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Emphysematous prostatic abscess: A case report and review of literature
Journal of Infection (2007) 54, e51ee54
www.elsevierhealth.com/journals/jinf
CASE REPORT
Emphysematous prostatic abscess: A case report and review of literature Huai-Ching Tai* Department of Urology, National Taiwan University Hospital, No. 7 Chung-Shan S. Road, Taipei 100, Taiwan Accepted 27 March 2006 Available online 2 June 2006
KEYWORDS Prostatic abscess; Digital rectal examination; Diabetes mellitus; Klebsiella pneumoniae; Transurethral incision of prostate
Summary Emphysematous prostatic abscess, namely, is an inflammatory process associated with gas and abscess formation in the prostate gland. It is a rare clinical condition and a few cases have been reported in the literature. We report a case of emphysematous prostatic abscess due to Klebsiella pneumoniae in a 60-year-old man with a 5-year history of diabetes mellitus and a 6-year history of alcoholic liver cirrhosis. Computerized tomography confirmed the clinical diagnosis. We successfully treated the patient with parenteral antimicrobial agents and surgical drainage. The patient was discharged without any voiding difficulty. ª 2006 The British Infection Society. Published by Elsevier Ltd. All rights reserved.
Case report A 60-year-old man presented to our emergency department with the complaint of dysuria and lower abdominal pain for several days. Perineal discomfort was also noted. He had a 5-year history of diabetes mellitus without regular control and a 6-year history of alcoholic liver cirrhosis. On initial physical examination, he was fully alert. His blood pressure was 107/60 mmHg, pulse rate 68/ min and respiratory rate 24/min. He was febrile with a body temperature of 38.9 C (102.02 F). A soft and tender prostate was palpated during
* Tel.: þ886 2 87735456; fax: þ886 2 27711697. E-mail address: [email protected]
digital rectal examination (DRE). A Foley catheter was indwelled and kept in place. A complete blood count demonstrated a white blood cell count of 10,500/mL, hemoglobin of 13.8 g/dL and platelets of 340,000/mL. A serum biochemical study revealed the following findings: glucose 346 mg/dL, urea nitrogen 16.4 mg/dL, creatinine 0.8 mg/dL, aspartate aminotransferase 54 U/L, alanine aminotransferase 21 U/L, alkaline phosphatase 459 U/L, total bilirubin 2.7 mg/dL, and gamma glutamyl transpeptidase 143 U/L. His prostate specific antigen (PSA) was 0.68 ng/mL at that time. Pyuria was noted from urianalysis. Klebsiella pneumoniae was isolated from his blood culture and his urine culture was sterile. A plain film of kidney, ureter and bladder (KUB) disclosed a butterfly-shaped gaseous shadow in the
0163-4453/$30 ª 2006 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2006.03.033
e52
H.-C. Tai
Figure 3 Transrectal ultrasound revealed bright echogenicity in the prostate gland, compatible with gas formation.
Figure 1 Plain film of kidney, ureter and bladder (KUB) demonstrated a butterfly-shaped gaseous shadow in the prostate region.
lower pelvic region suggestive of the location of the prostate gland (Fig. 1). Subsequent pelvic computerized tomography showed extensive gas and abscess formation in the prostate gland (Fig. 2). The urinary bladder was spared. Therefore, the diagnosis of emphysematous prostatic abscess was made. The transrectal ultrasound (TRUS) assisted in making the diagnosis (Fig. 3). Empiric antimicrobial treatment with the combination of ciprofloxacin 400 mg IV every 12 h and metronidazole 500 mg IV every 6 h was administered. Blood sugar was controlled with insulin meticulously. Transurethral incision of prostate (TUIP) was done on day 3 and lots of pus and air bubbles exuded after incising the prostate (Fig. 4). The prostate was collapsed and empty after the procedure. He was afebrile postoperatively and parenteral antibiotics
Figure 2 Pelvic computerized tomography showed extensive gas and abscess formation in the prostate gland.
were kept for 7 days. No pyuria was observed from follow-up urianalysis and antibiotic was then changed to oral ciprofloxacin 500 mg every 12 h. We removed his Foley catheter on day 15 after admission. Neither difficulty in urination nor perineal discomfort was complained. Follow-up KUB revealed complete resolution of the gaseous shadow. He was discharged in a stable condition.
