Prostatic Abscess: A Diagnostic and Therapeutic Approach

THE JOURNAL OF UROLOGY

Vol. 91, No. 5 May 1964 Copyright © 1964 by The Williams & Wilkins Co.

Printed in U.S.A.

PROSTATIC ABSCESS: A DIAGNOSTIC AND THERAPEUTIC APPROACH L. E. BECKER

AND

W.R. HARRIN

From the Urology Sections, Veterans Administration Center, Wadsworth, and the Kansas University Medical Center, Kansas City, Kansas; and the St. Luke's Hospital, Kansas City, Missouri

The incidence of prostatic abscess has dimin- and the local findings may be ambiguous or nonished significantly since the development of specific. The diagnosis has usually depended upon potent antibacterial drugs, which have affected the sudden change in the clinical course of a pathe pathogenetic conditions responsible for sup- tient suspected to have acute prostatitis or sepuration within the prostate gland. One can cite quential changes in the consistency or size of the the diminishing occurrence of complications re- prostate gland. Severe perinea! discomfort, suprasulting from gonorrhea and from urethral instru- pubic orsubpubic pain, rectalorurinarytenesmus, mentation as directly related to the use of anti- or sudden exacerbation of a low grade febrile course, microbial agents. The probability that some has often suggested the presence of a prostatic abprostatic abscesses evolve from pyemia, septi- scess. Reports in the literature have mentioned the cemia, or bacteremia originating from acute frequent occurrence of spontaneous rupture of an infections elsewhere in the body has been con- unsuspected prostatic abscess into the urethra, sidered in the past. Some infectious diseases have rectum or perineum, with cessation of signs and been complicated by metastatic suppurative symptoms. Neglect of, or delayed diagnosis of lesions in the prostate gland: Typhoid and para- · prostatic abscess may result in rupture of the typhoid fever, erysipelas, influenza, pneumonia, abscess into the ischio-anal fossae or into the and anthrax have been implicated. Metabolic prevesical space with severe and prolonged mordisorders such as diabetes and gout are occasion- bidity, sepsis, cellulitis, or death. The co-existence ally complicated by prostatic abscess. The wide- of debilitating diseases such as uncontrolled spread use of antimicrobial agents during these diabetes mellitus or carcinomatosis has also been episodes would tend to decrease the incidence of reported. The increasing use of percutaneous perinea! prostatic involvement. The large series of 42 cases reported by Sargent needle biopsy has suggested a simple method of in 1930 ;1 the series of 12 cases, collected in an early diagnosis of prostatic abscess. Review of 11-year period, reported by Persky in 1955, 2 the literature has indicated use of aspiration in the 27 cases collected in a 6-year period reported by past. 3 , 5-s The procedure is easily accomplished, Chitty in 1957,3 and the 3 cases, collected in a atraumatic and may occasionally result in resoluI-year period, reported by Klotz, in 1959,4 in- tion of these abscesses without further treatment. dicate, in a general way, the present scarcity For the past 5 years the Franklin modification of the Silverman needle has been used at this hosof prostatic abscess. pital for obtaining biopsies from the prostate. SYMPTOMS .A.ND DIAGNOSES During this period, 3 cases of prostatic abscess It has always been difficult to distinguish acute were diagnosed and treated by the Franklinprostatitis, with sepsis and bladder neck obstruc- Silverman needle, and one was discovered by panendoscopy. tion, from prostatic abscess with sepsis and bladCASE REPORTS der neck obstruction. The symptoms are similar Case 1. J. F. was a 53-year-old man. A diagAccepted for publication November 8, 1963. nosis of Hodgkin's disease was made in 1956. He 1 Sargent, J. C. and Irwin, R.: Prostatic ab5 Schwartz, scess: Clinical study of 42 cases. Amer. J. Surg., J.: Metastatic abscess of the 11: 334--337, 1931. prostate gland. J. Urol., 43: 108-115, 1940. 2 Persky, L., Austen, G., Jr. and Schatten, W. 6 Williams, D. I. and Martins, A. G.: PeriE.: Recent experiences with prostatic abscess. prostatic hematoma and prostatic abscess. Arch. Surg., Gynec. & Obst., 101: 629-633, 1955. Dis. Childh., 36: 177-181, 1960. 3 Chitty, K.: Prostatic abscess. Brit. J. Surg., 7 Prostatic abscess in early infancy. Brit. Med. 44: 599-602, 1957. J., 2: 1945-1946, 1960. 4 Klotz, P. G.: Recent experience with abscess 8 Pollock, S.: Prostatic abscess in the dog. J. of the prostate. Canad. J. Surg., 2: 387-389, 1959. Amer. Vet. Med. Ass., 129: 274--275, 1956. 582

