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Prostatic Abscess Owing to Anaerobic Bacteria
0022-534 7/87 /1385-1254$02.00/0 Vol. 138, November
THE JOURNAL OF UROLOGY
Copyright © 1987 by The Williams & Wilkins Co.
Printed in U.S.A.
PROSTATIC ABSCESS OWING TO ANAEROBIC BACTERIA MICHAEL K. BRAWER*
AND
THOMAS A. STAMEY
From the Division of Urology, Department of Surgery, University of Arizona Health Sciences Center and Veterans Administration Medical Center, Tucson, Arizona, and Stanford University School of Medicine, Stanford, California ABSTRACT
Abscess of the prostate is seen infrequently. We report a prostatic abscess owing to anaerobic bacteria in a 46-year-old man with a 10-year history of irritable voiding symptoms. Preoperative computerized tomography confirmed the diagnosis of prostatic abscess, which was treated with transurethral resection and broad-spectrum antibiotics. (J. Urol., 138: 1254-1255, 1987) Spontaneous prostatic abscess has become a relatively rare entity as a result of the development of effective antimicrobial agents. 1- 3The decreasing incidence of gonococcal urethritis and resulting stricture formation has caused a change in the associated pathogens from gram-positive to gram-negative infections.3-5 Prostatic abscess owing to anaerobic bacteria remains a rare lesion, with only 14 reported cases. We report a case of a prostatic abscess caused by anaerobic bacteria that was confirmed preoperatively with the aid of computerized tomography (CT). CASE REPORT
A 46-year-old man was referred with a 10-year history of worsening frequency, nocturia, dysuria, hesitancy, intermittent gross total painless hematuria and sterile pyuria. He had been given several antibiotic trials despite multiple sterile urine cultures and at least 1 sterile culture of expressed prostatic secretions. The antimicrobial therapy afforded no change in the symptom complex. Cultures for acid-fast bacteria on 6 occasions were negative. Because of the unremitting symptoms in the face of continual sterile pyuria, cystoscopy was performed 8 months before referral. Biopsy of an inflamed prostatic urethra disclosed chronic urethritis and scar. Postoperatively, the patient had a temperature of 104F. Two blood cultures yielded Peptostreptococcus asaccharolyticus. The patient was treated with metronidazole and penicillin with rapid defervescence. There was transient clearing of the pyuria. Because of rapid recurrence of the voiding symptoms the patient was referred to the Stanford University Medical Center. Medical history was noteworthy for osteomyelitis in the right tibia requiring multiple surgical procedures dating back to a fracture when he was 10 years old. General physical examination was unrevealing. Rectal examination disclosed an enlarged boggy prostate that was described as feeling like a "water balloon". M:"croscopy of the first voided 10 cc urine, midstream aliquot of mine, expressed prostatic secretions and first 10 cc voided urine after prostatic massage demonstrated marked pyuria. Culbres were sterile. Suprapubic needle aspirate of the bladder urine before prostatic examination revealed marked pyuria as well as intracellular and extracellular gram-positive cocci. Aerobic, anaerobic and Ureaplasma cultures were sterile. Cystoscopy revealed a stricture of the bulbar urethra. The prostatic urethra was unremarkable. A second suprapubic aspirate 12 days later again revealed pyuria and similar organisms. Aerobic cultures were sterile but gram-positive cocci and gram-negative rods were seen on anaerobic culture. Subculture was unsuccessful. Because of the clinical suspicion that this patient had a prostatic abscess owing to anaerobic bacteria a CT scan of the pelvis was obtained. The scan demonstrated an enlarged prostate, the posterior and lateral aspects of which were of a water density without contrast Accepted for publication April 21, 1987. * Requests for reprints: Division of Urology, Department of Surgery, University of Arizona Health Sciences Center, Tucson, Arizona 85724.