Discussion Emphysematous prostatic abscess is a rare condition characterized by gas and purulent exudate
Figure 4 The prostate was empty after transurethral incision of prostate (TUIP). Lots of pus and air bubbles exuded.
KUB, CT, TRUS K. pneumoniae
KUB, CT K. pneumoniae
60 6
DM, LC, AL
Fever, chills, abdominal pain
D, DU, PD
Enlargement heatness Tenderness D, F, DU Fever 50 5
DM, LC, BPH, TUMT 55 4
DM
CT K. pneumoniae Enlargement tenderness PD, R
SP e
e Abdominal pain, dyspnea, shock Fever, shock DM, pancreatitis DM, AL 60 45 2 3
Abbreviations: DM, diabetes mellitus; LC, liver cirrhosis; AL, alcoholism; BPH, benign prostatic hyperplasia; TUMT, transurethral microwave thermotherapy; D, dysuria; F, frequency; R, rectal tenesmus; SP, suprapubic pain; PD, perineal discomfort; DU, difficulty in urination; DRE, digital rectal examination; IVU, intravenous urography; KUB, plain film of kidney, ureter and bladder; CT, computerized tomography; TURP, transurethral resection.
Survived
Survived
Expired
Survived Expired
Cystostomy, TUR Transperineal aspiration Perineal incision and drainage, cystostomy Percutaneous drainage TUR
Survived Cystostomy, TUR
IVU, Gallium scan KUB, CT CT P. aeruginosa, B. fragilis Candida albicans K. pneumoniae Enlargement tenderness Enlargement soft e D, F, R Fever, chills 56
DM
e53
1
Surgical intervention Imaging modalities Microorganism DRE LUTS Symptom/sign Underlying disease Age (years)
Clinical characteristics of the six patients with emphysematous prostatic abscess Table 1
formation in the prostate gland. It was first described by Mariani et al. in 1983 and only six cases of emphysematous prostatic abscess have been published in the literature.1e6 Including our case, two of six patients died from the complications of this disease.3,4 Like prostatic abscess, the presenting signs and symptoms of emphysematous prostatic abscess are highly variable. Fever, abdominal pain, dysuria, frequency, perineal discomfort and even rectal tenesmus have been reported. Digital rectal examination may reveal an enlarged prostate with heat and tenderness. A boggy or soft prostate may also be palpated due to extensive pus and gas accumulation. The diagnosis of emphysematous prostatic abscess is based on clinical history, rectal examination and imaging modalities. The typical gaseous shadow in the lower pelvis can be seen on plain radiograph film. However, it is sometimes difficult because of the adjacent bowel gaseous shadows. CT scan of the pelvis is the imaging of choice. It may demonstrate an enlarged prostate with lowattenuated abscess and gas accumulation. TRUS can confirm the presence of gas and abscess collection in the prostate gland. The clinical characteristics of the six patients of emphysematous prostatic abscess are listed in Table 1. The reported etiologic microorganisms include K. pneumoniae in four cases, mixed infection of Pseudomonas aeruginosa and Bacteroides fragilis in one case1 and Candida albicans in one case.2 K. pneumoniae is the leading causative microorganism and especially in the patients with diabetes mellitus. Other concomitant underlying diseases predisposing to emphysematous prostatic abscess include cirrhosis of liver, chronic alcoholism and benign prostatic hyperplasia. In addition, a case of emphysematous prostatic abscess after transurethral microwave thermotherapy (TUMT) was also reported.4 The definite treatment of emphysematous prostatic abscess is surgical drainage. Surgical drainage can be done with transrectal, transperineal or transurethral approach.5 Transrectal aspiration of prostatic abscess is performed under TRUS guidance and local anesthesia. Perineal incision and transperineal prostatic puncture aspiration are also reported. The transrectal and transperineal approaches are recommended in older patients in emergent conditions such as septic shock and with increased anesthetic risk. Transurethral resection of prostate (TURP) or transurethral incision of prostate (TUIP) is indicated if patient’s condition can tolerate the procedure and general anesthesia. TURP can also be performed to remove
Prognosis
Emphysematous prostatic abscess: Case report and review of literature
e54 the residual abscess after primary aspiration. However, TURP may increase the risk of sepsis and bacteremia. Therefore, a thorough preoperative evaluation is mandatory to choose a feasible method. In clinical practice, patient with acute urinary retention secondary to acute prostatitis or prostatic abscess should be managed with a suprapubic cystostomy tube because urethral instrumentation may aggravate sepsis. However, in our case, bleeding tendency was highly suspected because the patient had a 6-year history of alcoholic liver cirrhosis. Therefore, insertion of a suprapubic cystostomy tube was contraindicated and we placed a urethral catheter instead. In conclusion, emphysematous prostatic abscess is a rare but potentially lethal occurrence. The mortality rate is more than 30% according to the reported literature. With high clinical suspicion, careful examination and imaging modalities such as CT scan and TRUS may assist in making the correct diagnosis. Prompt adequate drainage, appropriate antimicrobial treatment and strict
H.-C. Tai underlying disease control are the prerequisites for the effective treatment.
