International Urology and Nephrology 24 (4), pp. 397-- 401 (1992)
Percutaneous Drainage of Prostatic Abscess K. BIRCAN,* O. (3ZT/3RK,* C. HAKS6Z,* A. BILICI** Departments of *Urology and **Radiology, Dicle University, Faculty of Medicine, Diyarbakir, Turkey (Accepted September 13, 1991) The treatment results of 2 patients with prostatic abscess who underwent perineal percutaneous drainage under transrectal ultrasonographic guidance are described. Both patients were treated definitely and without complications. It is concluded that the use of transrectal ultrasound during the procedure increases the effectivity and safety of treatment. Introduction
Prostatic abscess is one of the urological emergencies. In the past the disease was more frequent than it is today, and in the majority of cases the causative agent was N. gonorrhoeae [1 ]. With the advent of effective antibiotic agents the disease has turned out to be less frequent, with E. coli being the causative agent in 70 per cent of cases [2, 3]. Prostatic abscess is a consequence of acute bacterial prostatitis. The predisposing factors for the development of prostatic abscess had been previously defined as diabetes, prostatic cancer, chronic prostatitis, chronic renal failure and urethral instrumentation [4]. Patient history and rectal digital examination are useful for diagnosis, but the exact pathology can best be confirmed by radiological imaging techniques such as computerized tomography (CT) and transrectal ultrasonography (TRU). If untreated, the abscess is likely to rupture spontaneously into the rectum, urethra or perineum [2]. The treatments for prostatic abscess are basically antibacterial therapy and drainage of the abscess. Transperineal percutaneous aspiration has been claimed to be effective and sufficient for the drainage procedure, but it has also been suggested that transurethral resection or perineal incision may frequently be necessary [5]. We describe our experience with transperineal percutaneous drainage in two patients with prostatic abscess. Patients and methods
Case 1. The 68-year-old patient came to the outpatient department with acute urinary retention. In the history he described that his complaints (dysuria, urgency, frequency and nocturia) had started one week earlier, after a 6-hour 5
VSP, Utrecht Akad~miai Kiad6, Budapest
398
Bircan et aL ." Prostatic abscess
horse riding. For the last 3 days he had had high fever and perineal pain. On physical examination he had 38.5 ~ fever. Rectal digital examination revealed a fluctuating mass on the prostate. T R U demonstrated the pathology (Fig. 1).
Fig. 1. Case
1.
Transrectal ultrasonogram: the abscess cavity and the catheter
C a s e 2. The 46-year-old patient was referred to our Department with a history of acute urinary retention. On arrival he had already had an indwelling urethral catheter. He had 38.7 ~ fever and perineal pain. Rectal digital examination revealed a fluctuating mass on the prostate. T R U confirmed the diagnosis of prostatic abscess (Fig. 2).
Fig. 2. Case
2.
Transrectal ultrasonogram: the abscess cavity and the catheter
International Urology and Nephrology 24, 1992
B i r c a n e t aL : P r o s t a t i c abscess
399
Before the drainage procedure both patients had undergone urinalysis, urine culture, blood cultures, blood chemistry, chest X-ray, plain abdominal film and abdominal ultrasonography. They were subjected to antibiotic treatment with 2 broad-spectrum antibiotics starting one hour before the procedure. Prior to percutaneous aspiration a suprapubic trocar cystostomy was placed into the bladder as a temporary urinary diversion. Procedure
The patients were in the knee-elbow position. The perineum was anaesthetized with 0.5 % lidocaine solution. The ultrasonic probe was inserted into the rectum and an image of the abscess cavity was obtained. For perineal puncture a 16-gauge intravenous catheter was used. The first pus specimen was sent to the laboratory for anaerobic and aerobic cultures. Under ultrasonographic guidance the catheter was moved in all directions allowing all the pus to be aspirated. Then the catheter was sutured to the perineal skin and a closed drainage system was established. The drainage catheter was withdrawn after it was confirmed by repeat TRU that no residual collection was present. The cystostomy tube was first clamped and then withdrawn after the patient was proven to have no voiding problem. Antibiotic treatment was continued until the 10th postprocedure day.
Results
In the first case, 35 ml of pus was initially aspirated and there was no further drainage on follow-up. On the 4th post-procedure day the drainage catheter was withdrawn. Both the urine and pus cultures revealed significant E. coli colonization. The blood cultures were negative. After 4 months the patient had no abnormal urological signs or symptoms. In the second case, 22 ml of pus was aspirated and on follow-up there was no further drainage. The catheter was withdrawn on the 3rd post-procedure day. Blood cultures were negative. The culture of the aspiration material revealed significant E. coli colonization. This patient had abnormal liver function tests and on further investigation he was found to have post-necrotic cirrhosis. After 2month follow-up he had no complaints related to the urogenital system.
