Case series: Diffusion weighted MRI appearance in prostatic abscess

Simultaneous prostatic and right seminal vesicle abscesses: a case report

BACKGROUND

Synchronous abscesses of the prostate and seminal vesicles represent a rare but clinically significant form of purulent retention. They pose diagnostic and therapeutic challenges and are associated with considerable morbidity and a high risk of sepsis.

CASE PRESENTATION

We present the case of a 60-year-old Caucasian man with a history of insulin-dependent diabetes mellitus, who had a voluminous prostatic abscess associated with a right seminal vesicle abscess due to compression of the right ejaculatory duct, and who presented to our department with sepsis. He had clinical and radiological confirmation with computed tomography scan and magnetic resonance imaging. The patient underwent percutaneous drainage of the prostatic abscess resulting in the subsidence of the seminal vesicle abscess. The treatment also consisted on prolonged antibiotic therapy. The clinical evolution was favorable.

CONCLUSION

We conclude that prostatic abscesses can lead to synchronous seminal vesicle abscesses due to ejaculatory duct compression. Percutaneous drainage of the prostatic abscess by transrectal ultrasound-guided drainage, combined with prolonged antibiotic therapy, can effectively treat both abscesses.

Imaging Spectrum of Severe Urinary Tract Infection Complications Presenting as a Seminal Vesicle Abscess, Prostatic Abscess, and Renal Abscess in Uncontrolled Diabetes Mellitus: A Case Report

Urinary tract infections are more common and severe, and they carry worse outcomes for patients with type 2 diabetes mellitus. The infections are typically caused by resistant pathogens, leading to many complications. Various impairments in the immune system, poor metabolic control, and incomplete bladder emptying due to autonomic neuropathy may all contribute to the enhanced risk of urinary tract infections in these patients. We present an imaging spectrum of a severe urinary tract infection presenting as renal, prostatic, and seminal vesicle abscesses in a patient with uncontrolled diabetes mellitus.

Extensive prostatic abscess drained by CT-guided percutaneous approach: Case report

Prostatic abscess is a rare entity that occurs most frequently after the age of 50. The main risk factors are immunosuppressive conditions such as diabetes, HIV infection and chronic renal failure. It is clinically manifested by signs of bladder irritation. The management of the disease involves antibiotic therapy and drainage of the abscess, which can be performed by various invasive methods. We report the case of a 60-year-old patient with a large prostatic abscess drained by CT-guided percutaneous approach.

More Than Detection of Adenocarcinoma - Indications and Findings in Prostate MRI in Benign Prostatic Disorders

BACKGROUND

 Multiparametric MRI of the prostate has become a fundamental tool in the diagnostic pathway for prostate cancer and is recommended before (or after negative) biopsy to guide biopsy and increase accuracy, as a staging examination (high-risk setting), and prior to inclusion into active surveillance. Despite this main field of application, prostate MRI can be utilized to obtain information in a variety of benign disorders of the prostate.

METHODS

 Systematic bibliographical research with extraction of studies, national (German) as well as international guidelines (EAU, AUA), and consensus reports on MRI of benign disorders of the prostate was performed. Indications and imaging findings of prostate MRI were identified for a) imaging the enlarged prostate, b) prostate MRI in prostatic artery embolization, c) imaging in prostatitis and d) imaging in congenital anomalies.

RESULTS AND CONCLUSIONS

 Different phenotypes of the enlarged prostate that partly correlate with severity of symptoms are discussed. We provide an overview of the different types of prostatitis and possible imaging findings, highlighting abscesses as a severe complication. The most common congenital anomalies of the prostate are utricular cysts, whereas anomalies like aplasia, hypoplasia, and ectopia are rare disorders. Knowledge of indications for imaging and imaging appearance of these conditions may improve patient care and enhance differential diagnosis.

KEY POINTS

  · Current guidelines do not implement indications for mpMRI apart from prostate carcinoma.. · MRI can distinguish different anatomical phenotypes of prostatic enlargement.. · Prostatic artery embolization represents a valuable treatment option in cases of symptomatic benign prostatic enlargement.. · Different forms of prostatitis exist and may mimic prostate carcinoma in MRI.. · MRI can be used to evaluate anatomical prostate anomalies..

