Prostate abscess

With unfavorable course of prostate diseases, various complications often develop. And one of the most serious complications is considered to be prostate abscess. We are talking about a severe infectious and inflammatory process, which can be the result of external infection, or a consequence of long-term pathology of the genitourinary organs.

Prostate abscess can be dangerous not only for the patient's health, but also for his life. Therefore, the treatment of this painful process should be urgent, immediate. Usually, the patient is urgently hospitalized, where they provide immediate assistance and carry out further therapeutic measures.

Epidemiology

Prostate abscess is diagnosed in most patients as a complication of an acute or chronic infectious process in the lower urinary tract. It develops as a result of localized purulent accumulation in the tissues of the prostate gland.

With the use of antibiotic therapy, prostate abscess has become much less common. Currently, the prevalence of this disease fluctuates between 0.5-2.5% among all prostate pathologies, or 0.2% among all genitourinary diseases.

In developed countries with a good level of medicine, prostate abscess is especially rare. In particular, this is due to a decrease in the incidence of gonococcal urethritis. Before the "era of antibiotics", 70 to 80% of prostate abscesses were caused by gonococcal infection. The mortality rate was 6-30%. [ 1 ]

At the same time, doctors draw attention to the difficulties with timely diagnosis and competent therapy of patients with prostate abscess: these problems are relevant, despite a noticeable decrease in the prevalence of the pathology.

Previously, the main pathogen was gonococcal infection, Koch's bacillus and Staphylococcus aureus were found less frequently. Now the situation has changed: the most common pathogens are gram-negative microorganisms, Escherichia coli, staphylococci.

Most cases of prostate abscess are the result of acute or chronic prostatitis, or a consequence of prostate biopsy. According to statistics, in 5% of cases, acute prostatitis is complicated by abscess. This occurs due to the growth of acute inflammation in the prostate parenchyma.

The disease is more common in men over 40 years of age. In elderly patients, abscess may be complicated by benign prostatic hyperplasia. Patients under 40 years of age may suffer from prostate abscess due to diabetes, liver cirrhosis or AIDS. It has been statistically proven that every second patient diagnosed with prostate abscess additionally suffers from diabetes.

Causes prostate abscess

An abscess is a limited area of prostate tissue in which purulent inflammation processes occur, caused by pathogenic microorganisms. There can be several such areas, which depends on the initial cause of the pathology.

Prostate abscess itself is a kind of cavity filled with purulent secretion. Most often, the problem arises as a result of insufficient treatment of acute inflammation of the prostate gland, but in some cases it can act as a separate, independent disease. [ 2 ]

Prostate abscess can occur as a result of external or internal influences. The overwhelming majority of external influences cause the development of a primary abscess.

Purulent secretion is dead microorganisms that have been attacked by the body's immune defense. Septicopyemia can occur for various reasons - for example, as a result of purulent tonsillitis or other similar diseases. Predisposing factors in this situation are hypothermia, weakened immunity, etc. This path of abscess development is possible, but it is not so common. [ 3 ]

A secondary process associated with prostatitis is considered much more common. According to statistics, about 5% of men with prostatitis face such a complication as a prostate abscess. In this case, the basis for the development of this complication is the lack of treatment or improper therapy (self-treatment) of acute inflammation. As a result, the inflammatory reaction worsens, fluid accumulates in the tissues, and blood circulation is disrupted. Metabolic products accumulate in the prostate gland, abscesses begin to form - initially small, which then merge into large elements - abscesses. [ 4 ]

Experts most often name the following causes of pathology:

• a sharp weakening of the immune defense;
• acute and chronic diseases of the genitourinary tract;
• hypothermia of the perineum and pelvic area;
• urolithiasis;
• sexually transmitted infections;
• unstable sexual activity;
• self-medication or lack of treatment for acute prostatitis;
• carelessness or violations during the performance of transurethral procedures.

Risk factors

Most representatives of the strong half of humanity, who have crossed the 40-year mark, are to some extent predisposed to the development of disorders of the prostate gland. The following risk groups can be conditionally identified:

• Men who have irregular or excessively active sex lives, who frequently change partners, or who do not have sex at all, have an increased risk of prostate diseases. Unfavorable factors include:

1. erection without ejaculation;
2. lack of sex;
3. constant interaction with foreign microflora (lack of a permanent partner).

Optimal sex is 3 times a week with one partner, without the practice of interrupted intercourse.

