Transrectal Ultrasound-Guided Transperineal Drainage of a Huge Prostatic Abscess:

Case Report
Transrectal Ultrasound-Guided Transperineal
Drainage of a Huge Prostatic Abscess:
A Case Report and Literature Review
Wing-Ming Lai, Kuan-Chou Chen, Yi-Kuang Chen, Han-Sun Chiang
Department of Urology, Taipei Medical University Hospital, Taipei, Taiwan, R.O.C.
Transrectal Ultrasound-Guided Transperineal Drainage of a Huge Prostatic Abscess: A Case
Report with Literature Review
A 73-year-old male patient who was suffering from acute urine retention and fever was diagnosed as having a huge prostatic abscess. Transrectal ultrasound-guided transperineal drainage
was performed, and adequate drainage was followed-up by pelvic computed tomography. We
conclude that transrectal ultrasound-guided transperineal drainage is an effective, minimally invasive treatment for a huge prostatic abscess. (JTUA 13:161-5, 2002)
Key words: prostatic abscess, transperineal drainage.
INTRODUCTION
Prostatic abscesses are a rare clinical entity, and
most have been identified in immunocompromised patients, such as those with diabetes mellitus or HIV infection, or on chronic hemodialysis [1]. They are prone
to neglect, because their related symptoms and clinical
findings are often nonspecific. Transrectal ultrasound
(TRUS) and computed tomography (CT) are commonly
utilized to detect a prostatic abscess [2-4].
Traditionally, drainage of a prostatic abscess was
achieved by a perineal incision or transurethral resection
[5,6]. However, some authors reported that prostatic
abscesses treated using transrectal ultrasound-guided
aspiration or drainage showed satisfactory results [7-11].
Herein, we report on a similar experience of managing a
huge prostatic abscess and include a literature review.
numerous/HPF), and hyperglycemia (GLU: 266 mg/dl).
Intravenous administration of broad-spectrum antibiotics was given initially, and hyperglycemia was treated
according to a sliding schedule of regular insulin by
subcutaneous administration. A digital rectal examination revealed marked enlargement of the prostate with a
smooth surface and elastic consistency, but without
tenderness or fluctuation.
A cystostomy was performed in order to relieve the
urinary retention. While transrectal ultrasound (TRUS)
showed a huge hypoechoic lesion (6.9 x 3.4 x 3.2 cm)
within the prostate (Fig. 1), some yellowish-white discharge flowed out from the urethra when the prostate
CASE REPORT
A 73-year-old male patient suffered from diabetes
mellitus with medical therapy for 3 years, and blood
glucose was determined to be well controlled. In addition, he had been treated for prostate enlargement for 2
years. A history of urinary tract infection was denied;
however, severe urinary symptoms were still noted (international prostate symptom score: 25). He was hospitalized because of intermittent fever for 2 days and urinary retention. The laboratory data revealed leukocytosis (WBC: 20240/μl; NEUT: 91.5%), pyuria (WBC:
Received: July 31, 2002
Fig. 1 TRUS revealing a huge hypoechoic lesion (6.9
x 3.4 x 3.2 cm) with a thick wall in the prostate
(arrow).
Revised: Sep. 24, 2002
Accepted: Dec. 3, 2002
Address reprint requests and correspondence to: Dr. Kuan-Chou Chen
Department of Urology, Taipei Medical University Hospital, No. 250, Wu-Hsing St., Taipei, Taiwan, 110, R.O.C.
台灣泌尿醫誌第十三卷第四期(91 年 12 月)
161
Percutaneous Drainage of a Prostatic Abscess
was pressed by the TRUS probe. The pelvic CT scan
findings were compatible with those of TRUS, and a
prostatic abscess was identified (Fig. 2).
To manage the huge prostatic abscess, we proceeded with transperineal drainage with the patient lying in the lithotomy position, under spinal anesthesia,
with a TRUS probe placed in the rectum for guidance,
and a 21-gauge Chiba needle inserted through the biopsy guidance device transperineally into the prostatic
abscess (Fig. 3). Two hundred milliliters of pus was
removed, and then an 8F pigtail catheter was placed in
the abscess cavity. In spite of the negative urine culture,
the pus culture revealed Staphylococcus aureus. The
appropriate antibiotic (augmentin at 1.2 g) was given
intravenously 3 times daily to eradicate the infectious
organism. Blood sugar was controlled to below 200
mg/dl with oral medicine alone. The drainage ceased 24
days later, and the perineal catheter was removed after a
repeat pelvic CT scan confirmed successful drainage
of the abscess (Fig. 4). The patient was followed-up for
2 months, and an open prostatectomy was subsequently
performed to solve the bladder outlet obstruction.