Discussion
In the majority of cases prostatic abscess is known to be a consequence of acute bacterial prostatitis. However, Kadmon and associates have previously stressed the importance of diabetes, urethral instrumentation, prostatic carcinoma, chronic prostatitis and chronic renal failure as predisposing factors [4]. We would like to add cirrhosis and prolonged horse riding to this list of predisposing factors, 5*
International Urology and Nephroloyy 24, 1992
400
B i r c a n e t aL ." P r o s t a t i c a b s c e s s
the former affecting the immune system adversely and the latter causing a considerable trauma to the prostate. In the diagnosis of prostatic abscess, history taking and rectal digital examination are of utmost importance. It has been previously stated that sometimes history taking and physical examination are not sufficient for an early diagnosis [5]. In the study by Dajani and O'Flynn, 49 cases of prostatic abscess had been investigated retrospectively [6 ]. Among these patients the distribution of symptoms was as follows: acute urinary retention 50~, frequency 50~, high fever 41~, epididymoorchitis 24 ~, rectal pain 14 ~, haematuria 10 ~, urethral discharge 6 and back pain 2 ~. When this wide variety of symptoms is coupled with the rarity of the disease, diagnostic diff• become apparent. Kadmon et al. had pointed out these difficulties and suggested pelvic CT as the method of choice for accurate diagnosis [4]. In their study Kadmon and associates used CT successfully both for the diagnosis and follow-up. TRU is another effective method for demonstrating prostatic abscesses. TRU has also many advantages over CT, since it is cheaper and easy to apply, available in most centers and can be used as a guide during the drainage process. The two main treatments of prostatic abscess are antibacterial therapy and drainage. In the past, abscess drainage had been accomplished by perineal incisions. More recently transurethral resection has also been used successfully. In 1986, Kadmon et al. reported on successful treatment of intraabdominal abscess by percutaneous drainage and planned to use the same method for prostatic abscess [4]. They have used pelvic CT for the diagnosis and follow-up of their patients. In our study we decided to use transrectal ultrasonography so as to make the drainage procedure more effective. During puncture and aspiration of the abscess cavity the catheter was monitored and moved under ultrasonographic guidance and this method enabled us to evacuate the cavity completely. Kadmon and associates reported 6 to 10 days of post-procedure drainage. In our study no post-procedure drainage was observed, indicating that transrectal ultrasonographic guidance is more sensitive than rectal digital examination for detecting residual pus in the cavity. The use of TRU during the process could be considered theoretically as a factor increasing the risk of septicaemia. However, we have not observed this condition in any of our patients. According to our experience with these two cases we totally agree with Kadmon and associates as regards the effectiveness of transperineal percutaneous drainage for the treatment of prostatic abscess and we suggest to use transrectal ultrasonographic guidance during the procedure. In our opinion the use of ultrasonographic guidance eliminates the necessity of prolonged catheter drainage. Although this conclusion needs to be verified in larger patient groups, we are entirely satisfied with the procedure and are planning not to leave a drainage catheter in place after aspiration in the treatment of our future patients.
International Urology and Nephrolo#y 24, 1992
Bircan et aL . Prostatic abscess
401
References 1. Sargent, J. C., Irwin, R.: Prostatic abscess: Clinical study of 42 cases. Am. J. Sur#., 11, 334 (1931). 2. Pfau, A.: Prostatitis: A continuing enigma in urinary tract infection. Urol. Clin. North Am., 13, 695 (1986). 3. Pai, M. G., Bhat, H. S.: Prostatic abscess. J. Urol., 108, 599 (1972). 4. Kadmon, D., Ling, D., Lee, J. K. T.: Percutaneous drainage of prostatic abscess. J. UroL, 135, 1259 (1986). 5. Meares, J. R. : Prostatitis and related disorders. In: P. C. Walsh, R. F. Gittes, A. D. Perlmutter, T. A. Stamey (eds): Campbell's Urology. Fifth edition. W. B. Saunders Company, Philadelphia 1986, Vol. 3, pp. 868-886. 6. Dajani, M. D., O'Flynn, J. D. : Prostatic abscess. Br. J. Urol., 40, 736 (1968).