References 1. Mariani AJ, Jacobs LD, Clapp PR, Hariharan A, Stams UK, Hodges CV. Emphysematous prostatic abscess: diagnosis and treatment. J Urol 1983;129:385e6. 2. Bartkowski DP, Lanesky JR. Emphysematous prostatitis and cystitis secondary to Candida albicans. J Urol 1987;139(5): 1063e5. 3. Lu DC, Lei MH, Chang SC. Emphysematous prostatic abscess due to Klebsiella pneumoniae. Diagn Microbiol Infect Dis 1998;31(4):559e61. 4. Lin CS, Lin YM, Tong YC. Emphysematous prostatic abscess after transurethral microwave thermotherapy. J Urol 2001; 166:625. 5. Bae GB, Kim SW, Shin BC, Oh JT, Do BH, Park JH, et al. Emphysematous prostatic abscess due to Klebsiella pneumoniae: report of a case and review of the literature. J Korean Med Sci 2003;18(5):758e60. 6. Monreal G de VF, Segarra TJ, Millan RF, Salvador J, Vicente J. Emphysematous prostatitis, apropos of a case. Arch Esp Urol 1998;51(1):85e8.
www.elsevierhealth.com/journals/jinf
CASE REPORT
Emphysematous prostatic abscess: A case report and review of literature Huai-Ching Tai* Department of Urology, National Taiwan University Hospital, No. 7 Chung-Shan S. Road, Taipei 100, Taiwan Accepted 27 March 2006 Available online 2 June 2006
KEYWORDS Prostatic abscess; Digital rectal examination; Diabetes mellitus; Klebsiella pneumoniae; Transurethral incision of prostate
Summary Emphysematous prostatic abscess, namely, is an inflammatory process associated with gas and abscess formation in the prostate gland. It is a rare clinical condition and a few cases have been reported in the literature. We report a case of emphysematous prostatic abscess due to Klebsiella pneumoniae in a 60-year-old man with a 5-year history of diabetes mellitus and a 6-year history of alcoholic liver cirrhosis. Computerized tomography confirmed the clinical diagnosis. We successfully treated the patient with parenteral antimicrobial agents and surgical drainage. The patient was discharged without any voiding difficulty. ª 2006 The British Infection Society. Published by Elsevier Ltd. All rights reserved.
Case report A 60-year-old man presented to our emergency department with the complaint of dysuria and lower abdominal pain for several days. Perineal discomfort was also noted. He had a 5-year history of diabetes mellitus without regular control and a 6-year history of alcoholic liver cirrhosis. On initial physical examination, he was fully alert. His blood pressure was 107/60 mmHg, pulse rate 68/ min and respiratory rate 24/min. He was febrile with a body temperature of 38.9 C (102.02 F). A soft and tender prostate was palpated during
* Tel.: þ886 2 87735456; fax: þ886 2 27711697. E-mail address: [email protected]
digital rectal examination (DRE). A Foley catheter was indwelled and kept in place. A complete blood count demonstrated a white blood cell count of 10,500/mL, hemoglobin of 13.8 g/dL and platelets of 340,000/mL. A serum biochemical study revealed the following findings: glucose 346 mg/dL, urea nitrogen 16.4 mg/dL, creatinine 0.8 mg/dL, aspartate aminotransferase 54 U/L, alanine aminotransferase 21 U/L, alkaline phosphatase 459 U/L, total bilirubin 2.7 mg/dL, and gamma glutamyl transpeptidase 143 U/L. His prostate specific antigen (PSA) was 0.68 ng/mL at that time. Pyuria was noted from urianalysis. Klebsiella pneumoniae was isolated from his blood culture and his urine culture was sterile. A plain film of kidney, ureter and bladder (KUB) disclosed a butterfly-shaped gaseous shadow in the
0163-4453/$30 ª 2006 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2006.03.033
e52
H.-C. Tai
Figure 3 Transrectal ultrasound revealed bright echogenicity in the prostate gland, compatible with gas formation.
