Prostatic abscess: A systematic review of current diagnostic methods, treatment modalities and outcomes

The harmful effects of overlooking acute bacterial prostatitis

Prostatitis is a major urological disease affecting 25%-50% of men over their lifetime. However, prostatitis is often overlooked in nonurologic departments due to its sometimes indeterminate symptoms. In this review, we describe how to recognize and treat acute bacterial prostatitis, which manifests as a clinical problem in other departments as well as urology, to help prevent this disease from being overlooked. There are several possible negative effects of not recognizing acute bacterial prostatitis (ABP). First, initial treatment can fail. In the hyperacute phase, common antibiotics are often effective, but in rare cases, such antibiotics may not be effective. In addition, once ABP progresses to form a prostate abscess, potentially avoidable surgical interventions are often needed. A second issue is the transition to chronic prostatitis. If chronic bacterial prostatitis progresses, treatment requires long-term antibiotic administration and the response rate is not high. Some patients may have to deal with urinary tract infections for the rest of their lives. Finally, there is the problem of overlooking the underlying disease. ABP is rare in healthy adult men without underlying disease, including sexually transmitted diseases as well as benign prostatic hyperplasia, urinary stones, and malignant tumors, and may not be obvious. When examining patients with fever of unknown origin, it is necessary to exclude not only infectious diseases but also collagen diseases and malignant tumors. If there are any doubts, we recommend a rectal exam and consultation with a urologist.

Transperineal drainage of prostate abscesses: A minimally invasive, low-risk management strategy that yields satisfactory results

Objectives

In this narrative review, we aim to present two cases of transperineal drainage of prostate abscesses with a good clinical outcome. Furthermore, we reviewed the literature on this treatment approach and aim to propose a minimally invasive protocol for managing this rare condition.

Patients and Methods

Our patients are 33- and 61-year-old males who both underwent uncomplicated transperineal drainage of prostate abscess with the use of a Precision Point device with rapid clinical improvement and complete resolution of the abscess within the follow-up period. We used PubMed to conduct a literature search and included and evaluated 16 relevant case reports and case series in which the authors utilized transperineal drainage techniques for prostatic abscesses.

Results

Our first patient was young and very unwell with sepsis and a pulmonary embolism. He had a complex abscess extending through the prostate to the left pelvic side wall. Trans-gluteal drainage of the pelvic side-wall collection was required in addition to transperineal drainage of the prostate abscess. After drainage and a prolonged course of antibiotics, he achieved resolution of the abscess by 7 weeks with ejaculatory function intact. Our second patient who was very keen on the preservation of ejaculatory function had multiple small abscesses and underwent transperineal drainage. He had significant interval improvement of his abscess burden at the 4-week follow-up and complete resolution at the 6-month follow-up. The total number of cases in the literature on our review is 22, with considerable variability in how the authors managed the prostate abscesses that underwent transperineal drainage, including variability in their follow-up time frame, choice of imaging modality, duration of antibiotic treatment, drain placement, and use of irrigation solutions (including antibiotics) into the abscess cavity. Furthermore, the sizes of the prostate abscesses were not consistently reported. Given the small sample size and variability in management from different authors, it was not possible to draw any statistical analysis.

Conclusion

Transperineal prostate abscess drainage combined with prolonged antibiotic therapy provides a less invasive alternative to treating prostate abscesses for those who which to preserve ejaculatory function and avoid the other adverse events of transurethral de-roofing. In itself, it can achieve complete resolution of abscess. It provides the benefit of drainage under real-time imaging; for percutaneous drain placement; prevents urethral injury; retrograde ejaculation; and can be done under local anaesthetic which is preferable for the unstable patient. The utility of the procedure may be limited by the complexity of the abscess or whether it has extended beyond the prostate. The patient should always be informed that further drainage via percutaneous methods or transurethral methods may be necessary if their clinical condition does not improve. We recommend this procedure be offered as an alternative to transurethral methods in younger patients and those who would like to preserve ejaculatory function. Furthermore, we highly encourage a prolonged course of antibiotic therapy and interval follow-up with clinical review of symptoms and imaging to confirm resolution.

Treatment of prostatic abscess concomitant with high-risk prostate cancer: A 2-steps approach

Prostatic abscess (PA) prevalence has decreased in the era of antibiotics. This condition is associated with chronic conditions, including diabetes, immunodeficiency, liver disease, or even severe diseases such as prostate cancer. Concomitant prostatic abscess and prostate cancer are very challenging to treat because of the lack of specific guidelines, significant complications, and controversial treatment approaches. By reporting a case with prostate cancer in the setting of a prostatic abscess treated successfully by surgery, we propose a 2-steps approach including transurethral resection drainage followed by laparoscopic radical prostatectomy.

Prostatic Abscesses in a Patient Receiving Tumor Necrosis Factor-Alpha Inhibitor Therapy for Hidradenitis Suppurativa: A Case Report

This report is the first to present the case of a patient who developed bacterial abscess-forming prostatitis while undergoing treatment with adalimumab, a tumor necrosis factor-alpha blocking therapy, for hidradenitis suppurativa. A 36-year-old male presented with persistent anogenital pain and dysuria for approximately three weeks. Two days before presentation at the emergency room (ER), a rubber band ligation was performed to address suspected hemorrhoids stages I-II. In the ER, clinical and laboratory examinations suggested acute prostatitis, prompting the initiation of antibiotic therapy. In the absence of an adequate response, magnetic resonance imaging was performed, which identified a complex abscess and fistulation system originating from the right prostatic lobe. Following the insertion of a drain, adalimumab was discontinued, and antibiotic therapy was intensified, resulting in the resolution of the abscess. After six weeks, follow-up showed the patient to be free of symptoms. This case highlights a rare adverse event of patients using immunomodulating medications and may help physicians to manage similar cases in the future. Immunomodulating drugs can lead to the development of prostatic abscesses in young patients, necessitating attentive and careful clinical examination with a low threshold for further diagnostic workup in uncommon case presentations.

A rare case of successful percutaneous drainage of a methicillin-resistant Staphylococcus aureus prostatic abscess extending into the penis and revealing diabetes mellitus

In the postantibiotic era, prostatic abscesses (PAs) are rare, affecting primarily immunocompromised men and/or caused by atypical drug-resistant pathogens, raising both diagnostic and management challenges. PA caused by methicillin-resistant Staphylococcus aureus (MRSA) is an uncommon condition and also a primary source of bacteremia. Nevertheless, the continued pattern of increase in reported cases, due especially to community-associated strains, is a growing concern regarding the significant morbidity and mortality. Besides proper antibiotics, drainage of a PA may be required, which is usually transrectal or transurethral. Herein, we describe the case of MRSA PA extending into the penis with concomitant MRSA bacteremia of unknown origin, whereupon diabetes mellitus was newly diagnosed in a previously healthy man residing in a community setting, and managed successfully by a transperineal drainage with good outcome. This case also highlights that individuals diagnosed with such rare deep-seated MRSA infections should be assessed for undiagnosed comorbidities. To the best of our knowledge, this is the first reported case of percutaneous drainage of a PA by using a double-lumen catheter.

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.