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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 29  |  Issue : 4  |  Page : 206-209

Treatment strategy for prostatic abscess: Eighteen cases' report and review of literature


Department of Urology, School of Medicine, Showa University, Tokyo, Japan

Date of Web Publication23-Jul-2018

Correspondence Address:
Kazuhiko Oshinomi
Department of Urology, School of Medicine, Showa University, Tokyo
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_59_18

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  Abstract 

Objectives: Prostatic abscesses are rare. The incidence of prostatic abscess has declined markedly with the widespread use of antibiotics. Obtaining improvement is difficult in many cases of prostate abscess. Today, there are no guidelines or algorithms for the treatment of prostatic abscess. In this study, the shape and size of the abscess, in addition to patient background characteristics and the clinical course, were evaluated, and the treatment strategy for prostatic abscess was examined. Methods and Material: All patients with a diagnosis of prostatic abscess in Showa University Hospital between 2003 and 2017 were retrospectively reviewed. Regarding the treatment options, the patients were divided into two groups, the conservative therapy group and the drainage group. In each group, background characteristics, culture reports, shape/size of abscess, and the presence of recurrence were evaluated. Results: All 18 patients with a diagnosis of prostatic abscess between 2003 and 2017 were retrospectively reviewed; 13 patients improved with conservative treatment alone, but drainage was performed in five patients with poor response to antibiotic therapy. All five cases requiring transurethral drainage were multifocal abscesses. Conclusions: In making a decision about the approach for drainage, it is important to assess the size and shape of the abscess using transrectal ultrasonography (TRUS), computed tomography (CT) and magnetic resonance imaging (MRI). If the abscess is the multifocal type, drainage should be considered. Based on the present study, whether the abscess is focal type or multifocal type, transurethral drainage should be considered if the abscess size exceeds 30 mm.

Keywords: Prostatic abscess, transrectal ultrasound, transurethral resection of the prostate


How to cite this article:
Oshinomi K, Matsui Y, Unoki T, Shimoyama H, Nakasato T, Morita J, Maeda Y, Naoe M, Fuji K, Ogawa Y. Treatment strategy for prostatic abscess: Eighteen cases' report and review of literature. Urol Sci 2018;29:206-9

How to cite this URL:
Oshinomi K, Matsui Y, Unoki T, Shimoyama H, Nakasato T, Morita J, Maeda Y, Naoe M, Fuji K, Ogawa Y. Treatment strategy for prostatic abscess: Eighteen cases' report and review of literature. Urol Sci [serial online] 2018 [cited 2018 Nov 15];29:206-9. Available from: http://www.e-urol-sci.com/text.asp?2018/29/4/206/237361




  Introduction Top


Prostatic abscesses are rare, and their incidence has tended to decrease with the use of broad-spectrum antibacterial drugs. However, prostatic abscesses are common in the developing countries and in high-risk patients with diabetes, hemodialysis, cirrhosis, or immunodeficiency. Because its symptoms overlap with those of acute prostatitis, the diagnosis of prostatic abscess is sometimes delayed. Treatment of a prostatic abscess involves adequate antibiotic administration and pus drainage. There are three ways to drain such an abscess: transrectal, transperineal, and transurethral. Each approach has its advantages and disadvantages [Figure 1]. Transrectal ultrasonography (TRUS) is considered useful in that it can be performed from diagnosis to drainage on a periodic basis in some cases. However, due to the limitation of the size of the puncture needle, it may be difficult to achieve sufficient drainage of viscous pus by transrectal drainage. Purkait et al. reported that it was advantageous that TRUS-guided transrectal drainage was less invasive than transurethral drainage, and that it could be performed multiple times under local anesthesia or sedation.[1] However, in multiple abscesses and large abscesses, although high invasiveness and complications are an issue, a high success rate of transurethral drainage has been reported. There are no guidelines on the management of prostatic abscess, on the use of drainage, and on the approach for drainage. In this study, the shape and size of the abscess, in addition to patient background characteristics and the clinical course, were evaluated, and the treatment strategy for prostatic abscess was examined.
Figure 1: Comparison of drainage approaches

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  Methods Top


All patients with a diagnosis of prostatic abscess in Showa University Hospital between 2003 and 2017 were retrospectively reviewed. A prostatic abscess was diagnosed in 18 patients. All patients received antibiotics as initial treatment, and drainage was performed in patients with a poor response to antibiotic therapy. Fever pattern was various, and the most common type was remittent fever.

