Case Reports

62
L. F. Susaníbar Napurí, C. Simón Rodríguez, L. López Martín, et al.
Case Reports
Arch. Esp. Urol. 2011; 64 (1): 62-66
PROSTATIC ABSCESS: DIAGNOSIS
AND TREATMENT OF AN INFREQUENT
UROLOGICAL ENTITY
Luis Fernando Susanibar Napuri, Carlos Simon
Rodriguez, Leticia Lopez Martíin, Juan Monzo
Gardinier, Ramiro Cabello Benavente and Carmen
Gonzalez Enguita.
Urology Department. Hospital Fundación Jiménez Díaz.
Madrid. Spain.
Summary.- OBJECTIVE: To report two cases of prostatic
abscess of difficult management and review the literature
on diagnosis and management of this entity.
METHODS /RESULTS: We describe two patients with
prostatic abscess. The first one, a 73-year-old diabetic
male, was treated using a more passive approach with
percutaneous transrectal drainage; after a slow response,
the patient passed away due to sepsis. The second case
was a 59-year-old male who experienced a negative
clinical response to antibiotic treatment. While under
antibiotic ambulatory care the patient was treated with
a transurethral resection of the prostate, which yielded a
successful outcome.
CONCLUSION: Prostatic abscess is a rare entity that
affects individuals experiencing weakness and can be a
serious condition. Measures taken to arrive at a resolution
must be rapid and appropriate.
Keywords: Prostatic abscess. Trasurethral prostate
resection. Transrectal ecography.
Resumen.- OBJETIVO: Presentar dos casos clínicos de
absceso prostático de difícil manejo y revisar el diagnóstico y tratamiento de esta entidad.
MÉTODOS/RESULTADOS: Descripción de dos pacientes
con absceso prostático. El primer caso es un varón diabético de 73 años a quien se le instaura un manejo conservador con drenaje percutáneo transrectal y quien tras
una evolución tórpida fallece de una sepsis urológica. El
segundo caso es un varón de 59 años con mala evolución
clínica tras tratamiento antibiótico ambulatorio realizándose una resección transuretral de próstata con resultado
satisfactorio.
CONCLUSIÓN: El absceso prostático es una entidad
rara. Afecta principalmente a personas debilitadas lo que
le confiere un carácter grave. Las medidas encaminadas a
su resolución deben ser rápidas y oportunas.
Palabras clave: Absceso Prostático. Resección
transuretral de próstata. Ecografía Transrectal.
INTRODUCTION
@
CORRESPONDENCE
Luis Fernando Susaníbar Napurí
Hospital Fundación Jiménez Díaz
Av. Reyes Católicos, 2.
28040 Madrid (Spain).
[email protected]
[email protected]
[email protected]
Accepted for publication: July 21st, 2010
Early diagnosis of prostatic pathology and the
widespread use of antibiotics have made prostatic
abscesses an infrequent occurrence. Prostate abscesses
are generally seen in diabetics and inmunodeficient
patients, often resulting in a serious condition which
requires rapid and correct treatment. Diagnosis tends
to be clinical, with the chosen method being a rectal
ultrasound. The treatment includes a series of intravenous
antibiotics as well as other minimally invasive techniques
such as transrectal ultrasound-guided drainage and
transurethral resection of the prostate. In some cases,
open surgery may be necessary.
FIRST CASE REPORT
71-year-old male with chronic renal insufficiency,
chronic hepatopathy due to hepatitis-B virus with
gastropathyportal hypertension, and diabetes being
PROSTATIC ABSCESS: DIAGNOSIS AND TREATMENT OF AN INFREQUENT UROLOGICAL ENTITY
treated with antibiotics is admitted via the Emergency
Room due to complaints of feeling generally unwell
and having a mass in the left groin region. Physical
examination reveals a lump of normal color but painful
to the touch in the left groin region. Rectal examination
shows a prostate volume IV / IV of a soft consistency
and not tender to palpation. Blood tests reveal
17.39 white blood cells with 90,8 % of segmented
neutrophils, the serum glues was 450 mg/ dl, and
serum creatinine 1.8 mg/dl. Coagulation test was
normal.. An abdominal ultrasound is performed with
a presumed diagnosis of incarcerated inguinal hernia.
Surgery is then preformed by the General Surgery and
Digestive Diseases Department. During surgery, a large
quantity of pus of unknown origin was observed exiting
the internal inguinal ring. A drainage system is fitted
to the skin in order to allow the abscess to continue
draining. Given that no determination as to the cause
of the infection has been made, a pelvic Tomography
(pelvic CT) is taken, revealing a large prostatic abscess
extending from the obturator region to the left groin
region (Figure 1).