• Men who lead a sedentary, inactive lifestyle, which contributes to poor circulation in the pelvic area.
• Motorcyclists, cyclists, and horseback riders are more susceptible to groin injuries and circulatory problems in the genitals.
• Fans of heavy feasts, consumption of fatty, salty, spicy food, abuse of alcoholic beverages, and smokers also have a tendency to develop dysfunction of the prostate gland.

All men who are in one or another risk group should visit a urologist regularly (preferably every year), and also follow all necessary preventive measures. [ 5 ]

The following factors predispose to the development of prostate abscess:

• immunosuppressive diseases, or immunodeficiency syndromes (eg, HIV); [ 6 ]
• some instrumental procedures (eg, prostate biopsy);
• permanent urethral catheterization;
• endocrine diseases (for example, diabetes mellitus);
• chronic kidney disease requiring long-term hemodialysis.

Pathogenesis

The prostate gland plays a vital role in the male body, and it is not for nothing that it is called the "second heart" for a man. The prostate is responsible for erectile function, sperm quality and production, etc. The main purpose of the organ is secretory.

The prostate has a strong natural resistance to internal and external infectious influences. Therefore, inflammation here appears only in the case of strong suppression or weakening of local immune protection against the background of high pathogenicity of microorganisms.

To understand the process of organ infection, you first need to know about its anatomical features. The prostate gland includes two lobes, each of which, in turn, consists of two dozen smaller lobes that open into one solid duct. [ 7 ]

The development of a prostate abscess occurs after infection enters the body through one of three routes:

• through the excretory duct openings located in the posterior segment of the urethra;
• through the lymphatic system (for example, during prolonged catheterization);
• through the circulatory system (during the circulation of bacteria in the blood).

The inflammatory reaction in the prostate is associated with a massive release of leukocytes and bacteria. Later, when the immune defense is triggered or against the background of adequate therapy, the inflammation focus is isolated.

Most experts believe that a prostate abscess is, first of all, an unfavorable outcome of a microbial inflammatory process in the organ. However, prostatitis most often bothers men from about 50 years of age, while an abscess can form in patients of all ages.

Today, the main provoking microorganisms in prostate abscess are considered to be enterobacteria. Less often, inflammation occurs under the influence of Klebsiella, Proteus, and Pseudomonas. A certain number of cases of the disease are associated with methicillin-resistant Staphylococcus aureus. [ 8 ], [ 9 ]

The inflammatory reaction causes stagnation and accumulation of fluid in the tissues, an increase in the concentration of metabolic products, which generally has a negative effect on the functioning of the organ. Purulent foci gradually form - small at first, which then merge with each other, forming a large abscess.

The prostate's excretory ducts are clogged with tissue decay products. At this point, diagnostics may show positive results, but in fact, the abscess can already be considered formed.

In some men, a purulent focus is formed in response to certain medical procedures affecting the gland or bladder. The causative factor may also be the blockage of the excretory ducts by formed organic and inorganic formations - most often calcification stones.

Symptoms prostate abscess

Over the past few decades, antibiotic therapy has taken a leading place in the treatment of many diseases. Antibiotics are prescribed frequently and not always justifiably, which has led to a change in the course of some pathologies. This is why certain diseases - in particular, prostate abscess - can "mask" as other disorders, for example, imitate inflammation of the lower genitourinary tract.

Often, the disease forces a person to see a doctor only when the first signs of severe septic complications appear:

• high temperature accompanied by chills, hectic fever;
• general intoxication (gray skin, coating on the tongue, feeling of weakness and fatigue, sleep disturbance, headache, etc.);
• increased sweating, tachycardia;
• dizziness, impaired consciousness.

Many patients have symptoms of a urological nature:

• frequent urge to urinate;
• urination disorders (decreased flow, pain, etc.);
• less common – acute urinary retention, presence of blood elements in the urine.

Patients complain of lumbar and inguinal pain. It is typical that the pain syndrome is characterized by a one-sided (left or right) location, depending on the side of the prostate gland lesion.

The pain can be described as follows: severe, sharp, pulsating, radiating to the lower back and/or rectal area. Sometimes problems with urination and defecation are added, and bloating (inability to pass gas) is possible.

The above symptoms are observed when the prostate abscess is at the infiltration stage. This is followed by the purulent-destructive stage, during which a period of "apparent improvement" is observed:

• pain sensations are relieved;
• temperature readings are decreasing.

But soon the picture deteriorates significantly, which is associated with the breakthrough of the purulent element into the periurethral or paravesical cellular structures. The next stage is characterized by the appearance of dangerous complications.

After a sudden rupture of the abscess into the periurethral tissue, the following clinical signs are possible:

• pyuria (pus in the urine);
• cloudy sediment and flakes in urine;
• worsening of urine odor.