material enhancement, consistent with an abscess (see figure). Perineal needle aspiration of the prostate revealed 20 cc malodorous pus. Transurethral resection of the prostate was performed with unroofing of the abscess cavity and debridement of the cavity wall. The patient had received 3 doses of piperacillin preoperatively, which was continued for 5 days. Aerobic and anaerobic cultures of the pus were sterile, and Gram stain showed intracellular and extracellular Gram-positive cocci. Pathological examination of the resected tissue demonstrated chronic inflammation. The patient had no urinary complaints 3 months postoperatively but pyuria was still present. A suprapubic aspirate 4 months postoperatively continued to show pyuria and grampositive cocci. Aerobic cultures were negative. Peptococcus anaerobius was grown anaerobically. Cystoscopy demonstrated an epithelialized prostatic fossa: The patient was given a 10day course of metronidazole A month after completing this regimen suprapubic urine was sterile aerobically and anaerobically but pyuria persisted. A followup CT scan revealed a decrease in the size of the prostate and a low density ringshaped collection within the central portion of the gland. A cystogram demonstrated a smooth-walled transurethral resection cavity with no filling defect. Five months after drainage of the abscess the patient began to experience again irritable voiding symptoms that had been absent in the preceding months. Suprapubic aspirate of the urine continued to reveal pyuria with sterile aerobic and anaerobic cultures. He was treated empirically with a 10-day course of clindamycin. A month after this regimen the patient was free of symptoms. At followup 4 years after drainage of the prostatic abscess and 28 months following the course of clindamycin he was without urological complaints or pyuria and aerobic as well as anaerobic urine cultures were sterile. DISCUSSION
The incidence of abscess of the prostate is decreasing owing to the increasing rarity of gonococcal urethritis and associated
Preoperative CT scan demonstrates enlarged prostate with low attenuating well defined lesion consistent with abscess (arrow).
1254
1255
PROSTATIC ABSCESS OWING TO ANAEROBIC BAC'I'ER.IA Prostatic abscess caused by anaerobic bacteria Reference Albarran and Cottet Persky and associates'
Pt. Age
Fever
Obstructive Voiding
Irritable Voiding
Prostate Tender
+
+ + + + +
+ + + +
Perinea! incision and drainage Perinea! incision and drainage Perinea! incision and drainage Perinea! incision and drainage Perinea! incision and drainage Transurethral resection of prostate
+ +
+ + + + + +
Perinea[ incision and drainage Perinea! incision and drainage Perinea! incision and drainage Cystoscopic rupture Spontaneous drainage Transurethral resection of prostate
Treatment
19
Fishbach and Finegold 14 Gorbach and Thadepa!i20 Bartlett and associates"
Corrado and associates 13 Mariani and associates•
42
57*
+
30 36* 66 56
+
77 33 23 58'' 44 56*
+ + + +
+
+
+
+ +
* Diabetes mellitus.