Figure 1 Plain film of kidney, ureter and bladder (KUB) demonstrated a butterfly-shaped gaseous shadow in the prostate region.
lower pelvic region suggestive of the location of the prostate gland (Fig. 1). Subsequent pelvic computerized tomography showed extensive gas and abscess formation in the prostate gland (Fig. 2). The urinary bladder was spared. Therefore, the diagnosis of emphysematous prostatic abscess was made. The transrectal ultrasound (TRUS) assisted in making the diagnosis (Fig. 3). Empiric antimicrobial treatment with the combination of ciprofloxacin 400 mg IV every 12 h and metronidazole 500 mg IV every 6 h was administered. Blood sugar was controlled with insulin meticulously. Transurethral incision of prostate (TUIP) was done on day 3 and lots of pus and air bubbles exuded after incising the prostate (Fig. 4). The prostate was collapsed and empty after the procedure. He was afebrile postoperatively and parenteral antibiotics
Figure 2 Pelvic computerized tomography showed extensive gas and abscess formation in the prostate gland.
were kept for 7 days. No pyuria was observed from follow-up urianalysis and antibiotic was then changed to oral ciprofloxacin 500 mg every 12 h. We removed his Foley catheter on day 15 after admission. Neither difficulty in urination nor perineal discomfort was complained. Follow-up KUB revealed complete resolution of the gaseous shadow. He was discharged in a stable condition.
Discussion Emphysematous prostatic abscess is a rare condition characterized by gas and purulent exudate
Figure 4 The prostate was empty after transurethral incision of prostate (TUIP). Lots of pus and air bubbles exuded.
KUB, CT, TRUS K. pneumoniae
KUB, CT K. pneumoniae
60 6
DM, LC, AL
Fever, chills, abdominal pain
D, DU, PD
Enlargement heatness Tenderness D, F, DU Fever 50 5
DM, LC, BPH, TUMT 55 4
DM
CT K. pneumoniae Enlargement tenderness PD, R
SP e
e Abdominal pain, dyspnea, shock Fever, shock DM, pancreatitis DM, AL 60 45 2 3
Abbreviations: DM, diabetes mellitus; LC, liver cirrhosis; AL, alcoholism; BPH, benign prostatic hyperplasia; TUMT, transurethral microwave thermotherapy; D, dysuria; F, frequency; R, rectal tenesmus; SP, suprapubic pain; PD, perineal discomfort; DU, difficulty in urination; DRE, digital rectal examination; IVU, intravenous urography; KUB, plain film of kidney, ureter and bladder; CT, computerized tomography; TURP, transurethral resection.