PROSTATIC ABSCESS

was seen by our urology service in 1959 because of recurrent bouts of pyelonephritis, the result of bilateral renal staghorn calculi. He had been on perennial chemotherapy for alleviation of acute episodes of pyelonephritis. He had undergone operations on both kidneys: on the right kidney in April 1944 and on the left kidney in May 1944. Since that time he had refused further kidney surgery. The urology service was consulted by the hematology service on November 7, 1959 because of recurrent right epidiclymitis. The patient was treated conservatively until his temperature was normal. On November 18 he complained of severe perinea! discomfort and difficulty in voiding. Examination revealed a bulky, induratecl prostate with a boggy sensation in the right lobe. A biopsy needle was inserted through the perineum to the boggy lobe. Pus was immediately obtained but could not be aspirated satisfactorily. Biopsy of the prostate was reported later to show acute and chronically inflamed fragments of prostatic tissue with areas of necrosis. The patient had a sudden temperature elevation 4 hours after needle biopsy, and was immediately started on polymyxin because of bacteriological report of Pseuclomonas aeruginosa sensitive to polymyxin from the earlier urine cultures and later from the pus obtained at biopsy. The temperature subsided promptly in 48 hours. Four clays following the biopsy acute contralateral epidiclymitis (left) developed; this responded to conservative treatment. The patient refused bilateral vasectomy for prevention of recurrent epidiclymitis. Pus drained from the perinea! puncture for 5 clays then ceased spon taneously. The prostate glancl felt normal 2 weeks later. Ccmment. This patient may have had multiple pus pockets ,,.ithin the prnstate which vvere not adequately eYacuatecl by needle. The persistence of purulent drainage through the needle puncture site, and sudden fever would indicate inadequate aspiration but would attest to the efficacy of the large bore needle tract for drainage. The availability of tissue for micrnpathological examination and pus for culture, without open surgery, was an advantage. It had been suspected that the prostate might contain neoplastic lymphoid tissue fron, Hodgkin's disease. Case 2. F. TV. K., a 65-year-old man, had an uneventful transurethral prostatectomy (5.2 gm.) for vesical neck contracture, on July 28, 1960.

583

The postoperative course was uncomplicated. A meatal stricture that developed was treated periodically. Following the passage of sounds January 11, 1961 the patient had a slight rise in temperature the following 2 days. On January 19, he came to the clinic complaining of frequent voiding every one-half to one hour, of 3 to 4 days' duration associated with scanty urination and difficulty in starting the stream. He also had another sudden fibrile episode 24 hours before his visit, with chills and he had noticed burning on urination. The patient was unable to void for a residual urine test but a 16F catheter passed easily into the bladder and evacuated 120 cc of clear urine containing shreds. The prostate was tender and asymmetrical on the right side, with a tense mass in the area ·where asymmetry was noted. A biopsy needle was inserted percutaneously through the perineum towards the asymmetrical mass and 5 cc thick pus was aspirated. The abscess was then flushed through the needle with normal saline followed by an antibacterial solution. The temperature fell from I02F to normal within 24 hours, follmYed by slight rise to IOOF on the second post-aspiration day and IOIF on the third post-aspiration clay Thereafter the temperature was normal. Culture of the pus was sterile after 3 days of incubation. Ko bacteria were seen in the exudate. The pros· tate was flat, firm, and smooth 10 clays later. Comment. The previous transurethral prostatectomy had left the prostatic area flat and smooth. Therefore, when the tense mass and asymmetry were palpated, a prostatic abscess was suspected. It is believed that instrumentation was a contributory factor. Case 3. G. A. R., a 43-year-old man and a severe diabetic, was first seen in consultation by the urology service on l:VIarch 29, 1962 because of terminal hematuria. The antecedent history pertinent to this complaint occurred when he was admitted to the medical service in diabetic coma on March 12. A catheter was passed and left indwelling for a day. The patient had bloody urinary drainage and bladder spasm during this period. He experienced total gross hematuria for 2 days following removal of the catheter. He was referred to us 14 days after total gross hematuria had ceased, complaining of terminal hematuria with urgency and ardor urinae. He also complained of perinea! discomfort. The voided urine was blood-tinged and con-