stricture disease combined with improved antimicrobial agents. 1~3 In the series of Dajani and O'Flynn, 3 and Pai and Bhat6 the incidence was 0.5 and 2.5 per cent, respectively, of the patients hospitalized with prostatic disease. Nevertheless, it remains a potentially serious entity with mortalities in published series ranging from 3 to 30 per cent. 1· 4-6 The 2 pathophysiological patterns that are recognized include abscesses arising in the setting of underlying lower genitourinary tract disease and metastatic lesions. The former typically are caused by gram-negative pathogens, presumably ascending to the prostatic ducts, and the latter are caused by gram-positive species.1,a,s-,i The diagnosis of prostatic abscess often is elusive with a reported preoperative diagnosis being made in 21 to 88 per cent of the cases. 5· 6 Modern imaging techniques have assisted in making the diagnosis. Gammelgaard and Holm reported on the use of transurethral and transrectal ultrasound in this entity. 9 Recently, Dennis and Donohue reported the first case of CT of prostatic abscess. 10 The treatment of prostatic abscesses requires definitive drainage. Transurethral resection, as suggested originally by Timberlake, 11 has become the most favored approach. In addition to surgical drainage broad-spectrum antimicrobial coverage is indicated. Potential anaerobic organisms must be considered in selecting therapeutic regimens as demonstrated by our case and others. Anaerobes have a major role in the bacteriology of most human abscesses. 12 The scarcity of reports of prostatic abscesses owing to anaerobic bacteria reflects the fact that often anaerobic cultures are not obtained. 13· 14 Alternatively, the fastidiousness of these organisms is well recognized. Anaerobes are known to inhabit the normal urethra. Headington and Beyerlein found 158 anaerobes in 147 of 15,250 consecutive urine cultures. 15 None of the patients who were shown to have anaerobic organisms was infected clinically. Mardh and Colleen studied 79 patients with a clinical diagnosis of chronic prostatitis.16 Semen specimens were cultured under anaerobic conditions and 7 patients had Peptostreptococcus. However, the authors concluded that there was no evidence to incriminate anaerobes in chronic prostatitis. Meares used bacteriological localization techniques and found no evidence to implicate anaerobic bacteria in "prostatosis" (abacterial prostatitis) in 20 patients. 17· 18 We are aware of 14 cases of prostatic abscesses caused by anaerobic bacteria. 1· 8• 13· 16· 19-21 Patient age, clinical findings and treatment modalities are summarized in the table. All patients were treated with broad-spectrum antimicrobial agents. The anaerobes isolated in published reports of prostatic abscess with culture results include Actinomyces viscosus, Bacteroides fragilis (5 cases), Bacteroides melaninogenicus (2 cases), Bacteroides (species not given), Clostridium perfringens, Clostridium ramosum, Clostridium (species not given), Eubacterium aerofaciens, Eubacterium lentum, Fusobacterium gonidiaformans, Peptococcus anaerobius, Peptococcus asaccharolyticus
(2 cases), Peptococcus intermedius, Peptococcus (species not given) and Sphaerophorus gonidiaformans. 8 • 13 · 14· 19~21 All but 2 patients had at least 2 anaerobes isolated. Abscess of the prostate, while not a common entity, must be recognized and treated appropriately. Modern imaging modalities (transrectal ultrasound and CT scanning) may assist in making the often difficult diagnosis. Cultures should include aerobic and anaerobic methods. Complete transurethral resection of the gland is the preferred method of drainage. Adjuvant broad-spectrum antimicrobial agents should be administered. Anaerobic as well as aerobic pathogens must be covered, and long-term followup may be required.
REFERENCES
1. Persky, L., Austen, G., Jr. and Schatten, W. E.: Recent experiences
