Student, Resident AND Fellow Research

Acute complicated by prostatic BY CHRISTOPHER WIGER AND SAMUEL IVES, MD

prostatic abscess is a localized col- Prostatic are commonly lection of fluid in the and caused by Gram-negative ; Esch- A is a rare complication of prostatitis. erichia coli causes more than 70 percent of Although the incidence of prostatic ab- cases, followed by Klebsiella, Pseudomo- scess is low with the use of appropriate an- nas, Proteus, Enterobacter, and Enterococ- tibiotic therapy, significant morbidity can cus species.1,3 Organisms enter the pros- result if undetected and untreated.1 tate via reflux of urine into the prostatic FIGURE 1. ducts.1 Since prostatic abscesses usually Case report result from ascending urinary tract infec- Prostatic abscess on CT A 50-year-old man with type 2 diabetes tions, patients frequently present with uri- Prostate is markedly enlarged, with a large abscess in the posteroinferior aspect of the prostate (arrow). mellitus (DM) and hypertension presented nary symptoms. Exam often reveals to the clinic with a five-day history of pel- and a tender, fluctuant prostate.⁴,⁵ Many especially in patients with risk factors, vic pain with urination. He also showed of these symptoms overlap with symptoms should lead to evaluation of an abscess fol- , urgency, frequency, and of acute prostatitis. It is important to have lowed by expeditious treatment. MM constipation. Examination was notable for a low threshold for suspecting an abscess Christopher Wiger is a fourth-year medical student fever, suprapubic tenderness, and an en- and imaging a man with prostatitis and at the University of Minnesota Medical School. larged, tender prostate. Urinalysis revealed DM, since these patients are at higher risk Samuel Ives, MD, is an internal medicine specialist at Hennepin Healthcare. proteinuria, hematuria, and ketonuria. for an abscess.⁶ The initial diagnostic test Urine culture grew Klebsiella pneumoniae for prostate abscess is usually TRUS.⁵,⁷ In and the patient was prescribed nitrofuran- more severe cases, CT can show spread REFERENCES toin. Due to persistent symptoms after one of to adjacent organs. MRI can 1 Abdelmoteleb H, Rashed F, Hawary A. Management week, a CT was obtained, which revealed be used when TRUS is inconclusive and of prostate abscess in the absence of guidelines. Int Braz J Urol. 2017;43(5):835‐840. doi:10.1590/S1677-5538. an enlarged prostate and prostatic abscess when higher image resolution is desired.⁸ IBJU.2016.0472. (Figure 1). The patient was admitted Most patients require surgery with 2 Ingalsbe ML, Wojciechowski AL, Smith KA, Mergenhagen KA. Effectiveness and safety of nitro- for further management of the prostatic adjunctive treatment.⁷ Medical furantoin in outpatient male veterans. Ther Adv Urol. abscess, which consisted of changing the management can be used for patients with 2015;7(4):186‐193. doi:10.1177/1756287215581556. to , transrectal abscesses less than 1 cm who are not clini- 3 Lee DS, Choe HS, Kim HY, et al. Acute bacterial pros- tatitis and abscess formation. BMC Urol. 2016;16(1):38. ultrasound (TRUS)-guided drainage, and cally ill, but surgery is required for larger Published 2016 Jul 7. doi:10.1186/s12894-016-0153-7. transurethral unroofing of the abscess. abscesses.⁸ Preferred antibiotics target 4 Jang K, Lee DH, Lee SH, Chung BH. Treatment of prostatic abscess: case collection and comparison of Gram-negative organisms and achieve ad- treatment methods. Korean J Urol. 2012;53(12):860‐864. Discussion equate levels in the prostate. Quinolones, doi:10.4111/kju.2012.53.12.860. Predisposing factors for prostatic abscesses such as ciprofloxacin, have historically 5 Elshal AM, Abdelhalim A, Barakat TS, Shaaban AA, Nabeeh A, Ibrahiem E-H. Prostatic abscess: Objective include urinary tract obstruction, DM, im- been used, but their use is decreasing assessment of the treatment approach in the absence of guidelines. Arab Journal of . 2014;12(4):262-268. munosuppression, and incomplete therapy due to safety concerns and increasing doi:10.1016/j.aju.2014.09.002. for acute prostatitis.1 In addition to having resistance. Other antibiotic options in- 6 Khudhur H, Brunckhorst O, Muir G, Jalil R, Khan A, DM, this patient was inadequately treated clude third-generation cephalosporins, Ahmed K. Prostatic abscess: A systematic review of current diagnostic methods, treatment modalities for prostatitis with nitrofurantoin leading aztreonam, or a combination of an ami- and outcomes [published online ahead of print, 2020 to abscess formation. Nitrofurantoin is not noglycoside with ampicillin.⁷ If patients May 27]. Turk J Urol. 2020;46(4):262-273. doi:10.5152/ tud.2020.19273. recommended for urinary tract do not improve, there is a low threshold to 7 Ackerman AL, Parameshwar PS, Anger JT. Diagnosis and (UTI) in men or for prostatitis because it proceed to surgical intervention. TRUS- treatment of patients with prostatic abscess in the post- antibiotic era. Int J Urol. 2018;25(2):103‐110. doi:10.1111/ does not achieve therapeutic concentra- guided drainage is the first choice because iju.13451. tions in the prostate.2 In this patient, the of its low risk of complications and ability 8 Chou YH, Tiu CM, Liu JY, et al. Prostatic abscess: tran- diagnosis was delayed because the patient to use local anesthesia.⁹ Transurethral un- srectal color Doppler ultrasonic diagnosis and minimally invasive therapeutic management. Ultrasound Med was misidentified as having a UTI, which roofing is appropriate for large, multilocu- Biol. 2004;30(6):719‐724. doi:10.1016/j.ultrasmed- led to the use of nitrofurantoin instead of lated, or recurrent prostatic abscesses.⁷ bio.2004.03.014. 9 Basiri A, Javaherforooshzadeh A. Percutaneous a different antibiotic that would have been In conclusion, the persistence of uri- drainage for treatment of prostate abscess. Urol J. appropriate for prostatitis. nary symptoms in patients with prostatitis, 2010;7(4):278‐280.

42 | MINNESOTA MEDICINE | NOVEMBER/DECEMBER 2020