Prostatic Abscess

What is Prostatic Abscess?

An abscess, a pocket of pus that forms in response to an infection, consists of broken down tissue, white blood cells, bacteria, and enzymes. A prostatic abscess is an abscess that forms within the prostate, often due to a severe prostate infection known as acute bacterial prostatitis. This condition can be hard to distinguish from more common prostate infections based purely on the symptoms, medical history, and physical examination. If not treated properly, a prostatic abscess could lead to severe complications like bloodstream infection or septic shock, which could be fatal.

Acute bacterial prostatitis mainly affects men between 20 to 40 years old and over 60. Symptoms typically appear suddenly and include frequent urination, pain in the perineal area (the region between the genitals and the rectum), and painful urination. Additionally, the infected urine may be accompanied by fever, discomfort, chills, and muscle ache. Some men may have trouble urinating or be unable to urinate at all. Moreover, men who use catheters intermittently may have a chance of up to 33% of getting this condition in their lifetime. Any male with a urinary tract infection and a fever is considered to be at risk for acute bacterial prostatitis.

Wiser use of antibiotics today has greatly decreased the number of prostatic abscess cases. Nonetheless, the condition is still common in developing countries and among high-risk individuals. Men who carry the greatest risk include those who have undergone procedures like prostate biopsies, men with chronic conditions like diabetes or liver cirrhosis, men receiving chemotherapy for cancer or those who have had organ transplants, men with HIV/AIDS, men with improperly managed enlarged prostate (also known as benign prostatic hyperplasia), and more broadly, people with weakened immune systems. While the condition is rare and there’s limited clear guidance on how to investigate and treat it, a prostatic abscess poses a real-life challenge.

Many doctors might not be very familiar with this condition because of how infrequently it presents itself. This unfamiliarity might lead to significant health problems.

What Causes Prostatic Abscess?

A prostate abscess is often a result of a condition known as acute prostatitis or severe inflammation of the prostate. This often happens when urine infected with bacteria backs up into the ducts of the prostate when a person urinates. Men with diabetes or a weakened immune system are more likely to develop a prostate abscess. In fact, more than half of men with this type of abscess are diabetics.

Although relatively rare due to the widespread use of antibiotics, untreated acute prostatitis can escalate into an abscess. Additionally, a prostate abscess is more common among men with chronic medical devices like catheters, those with difficulties emptying their bladder due to nervous system issues or conditions like diabetes, liver disease, and weakened immune systems, including those with HIV. High-risk patients also include those who need to self-catheterize or who have a blockage in their bladder outlet which can lead to abscess formation.

In the past, before antibiotics, sexually transmitted organisms like Neisseria gonorrhoeae and Chlamydia were often responsible for prostatic abscesses. In our current day, the bacteria most commonly seen in these abscesses is gram-negative bacteria such as Escherichia coli followed by Klebsiella, Pseudomonas, Proteus, Enterobacter, Serratia and Enterococcus species. The bacteria Staphylococcus aureus has also been associated with prostate abscesses severe skin infection or rheumatic fever.

Infections acquired in a hospital or similar environment tend to involve different bacteria like Pseudomonas aeruginosa, Enterococcus, or Staphylococcus aureus. These infections often lead to a more aggressive illness and are higher risk for progressing into an abscess. They are also more likely to demonstrate resistance to antibiotics.

The cause of prostate abscesses in older males tends to involve complications arising from a prostate biopsy, benign prostatic hyperplasia (non-cancerous prostate enlargement), or inadequately treated acute bacterial prostatitis. In younger males, a prostate abscess could be a sign of a previously undiagnosed chronic or severe medical condition such as diabetes.

Risk Factors and Frequency for Prostatic Abscess

A prostatic abscess is a condition that can occur in up to 0.5% of all diseases related to the urinary system. The chances of dying from it range from 1% to 16%, and about 6% of acute bacterial prostatitis patients might develop a prostatic abscess. This condition is more common in older men because they have a higher risk of underlying medical conditions and are more prone to undergo certain medical procedures like prostate biopsies. However, prostatic abscesses that are caused by sexually transmitted organisms often affect younger men. It’s also worth noting that younger men who develop prostatic abscesses may actually have a chronic medical condition that hasn’t been diagnosed yet.

• A prostatic abscess can occur in up to 0.5% of all urologic diseases.
• The mortality rate for this condition is between 1% and 16%.
• About 6% of acute bacterial prostatitis patients might develop a prostatic abscess.
• This condition is more common in older men because of higher risk factors and the greater likelihood of undergoing prostate biopsies.
• Prostatic abscesses that are caused by sexually transmitted organisms often affect younger men.
• Younger men who get prostatic abscesses may have an undiagnosed chronic medical condition.

Signs and Symptoms of Prostatic Abscess

Bacterial prostatitis is a condition where the prostate gland becomes inflamed due to a bacterial infection. When patients come in with this condition, doctors should quickly gather information about their medical history and whether they might have any factors that make them more prone to infections. This can help doctors assess whether there’s a risk of the infection turning into a prostate abscess.