with prostatic abscess. Surg., Gynec. & Obst., 101: 629, 1955. 2. Becker, L. E. and Harrin, W. R.: Prostatic abscess: a diagnostic and therapeutic approach. J. Urol., 91: 582, 1964. 3. Dajani, A. M. and O'Flynn, J. D.: Prostatic abscess. A report of 25 cases. Brit. J. Urol., 40: 736, 1968. 4. Youngen, R., Mahoney, S. A. and Persky, L.: Prostatic abscess. Surg., Gynec. & Obst., 124: 1043, 1967. 5. Trapnell, J. and Roberts, M.: Prostatic abscess. Brit. J. Surg., 57: 565, 1970. 6. Pai, M. G. and Bhat, H. S.: Prostatic abscess. J. Urol., 108: 599, 1972. 7. Nkposong, E. 0. and Osunkoya, B. 0.: Metastatic prostatic abscess in the newborn. Nigerian Med. J., 8: 389, 1978. 8. Mariani, A. J., Jacobs, L. D., Clapp, P.R., Hariharan, A., Starns, U. K. and Hodges, C. V.: Emphysematous prostatic abscess: diagnosis and treatment. J. Urol., 129: 385, 1983. 9. Gammelgaard, J. and Holm, H. H.: Transurethral and transrectal ultrasonic scanning in urology. J. Urol., 124: 863, 1980. 10. Dennis, M. A. and Donohue, R. E.: Computed tomography of prostatic abscess. J. Comp. Asst. Tomogr., 9: 201, 1985. 11. Timberlake, G.: An electro-prostatome; relief ofprostatic abscesses and acute obstructive prostatitis by transurethral prostatotomyc J. Urol., 40: 343, 1938. 12. Gorbach, S. L. and Bartlett, J. G.: Anaerobic infections. New Engl. J. Med., 290: 1177, 1237, 1289, 1974. 13. Corrado, M. L., Sierra, M. F., Eng., R. and Simenowsky, E. G.: Anaerobic prostatic abscess. N. Y. State J. Med., 80: 652, 1980. 14. Fishbach, R. S. and Finegold, S. M.: Anaerobic prostatic abscess with bacteremia. Amer. J. Clin. Path., 59: 408, 1973. 15. Headington, J. T. and Beyerlein, B.: Anaerobic bacteria in routine urine culture. J. Clin. Path., 19: 573, 1966. 16. Mardh, P.-A. and Colleen, S.: Search for mo-genital tract infections in patients with symptoms of prostatitis. Scand. J. Urol. Nephrol., 9: 8, 1975. 17. Meares, E. M., Jr.: Bacterial prostatitis vs. "prostatosis". A clinical and bacteriological study. J.A.M.A., 224: 1372, 1973. 18. Meares, E. M. and Stamey, T. A.: Bacteriologic localization patterns in bacterial prostatitis and urethritis. Invest. Urol., 5: 492, 1968. 19. Albarran, J. and Cottet, J.: Des infections urinaries anaerobies. Trans. Congr. Internat. de Med., 11: 281, 1900. 20. Gorbach, S. L. and Thadepalli, H.: Isolation of clostridium in human infections: evaluation of 114 cases. J. Infect. Dis., 131: S81, 1975. 21. Bartlett, J. G., Weinstein, W. M. and Gorbach, S. L.: Prostatic abscesses involving anaerobic bacteria. Arch. Intern. Med., 138: 1369, 1978.
THE JOURNAL OF UROLOGY
Copyright © 1987 by The Williams & Wilkins Co.
Printed in U.S.A.
PROSTATIC ABSCESS OWING TO ANAEROBIC BACTERIA MICHAEL K. BRAWER*
AND
THOMAS A. STAMEY
From the Division of Urology, Department of Surgery, University of Arizona Health Sciences Center and Veterans Administration Medical Center, Tucson, Arizona, and Stanford University School of Medicine, Stanford, California ABSTRACT
Abscess of the prostate is seen infrequently. We report a prostatic abscess owing to anaerobic bacteria in a 46-year-old man with a 10-year history of irritable voiding symptoms. Preoperative computerized tomography confirmed the diagnosis of prostatic abscess, which was treated with transurethral resection and broad-spectrum antibiotics. (J. Urol., 138: 1254-1255, 1987) Spontaneous prostatic abscess has become a relatively rare entity as a result of the development of effective antimicrobial agents. 1- 3The decreasing incidence of gonococcal urethritis and resulting stricture formation has caused a change in the associated pathogens from gram-positive to gram-negative infections.3-5 Prostatic abscess owing to anaerobic bacteria remains a rare lesion, with only 14 reported cases. We report a case of a prostatic abscess caused by anaerobic bacteria that was confirmed preoperatively with the aid of computerized tomography (CT). CASE REPORT