An immediate assessment by the Urology Departament of
the Fundación Jiménez Díaz is requested. As a primary
measure, treatment with the antibiotic Metronidazole is
administered and an immediate urinary derivation is
performed using a suprapubic catheter (percutaneous
cystostomy). A subsequent CT-guided transrectal
drainage , placed bilaterally and intraparenchymatous
in the periphery of the prostate, was carried out, and
obtained approximately 20 ml of whitish puss. Initial
patient response is favorable: his state improves, fever
reduces, and suprapubic catheter is permeable and
the urine clear. As planned, an examination of the
FIGURE 1. Abdomino pelvic TAC where great prostate
abscess is demonstrated.
63
digestive tract is carried out by means of an opaque
enema in order to rule out a relationship between the
abscess and digestive pathology. The examination
yields negative results for fistula of the digestive system,
tumor, and diverticulitis (Figure 2).
Two weeks after admission, the patient is released
in good general health, with permeable suprapubic
vesical catheter, being afebrile and in a normal state
to continue with routine outpatient oral antibiotic
treatment. The patient has a follow-up appointment with
the urology department in two weeks.
Eight days later, the patient is readmitted via the
Emergency Room with complaints of pain in the
suprapubic vesical catheter. He presents with
hypoglucemia that are uncontrolled, often associated
with regular doses of oral antibiotics. Initial examination
rules out a urological complication with the vesical
suprapubic cateter and reveals a purulent discharge
from the abdominal drainage wound. He is admitted to
the Endocrinology Service for glycemia treatment. The
patient progresses slowly, showing a decline in general
health, fever, and blood-sugar levels that are difficult to
manage. There is also a marked loss of urine peri vesical
suprapubic catheter, for which another tomography is
carried out. The tomography reveals a large volume of
FIGURE 2. Opaque enema. There is no evidence of
digestive pathology.
64
L. F. Susaníbar Napurí, C. Simón Rodríguez, L. López Martín, et al.
SECOND CASE REPORT
FIGURE 3. Observed the irregular disposition to contrast
- way on having entered for the vesical suprapubic
catheter and the tenuous bladder insolated shade.
FIGURE 4. After instillation of contrast - way for the vesical
catheter there are irregular bladder without fistulas.
residual urine and difficulty to assess the distal vesical
suprapubic catheter, which, surprisingly, is external and
in the periphery of the bladder. After our department
evaluates the current condition of the patient, the
decision is made to perform a cystography in order
to evaluate the suprapubic catheter permeability. The
cystography is carried out in the urology department
under radiological control. The first administration of
contrast dye through the suprapubic catheter shows
an irregular image underneath the pelvic floor which,
surprisingly, has no contact with the bladder, whose
shadow appears to be underneath the image described
(Figure 3-4). A contrast dye is administered through
the urethra by vesical catheter. A normal bladder is
revealed without filling defects and without relation to
the image shown previously. The images are analyzed
together with the General Surgery Department and
the conclusion was reached that the dye contrast
extravasates toward the peritoneum, without showing
continuity with the digestive tract (Figure 4). The vesical
suprapubic catheter is removed and the vesical catheter
is maintained in order to support strict diuresis control.
In the days following this procedure, the condition of
the patient becomes serious, showing signs of severity
and sudden onset of sepsis. The patient dies two days
later.
59-year-old male with a history of chronic prostatitis
with two clinical illnesses on two previous occasions,
is admitted via the Emergency Room with an insidious
condition that has been evolving over the course of
three weeks. The condition is characterized by fever,
lower urinary tract symptoms (LUTS) and perineal pain
occasionally radiating to the glutei and also the right
knee. He had been treated for the same condition
on three separate occasions by his doctor and had
not responded to three separate cycles of antibiotics
(Ciprofloxacin, Co-trimoxazole, and Amoxicillin
+ Clavulanic acid). Physical examination showed
sensitivity in the right testicle, and genital exploration
was normal, without lesions or urethral discharge.
Rectal examination reveals a painful prostate, volume
II–III / IV, of a soft consistency and without evidence of
fluctuation areas. Upon admittance, a mild leukocytosis
at 11.600 without left deviations Pyuria is observed
in a urine study. Given the presumed diagnosis of a
prostatic abscess, the decision is made to perform an
abdominal pelvic CT scan, which subsequently confirms
the initial diagnosis.
With these findings, the decision is made to perform
ultrasound guided fine needle drainage of the abscess,
which obtains 9cc. of pus. The symptomatology of the
patient decreases in the days following the drainage.