CITATION FORMAT

· Oerther B, Sigle A, Franiel T et al. More Than Detection of Adenocarcinoma - Indications and Findings in Prostate MRI in Benign Prostatic Disorders. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1719-1463.

Differential diagnosis of uncommon prostate diseases: combining mpMRI and clinical information

The differential diagnosis of abnormalities in the prostate is broad, covering common (acinar adenocarcinoma, benign prostatic hyperplasia, chronic prostatitis, hemorrhage, cysts, calcifications, atrophy and fibrosis) and less common conditions (tumors other than acinar adenocarcinoma, granulomatous prostatitis containing tuberculosis, abscesses and other conditions, and idiopathic disorders such as amyloidosis and exophytic benign prostatic hyperplasia). Recent advances in magnetic resonance imaging (MRI) of the prostate gland and imaging guidelines, such as the Prostate Imaging Reporting and Data System version 2.1 (PI-RADS v2.1), have dramatically improved the ability to distinguish common abnormalities, especially the ability to detect clinically significant prostate cancer (csPCa). Overlap can exist in the clinical history and imaging features associated with various common/uncommon prostate abnormalities, and biopsy is often required but is invasive. Prostate abnormalities can be divided into two categories: category 1, diseases for which PI-RADS scores are suitable for use, and category 2, diseases for which PI-RADS scores are unsuitable for use. Radiologists must have an intimate knowledge of other diseases, especially uncommon conditions. Past relevant history, symptoms, age, serum prostate-specific antigen (PSA) levels, MRI manifestations, and the applicability of the PI-RADS assessment should be considered when diagnosing prostate abnormalities.

Imaging spectrum of common and rare infections affecting the lower genitourinary tract

In this review, we will discuss the imaging findings of common as well as uncommon lower genitourinary tract infections. For both clinicians and radiologists, it is imperative to understand etiopathogenesis, epidemiological information, clinical presentation, imaging findings and management options of such conditions. Knowledge of salient imaging features of these infections is of utmost importance because prompt recognition enables appropriate management.

A population-based analysis of risk factors and outcomes of prostatic abscess

BACKGROUND

Prostate abscess is a severe complication of acute bacterial prostatitis. To date, a population-based analysis of risk factors and outcomes of prostatic abscess has not been performed.

METHODS

Using the National Inpatient Sample from 2010 to 2015, we identified rates of prostatic abscess among non-elective hospitalizations for acute prostatitis. Significant Elixhauser comorbidities and risk factors were analyzed using survey-weighted logistic regression. Additional survey-weighted regression models were constructed to analyze sepsis, in-hospital mortality, length of hospital stay (LOS), and total hospital charges.

RESULTS

A weighted total of 126,103 hospitalizations for acute prostatitis was identified, with 6,775 (5.4%) hospitalizations with prostatic abscess. Numerous risk factors for prostatic abscess were identified, with a history of prostate biopsy (adjusted OR: 5.7; p < 0.001), complicated diabetes mellitus (adjusted OR: 3.23, p < 0.001), and urethral stricture (adjusted OR: 3.15; p < 0.001) having the greatest magnitude of developing abscess. Moreover, those diagnosed with prostatic abscess had increased odds of sepsis (adjusted OR: 1.71, p < 0.001), in-hospital mortality (adjusted OR: 2.73, p < 0.001), LOS (adjusted Incidence Rate Ratio: 1.86, p < 0.001), and total hospital charges (adjusted Ratio: 2.06, p < 0.001).

CONCLUSIONS

Numerous risk factors were associated with the development of prostatic abscess, with those diagnosed experiencing greater odds of sepsis, in-hospital mortality, longer LOS, and greater hospital charges. Ultimately, better understanding of risk factors associated with this condition will enable clinicians to identify patients at high risk, thereby expediting and tailoring management.

Prostatitis: imaging appearances and diagnostic considerations

Acute and chronic inflammation of the prostate gland can be attributed to several underlying aetiologies, including but not limited to, bacterial prostatitis, granulomatous prostatitis, and Immunoglobulin G4-related prostatitis. In this review, we provide an overview of the general imaging appearances of the different types of prostatitis, their distinguishing features and characteristic appearances at cross-sectional imaging. Common imaging pitfalls are presented and illustrated with examples.