A 46-year-old man was referred with a 10-year history of worsening frequency, nocturia, dysuria, hesitancy, intermittent gross total painless hematuria and sterile pyuria. He had been given several antibiotic trials despite multiple sterile urine cultures and at least 1 sterile culture of expressed prostatic secretions. The antimicrobial therapy afforded no change in the symptom complex. Cultures for acid-fast bacteria on 6 occasions were negative. Because of the unremitting symptoms in the face of continual sterile pyuria, cystoscopy was performed 8 months before referral. Biopsy of an inflamed prostatic urethra disclosed chronic urethritis and scar. Postoperatively, the patient had a temperature of 104F. Two blood cultures yielded Peptostreptococcus asaccharolyticus. The patient was treated with metronidazole and penicillin with rapid defervescence. There was transient clearing of the pyuria. Because of rapid recurrence of the voiding symptoms the patient was referred to the Stanford University Medical Center. Medical history was noteworthy for osteomyelitis in the right tibia requiring multiple surgical procedures dating back to a fracture when he was 10 years old. General physical examination was unrevealing. Rectal examination disclosed an enlarged boggy prostate that was described as feeling like a "water balloon". M:"croscopy of the first voided 10 cc urine, midstream aliquot of mine, expressed prostatic secretions and first 10 cc voided urine after prostatic massage demonstrated marked pyuria. Culbres were sterile. Suprapubic needle aspirate of the bladder urine before prostatic examination revealed marked pyuria as well as intracellular and extracellular gram-positive cocci. Aerobic, anaerobic and Ureaplasma cultures were sterile. Cystoscopy revealed a stricture of the bulbar urethra. The prostatic urethra was unremarkable. A second suprapubic aspirate 12 days later again revealed pyuria and similar organisms. Aerobic cultures were sterile but gram-positive cocci and gram-negative rods were seen on anaerobic culture. Subculture was unsuccessful. Because of the clinical suspicion that this patient had a prostatic abscess owing to anaerobic bacteria a CT scan of the pelvis was obtained. The scan demonstrated an enlarged prostate, the posterior and lateral aspects of which were of a water density without contrast Accepted for publication April 21, 1987. * Requests for reprints: Division of Urology, Department of Surgery, University of Arizona Health Sciences Center, Tucson, Arizona 85724.
material enhancement, consistent with an abscess (see figure). Perineal needle aspiration of the prostate revealed 20 cc malodorous pus. Transurethral resection of the prostate was performed with unroofing of the abscess cavity and debridement of the cavity wall. The patient had received 3 doses of piperacillin preoperatively, which was continued for 5 days. Aerobic and anaerobic cultures of the pus were sterile, and Gram stain showed intracellular and extracellular Gram-positive cocci. Pathological examination of the resected tissue demonstrated chronic inflammation. The patient had no urinary complaints 3 months postoperatively but pyuria was still present. A suprapubic aspirate 4 months postoperatively continued to show pyuria and grampositive cocci. Aerobic cultures were negative. Peptococcus anaerobius was grown anaerobically. Cystoscopy demonstrated an epithelialized prostatic fossa: The patient was given a 10day course of metronidazole A month after completing this regimen suprapubic urine was sterile aerobically and anaerobically but pyuria persisted. A followup CT scan revealed a decrease in the size of the prostate and a low density ringshaped collection within the central portion of the gland. A cystogram demonstrated a smooth-walled transurethral resection cavity with no filling defect. Five months after drainage of the abscess the patient began to experience again irritable voiding symptoms that had been absent in the preceding months. Suprapubic aspirate of the urine continued to reveal pyuria with sterile aerobic and anaerobic cultures. He was treated empirically with a 10-day course of clindamycin. A month after this regimen the patient was free of symptoms. At followup 4 years after drainage of the prostatic abscess and 28 months following the course of clindamycin he was without urological complaints or pyuria and aerobic as well as anaerobic urine cultures were sterile. DISCUSSION
The incidence of abscess of the prostate is decreasing owing to the increasing rarity of gonococcal urethritis and associated
Preoperative CT scan demonstrates enlarged prostate with low attenuating well defined lesion consistent with abscess (arrow).