Pathologic study revealed an enlarged prostate weighing
83 g and nodular hyperplasia microscopically. No additional abscess was found during the operation or inside
the specimen. The patient was then followed-up for
more than 1 year, and the entire course was uneventful.
The causative organism is usually Staphylococcus sp.,
suggesting a hematogenous spread of an infectious
source from a distant site in the body. Anaerobic organisms and fungal infection are relatively rare causes
[12,13]. Symptoms of our patient were compatible with
the former; however, pus culture revealed Staphylococcus aureus. No evidence of the original infectious
source was found, so we suspect that the abscess may
have been established from an occult source such as a
skin abrasion [14].
Patients with an immunocompromised status, diabetes, or chronic renal failure on perpetual hemodialysis
are all at higher risk for this disease. Other predisposing
factors include urethral instrumentation and prostate
carcinoma [1,15]. Our patient had steady glycemic control with medical therapy; hyperglycemic exacerbation
was noted during the acute status of the infection and
was relieved after management of the infection. Therefore, we suggest that the adequacy of diabetic control
appears unrelated to the development of a prostatic abscess.
The clinical picture of a prostatic abscess often
mimics that of acute bacterial prostatitis such as fevers,
chills, perineal pain, and lower urinary tract obstructive
DISCUSSION
Prostatic abscesses are uncommon in recent years
because of early antibiotic therapy. Effective treatment
of Neisseria gonorrhoeae, a major cause of prostatic
abscesses in the past, has contributed significantly to
this phenomenon [12].
The most common mechanism which occurs in
older individuals with preexisting bladder outlet obstruction is reflux of infected urine into the prostatic
ducts causing prostatitis and then abscess formation.
The major pathogen is E. coli or other gram-negative
enterobacteria. The other mechanism involves a much
smaller group of patients with a wide age distribution.
Fig. 2 Pelvic CT scan showing a large cystic mass in
the prostate (arrow), consistent with a
prostatic abscess.
162
Fig. 3 Transperineal puncture of the prostatic abscess under TRUS guidance. A perineal guidance device was utilized to assist the puncture
procedure.
Fig. 4 Follow-up CT scan demonstrating resolution
of the process (arrow head).
JTUA Vol.13 No.4, Dec. 2002
WM Lai, KC Chen, YK Chen, et al
symptoms but can be highly variable. The distinguished
finding of a tender, fluctuant prostatic mass on rectal
examination has not been a constant and uniform occurrence [1]. A complete blood count usually discloses
pronounced leukocytosis, with a shift toward neutrophils. Urinalysis may show pyuria and bacteriuria,
however, these findings may be absent especially in
gram-positive (Staphylococcus) abscesses because of
the significant hematogenous route [12]. Since the
clinical presentation and laboratory findings are nonspecific, imaging studies are crucial in the diagnosis of a
prostatic abscess. Transrectal ultrasound and pelvic
computed tomography have been suggested as noninvasive techniques helpful for the diagnosis and follow-up
of a prostatic abscess [2-4]. Our experience confirms the
usefulness of both imaging techniques.
In 1999, Ludwig reviewed a series of 18 patients
and suggested that a monofocal abscess of less than 1
cm in diameter be treated with intravenous
broad-spectrum antibiotic therapy and a suprapubic
catheter. Surgical drainage should be performed for
multifocal abscesses greater than 1 cm in diameter, septic shock, recurrent abscess, or in patients responding
poorly to antibiotics for 3 days or longer [1]. Hence,
surgical drainage is the most important strategy for
treatment of a prostatic abscess. Traditionally, a perineal
incision or transurethral resection was recommended as
the method of choice [5,6]. Problems with these methods include dissemination of bacteria, poor wound
healing, incomplete drainage of multiloculated or peripheral abscesses, and retrograde ejaculation [10].
Needle aspiration of a prostatic abscess was considered
primarily a diagnostic tool [6]. However, Becker (1964)
first reported that needle aspiration with adjuvant antibiotic therapy could produce a cure [16]. Needle aspiration subsequently became the first choice of treatment
because of the excellent safety and efficacy. TRUS not
only serves to identify a prostatic abscess but can also
be used as a guidance for drainage of the abscess with
high accuracy. Multiple, peripheral, or multiloculated
abscesses can be visualized, and procedures can easily
be performed with minimal morbidity. The risks of dissemination and retrograde ejaculation are negligible.