Patients often show up with symptoms that indicate a urinary tract infection, which is usually the source of the bacterial prostatitis. These symptoms may include:

• Frequent urination
• Urgency to urinate
• Painful urination
• Blood in the urine
• Burning sensation in the urethra
• Difficulty urinating or inability to urinate

Specifically, pain in the area between the genitals and the anus (perineal discomfort) can indicate a prostate problem.

Other signs that the infection has spread throughout the body may include fever, chills, muscle aches, and low back pain. Some patients may also experience blood at the end of urination or pus coming from the urethra, although these are less common. Around one-third of patients with prostate abscesses might only show widespread signs of infection.

Physical examinations can reveal symptoms like pus coming out of the urethra, a painful prostate exam, and possibly a soft, squishy area (fluctuant area) on the prostate. However, just having a painful, swollen, and tender prostate does not necessarily mean a patient has a prostate abscess, and these soft areas are found in as few as 16% of patients with a prostate abscess. Almost all patients will have sensitive and inflamed prostates, and over 90% will show signs of infection in the blood and urine. Additionally, a prostate exam can be quite painful and sometimes risk spreading the infection further, leading to sepsis. As such, doctors should be very suspicious of a prostate abscess in any patient with severe prostatitis, particularly in those who are high-risk due to their health problems or who don’t quickly respond to treatment within 48 hours.

Testing for Prostatic Abscess

Diagnosing a prostatic abscess based on patient history and physical examinations can be challenging as symptoms usually overlap with other urinary tract issues. That’s why, if you have been diagnosed with acute prostatitis but do not respond to treatment within 48 hours, your doctor will consider the possibility of a prostatic abscess.

Getting a clear diagnosis often requires a range of tests including a detailed blood count, urinalysis, and blood and urine cultures. These tests help understand if an infection or chronic disease is present. If your symptoms and these initial test results point towards a prostatic abscess, your doctor will ask for imaging studies. These not only confirm the diagnosis but help plan the treatment, including deciding where and how to drain the abscess if required.

Imaging can be done in a few ways, including a transrectal prostate ultrasound, a CT scan, or a prostatic MRI. The transrectal ultrasound is usually the first choice as it is able to accurately identify a prostatic abscess in around 80% of patients. The ultrasound looks for hypoechoic areas (dark patches) within the prostate with well-defined walls, indicating the presence of an abscess. The major advantage of an ultrasound is that it allows immediate treatment through needle aspiration for both drainage and culture. However, it can be uncomfortable for the patient and is operator-dependent.

If an CT scan of the abdomen and pelvis is performed, it can further identify if the infection has spread to surrounding organs. CT scans are especially useful in severe cases or when the abscess is filled with gas. However, a CT scan may struggle to differentiate small abscesses from benign cystic prostatic nodules.

MRI imaging offers another option for a more detailed view of the prostate, even in very ill patients. In an MRI scan, an abscess usually appears as a dark area on the T1 image and light area in T2 images. The benefit of an MRI is its capacity to show fluid collections more clearly and to identify if the inflammation has spread beyond the prostate. If clear visibility is required during an abscess drainage, an MRI- guided transrectal ultrasound can also be used.

Overall, if you’re at high risk or if your acute prostatitis is not getting better within 48 hours, your doctor will consider looking for a prostatic abscess. However, it’s important to remember that only specialized imaging can confirm the diagnosis because the symptoms of a prostatic abscess and bacterial prostatitis are similar. Although transrectal ultrasound is frequently the first step for imaging, your doctor might recommend an MRI as this provides a clearer image of the prostate without radiation risk or any invasive procedures.

Treatment Options for Prostatic Abscess

Prostate abscesses are pockets of pus that form due to an infection in the prostate. Diagnosing them early is crucial since they need long-term treatment and sometimes surgery. Doctors will typically use ultrasound or other imaging tests to locate and measure the size of the abscesses. If the abscesses are small (up to 1cm across), they are often managed without surgery. However, if they’re between 1cm and 2cm, surgery can be considered to speed up recovery and cut hospital stays.

If a patient’s condition doesn’t improve with non-surgical treatment, it might be necessary to perform a surgical drainage procedure. Further imaging tests, like a CT scan or MRI, can be used if a patient doesn’t respond to initial drainage to ensure the infection hasn’t spread outside the prostate. Smaller abscesses often respond well to non-surgical treatment, while larger ones tend to need surgical treatment.

Patients undergoing non-surgical treatment are closely monitored and given strong antibiotics via an IV drip. These treatments often require a hospital stay. Initial antibiotics are chosen to fight off common types of bacteria (known as gram-negative bacteria), but can be adjusted based on urine test results if unusual causes are suspected. Antibiotics are typically required for a minimum of two weeks, and in many cases, treatment might need to continue for over a month. Regular imaging tests are also important to track the abscess’s progress.

Unfortunately, some bacteria have become more resistant, making some abscesses harder to treat. For these cases, a range of stronger antibiotics may be needed. After about a week, a new culture is recommended to reassess the treatment approach.