On the other hand, a culture performed of the extracted
liquid indicates the presence of Escherichia Coli bacteria
sensitive to normal antibiotics (amoxicillin/ clavulamic
acid, cefazolin, etc.). The patient is released from
the Emergency Room four days after the intravenous
antibiotic treatment and scheduled to start a one-month
course of Ofloxacin, the drug that had been selected
during the antibiogram.
Two weeks after being released from hospital, the
patient is readmitted via the Emergency Room with
an initial medical examination revealing dysuria and
unspecified pain in the thigh, groin, and scrotum, similar
to those that had been observed in the early stage
of his illness. A physical examination revealed fever
without any other abnormal findings. The analytical
parameters were normal and in the urinary sediment
2 to 3 leukocytes/field were observed. The abdominal
ultrasound performed in the Emergency Room reveals
a round image with a maximum diameter of 3cm and
with interior cystic areas consistent with a prostatic
abscess.
The patient is admitted to the urology department and
conservative treatment of levofloxacin y gentamicin is
started. On the twelveth day of his hospital stay, a TURP
(Transurethral Resection of the Prostate) procedure is
performed without complications. Three days after
the TURP, the patient is released from hospital with
no complications at 6 weeks after the initiation of the
process.
PROSTATIC ABSCESS: DIAGNOSIS AND TREATMENT OF AN INFREQUENT UROLOGICAL ENTITY
DISCUSSION
The extensive use of antibiotics in the treatment of
diverse pathological infections and the decrease of the
gonococcal urethritis associated with urethral stenosis,
which previously favored chronic genitourinary
infections, have, without doubt, had a great impact
on reducing the incidence of and mortality from
prostatic abscesses. This improvement is due to the
early diagnosis and treatment of the pathological
prostate, something which has benefitted from multiple
worldwide campaigns and an increased awareness
of prostatic illnesses. It is estimated that current
occurrences constitute 0.5% of pathological urology
and that the mortality rate is between 1% and 16%. The
most common bacteria related with prostatic abscessis
is E. coli, with an occurrence of up to 70% in such
cases (1).
The clinical identification of this uncommon condition
tends to be difficult. This difficulty is primarily due
to its insidious onset with -specific symptoms (3),
with antimicrobial treatment in course and with nonspecific symptoms of the lower urinary tract. These
conditions tend to manifest themselves in older diabetic
patients with frequent urinary manipulation, low-level
obstructive uropathy or inmunodeficient conditions (4).
It is important to mention, however, that abscesses have
been reported amongst a wide range of age groups,
including newborns.
In terms of etiopathogenesis, as in the majority of urinary
tract infections, its dissemination tends to increase from
urinary reflux from the urethra toward the prostate
acinus, favored by the different phases of ejaculation and
micturition (5, 6). This means that prostatic abscesses are
made up of small micro abscesses that coalesce in order
to form larger ones which, eventually, on their natural
course, could complicate spontaneous drainage through
the urethra or even cause peritonitis (4), conditions
which are currently rare. Hematogen dissemination has
also been described from a septic perspective and can
be respiratory, digestive, urinary or of soft parts. In these
cases the most frequent microorganisms are S. aureus,
M. tuberculosis, Escherichie coli and Candida spa.
As has been mentioned, clinical presence is completely
unspecific. Initially the illness manifests itself with
symptoms of irritation in 96% of cases, urinary retention
in 30%, perineal pain in 20%, and fever in 30% to
72% (6 ,9 ,10) of cases. The most characteristic finding
during physical examination is the presence of a soft
prostate with areas of fluctuation 16% (1) - 18% (6).
Depending on the location of the gland, the prostatic
abscess can, under normal circumstances, bring about
proximal urethral or bladder fistulas if it is located in
the base of the gland, or rectal or perineal fistulas if it is
located in the apex. In all of the aforementioned cases,
the fistula tends to become chronic (7).
65
The method of choice for the diagnosis and treatment
of prostatic abscesses is, without doubt, the transrectal
ultrasound, a test which provides clinicians with a shortand long-term analysis of the condition (7). The most
common findings are one or more liquid-containing
hypoechogenic areas of differing sizes located in the
transition and central zones of the prostate and having
a hyperechogenic halo, such as the distortion of the
gland anatomy. Differential diagnosis of these images
will be carried out with neoplasias, cystics lesions,
granulomas, and acute prostatitis. There are other
diagnostic tests, such as CT scan or NMR, which will be
useful when there are doubts with respect to diagnosis
or other types of procedures that are being planned
after patient diagnosis. Both Intravenous Uroghaphy
(IVU) and Cystoscopy only offer indirect indications
of the prostate disease based on images suggestive of
pathology in the gland. (6, 9, 10).