In some patients, the abscess breaks through not into the urethra, but into the rectal cavity, which leads to the formation of a fistula of the rectum. This complication is characterized by the detection of purulent and mucous mass in the feces.

It is important to understand that the breakthrough of a purulent element is not accompanied by its complete cleansing from pus. This indicates that after some time, a repeated growth of the prostate abscess is possible.

In HIV-infected patients with immunodeficiency, the clinical picture may differ somewhat, with the prevalence of intoxication signs:

• severe weakness, fatigue, apathy;
• myalgia, arthralgia;
• prolonged subfebrile hyperthermia.

The development of septicopyemia is possible, with the formation of metastatic abscesses in other tissues and organs (more typical for people suffering from heroin addiction).

If a prostate abscess opens into the pelvic or abdominal cavity, then in the absence of medical care, peritonitis and septic complications rapidly develop, after which the patient dies.

Stages

A prostate abscess is an infectious and inflammatory reaction that occurs in several stages, accompanied by purulent tissue melting and the formation of cavity formations with purulent contents.

There are two main stages of the disease:

• infiltration, with pronounced clinical signs;
• purulent-destructive, or stage of false improvement.

The clinical picture during the first infiltration stage is quite vivid and is manifested by a strong deterioration in the patient’s condition.

During the next stage of purulent destruction, the patient notes a clear improvement. However, it is at this stage that the abscess usually breaks through and the pathology subsequently worsens, up to the appearance of complications.

The duration of each stage is 3-9 (on average – five) days, which depends on such factors as the pathogenicity of the microflora, the stability of the patient’s immunity, the adequacy of antibiotic therapy, etc.

Forms

There are several types of prostate abscess:

• primary, occurring as an independent disease;
• secondary, which is a complication of other pathologies (most often prostatitis).

Since inflammation of the prostate gland is the most common underlying cause of abscess development, it is often necessary to know the classification of this disease based on symptoms and analytical characteristics.

• Acute bacterial prostatitis is a clinically expressed inflammatory process.
• Chronic bacterial prostatitis is a long-term and periodically recurring inflammatory process.
• Chronic pelvic pain syndrome is characterized by long-term discomfort without obvious inflammatory reaction.
• Chronic pelvic inflammatory pain syndrome is a painful condition in which inflammatory factors can be detected in urine, sperm, and prostate secretions.
• A hidden inflammatory process in the prostate gland is discovered by chance, only during a biopsy of the organ.

Complications and consequences

In case of prostate abscess, you should act quickly, otherwise very unfavorable complications may develop soon. Any delay in medical care will contribute to the aggravation of the process: the inflammation will spread to other healthy tissues and further, to the pelvic organs and abdominal cavity.

The most common consequences of a prostate abscess are:

• inflammation of the peritoneum (peritonitis);
• blood poisoning (systemic inflammation, sepsis);
• acute diffuse purulent inflammation (phlegmon);
• pararectal abscess (paraproctitis);
• rectal fistula;
• pelvic venous thrombosis;
• death of the patient.

The development of complications can only be prevented by early seeking of medical help, timely diagnosis and subsequent competent treatment of the disease. [ 10 ]

Complications develop under the following circumstances:

• pus from the abscess breaks through into the pelvic cavity (peritonitis develops);
• the infection penetrates directly into the bloodstream (blood poisoning or septic complications develop);
• the abscess opens into the lumen of the urethra or into the rectal cavity, which leads to the formation of a fistula - a pathological channel that is extremely difficult to treat;
• The purulent inflammatory process completely melts the tissues of the prostate gland, which requires complete resection of the prostate.

In severe cases, with generalized spread of infection, the person dies.

Diagnostics prostate abscess

There are often difficulties with early diagnosis of prostate abscess, since the symptoms of the pathology are difficult to distinguish from the clinical picture of acute prostatitis. Early diagnosis is possible using ultrasound, magnetic resonance imaging and multispiral computed tomography. [ 11 ]

Laboratory tests are usually limited to general clinical studies. A comprehensive blood test is performed, the results of which indicate the presence of an acute form of inflammation:

• increased white blood cell count;
• ESR increased.

A general urine test helps determine:

• leukocyturia;
• protein in urine;
• pus in urine;
• erythrocyturia (hematuria).

Urine culture or urethral smear allows to assess the identity of pathogenic microorganisms.