584

BECKER AND HARRIN

tained many red and white blood cells. Panendoscopy disclosed a patent urethra and a normalappearing prostatic urethra. The bladder neck was congested and there was suffusion with punctate ecchymoses throughout the bladder. The bladder wall appeared edematous. It was the impression that the patient had hemorrhagic cystitis following traumatic catheterization. A specimen of urine was collected for culture and the patient was placed on an antibacterial drug. The culture became sterile within 2 days after therapy. The patient was again referred to the urology service on April 2 complaining of subpubic discomfort, perineal pain, and increasing burnin" on . . "' urmation. He voided a forceful stream of clear urine. A small catheter was passed and 90 cc of residual urine was evacuated. The prostate was boggy, tender, and generally enlarged, about grade 1. Excretory urography disclosed a normal upper urinary tract and some evidence of prostatic intrusion into the bladder. Antibacterial drugs were resumed. For the next 3 days, the patient continued to complain of the same symptoms. The impression at this time was prostatitis with prostatic congestion. Persistence of the local complaints and the changes in the prostate led to the suspicion that the patient might have a prostatic abscess. Therefore, on April 5 under caudal analgesia, a biopsy needle was passed through the perineum towards the left lobe of the prostate which was noted to be larger than the right lobe and somewhat firmer. As the needle entered the left lobe of the prostate thick yellow pus was seen to exude from th~ needle; 25 cc pus was easily evacuated. The abscess cavity was flushed with antibacterial solution until clear. The patient had no fever at this time. The pus evacuated from the prostate contained many pus cells and many gram-positive cocci. The cultures which had been obtained revealed hemolytic Staphylococcus (coagulase positive), sensitive to chloramphenicol, furadantin, bacitracin, oleandomycin, staphcillin, ristocetin, novobiocin and erythromycin. The patient was therefore placed on staphcillin and furadantin. His symptoms were relieved without further complaints. When last seen for followup evaluation the patient complained of sexual impotence. His urine culture was sterile on May 1. The prostate was normal to palpation. Comment. The probability that panendoscopy during the period of acute hemorrhagic cystitis was the aggTavating cause for development of the

prostatic abscess must be considered. It is also possible that the traumatic catheterization on March 19 had already set the stage for development of an abscess in this diabetic patient.

Case 4. L. R. B., a 45-year-old man, was admitted to the hospital on June 13, 1963. The patient had noticed some diminution in force and caliber of the stream for the past 10 months. Nocturia had occurred 5 to 6 times and questionable hematuria on 1 occasion. The patient had had some suprapubic discomfort and stated that he had had fever and night sweats. He had undergone no prior urogenital procedures. Physical examination revealed temperature 99, pulse 130, blood pressure 148/110. The patient was an anxi?us, _ambulatory man who appeared chronically ill with poor color and diaphoresis. The patient vo~ded cloudy urine. A small amount of milky unne was recovered from the bladder after passage of a 20F catheter. The prostate was slightly enlarged and boggy. Urinalysis revealed microscopic pyuria. Excretory urography revealed normal upper tracts, trabeculated bladder and prostatic calculosis. A hemogram, serological test for syphilis, blood chemistry determinations and chest x-ray were negative. After collecting a specimen of urine for culture, a cystoscopic examination was made under direct vision. Immediately upon entering the prostatic urethra a ragged crater was encountered at the apex of the right lobe from which pus exuded. The bladder was reddened, irritable and filled with purulent debris. The patient was started on appropriate anti-