Without a doubt, the procedure of choice is ultrasoundguided percutaneous drainage (transperineal or
transrectal) (2, 8-10). This is a simple procedure that
can be performed with local anaesthesia or sedation
and requires no special prior experience and can be
repeated if necessary (8 -10).
If this procedure fails or in the case of larger abscesses,
one of the following measures should be considered:
implementation of a transurethral incision with a Collins
knife, a transurethral resection of prostate (TURP), or
even, in case the abscess is significant, conventional
open surgery (8, 9, 10).
CONCLUSION
Prostatic abscess is a rare entity that affects a particular
group of patients whose condition confers a high risk
of developing serious illness (sepsis) and eventually
death. Treating the disease is often difficult given that
it presents a variable condition of fever, lower urinary
tract symptoms and perineal pain. Rectal examination
serves as a guide and transrectal ultrasound is an
essential tool for diagnosis. Management can be
conservative or require surgical intervention, which is
why the primary approach continues to be ultrasound
guided percutaneous drainage.
REFERENCES AND RECOMMENDED READINGS
(*of special interest, **of outstanding interest)
*1. Weinberger M, Cytron S, Servadio C, Block C, Rosendeld JB, Pitlik SD. Prostatic abscess in the antibiotics era. Rev Infect Dis. 1988; 10: 239 - 49.
2. Collado A, Palou J, García - Penit J. Ultrasound guided needle aspiration in prostatic abscess. Urology
1999; 53: 548-552.
66
A. Palacios Hernández, P. Eguíluz Lumbreras, O. Heredero Zorzo, et al.
3. Weiberger M, PitlikSD, Rabinovitz M. Per - rectal
ultrasonography for diagnosis of abd guide to drainage of prostatic abscess. Lancet 1985; 5: 772.
4. Barozzi L, Pavlica P, Menchi, De Matteis M, Canepari M. Prostatic abscess: Diagnosis and treatment
of prostatic abscess. Urol, 1998; 32: 454-8.
*5. Simon, N.; Mc Rae, M.D; Linde M. Dairiki Shorlife,
M. D. Infecciones bacterianas del tracto genitourinario. En Urología general de Smith. Editado por Emil
A. Tanagho y Jack W. Mc Aninch. México: Editorial
El manual Moderno, S.A. 2001; 14; 239-269.
*6. Mears EM, Jr. Prostatic abscess. J Urol, 1996; 129:
1281 - 1282
**7. Barozzi L, Pavlica P. Menchi I. Prostatic abscess:
diagnosis and treatment. AJR, 1998; 170: 753-757.
8. Lopez VM, Castro VF, Pallas MP, García JA, González PC. Drenaje transperineal de un absceso prostático. Arch. Esp de Urol, 1994; 47:290-1
*9. Bachor R, Gottfried HW, Hautmann, R: Minimal invasive therapy of prostatic abscess by transrectal ultrasound-guided perineal drainage. Eur Urol, 1995;
28: 320-324
**10. M Bosquet Sanz, Gimeno Argente, JL. Palmero
Martín, Bonillo Garcí, JV. Salom Fuster, JF. Jimeénez Cruz. Absceso prostático: revisión de la literatura y presentación de un caso. Actas Urol Esp, 2005;
11. 29 (1) 100-104
Case Reports
Arch. Esp. Urol. 2011; 64 (1): 66-69
SPONTANEOUS RESOLUTION OF
URETEROVAGINAL FISTULA
Alberto Palacios Hernandez, Pablo Eguiluz Lumbreras,
Oscar Heredero Zorzo, Javier Garcia Garcia,
Florencio Cañada de Arriba, Federico Perez Herrero,
Manuel Herrero Polo and Ramon Gomez Zancajo.
Urology Department. Hospital Clínico Universitario de
Salamanca. Salamanca. Spain.
Summary.- OBJECTIVE: We report one case of a
spontaneous resolution of a uretero-vaginal fistula, and we
review the current diagnostic and therapeutic features of
this condition in the literature.
METHODS: We present the case of a 41-year-old woman
who, during the late postoperative period of a radical
hysterectomy, presented episodes of daily and nocturnal
@
CORRESPONDENCE
Alberto Palacios Hernández
Servicio de Urología
Hospital Clínico Universitario de Salamanca
Salamanca (Spain).
[email protected]
Accepted for publication: April 13th, 2010