1254
1255
PROSTATIC ABSCESS OWING TO ANAEROBIC BAC'I'ER.IA Prostatic abscess caused by anaerobic bacteria Reference Albarran and Cottet Persky and associates'
Pt. Age
Fever
Obstructive Voiding
Irritable Voiding
Prostate Tender
+
+ + + + +
+ + + +
Perinea! incision and drainage Perinea! incision and drainage Perinea! incision and drainage Perinea! incision and drainage Perinea! incision and drainage Transurethral resection of prostate
+ +
+ + + + + +
Perinea[ incision and drainage Perinea! incision and drainage Perinea! incision and drainage Cystoscopic rupture Spontaneous drainage Transurethral resection of prostate
Treatment
19
Fishbach and Finegold 14 Gorbach and Thadepa!i20 Bartlett and associates"
Corrado and associates 13 Mariani and associates•
42
57*
+
30 36* 66 56
+
77 33 23 58'' 44 56*
+ + + +
+
+
+
+ +
* Diabetes mellitus.
stricture disease combined with improved antimicrobial agents. 1~3 In the series of Dajani and O'Flynn, 3 and Pai and Bhat6 the incidence was 0.5 and 2.5 per cent, respectively, of the patients hospitalized with prostatic disease. Nevertheless, it remains a potentially serious entity with mortalities in published series ranging from 3 to 30 per cent. 1· 4-6 The 2 pathophysiological patterns that are recognized include abscesses arising in the setting of underlying lower genitourinary tract disease and metastatic lesions. The former typically are caused by gram-negative pathogens, presumably ascending to the prostatic ducts, and the latter are caused by gram-positive species.1,a,s-,i The diagnosis of prostatic abscess often is elusive with a reported preoperative diagnosis being made in 21 to 88 per cent of the cases. 5· 6 Modern imaging techniques have assisted in making the diagnosis. Gammelgaard and Holm reported on the use of transurethral and transrectal ultrasound in this entity. 9 Recently, Dennis and Donohue reported the first case of CT of prostatic abscess. 10 The treatment of prostatic abscesses requires definitive drainage. Transurethral resection, as suggested originally by Timberlake, 11 has become the most favored approach. In addition to surgical drainage broad-spectrum antimicrobial coverage is indicated. Potential anaerobic organisms must be considered in selecting therapeutic regimens as demonstrated by our case and others. Anaerobes have a major role in the bacteriology of most human abscesses. 12 The scarcity of reports of prostatic abscesses owing to anaerobic bacteria reflects the fact that often anaerobic cultures are not obtained. 13· 14 Alternatively, the fastidiousness of these organisms is well recognized. Anaerobes are known to inhabit the normal urethra. Headington and Beyerlein found 158 anaerobes in 147 of 15,250 consecutive urine cultures. 15 None of the patients who were shown to have anaerobic organisms was infected clinically. Mardh and Colleen studied 79 patients with a clinical diagnosis of chronic prostatitis.16 Semen specimens were cultured under anaerobic conditions and 7 patients had Peptostreptococcus. However, the authors concluded that there was no evidence to incriminate anaerobes in chronic prostatitis. Meares used bacteriological localization techniques and found no evidence to implicate anaerobic bacteria in "prostatosis" (abacterial prostatitis) in 20 patients. 17· 18 We are aware of 14 cases of prostatic abscesses caused by anaerobic bacteria. 1· 8• 13· 16· 19-21 Patient age, clinical findings and treatment modalities are summarized in the table. All patients were treated with broad-spectrum antimicrobial agents. The anaerobes isolated in published reports of prostatic abscess with culture results include Actinomyces viscosus, Bacteroides fragilis (5 cases), Bacteroides melaninogenicus (2 cases), Bacteroides (species not given), Clostridium perfringens, Clostridium ramosum, Clostridium (species not given), Eubacterium aerofaciens, Eubacterium lentum, Fusobacterium gonidiaformans, Peptococcus anaerobius, Peptococcus asaccharolyticus
(2 cases), Peptococcus intermedius, Peptococcus (species not given) and Sphaerophorus gonidiaformans. 8 • 13 · 14· 19~21 All but 2 patients had at least 2 anaerobes isolated. Abscess of the prostate, while not a common entity, must be recognized and treated appropriately. Modern imaging modalities (transrectal ultrasound and CT scanning) may assist in making the often difficult diagnosis. Cultures should include aerobic and anaerobic methods. Complete transurethral resection of the gland is the preferred method of drainage. Adjuvant broad-spectrum antimicrobial agents should be administered. Anaerobic as well as aerobic pathogens must be covered, and long-term followup may be required.