Instrumental diagnostics is the basis for making a correct diagnosis:

• Transrectal ultrasound is considered an accurate method for determining a prostate abscess. Often, this procedure alone is enough to correctly identify the disease. The nature of the ultrasound image may vary, depending on the stage of the inflammatory reaction. For example, the initial stage of abscess development looks like a hypoechoic formation in the edema zone, with the formation of anechoic areas of necrosis, in accordance with the pathology. Subsequent stages are characterized by the appearance of a capsulated formation with a pyogenic wall. At the same time, a decrease in edema and normalization of the gland size are noted. In some patients, cysts and granulomas are visualized on ultrasound.
• Digital diagnostics of the prostate is performed very carefully so as not to provoke the development of infectious toxic shock. During the procedure, sharp pain, hypersensitivity and an increase in the volume of the prostate gland are noted. Digital rectal examination in 80% of cases helps to detect tissue softening and fluid fluctuation (fluctuation) of the formation.
• CT and MRI are particularly informative diagnostic procedures that help examine tissues close to the lesion and detect distant abscess foci. Magnetic resonance imaging visualizes destructive zones - these are spherical fluid foci whose borders are smoothed and uneven. Pus inside the capsule is detected by an intermediate type of magnetic resonance impulse, as for a high-protein substance.
• Prostate abscess puncture is performed to identify the pathogen that caused the inflammatory process, as well as to remove purulent contents from the lesion. Identification of the pathogen will help the doctor prescribe appropriate antibacterial drugs. However, this procedure is performed relatively rarely, due to its traumatic nature and the risk of infecting healthy tissue.
• If complications such as fistula formation are suspected, urethroscopy, ultrasound examination of the bladder, and anoscopy are additionally prescribed.

Differential diagnosis

Pathology	Distinctive symptoms	Methods of differential diagnostics
Prostate adenoma (hyperplasia)	Gradual decrease in urinary flow, urinary retention, nocturia, sometimes acute urinary retention.	Histology of the prostate gland.
Prostate cancer	Symptoms similar to adenoma, and in advanced cases – bone pain and other signs of metastatic lesions.	Study of prostate-specific antigen levels, histology of the prostate gland.
Urethral infection	No signs of urinary outflow obstruction.	Bacteriological analysis of urine to exclude acute prostatitis.
Colorectal cancer	Changes in intestinal function, sometimes rectal bleeding, weight loss.	Rectal and colonic endoscopy, visualization methods (barium enema).
Epididymitis	Scrotal pain, signs of urinary dysfunction.	Color duplex sonography reveals dilatation and redness of the epididymus.

Treatment prostate abscess

The scale of treatment for prostate abscess depends on the stage of the pathology. At the infiltration stage, antibiotic therapy and immunostimulating drugs are prescribed. To eliminate acute pain syndrome, paraprostatic and presacral blockades are performed, and intravenous infusion of solutions is performed to relieve intoxication.

If, however, during the diagnostics, an already formed prostate abscess is detected, then it is necessary to open the abscess with subsequent installation of drainage. To avoid damage to the urethra, a bougienage is performed: a metal bougie is first inserted into the urethra.

In most cases, the dissection is performed in the perineal area, which allows for extensive operations to be performed without the risk of relapse or fistula formation. Antibacterial and detoxifying treatment is prescribed at the postoperative stage. [ 12 ]

The stage of purulent destruction is irreversible. For its treatment, surgical intervention is mandatory - in particular, fine-needle puncture and drainage of the abscess under TRUS guidance.

Medicines

At the moment, doctors do not have a single algorithm for treating prostate abscess. It is considered mandatory to prescribe antibiotics at any stage, and in case of purulent destruction, drainage of the purulent focus is performed in hospital conditions.

At the infiltration stage, the following actions are appropriate:

• administration of antibiotics with a broad spectrum of antibacterial activity (cephalosporin or fluoroquinolone drugs, aminoglycosides);
• intravenous infusion of detoxifying solutions, as well as immunostimulation.

To relieve pain, point injections of local anesthetics (for example, lidocaine) and various types of blockades are used.

Detoxification therapy includes:

• drink plenty of fluids (preferably alkaline);
• intravenous drip infusion of 200 ml 4% sodium bicarbonate, 400 ml 5% glucose solution with 4 U of insulin, 100 mg cocarboxylase, 5 ml 5% ascorbic acid, 200 ml saline, 10 ml calcium gluconate, 20 mg lasix.

Treatment is carried out under the control of the body's sensitivity: if allergic reactions or other side effects occur, the prescriptions are revised.