Aspiration can be performed via either transrectal or
transperineal approaches. Patients are followed-up with
TRUS weekly after aspiration, and the procedure should
be repeated for adequate drainage in case of failure.
Approximately 83%-86% of patients were able to
achieve complete resolution without a second procedure
[8-11]. In addition to the aspiration of all drainable pus,
a catheter is suggested to be left in the abscess cavity
especially with abscesses greater than 3 cm in diameter,
because most of them will require repeat aspiration.
This procedure should be performed transperineally to
avoid fecal contamination and possible risk of a rectourethral fistula [7]. When drainage ceases, usually 6 to
10 days later, and TRUS and/or a pelvic CT scan confirm adequate drainage of the abscess, the perineal
catheter can be removed. Gentle irrigation with sterile
saline or repeat aspiration is required for incomplete
drainage [7,17,18]. The well-tolerated procedure and
台灣泌尿醫誌第十三卷第四期(91 年 12 月)
good long-term result are satisfactory in our experience.
In conclusion, transrectal ultrasound is useful in the
diagnosis of prostatic abscesses as well as in providing
guidance for aspiration or drainage of such abscesses.
Transrectal ultrasound-guided transperineal drainage is
an effective, minimally invasive treatment for a huge
prostatic abscess with few or no adverse effects.
REFERENCES
1. Ludwig M, Schroeder-Printzen I, Schiefer HG,
Weidner W. Diagnosis and therapeutic management
of 18 patients with prostatic abscess. Urology 1999;
53(2):340-5.
2. Sugao H, Takiuchi H, Sakurai T. Transrectal
longitudinal ultrasonography of prostatic abscess. J
Urol 1986;136(6):1316-7.
3. Vaccaro JA, Belville WD, Kiesling VJ Jr, Davis R.
Prostatic abscess: computerized tomography scanning as an aid to diagnosis and treatment. J Urol
1986;136(6):1318-9.
4. Thornhill BA, Morehouse HT, Coleman P, Hoffman-Tretin JC. Prostatic abscess: CT and sonographic findings. Am J Roentgenol 1987;148(5):
899-900.
5. Chitty K. Prostatic abscess. B J Surg 1957;44:599.
6. Dajani AM, O'Flynn JD. Prostatic abscess: a report of
25 cases. Br J Urol 1968;40(6):736-9.
7. Bachor R, Gottfried HW, Hautmann R. Minimal invasive therapy of prostatic abscess by transrectal
ultrasound-guided perineal drainage. Eur Urol
1995;28(4):320-4.
8. Barozzi L, Pavlica P, Menchi I, De Matteis M, Canepari M. Prostatic abscess: diagnosis and treatment.
Am J Roentgenol 1998;170(3):753-7.
9. Collado A, Palou J, Garcia-Penit J, Salvador J, de la
Torre P, Vicente J. Ultrasound-guided needle aspiration in prostatic abscess. Urology 1999;53(3):548-52.
10. Gan E. Transrectal ultrasound-guided needle aspiration for prostatic abscesses: an alternative to transurethral drainage. Techn Urol 2000;6(3):178-84.
11. Lim JW, Ko YT, Lee DH, Park SJ, Oh JH, Yoon Y,
Chang SG. Treatment of prostatic abscess: value of
transrectal ultrasonographically guided needle aspiration. J Ultras Med 2000;19(9):609-17.
12. Weinberger M, Cytron S, Servadio C, Block C,
Rosenfeld JB, Pitlik SD. Prostatic abscess in the
antibiotic era. Rev Infect Dis 1988;10(2):239-49.
13. Meares EM. Prostatic abscess. J Urol 1986;136(6):
1281-2.
14. Gill SK, Gilson RJ, Rickards D. Multiple prostatic
abscesses presenting with urethral discharge. Genitourin Med 1991;67(5):411-2.
15. Gulanikar A, Clark J, Feliz T. Prostatic abscess: an
unusual presentation of metastatic prostate cancer.
Br J Urol 1998;82(2):309-10.
16. Becker LE, Harrin WR. Prostatic abscess: a diagnostic and therapeutic approach. J Urol 1964;91:
582.
17. Kadmon D, Ling D, Lee JK. Percutaneous drainage
163
Percutaneous Drainage of a Prostatic Abscess
of prostatic abscesses. J Urol 1986;135(6):1259-60.
18. Bircan K, Ozturk O, Haksoz C, Bilici A. Percuta-
164
neous drainage of prostatic abscess. Int Urol
Nephrol 1992;24(4):397-401.
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