REFERENCES
1. Persky, L., Austen, G., Jr. and Schatten, W. E.: Recent experiences
with prostatic abscess. Surg., Gynec. & Obst., 101: 629, 1955. 2. Becker, L. E. and Harrin, W. R.: Prostatic abscess: a diagnostic and therapeutic approach. J. Urol., 91: 582, 1964. 3. Dajani, A. M. and O'Flynn, J. D.: Prostatic abscess. A report of 25 cases. Brit. J. Urol., 40: 736, 1968. 4. Youngen, R., Mahoney, S. A. and Persky, L.: Prostatic abscess. Surg., Gynec. & Obst., 124: 1043, 1967. 5. Trapnell, J. and Roberts, M.: Prostatic abscess. Brit. J. Surg., 57: 565, 1970. 6. Pai, M. G. and Bhat, H. S.: Prostatic abscess. J. Urol., 108: 599, 1972. 7. Nkposong, E. 0. and Osunkoya, B. 0.: Metastatic prostatic abscess in the newborn. Nigerian Med. J., 8: 389, 1978. 8. Mariani, A. J., Jacobs, L. D., Clapp, P.R., Hariharan, A., Starns, U. K. and Hodges, C. V.: Emphysematous prostatic abscess: diagnosis and treatment. J. Urol., 129: 385, 1983. 9. Gammelgaard, J. and Holm, H. H.: Transurethral and transrectal ultrasonic scanning in urology. J. Urol., 124: 863, 1980. 10. Dennis, M. A. and Donohue, R. E.: Computed tomography of prostatic abscess. J. Comp. Asst. Tomogr., 9: 201, 1985. 11. Timberlake, G.: An electro-prostatome; relief ofprostatic abscesses and acute obstructive prostatitis by transurethral prostatotomyc J. Urol., 40: 343, 1938. 12. Gorbach, S. L. and Bartlett, J. G.: Anaerobic infections. New Engl. J. Med., 290: 1177, 1237, 1289, 1974. 13. Corrado, M. L., Sierra, M. F., Eng., R. and Simenowsky, E. G.: Anaerobic prostatic abscess. N. Y. State J. Med., 80: 652, 1980. 14. Fishbach, R. S. and Finegold, S. M.: Anaerobic prostatic abscess with bacteremia. Amer. J. Clin. Path., 59: 408, 1973. 15. Headington, J. T. and Beyerlein, B.: Anaerobic bacteria in routine urine culture. J. Clin. Path., 19: 573, 1966. 16. Mardh, P.-A. and Colleen, S.: Search for mo-genital tract infections in patients with symptoms of prostatitis. Scand. J. Urol. Nephrol., 9: 8, 1975. 17. Meares, E. M., Jr.: Bacterial prostatitis vs. "prostatosis". A clinical and bacteriological study. J.A.M.A., 224: 1372, 1973. 18. Meares, E. M. and Stamey, T. A.: Bacteriologic localization patterns in bacterial prostatitis and urethritis. Invest. Urol., 5: 492, 1968. 19. Albarran, J. and Cottet, J.: Des infections urinaries anaerobies. Trans. Congr. Internat. de Med., 11: 281, 1900. 20. Gorbach, S. L. and Thadepalli, H.: Isolation of clostridium in human infections: evaluation of 114 cases. J. Infect. Dis., 131: S81, 1975. 21. Bartlett, J. G., Weinstein, W. M. and Gorbach, S. L.: Prostatic abscesses involving anaerobic bacteria. Arch. Intern. Med., 138: 1369, 1978.