International Urology and Nephrology 24, 1992
Percutaneous Drainage of Prostatic Abscess K. BIRCAN,* O. (3ZT/3RK,* C. HAKS6Z,* A. BILICI** Departments of *Urology and **Radiology, Dicle University, Faculty of Medicine, Diyarbakir, Turkey (Accepted September 13, 1991) The treatment results of 2 patients with prostatic abscess who underwent perineal percutaneous drainage under transrectal ultrasonographic guidance are described. Both patients were treated definitely and without complications. It is concluded that the use of transrectal ultrasound during the procedure increases the effectivity and safety of treatment. Introduction
Prostatic abscess is one of the urological emergencies. In the past the disease was more frequent than it is today, and in the majority of cases the causative agent was N. gonorrhoeae [1 ]. With the advent of effective antibiotic agents the disease has turned out to be less frequent, with E. coli being the causative agent in 70 per cent of cases [2, 3]. Prostatic abscess is a consequence of acute bacterial prostatitis. The predisposing factors for the development of prostatic abscess had been previously defined as diabetes, prostatic cancer, chronic prostatitis, chronic renal failure and urethral instrumentation [4]. Patient history and rectal digital examination are useful for diagnosis, but the exact pathology can best be confirmed by radiological imaging techniques such as computerized tomography (CT) and transrectal ultrasonography (TRU). If untreated, the abscess is likely to rupture spontaneously into the rectum, urethra or perineum [2]. The treatments for prostatic abscess are basically antibacterial therapy and drainage of the abscess. Transperineal percutaneous aspiration has been claimed to be effective and sufficient for the drainage procedure, but it has also been suggested that transurethral resection or perineal incision may frequently be necessary [5]. We describe our experience with transperineal percutaneous drainage in two patients with prostatic abscess. Patients and methods
Case 1. The 68-year-old patient came to the outpatient department with acute urinary retention. In the history he described that his complaints (dysuria, urgency, frequency and nocturia) had started one week earlier, after a 6-hour 5
VSP, Utrecht Akad~miai Kiad6, Budapest
398
Bircan et aL ." Prostatic abscess
horse riding. For the last 3 days he had had high fever and perineal pain. On physical examination he had 38.5 ~ fever. Rectal digital examination revealed a fluctuating mass on the prostate. T R U demonstrated the pathology (Fig. 1).
Fig. 1. Case
1.
Transrectal ultrasonogram: the abscess cavity and the catheter
C a s e 2. The 46-year-old patient was referred to our Department with a history of acute urinary retention. On arrival he had already had an indwelling urethral catheter. He had 38.7 ~ fever and perineal pain. Rectal digital examination revealed a fluctuating mass on the prostate. T R U confirmed the diagnosis of prostatic abscess (Fig. 2).
Fig. 2. Case
2.
Transrectal ultrasonogram: the abscess cavity and the catheter
International Urology and Nephrology 24, 1992
B i r c a n e t aL : P r o s t a t i c abscess
399
Before the drainage procedure both patients had undergone urinalysis, urine culture, blood cultures, blood chemistry, chest X-ray, plain abdominal film and abdominal ultrasonography. They were subjected to antibiotic treatment with 2 broad-spectrum antibiotics starting one hour before the procedure. Prior to percutaneous aspiration a suprapubic trocar cystostomy was placed into the bladder as a temporary urinary diversion. Procedure
The patients were in the knee-elbow position. The perineum was anaesthetized with 0.5 % lidocaine solution. The ultrasonic probe was inserted into the rectum and an image of the abscess cavity was obtained. For perineal puncture a 16-gauge intravenous catheter was used. The first pus specimen was sent to the laboratory for anaerobic and aerobic cultures. Under ultrasonographic guidance the catheter was moved in all directions allowing all the pus to be aspirated. Then the catheter was sutured to the perineal skin and a closed drainage system was established. The drainage catheter was withdrawn after it was confirmed by repeat TRU that no residual collection was present. The cystostomy tube was first clamped and then withdrawn after the patient was proven to have no voiding problem. Antibiotic treatment was continued until the 10th postprocedure day.
Results
In the first case, 35 ml of pus was initially aspirated and there was no further drainage on follow-up. On the 4th post-procedure day the drainage catheter was withdrawn. Both the urine and pus cultures revealed significant E. coli colonization. The blood cultures were negative. After 4 months the patient had no abnormal urological signs or symptoms. In the second case, 22 ml of pus was aspirated and on follow-up there was no further drainage. The catheter was withdrawn on the 3rd post-procedure day. Blood cultures were negative. The culture of the aspiration material revealed significant E. coli colonization. This patient had abnormal liver function tests and on further investigation he was found to have post-necrotic cirrhosis. After 2month follow-up he had no complaints related to the urogenital system.