The prostatic abscesses were classified into three types by shape on computed tomography (CT) and TRUS [Figure 2]. The shapes of the abscess were classified as diffuse, focal, and multifocal types. Transrectal drainage was done in the left lateral decubitus position under local anesthesia. A 20–21G needle was inserted along the track on the ultrasound screen, and pus was aspirated manually. Transurethral drainage was performed in accordance with transurethral resection of the prostate (TURP) under spinal anesthesia or general anesthesia. An incision was made initially at either the 5 o'clock or the 7 o'clock position depending on the abscess as determined by the preoperative CT imaging. Regarding the treatment options, the patients were divided into two groups: the conservative therapy group and the drainage group. In each group, background characteristics, culture reports, shape/size of abscess, and the presence of recurrence were evaluated.
Figure 2: Classification by abscess form

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  Results Top


A total of 18 patients were diagnosed with a prostatic abscess by CT. There were no cases diagnosed by transrectal ultrasound alone. In the most cases, the patients had conditions that made them easily compromised [Figure 3]. All patients were administered antibiotics intravenously as initial treatment. In five patients, the clinical symptoms failed to improve, and drainage was performed [Figure 4]. Drainage was transrectal or transurethral. There were no cases of transperineal drainage. Comparing the background characteristics between the conservative group and the drainage group, the long axis of the abscess tended to be larger in the drainage group. In all cases of transurethral drainage, the long axis of the abscess was >30 mm. In some cases, because some antibiotics were already administered before the diagnosis, the culture-positive rate was not high. In the conservative treatment group, if the treatment effect was poor, a suprapubic catheter was placed. In all cases of transurethral drainage, there were no major complications.
Figure 3: Characteristics of patients diagnosed with prostatic abscess

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Figure 4: Cases that required drainage

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However, we have not evaluated long-term sexual and sexual function.


  Discussion Top


A prostatic abscess is a rare condition, accounting for 0.5% of all prostatic diseases.[2] The major pathogens are Gram-negative bacilli, which are isolated in 60% to 80% of cases.[2],[3],[4],[5],[6] Major risk factors for prostatic abscesses are reported to be lower urinary tract obstruction, urethral manipulation (iatrogenic factor), diabetes mellitus, liver disease, and immunodeficiency states. Two pathologic mechanisms, reflux of infected urine and hematogenous dissemination from a primary infected focus, are suggested as the etiologies of prostatic abscesses.[7] Clinical diagnosis is difficult because the symptoms are nonspecific. This condition presents as micturition pain, perineal pain, fever, and dysuria, but these symptoms overlap with those of acute prostatitis. We should suspect a prostatic abscess and investigate with appropriate diagnostic imaging when symptoms do not improve after 48 h of intravenous antibiotic therapy.[7] According to previous reports, appropriate antibiotics and drainage are the optimal therapeutic option for prostatic abscess. For patients who fail to respond to intravenous antibiotic therapy, drainage should be performed immediately. There are three ways to drain such an abscess: transrectal, transperineal, and transurethral. Each approach has its advantages and disadvantages [Figure 1]. Transrectal drainage is easy to perform and has few complications. However, it is difficult to achieve adequate drainage of a cavity with thick viscous contents, as in the present cases, because this procedure is performed with a thin needle. On the other hand, El-Shazly et al.[8] reported that transurethral drainage achieved the highest success rates without major complications compared to the two other drainage methods. Additional surgical manipulations were unnecessary in the most cases treated with transurethral drainage. However, Collad et al. noted that transrectal drainage should precede transurethral drainage, because transurethral procedures have a potential risk of sexual dysfunction or severe complications.[7] Furthermore, Vyas et al. noted that patients with abscesses larger than 20 mm with severe lower urinary tract symptoms and/or leukocytosis benefitted from transrectal drainage. They also suggested that transurethral drainage is an efficacious treatment procedure for patients who fail attempted TRUS-guided aspiration.[9] There are no guidelines on the management of prostatic abscess. For decision of therapeutic strategy, prostatic abscess was classified into three types with their forms [Figure 2]. We considered that conservative management with antibiotics may be adequate in diffuse type. In contrast, multifocal type is needed in TRUS-guided transrectal drainage or TURP in most of the cases. Classification was done at diagnosis, but it was not certain whether focal type or diffuse type progresses to multifocal type. In the present series, there were cases in which conservative treatment was possible even if the long axis of the abscess was 20 mm or more. In all cases of transurethral drainage, the long axis of the abscess was >30 mm.