FIG. 1

585

PROSTATIC ABSECSS

bacterial drugs pending a report on the urine culture. His temperature was slightly elevated on admission but had remained normal thereafter. The urinary symptoms subsided rapidly. The urine culture revealed Escherichia coli, sensitive to routine drugs. Cultures were negative for tuberculosis. Comment. It is possible that an abscess developed around one of the prostatic calculi and :finally exfoliated and sloughed with the pus. The cystoscopic examination apparently improved drainage from the abscess cavity. A urethrogram, performed on June 17, confirmed the presence of an abscess at the apex of the prostatic urethra on the right side (fig. 1). DISCUSSION

The treatment of prostatic abscess has included rupture of the abscess over a urethral instrument, perineal section with blind digital rupture, perinea! section with prostatotomy, and transurethral resection of the prostate to evacuate the pus. Less common methods mentioned in previous reports include transvesical or retropubic incision and drainage of the prostate, endoscopic incision of the prostate, lateral perinea! incision with drainage of the prostate, and perineal prostatectomy. The more popular methods mentioned in recent articles are transurethral resection3 • 4 , 9 and open perineal incision and drainage. 2 There are disadvantages to each method. Rupture of the abscess over a sound is a blind procedure and may disseminate bacterial products causing sepsis. This method may also fail to adequately drain the abscess resulting in pyuria, irritable bladder symptoms, smoldering prostatic suppuration or catastrophic extravasation. The perineal approach may occasionally result in sphincter damage and urinary incontinence or delayed wound healing with prolonged drainage and the possibility of fecal or urinary fistula. 10 Transurethral resection of a suppurative prostate may result in late vesical neck contracture, postoperative bleeding, or sepsis. The use of needle aspiration for diagnosis is not new. It has been mentioned by Chitty 3 and Schwartz 5 and several others. 5-s The current popularity of perineal needle biopsy has brought ~! 9 Timberlake, G.: An electro-prostatome: Relief of prostatic abscesses. J. Urol., 40: 343-347,

diagnostic aspiration of the prostate to the forefront of urological diagnostic procedures. It would seem reasonable therefore that this method could be adopted for early and more frequent use in cases of suspected prostatic abscess. The procedure is usually done under local analgesia in the conventional dorsal recumbent lithotomy position. By digital guidance, the prostate may be punctured in several directions and in as many areas as necessary. Biopsy may be obtained at the same time by the same maneuver (see case 1). Complications of this procedure in our experience have included hematuria, epididymitis, and occasional urinary retention from clots. It is possible that the epididymitis in case I resulted from needling of the prostate. None of the other complications mentioned have occurred in the cases presently reported. The occurrence of sexual impotence following perineal incision has been investigated and reported upon in several articles11 - 13 but its incidence following needle puncture of the prostate is unlikely and unsupportable in case 4, since premature sexual impotence is known to follow early-onset diabetes. SUMMARY

The decreasing incidence of prostatic abscess seems to be related to the ubiquitousness of current antibacterial therapy in preventing complications of gonorrhea, urethral instrumentation, and metastasizing local or focal infection elsewhere in the body. The symptomatology and findings leading to a diagnosis of prostatic abscess are not usually clear-cut and the differentiation of acute prostatitis, prostatic congestion with enlargement and prostatic abscess depends mostly upon sudden or unexpected changes in prior symptoms or local palpatory findings. Four cases of prostatic abscess are presented, in three of which the diagnosis was made by percutaneous needling of the prostate and in one by urethroscopy. The results were good. These cases received only adjuvant therapy following needle aspiration. It is suggested that use of the prostatic biopsy needle be extended to diagnosis, and, in some cases, treatment of prostatic abscess. 11 Dahlen, C. P. and Goodwin, W. E.: Sexual potency after perineal biopsy. J. Urol., 77: 660-

669, 1957.

10 Lazarus, J. and Rosenthal, A. A.: Abscesses of the prostate gland. Amer. J. Surg., 34: 348-351,

12 Pearlman, C. K.: Transrectal biopsy of the prostate. J. Urol., 74: 387-392, 1955. 13 Finkle, A. L. and Saunders, J. B.: Sexual potency in aging males. Amer. J. Surg., 99: 23-26,

1936.

1960.

1938.