The main analgesics used are:

• Analgin in the form of powder, 500 mg tablets, 1 or 2 ml ampoules of 50% solution (single dose - 1 g, daily - 3 g orally; single injection dose - 0.5 g, daily - 1.5 g);
• Baralgin in the form of tablets, suppositories, ampoules of 5 ml (taken orally 1-2 tablets up to three times a day; intramuscular or intravenous injections of 5 ml every 7-8 hours);
• Paracetamol in powder form, tablets of 0.2 g (single dose 500 mg, daily dose – 1.5 g).

Possible side effects during treatment with analgesics: allergic reactions, irritability, sleep disturbances, tachycardia.

Recommended antibiotic therapy regimens:

• Cefotetan 2 g IV every 12 hours, or Cefoxitin 2 g IV every 6 hours + Doxycycline 100 mg orally or IV every 12 hours.
• Clindamycin 900 mg IV every 8 hours + Gentamicin 1.5-2 mg/kg IV or IM every 8 hours.
• Ampicillin or Sulbactam 3 g IV every 6 hours + Doxycycline 100 mg orally or IV every 12 hours.

If allergic reactions, dyspepsia, severe headaches and other pronounced side effects occur, the prescription may be revised by the attending physician.

Surgical treatment

There are several known methods of surgical treatment of prostate abscess, and each of them has its own advantages and disadvantages:

• transrectal method of access to the lesion (the rectus abdominis muscle is cut);
• transurethral access technique (through the urethra);
• transperineal access technique (through the perineal area).

Opening of the prostate abscess is performed with minimal possible tissue trauma, using local anesthesia.

The procedure is performed using transrectal ultrasound, which allows for full control of the process. In the case of deep lesions, percutaneous drainage with control computed tomography is used. [ 13 ]

The standard open surgical method involves transperineal dissection with capsule drainage and subsequent antibiotic therapy. Most surgeons prefer to perform the perineal access technique due to the possibility of extensive manipulations, minimal risk of secondary infection and development of postoperative complications.

At the postoperative stage, antibiotic therapy is prescribed against the background of detoxifying infusion treatment.

Prevention

Prostate abscess is a relatively rare disease. However, in general, prostate pathologies are considered very common, which indicates the need for their prevention, early detection and high-quality timely therapy.

Regular preventive visits to a urologist help to identify most problems of the male genitourinary sphere and start treatment in a timely manner. Such periodic examinations are very important and should not be ignored.

Experts advise all men over 40, even if they feel well and have no painful symptoms, to have their health checked by a urologist at least once every 2 years. A standard preventive visit usually includes:

• conversation with the doctor;
• digital examination of the prostate;
• Ultrasound of the prostate gland;
• blood test for PSA (prostate specific antigen).

All of the above diagnostics can usually be completed in one visit to the doctor.

Every male patient should understand:

• any man always has a risk of developing prostate gland pathologies;
• A routine preventive visit to the doctor can help identify many problems at an early stage;
• If you notice painful symptoms, you should not look for self-treatment options; you should immediately go to the doctor.

General rules for the prevention of prostate diseases are as follows:

• you need to eat properly and with high quality, excluding fatty, heavy foods, alcohol and processed foods;
• It is important to carefully observe the rules of intimate hygiene, take a shower regularly and change underwear;
• During sexual intercourse, one should not forget about barrier contraception;
• It is necessary to lead an active lifestyle, since physical inactivity contributes to the development of many diseases of the genitourinary system;
• You should take good care of your health and avoid injury to your genitals;
• do not overcool;
• It is necessary to regulate your intimate life, since both too rare and too frequent sexual contacts can cause blood flow disorders in the prostate gland;
• It is important to treat any inflammatory or urological pathologies in a timely manner and regularly consult a specialist for preventive examinations.

We must not forget that a healthy genitourinary system is the key to high-quality functionality, positive overall tone and a full life for a man.

Forecast

Modern medical methods of treating urological and proctological diseases allow doctors to cure various types of prostate abscess, even against the background of the development of adverse complications. We can talk about a positive outcome of the pathology if the abscess is not widespread, there are no violations of the functions of other organs and systems. As a rule, the patient's body is restored in a relatively short term, provided that all the instructions of the attending physician are followed.

Of course, without prompt and timely medical care, the prognosis will not be favorable: and here it is worth talking about a threat to the patient's life. If the treatment was complete and competent, then we talk about a positive outcome. Nevertheless, it is necessary to take into account that a past prostate abscess almost always affects the further functional capacity of the prostate gland. The likelihood of complications in the form of repeated abscess development, erectile dysfunction and reproductive capacity of a man cannot be ruled out. It is reasonable to carry out possible preventive measures, follow all doctor's orders, and generally monitor your health.