Waiting for remission of fever, general condition, and the inflammatory findings, we removed catheter about a week later. However, there is no rule, especially in the period of removal.

In the present cases, even in patients with an indication for drainage, cases with poor general condition due to pelvic fracture and spinal cord injury were only given antibiotics. There are reports that a prostatic abscess was caused by the appearance of resistant bacteria after antibacterial treatment. There is also a report that the hospitalization period was shorter for the transurethral drainage group than for the transrectal drainage group.[1] Although it may be necessary to consider sufficient drainage at an early stage, it is possible that early TURP may exacerbate infection, leading to the onset of sepsis. With the transurethral drainage method, it was reported that a good treatment outcome was obtained even with holmium laser enucleation of the prostate instead of conventional TURP.[10] Elshal et al. also advocated a treatment algorithm that included drainage based on the patient age and prostate volume.[11] In the algorithm, regardless of age and volume, TURP was indicated for multiple abscesses. In diabetic patients, neurogenic bladder may coexist. Because the state of urination before the onset of prostatic abscess is also unknown, it may be difficult for the treatment policy to have to rely on the volume of the prostate. In making a decision about the approach for drainage, it is important to assess the size and shape of the abscess using TRUS, CT, and magnetic resonance imaging. At present, transurethral drainage should be considered in cases of multiple abscesses with a long axis exceeding 30 mm.


  Conclusion Top


There is no guideline on the management of prostatic abscesses. Conservative treatment may require prolonged antibiotic administration, and the appearance of resistant bacteria may lead to longer treatment periods. Transrectal drainage is less invasive, but transurethral drainage should be considered in cases of multiple abscesses with a long axis exceeding 30 mm. A randomized trial with a larger sample is needed for optimal selection of drainage methods.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Purkait B, Kumar M, Sokhal AK, Bansal A, Sankhwar SN, Bhaskar V, et al. Outcome analysis of transrectal ultrasonography guided aspiration versus transurethral resection of prostatic abscess: 10 years' experience from a tertiary care hospital. Arab J Urol 2017;15:254-9.  Back to cited text no. 1
    
2.
Granados EA, Riley G, Salvador J, Vincente J. Prostatic abscess: Diagnosis and treatment. J Urol 1992;148:80-2.  Back to cited text no. 2
    
3.
Jacobsen JD, Kvist E. Prostatic abscess. A review of literature and a presentation of 5 cases. Scand J Urol Nephrol 1993;27:281-4.  Back to cited text no. 3
    
4.
Trauzzi SJ, Kay CJ, Kaufman DG, Lowe FC. Management of prostatic abscess in patients with human immunodeficiency syndrome. Urology 1994;43:629-33.  Back to cited text no. 4
    
5.
Bachor R, Gottfried HW, Hautmann R. Minimal invasive therapy of prostatic abscess by transrectal ultrasound-guided perineal drainage. Eur Urol 1995;28:320-4.  Back to cited text no. 5
    
6.
Angwafo FF 3rd, Sosso AM, Muna WF, Edzoa T, Juimo AG. Prostatic abscesses in Sub-Saharan Africa: A hospital-based experience from Cameroon. Eur Urol 1996;30:28-33.  Back to cited text no. 6
    
7.
Collado A, Palou J, García-Penit J, Salvador J, de la Torre P, Vicente J, et al. Ultrasound-guided needle aspiration in prostatic abscess. Urology 1999;53:548-52.  Back to cited text no. 7
    
8.
El-Shazly M, El-Enzy N, El-Enzy K, Yordanov E, Hathout B, Allam A, et al. Transurethral drainage of prostatic abscess: Points of technique. Nephrourol Mon 2012;4:458-61.  Back to cited text no. 8
    
9.
Vyas JB, Ganpule SA, Ganpule AP, Sabnis RB, Desai MR. Transrectal ultrasound-guided aspiration in the management of prostatic abscess: A single-center experience. Indian J Radiol Imaging 2013;23:253-7.  Back to cited text no. 9
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10.
Lee CH, Ku JY, Park YJ, Lee JZ, Shin DG. Evaluation of holmium laser for transurethral deroofing of severe and multiloculated prostatic abscesses. Korean J Urol 2015;56:150-6.  Back to cited text no. 10
    
11.
Elshal AM, Abdelhalim A, Barakat TS, Shaaban AA, Nabeeh A, Ibrahiem el-H, et al. Prostatic abscess: Objective assessment of the treatment approach in the absence of guidelines. Arab J Urol 2014;12:262-8.  Back to cited text no. 11
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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