Survived
Survived
Expired
Survived Expired
Cystostomy, TUR Transperineal aspiration Perineal incision and drainage, cystostomy Percutaneous drainage TUR
Survived Cystostomy, TUR
IVU, Gallium scan KUB, CT CT P. aeruginosa, B. fragilis Candida albicans K. pneumoniae Enlargement tenderness Enlargement soft e D, F, R Fever, chills 56
DM
e53
1
Surgical intervention Imaging modalities Microorganism DRE LUTS Symptom/sign Underlying disease Age (years)
Clinical characteristics of the six patients with emphysematous prostatic abscess Table 1
formation in the prostate gland. It was first described by Mariani et al. in 1983 and only six cases of emphysematous prostatic abscess have been published in the literature.1e6 Including our case, two of six patients died from the complications of this disease.3,4 Like prostatic abscess, the presenting signs and symptoms of emphysematous prostatic abscess are highly variable. Fever, abdominal pain, dysuria, frequency, perineal discomfort and even rectal tenesmus have been reported. Digital rectal examination may reveal an enlarged prostate with heat and tenderness. A boggy or soft prostate may also be palpated due to extensive pus and gas accumulation. The diagnosis of emphysematous prostatic abscess is based on clinical history, rectal examination and imaging modalities. The typical gaseous shadow in the lower pelvis can be seen on plain radiograph film. However, it is sometimes difficult because of the adjacent bowel gaseous shadows. CT scan of the pelvis is the imaging of choice. It may demonstrate an enlarged prostate with lowattenuated abscess and gas accumulation. TRUS can confirm the presence of gas and abscess collection in the prostate gland. The clinical characteristics of the six patients of emphysematous prostatic abscess are listed in Table 1. The reported etiologic microorganisms include K. pneumoniae in four cases, mixed infection of Pseudomonas aeruginosa and Bacteroides fragilis in one case1 and Candida albicans in one case.2 K. pneumoniae is the leading causative microorganism and especially in the patients with diabetes mellitus. Other concomitant underlying diseases predisposing to emphysematous prostatic abscess include cirrhosis of liver, chronic alcoholism and benign prostatic hyperplasia. In addition, a case of emphysematous prostatic abscess after transurethral microwave thermotherapy (TUMT) was also reported.4 The definite treatment of emphysematous prostatic abscess is surgical drainage. Surgical drainage can be done with transrectal, transperineal or transurethral approach.5 Transrectal aspiration of prostatic abscess is performed under TRUS guidance and local anesthesia. Perineal incision and transperineal prostatic puncture aspiration are also reported. The transrectal and transperineal approaches are recommended in older patients in emergent conditions such as septic shock and with increased anesthetic risk. Transurethral resection of prostate (TURP) or transurethral incision of prostate (TUIP) is indicated if patient’s condition can tolerate the procedure and general anesthesia. TURP can also be performed to remove
Prognosis
Emphysematous prostatic abscess: Case report and review of literature
e54 the residual abscess after primary aspiration. However, TURP may increase the risk of sepsis and bacteremia. Therefore, a thorough preoperative evaluation is mandatory to choose a feasible method. In clinical practice, patient with acute urinary retention secondary to acute prostatitis or prostatic abscess should be managed with a suprapubic cystostomy tube because urethral instrumentation may aggravate sepsis. However, in our case, bleeding tendency was highly suspected because the patient had a 6-year history of alcoholic liver cirrhosis. Therefore, insertion of a suprapubic cystostomy tube was contraindicated and we placed a urethral catheter instead. In conclusion, emphysematous prostatic abscess is a rare but potentially lethal occurrence. The mortality rate is more than 30% according to the reported literature. With high clinical suspicion, careful examination and imaging modalities such as CT scan and TRUS may assist in making the correct diagnosis. Prompt adequate drainage, appropriate antimicrobial treatment and strict
H.-C. Tai underlying disease control are the prerequisites for the effective treatment.
References 1. Mariani AJ, Jacobs LD, Clapp PR, Hariharan A, Stams UK, Hodges CV. Emphysematous prostatic abscess: diagnosis and treatment. J Urol 1983;129:385e6. 2. Bartkowski DP, Lanesky JR. Emphysematous prostatitis and cystitis secondary to Candida albicans. J Urol 1987;139(5): 1063e5. 3. Lu DC, Lei MH, Chang SC. Emphysematous prostatic abscess due to Klebsiella pneumoniae. Diagn Microbiol Infect Dis 1998;31(4):559e61. 4. Lin CS, Lin YM, Tong YC. Emphysematous prostatic abscess after transurethral microwave thermotherapy. J Urol 2001; 166:625. 5. Bae GB, Kim SW, Shin BC, Oh JT, Do BH, Park JH, et al. Emphysematous prostatic abscess due to Klebsiella pneumoniae: report of a case and review of the literature. J Korean Med Sci 2003;18(5):758e60. 6. Monreal G de VF, Segarra TJ, Millan RF, Salvador J, Vicente J. Emphysematous prostatitis, apropos of a case. Arch Esp Urol 1998;51(1):85e8.