Presentation, diagnosis, management, and outcomes of prostatic abscess: comparison of three treatment modalities

Purpose

The lack of available guidelines for the management of prostatic abscess (PA) results in inconsistencies in its management. The most commonly used management modalities were conservative treatment with parenteral antibiotics alone, transrectal ultrasound-guided (TRUS) needle aspiration, or transurethral deroofing (TUD).The current study is a retrospective study and examines prostatic abscess cases treated by either one or more of the different modalities. We assess and compare presentation, diagnosis, management, and outcomes of prostatic abscess and we compare the outcomes of the three management modalities.

Methods

We retrieved the records of all patients (n = 23) admitted to the Urology department at Al Wakra hospital with the computed tomography (CT) diagnosis of prostatic abscess from January 2013 to March 2018. Data collected included demographic, clinical, laboratory, and imaging findings, as well as management modality, duration of hospital stay, duration of follow up, outcome, and recurrence.

Results

A total of nine (39.1%) patients had conservative treatment only; eight (34.8%) had TUD, and six (26.1%) had TRUS needle aspiration. The mean age was 52.7 years. Lower urinary tract symptoms and fever were the most common presentations (95.7% and 82.6%, respectively). CT scan of the abdomen and pelvis with contrast was undertaken for all patients and it showed that multiple abscesses were observed in 14 (60.9%) cases.The overall mean hospital stay was 8.45 days (range 2-21 days). We observed no recurrences for patients treated conservatively or those who undertook TUD, but three patient (50%) recurrences were noted in TRUS aspiration patients. There was no mortality across the sample.

Conclusion

Early diagnosis of prostatic abscess and prompt management may have decreased the morbidity and mortality. Conservative management can succeed in subcentimeter abscesses but TUD is the definite therapy for large and multiloculated abscess. TRUS aspiration does have a role in treatment, but it has higher recurrence and longer hospital stay.

Prostate abscess: A comprehensive review of the literature

Prostate abscess (PA) is a rare but serious infection of the prostate gland. Traditionally a complication of urethral gonococcal infection, the majority of PAs are now seen in the older or immunosuppressed populations, in men with existing prostatic disease, or those who have undergone recent instrumentation of the lower urinary tract. Aetiological organisms are diverse, often with non-specific presentations posing a diagnostic challenge. Multiple management options have been described, however no consensus exists on what is the best practice. This comprehensive review examines the literature surrounding this condition in detail, with a focus on diagnostic and surgical treatment options. Recommendations for practice are made where appropriate. This article aims to edge towards a national guideline for the management of PA and inspire more research in the field.

Level of evidence - 3a

Role and Application of Diffusion-weighted Imaging in Evaluation of Prostate Cancer

Introduction: Diffusion-weighted imaging (DWI) is an important part of magnetic resonance imaging (MRI) in the evaluation of specific organs, including the breast, kidney, liver, and prostate. Prostate cancer lesions are composed of tightly packed cells with reduced extracellular space, which can be visualized on DWIs as areas of restricted diffusion (i.e., high-signal intensity), with corresponding low-signal intensity on apparent diffusion coefficient (ADC) maps and low mean ADC value. Objective: The objective of this study is to identify the appropriate cutoff and mean ADC value to diagnose neoplastic prostatic lesions in central India. Materials and Methods: Sixty-six patients with suspected prostatic pathology were included in this study. All patients underwent MRI on a 1.5-T scanner with a phased-array body coil. MRIs were evaluated compared with the histopathological staging. Results:: The diagnostic accuracy of DWI in predicting malignancy was 39/41, i.e., 95.12%, which is the positive predicted value. The mean ADC for benign category was 1.14 with standard deviation (SD) of 0.14 while mean for prostatitis was 0.91 with SD of 0.26 and for carcinoma was 0.75 with SD of 0.19. The difference in the means was statistically highly significant. Conclusion: DWI demonstrates the restriction of diffusion and the reduction of ADC values in neoplastic tissue and improves the diagnostic accuracy in lesion characterization. This technique allows short acquisition time and provides high-contrast resolution between neoplastic and normal tissue. This technique can be a useful adjunct to the established dynamic contrast-enhanced-MRI.