For the draining of the bladder, there’s a bit of controversy between using a catheter and a suprapubic tube. The latter is often recommended as it doesn’t irritate the inflamed prostate.

Many patients, about 80%, will eventually need surgical intervention. There are several ways a doctor can perform this surgery, each with its own pros and cons. The most commonly chosen is transurethral drainage due to it causing shorter hospital stays. It’s particularly beneficial in cases with larger abscesses or where just draining the abscess wasn’t enough. In some cases, though, it might not be suitable due to potential risks and complications.

At present, drainage guided by ultrasound done through the rectum (transrectally) is usually the top choice. It’s less invasive as it only requires local anesthesia and is often used for smaller abscesses. This procedure can be repeated if needed. If transrectal drainage doesn’t work, the next step might be surgically opening up the abscess (transurethral resection or unroofing). In severe cases where the infection has spread, an open surgical drainage may be warranted though this is avoided whenever possible due to potential complications.

What else can Prostatic Abscess be?

The symptoms of certain medical conditions can be very similar to each other. For instance, the problems listed below can show the same signs as a prostate abscess:

• Urethritis (inflammation of the urethra)
• Urinary tract infection (an infection in any part of your urinary system)
• Acute or chronic bacterial prostatitis (swelling and inflammation of the prostate gland)
• Benign prostatic hyperplasia (an enlarged prostate)
• Perirectal and perineal abscess (pockets of pus formed around the rectal area).

If a doctor can feel a soft, tender mass, this strongly suggests a prostate abscess. However, a perirectal or perineal abscess might also feel like this, too, as they can also cause pain and swell in the local area, making them very similar to a prostate abscess.

What to expect with Prostatic Abscess

The chances of successful recovery for patients with a prostate abscess, which is a pocket of pus in the prostate, greatly depends on how quickly the condition is diagnosed and treated, as well as the overall health of the patient and any other health conditions they may have. When this condition is identified and managed promptly and correctly, patients are highly likely to improve.

For some patients, they might be able to avoid surgery and instead receive a treatment plan that largely involves antibiotics. However, the period of treatment with antibiotics tends to be longer in these cases than for patients with a similar condition known as acute bacterial prostatitis, but without any abscesses.

Unfortunately, a number of factors can negatively affect the outcome. These include being older than 65, having a fever higher than 100.4 F (38 C), a history of urinary retention or an enlarged prostate that causes symptoms, long-term use of a urinary catheter, poor control of diabetes, HIV/AIDS, poor overall health, and kidney failure.

It’s important to know that a prostate abscess can be a life-threatening condition if it’s not identified and treated quickly and correctly.

Possible Complications When Diagnosed with Prostatic Abscess

Delaying the diagnosis or treatment of a prostate abscess can cause serious complications, and in some cases, could even be deadly. This infection could spread to surrounding areas in the body, which might lead to further invasive medical procedures with possible long-term complications affecting urinary and sexual functions. In severe cases, bacteria could enter the bloodstream, leading to serious body-wide inflammation and failure of multiple organs. A certain form of prostatitis, where gas is found within the abscess, is particularly severe and can often be fatal.

Common Complications:

• Infection spreading to surrounding body areas
• Need for further invasive medical procedures
• Possible long-term complications affecting urinary and sexual functions
• Possibility of severe body-wide inflammation
• Multiple organs failing
• Emphysematous prostatitis, a particularly severe form of infection
• Potential death

Recovery from Prostatic Abscess

After having a surgical procedure to drain fluid, patients usually start to feel better quite quickly. To make sure the treatment is working and the infection fully clears, doctors will do regular imaging tests and take samples of the urine for testing. Oral antibiotics, usually either a fluoroquinolone or trimethoprim-sulfamethoxazole, can be used instead of antibiotics given through a vein, depending on the results of the culture tests. The traditional treatment usually requires at least four weeks of antibiotics, but some patients have been fine with just two weeks. One approach may be to give the patient antibiotics for a bit longer to avoid the infection coming back.

Preventing Prostatic Abscess

Nowadays, we can’t assume that prostate abscess, a collection of pus in the prostate gland, only happens due to untreated prostate inflammation. Often, men suffering from this condition usually have serious medical issues. They might be weakened due to other health problems or have weak immune systems. In some younger men, a prostate abscess could be an early sign of a previously unknown condition that affects the immune system. It’s also becoming increasingly common in older men as a side effect of an enlarged prostate or a prostate biopsy.

The process of determining whether a patient has a prostate abscess or bacterial inflammation of the prostate can be challenging, and it’s important to stick to the recommended long-term antibiotic treatments. Hence, patients must be well-informed about the seriousness of the condition. Doctors, on the other hand, should be on high alert for the disease to diagnose and start treatment quickly.

Men with infections in their lower urinary tract and prostate should be taught how to identify the early signs and symptoms of abscess formation. Specifically, those who suffer from fever-related urinary tract infections after a prostate biopsy should be considered at high risk of developing a prostate abscess and need to be adequately educated about the condition. The emergence of more-resistant bacteria and the condition often affecting patients with diabetes or weakened immune systems are making diagnosis and treatment more challenging.