within the prostate was confirmed by TRUS-guided needle aspiration in four patients, and successful treatment with needle aspiration was donein all four patients. TRUS-guided aspiration was performed withan 18 gauge (20 cm long) Chiba needle. No anesthesia was required in patients undergoing aspiration of abscess. Patients were placed in the left lateral decubitus position with a knee-chest position.
Transrectal probe was covered with a condom, and a biopsy guide attachment was used for needle aspiration. The needle was inserted under TRUS guidance through the rectal wall into the abscess cavity. After the aspiration of pus saline was instilled into the cavity and re-aspirated till the effluent was clear. Re-accumulation of pus was monitored by TRUS at one week.Postoperatively patients were given antibiotics for four weeks as per culture results. Criteria for successful treatment were clinical improvement and no pus collection on follow-up. Pus was sent for culture/sensitivity testing and antibiotics continued for four weeks. One patient with a large abscess underwent deroofing of the prostatic abscess perurethrally.
| Results|| |
Patient profile sare presented in [Table 1]. Clinical presentations most often included dysuria, urinary frequency, fever and pain in the perineum. One young boym presented with fever and acute retention of urine. He had history of UTI and most likely had developed prostatic abscess as acomplication of acute prostatitis. During catheterization, the patienthad spontaneous rupture of the abscess into urethra with resolutionof symptoms. We tested for leukocytes in midstream urine in allpatients; six had more than 10 leukocytes per highpower field and two had fewer than four. Urine culture obtained inthese patients yielded a negative result in six. E. coli was isolatedin two patients; one with history of acute prostatitis and the otherwith history of prostatic biopsy. Blood counts revealed elevated leukocyte counts in seven patients. Digital rectal examination was performed in all patients and only three cases revealed tenderness.
Of these three, one had acute prostatitis, one had a history of prostatic biopsy and only one was a diabetic. Since the classic finding on rectal examination of a tender fluctuant mass was absentin most of the cases, no case of prostatic abscess was diagnosed by digital rectal examination. Abdominal ultrasound performed in all patients revealed hypoechoic irregular area within the prostatic parenchyma suggesting the diagnosis of prostatic abscess [Figure 1].
Two patients presented with micro abscess and were treated exclusively with antibiotics, showing good results. TRUS was performed and revealed one or more hypoechoic areas containing in homogeneous material within the prostate in all the patients (100%) [Figure 2]. The prostate showed aperilesional hypoechoic area, indicating inflammatory change, in three patients. The estimated volume of the abnormal fluid collection ranged between 6 and 70 ml (mean 24.0 ml). The number of fluid collections within the prostate was one each in five patients and micro abscess in two patients. One of the patients hada computerized tomography scan of the pelvis performed before presenting to us suggesting the presence of prostatic abscess [Figure 3].
After the TRUS-guided needle aspiration in four patients antibiotictherapy was continued and changed as per C/S report. TRUS guided aspiration allowed us to identify Staphylococcus aureus in all four patients. Two patients showed growth of E. coli, out of which, one was following acute prostatitis and one following prostatic biopsy. All diabetics with prostatic abscess had Staphylococcus aureus on culture .There was no complication associated with the procedure. All patients improved symptomatically. On follow up TRUS at one week no remaining abscess pockets were found within the prostate in any of the cases. One patient who had undergone prostatic biopsy followed by development of prostatic abscess underwent trans urethralderoofing of prostatic abscess along with TURP. This patient hadgood symptomatic response to intravenous antibiotics and was taken for TURP along with treatment of prostatic abscess. The patient developed high grade post operative fever which continued for 48 hrs.
Mean hospital stay of patients with prostatic abscess requiring TRUS guided aspiration was 9.4 days, and patients were discharged on oral antibiotics for fourweeks.