Discussion
In the majority of cases prostatic abscess is known to be a consequence of acute bacterial prostatitis. However, Kadmon and associates have previously stressed the importance of diabetes, urethral instrumentation, prostatic carcinoma, chronic prostatitis and chronic renal failure as predisposing factors [4]. We would like to add cirrhosis and prolonged horse riding to this list of predisposing factors, 5*
International Urology and Nephroloyy 24, 1992
400
B i r c a n e t aL ." P r o s t a t i c a b s c e s s
the former affecting the immune system adversely and the latter causing a considerable trauma to the prostate. In the diagnosis of prostatic abscess, history taking and rectal digital examination are of utmost importance. It has been previously stated that sometimes history taking and physical examination are not sufficient for an early diagnosis [5]. In the study by Dajani and O'Flynn, 49 cases of prostatic abscess had been investigated retrospectively [6 ]. Among these patients the distribution of symptoms was as follows: acute urinary retention 50~, frequency 50~, high fever 41~, epididymoorchitis 24 ~, rectal pain 14 ~, haematuria 10 ~, urethral discharge 6 and back pain 2 ~. When this wide variety of symptoms is coupled with the rarity of the disease, diagnostic diff• become apparent. Kadmon et al. had pointed out these difficulties and suggested pelvic CT as the method of choice for accurate diagnosis [4]. In their study Kadmon and associates used CT successfully both for the diagnosis and follow-up. TRU is another effective method for demonstrating prostatic abscesses. TRU has also many advantages over CT, since it is cheaper and easy to apply, available in most centers and can be used as a guide during the drainage process. The two main treatments of prostatic abscess are antibacterial therapy and drainage. In the past, abscess drainage had been accomplished by perineal incisions. More recently transurethral resection has also been used successfully. In 1986, Kadmon et al. reported on successful treatment of intraabdominal abscess by percutaneous drainage and planned to use the same method for prostatic abscess [4]. They have used pelvic CT for the diagnosis and follow-up of their patients. In our study we decided to use transrectal ultrasonography so as to make the drainage procedure more effective. During puncture and aspiration of the abscess cavity the catheter was monitored and moved under ultrasonographic guidance and this method enabled us to evacuate the cavity completely. Kadmon and associates reported 6 to 10 days of post-procedure drainage. In our study no post-procedure drainage was observed, indicating that transrectal ultrasonographic guidance is more sensitive than rectal digital examination for detecting residual pus in the cavity. The use of TRU during the process could be considered theoretically as a factor increasing the risk of septicaemia. However, we have not observed this condition in any of our patients. According to our experience with these two cases we totally agree with Kadmon and associates as regards the effectiveness of transperineal percutaneous drainage for the treatment of prostatic abscess and we suggest to use transrectal ultrasonographic guidance during the procedure. In our opinion the use of ultrasonographic guidance eliminates the necessity of prolonged catheter drainage. Although this conclusion needs to be verified in larger patient groups, we are entirely satisfied with the procedure and are planning not to leave a drainage catheter in place after aspiration in the treatment of our future patients.
International Urology and Nephrolo#y 24, 1992
Bircan et aL . Prostatic abscess
401
References 1. Sargent, J. C., Irwin, R.: Prostatic abscess: Clinical study of 42 cases. Am. J. Sur#., 11, 334 (1931). 2. Pfau, A.: Prostatitis: A continuing enigma in urinary tract infection. Urol. Clin. North Am., 13, 695 (1986). 3. Pai, M. G., Bhat, H. S.: Prostatic abscess. J. Urol., 108, 599 (1972). 4. Kadmon, D., Ling, D., Lee, J. K. T.: Percutaneous drainage of prostatic abscess. J. UroL, 135, 1259 (1986). 5. Meares, J. R. : Prostatitis and related disorders. In: P. C. Walsh, R. F. Gittes, A. D. Perlmutter, T. A. Stamey (eds): Campbell's Urology. Fifth edition. W. B. Saunders Company, Philadelphia 1986, Vol. 3, pp. 868-886. 6. Dajani, M. D., O'Flynn, J. D. : Prostatic abscess. Br. J. Urol., 40, 736 (1968).
International Urology and Nephrology 24, 1992