Role of Magnetic Resonance Imaging, Magnetic Resonance Spectroscopy and Transrectal Ultrasound in Evaluation of Prostatic Pathologies with Focus on Prostate Cancer

Background

Prostate cancer (PC) is an important medical and socio-economical problem due to its increasing incidence. The development of the prostate specific antigen (PSA) test, and a continuing decrease in the rates of other common neoplasms, such as lung and stomach since mid-1980s, prostate cancer has become one of the most common cancers among men. Prostate cancer (PC) is the second most common cancer in men, preceded only by lung cancer, and its early diagnosis is crucial for a successful treatment, that will prolong survival and improve quality of life.The main objective of our study was to evaluate the role of magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS) and transrectal ultrasound (TRUS) in detecting prostatic pathologies and staging of prostate cancer by correlating these methods with histopathological results.

Material/Methods

The study is a cross-sectional diagnostic study performed in 66 patients with a high degree of clinical suspicion of prostatic pathology. All patients underwent TRUS, T1W, T2W, DWI, and 3D PRESSMRS sequences, and we also calculated ADC values and Cho Cr/Cit MRS ratios for all patients.

Results

Combination of MRI and MRS showed the highest diagnostic accuracy among the imaging modalities in detecting of prostatic neoplasm, followed by MRI, and then by TRUS. MRS plays a complementary role to MRI, by increasing its diagnostic accuracy. Due to a high cost, limited availability and increased scanning time, combination of MRI and MRS is currently not recommended as a first line investigation for detecting prostate neoplasms, hence USG (TRUS) remains the first line investigation due to its low cost, easy availability, time effectiveness and comparable efficacy.

Conclusions

MRI MRS has more diagnostic accuracy than MRI alone for detection of prostate pathologies. MRS, plays significant complementary role and should be included in the routine MR imaging protocols. MRI helps in diagnosis, localization, better tissue characterization and staging of prostate cancer. TRUS is easily available, cost effective and has comparable efficacy.

Management of prostate abscess in the absence of guidelines

In contemporary practice, the number of patients presenting with prostatic abscess have significantly declined due to the widespread use of antibiotics. However, when faced with the pathology, prostatic abscess tends to pose a challenge to clinicians due to the difficulty of diagnosis and lack of guidelines for treatment. Treatment consists of an array of measures including parenteral broad-spectrum antibiotic administration and abscess drainage.

A rare presentation of disseminated tuberculosis: Prostatic abscess

Involvement of the prostate by tuberculosis (TB) occurs rarely and tuberculosis prostate abscess is an even rarer occurrence. It has been reported in immunocompromised patients, mainly human immunodeficiency virus seropositive individuals. We are reporting a case of tuberculosis prostatic abscess in an immunocompetent patient with relapse of TB.

Non-oncologic applications of diffusion-weighted imaging (DWI) in the genitourinary system

Diffusion-weighted imaging (DWI) has become an increasingly used tool in abdominal and pelvic magnetic resonance imaging (MRI), primarily in the oncologic setting. DWI sequences are being added to routine MRI protocols at many institutions, and as its use has spread, more non-oncologic applications have been explored. The purpose of this article is to provide a review of DWI applications in inflammatory, infectious, autoimmune-mediated, and ischemic processes affecting the genitourinary system.

A case of prostatic abscess with malignant lymphoma involving the prostate

Here, we report a case of prostatic abscess probably due to malignant lymphoma of the prostate. An 82-year-old man was referred to our hospital with chief complaints of urinary frequency and discomfort on urination. Antibiotics were prescribed, but the symptoms remained and intermittent fever appeared. The patient was diagnosed with prostatic abscess by computed tomography (CT). Digital rectal examination (DRE) revealed soft prostate, and thick pus was milked out from the extrameatus by prostatic massage. For drainage, we performed transurethral resection of the prostate (TURP). Drainage by TURP was successful as CT clearly showed reduction of prostatic abscess after the operation. Nevertheless, intermittent fever did not improve and the patient's general condition deteriorated. The day before the patient died, histopathological analysis showed prostatic abscess probably due to malignant lymphoma of the prostate and incidental adenocarcinoma. This is the first report of prostatic abscess with malignant lymphoma involving the prostate.