| Discussion|| |
Prostatic abscess is an unusual condition. The prevalence ofprostatic abscess is about 0.5% of all prostatic diseases. In the pastsuch abscesses usually were complications of untreated orin appropriately treated acute bacterial prostatitis. ,,
Delay in diagnosis can have grave sequelae, including rupture ofthe abscess into is chiorectalfossa or perivesical space with associated morbidity and death. , Various factors have influenced the decrease in incidence of prostatic abscess especially routine and widespread use of broad-spectrum antibiotics and better control of chronic diseases. ,, Finding spontaneous abscess drainageto the urethra,  and peritonitis,  is sporadic today. It is thought that the retrograde flow of contaminated urine within the prostate during micturition is the most prevalent pathogenic factor.  Some authors suggest that prostatic abscess is a complication of bacterial prostatitis, acute or chronic, but the actual incidence and frequency of these events is not known.  Bacterial hematogenous spread from distant foci are also described. In this series, patients presented with a mean age comparable to that found in literature i.e. fifth and the sixth decade. The signs and symptoms of prostatic abscess as detailed in literature in order off mrequency are acute urinary retention, fever, dysuria, urinary frequency, perineal pain, hematuria, urethral discharge, and lowback pain. ,, However, with the changing etiology of prostatic abscess the presenting features have also changed with dysuria, fever and urinary frequency as the main presenting features. Acute urinary retention is rare and is usually present when prostatic abscess occurs as a complication of local inflammatory process. Clinicians need to have a high index of suspicion in patents having fever with LUTS especially diabetics. The classic finding on a digital rectal examination of a tender fluctuant mass often is exceptional. Because signs, symptoms, and physical findings of prostatic abscess are similar to those of acute bacterial prostatitis, the diagnosis is often difficult on clinical basis alone. Prostatic imaging is important in the diagnosis and management.
The diagnostic study of choice to assist the treatment and follow-up of patients with prostatic abscess is transrectal ultrasonography of theprostate.  The most common finding is presence of one or morehypoechogenic areas, of several sizes, containing thick liquidprimarily in the transition zone and in central zone of the prostate, permeated by hyperechogenic areas and distortion of the anatomyof the gland. In this series this finding was observed in 100% of thecases for which the examination was performed. Other conditionsthat may have a similar appearance on TRUS are neoplasticprocesses, cystic lesions, and granulomas.  However, theTRUS appearance of prostatic abscess isquite characteristic andcan be differentiated from that of other conditions. Reportedcriteria discriminating abscess from prostate cancer include thefollowing: (1) prostate carcinoma usually appears small and areeasily distinguishable from the surrounding gland, whereasabscess occupies a large area of one or both glands; (2) carcinomais found more frequently in the peripheral zone of the prostate,whereas the abscess is usually located in the central gland; (3) Color Doppler sonographic examinations show a high perilesionalvascularity that is absent within the tumor.  Computed tomographyaddsa few benefits to transrectal ultrasonography for the diagnosisof prostatic abscess, especially when there are extraprostatic collections.
Treatment of prostatic abscess includes parenteral broad-spectrumantibiotics and abscess drainage. This may be performed bytransrectal puncture or transperineal ultrasound-guided, digital guided puncture/drainage by perineal route, transurethral incision of the prostate, TURP, or open perineal drainage. , No anesthesia is required for TRUS guided aspiration and repeat procedures can be performed easily with minimal morbidity.  There is a preference for minimally invasive procedures that may be performed under local anesthesia or sedation, and repeated if necessary. TRUS is diagnostic as well as highly effective in management as shown by other studies too. TRUS needle aspiration for prostatic abscess is a feasible alternative to transurethral drainage.  TRUS-guided transrectal placement of a drainage tube is a feasible and safe treatment alternative for prostatic abscess; it is also easy to perform and well tolerated by the patients.  CT guided percutaneous drainage, along with appropriate antibiotics, is an effective approach to treat deep prostatic abscess as has been recently reported.  Gram-negative bacilli (chiefly E. coli) have caused about 60 to 80% of cases in recent studies. However Staphaureushas also been one of the major etiological agents isolated in 4 out of 12 cases in a similar study.  Lack of uniformity in antibiotics prescription occurs due to the rarity of the disease, varied etiological agents in different studies and no uniform guidelines for these cases. The increased rate of incidence of Staphaureus in the present study could be because most patients had already received fluoroquinolones in the community before referral. Most of the patients were diabetics and hematogenous spread from distant foci cannot be ruled out. So an antibiotic with staphylococcal coverage should be used empirically especiallyin this subset of patients. Anaerobic cover should be given especially around the time of transrectal drainage to minimize any complications associated with the procedure. Deroofing of prostatic abscess preferably should not be combined with other endo-urological procedures such as TURP because of the high complication rate as happened in one of our patients.
Patients of prostatic abscess who are symptomatic and have alarge volume of collection of pus usually need hospital admission for aspiration. Micro-abscess can be treated on an outdoor basis.The diagnosis of prostatic abscess should be proposed for patients presenting with fever and persistentirritative voiding symptoms despite antimicrobials use, in diabetics with protracted symptoms, for those with lower urinary tract symptoms andfever progressing to urinary retention, and after the performance of prostatic biopsy.
| Conclusion|| |
TRUS guided drainage of prostatic abscess is the preferred treatment because of its lower risk of complications. Transrectal sonography also makes it possible to follow up abscesses that were not treated with drainageor puncture but with antibiotic therapy only.
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[Figure 1], [Figure 2], [Figure 3]