Prostatic abscess: Objective assessment of the treatment approach in the absence of guidelines

Abstract

ObjectiveTo assess the outcome of the drainage procedure used for treating a prostatic abscess, and to propose a treatment algorithm to reduce the morbidity and the need for re-treatment.Patients and methodsWe retrospectively reviewed patients who were admitted and received an interventional treatment for a prostatic abscess. All baseline relevant variables were reviewed. Details of the intervention, laboratory data, duration of hospital stay, follow-up data and re-admissions were recorded.ResultsA prostatic abscess was diagnosed in 42 patients; 30 were treated by transurethral deroofing and 12 by transrectal needle aspiration. The median (range) size of the abscess was 4.5 (2–23) mL and 2.7 (1.5–7.1) mL in the deroofing and aspiration groups, respectively (P = 0.2). In half of the cases multiple abscesses were evident on imaging before the intervention. The median (range) hospital stay after deroofing and aspiration was 2 (1–11) and 1 (1–19) days, respectively (P = 0.04). Perioperative complications occurred only in the deroofing group, in which two patients developed septic shock requiring intensive care (Clavien 4) and one developed epididymo-orchitis (Clavien 2). There were two late complications in the deroofing group, in which one patient developed a urethral stricture that required endoscopic urethrotomy (Clavien 3a) and one developed a urethral diverticulum and urinary incontinence that required diverticulectomy and a bulbo-urethral sling procedure (Clavien 3b). A urethro-rectal fistula developed after aspiration in one patient. Re-treatment for the abscess was indicated in two (7%) patients in the deroofing group, which was treated by aspiration.ConclusionTransrectal needle aspiration for a prostatic abscess, when done for properly selected cases, could minimise the morbidity of the drainage procedure.

Diagnosis and treatment of patients with prostatic abscess in the post‐antibiotic era

“…These patients, who are frequently older with coincident outlet obstruction, are at risk for PA from direct introduction of bacteria into the prostate. Along with multiple case reports, previous cross‐sectional studies have shown that 8–11% of patients presenting with PA had recently undergone prostate biopsies . In two such cases, PA was the result of infection with multidrug‐resistant Escherichia coli .…”

“…Drainage can be carried out transperineally, but no evidence supports this technique as superior in fact, reports have detailed the development of periurethral or perineal abscesses after perineal aspiration requiring open incision and drainage . As most urologists are comfortable with the transrectal approach, we recommend this as the standard for ultrasound‐guided drainage . Of the multiple advantages to this technique, foremost is the ability to carry out aspiration at the bedside with local anesthesia.…”

“…The incidence of infectious complications after TRUS‐guided aspiration is low, but can be severe; in several series, low rates of severe, even fatal, sepsis have been reported despite adequate abscess drainage . There is one report of rectourethral fistula formation after aspiration . The greatest limitation to this method remains to be abscess recurrence and/or incomplete treatment.…”

“…Studies examining recurrence after aspiration disagree, ranging from 15% to 33% . Based on outcomes from several large case series studies, some authors recommend the use of TRUS‐guided aspiration before progressing to other therapies …”

Management of prostatic abscess: about one case and literature review

“…In the series of LIM JW et al [17], transrectal ultrasound drainage resulted in 86% success, out of only 14 treated patients, two necessitated another therapeutic modality, namely perineal incision drainage in one Case and trans-urethral resection in the second case. ELSHAL AM et al [18] propose an algorithm for the management of prostatic abscess (Figure 3) based on the age of the patient, the size of the prostate and the associated urinary disorders.…”