Methicillin-Resistant Staphylococcus aureus Prostatic Abscess in a Liver Transplant Recipient

Prostatic abscesses are usually related to gram-negative bacilli. However, methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a substantial cause of prostatic abscesses in recent years. Herein, we report the case of a 31-year-old man with a history of orthotopic liver transplantation 10 years ago who presented with acute onset dysuria and abdominal pain and was diagnosed with a MRSA prostatic abscess. To our knowledge, this is the first case describing a prostatic abscess in a liver transplant recipient and the first reporting MRSA as the causative organism of a prostatic abscess in a solid organ transplant recipient.

Can diffusion-weighted imaging be used to differentiate brain abscess from other ring-enhancing brain lesions? A meta-analysis

AIM

To explore the role of diffusion-weighted imaging (DWI) in the discrimination of brain abscess from other ring-enhancing brain lesions through meta-analysis.

MATERIALS AND METHODS

The PUMBED, OVID, and China National Knowledge Infrastructure (CNKI) databases, from January 1995 to March 2013, were searched for studies evaluating the diagnostic performance of DWI in the discrimination of brain abscess lesions. Using the data collected, pooled sensitivities and specificities across studies were determined, positive and negative likelihood ratios (LR) were calculated, and summary receiver operating characteristic (SROC) curves were constructed.

RESULTS

A total of 11 studies fulfilled all of the inclusion criteria and were considered for the analysis. The pooled sensitivity values and pooled specificity values including 95% confidence intervals (CI) were 0.95 (0.87-0.98) and 0.94 (0.88-0.97). The pooled positive LR (95% CI) was 4.13(2.55-6.7); the pooled negative LR (95% CI) was 0.01 (0-1.7); and the area under the curve of the symmetric SROC was 0.98.

CONCLUSIONS

DWI has high sensitivity and specificity for the differentiation of brain abscess from other intracranial cystic mass lesions.

Transrectal ultrasound-guided aspiration in the management of prostatic abscess: A single-center experience

Objectives:

The safety and efficacy of transrectal ultrasound (TRUS) guided aspiration of prostatic abscess (PA) is known. The objective of this study is to describe a treatment algorithm for management of PA with TRUS-guided aspiration, emphasizing on indications and factors predicting the treatment outcome.

Materials and Methods:

After the institutional review board approval was obtained, a retrospective study was done of all patients suspected with PA on digital rectal examination (DRE) and confirmed on TRUS. An 18-gauge two-part needle was used for aspiration. The real-time TRUS-guided aspiration of PA was done in the longitudinal axis. The aspiration of pus and the sequential collapse of cavity was seen “real time.” A suprapubic catheter was placed, if the patient had urinary retention, persistent dysuria, and/or severe lower urinary tract symptoms (LUTS). Success was defined as complete resolution of the abscess and/or symptoms.

Results:

Forty-eight patients were studied with PA, with a mean age of 54.6 ± 14.6 (range 26-79) years. The DRE diagnosed PA in 22 (45.83%) patients, while abdominal sonography diagnosed PA in 13 (27.08%) patients. TRUS revealed a hypoechoic area with internal echoes in all 48 (100%) patients. The diagnosis was confirmed in all 48 cases with aspiration. The mean size of the lesion was 3.2 ± 1.2 (range 1.5-8) cm. Mean volume aspirated was 10.2 ml (range 2.5-30 ml). Complete resolution after first aspiration was observed in 20 (41.66%) patients. An average of 4.1 (range 1-7) aspirations was required for complete resolution which was seen in 41 patients (85.42%). Seven (14.58%) patients required transurethral resection (deroofing) of the abscess cavity. We formulated a treatment algorithm based on the above findings.

Conclusion:

The proposed algorithm based on our experience suggests that patients with PA larger than 2 cm with severe LUTS and/or leukocytosis benefit from TRUS-guided aspiration. In addition, these patients are benefitted from urinary drainage (either perurethral or suprapubic). The algorithm also suggests that if two attempts of TRUS aspiration fail, these patients benefit from transurethral drainage.

Treatment of prostatic abscess: case collection and comparison of treatment methods

Purpose

Prostatic abscess is an uncommon urologic disease but has a high mortality rate if not treated properly. Furthermore, diagnosis and proper treatment of prostatic abscesses remains a challenge for physicians. Therefore, we compared data on conservative treatments, transurethral resection of prostatic abscess, and transrectal ultrasound (TRUS)-guided needle aspiration in 52 cases over a 10-year period.

Materials and Methods

The records of 52 patients diagnosed with prostatic abscess by computed tomography at Gangnam Severance Hospital between January 2000 and September 2010 were retrospectively reviewed. All patients were discharged when their leukocytosis had normalized and they had been free of fever for 2 days. Multivariate regression analysis was done to determine independent risk factors for the length of hospitalization.

Results

At the time of diagnosis, the average age of the 52 patients was 61.3 years (range, 33 to 81 years), the average volume of the prostate was 56.3 ml (range, 21 to 223 ml), the average prostate-specific antigen was 18.54 ng/ml (range, 2.0 to 57.0 ng/ml), and the average abscess size was 3.8 cm (range, 2.1 to 5.5 cm). All patients were treated with parenteral antibiotics during their hospital stay with intravenous antibiotics (fluoroquinolone monotherapy or 3rd-generation cephalosporin in combination with an aminoglycoside). Of 52 patients, 22 had diabetes mellitus (42.3%), 19 had hypertension (36.5%), and 7 (13.5%) had paraplegia due to spinal cord injury. The most common symptoms were fever (47, 90.4%), perineal discomfort (43, 82.7%), dysuria (40, 76.9%), and urinary retention (29, 55.8%). Prostatic abscesses were treated by conservative treatment (11 cases), transurethral resection of prostatic abscess (23 cases), and TRUS-guided needle aspiration (18 cases). The average hospitalization stay was 17.5 days (range, 6 to 39 days); that of conservative treatment patients was 19.1 days (range, 9 to 39 days). Patients treated by transurethral resection of prostatic abscess and TRUS-guided needle aspiration stayed 10.2 days (range, 6 to 15 days) and 23.25 days (range, 18 to 34 days), respectively. Of the 18 cases who underwent needle aspiration, prostatic abscesses recurred in 4 cases (22.2%) within 1 month after patient discharge. The 2 patients subjected to conservative treatment died due to sepsis. We found no independent factors that affected the average hospitalization period.

Conclusions

Patients with prostatic abscess treated by transurethral resection of the prostate had a significantly shorter hospitalization length compared with needle aspiration.

Diffusion-weighted MRI of abscess formations in children and young adults

BACKGROUND

Diffusion-weighted MRI (DWI) is helpful for detection of brain abscess and pelvic abscess in adults. In the present study, we evaluated the diagnostic performance of DWI in children and young adults with abdominal and soft tissue abscess formations.

METHODS

Seventeen patients (11 females, aged 13 ± 6 years) with suspected abdominal or soft-tissue abscess underwent routine MRI including free-breathing DWI and contrast-enhanced T1w imaging. Seventeen random age-matched patients with non-purulent abdominal fluid collections served as controls. Mean apparent diffusion coefficent (ADC) was measured for abscess, muscle, liver, spleen and kidney tissue as well as for cerebrospinal fluid, urine and free abdominal fluid.

RESULTS

All fluid collections were identified on diffusion-weighted images. Thirteen of 14 confirmed abscess formations showed an ADC < 1.0 × 10(-3) mm(2)/s with a mean value of 0.80 ± 0.38 mm(2)/s. One tuberculous soft-tissue abscess had a higher ADC of 1.85 × 10(-3) mm(2)/s. Ring enhancement on T1w imaging was seen in three non-purulent fluid collections. There were no false-positive findings in the control group.

CONCLUSIONS

Diffusion-weighted MRI is highly sensitive for abscess and may add specificity to contrast-enhanced T1w imaging of ring-enhancing fluid collections. DWI with free-breathing rapid image acquisition and without the need of intravenous contrast application constitutes a particularly useful choice in pediatric imaging.