Prostate abscess

With an unfavorable course of prostate diseases, various complications often develop. And one of the most serious complications is considered an abscess of the prostate. This is a serious infectious and inflammatory process, which may be the result of an external infection, or a consequence of a long pathology of the genitourinary organs.

An abscess of the prostate can be dangerous not only for the health of the patient, but also for his life. Therefore, the treatment of this painful process should be urgent, immediate. Usually the patient is urgently hospitalized in a hospital, where they provide urgent care and conduct further therapeutic measures.

Epidemiology

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

With the use of antibiotic therapy, prostate abscesses began to appear much less frequently. Currently, the degree of spread of this disease ranges from 0.5-2.5% among all pathologies of the prostate gland, or 0.2% among all diseases of the genitourinary sphere.

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 start of the “antibiotic era”, 70 to 80% of prostate abscesses were triggered by a gonococcal infection. The mortality rate was 6-30%. [1]

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

Previously, the main causative agent of the disease was a gonococcal infection, less often found Koch's wand and Staphylococcus aureus. 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 an acute or chronic form of prostatitis, or a consequence of a prostate biopsy. According to statistics, in 5% of cases, acute prostatitis complicates an abscess. This is due to an increase in the acute inflammatory process in the parenchyma of the prostate.

The disease is more common in men older than 40 years. In elderly patients, benign prostatic hyperplasia can be complicated by an abscess. Patients under the age of 40 may have a prostate abscess with diabetes mellitus, liver cirrhosis or AIDS. It is statistically proven that every second patient with a diagnosed prostate abscess additionally suffers from diabetes.

Causes of the prostate abscess

An abscess is a limited area of prostate tissue in which purulent inflammation occurs due to pathogens. There are several such zones, which depends on the initial cause of the pathology.

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

An abscess of the prostate can occur as a result of external or internal exposure. The vast majority of external influences causes the development of a primary abscess.

Purulent secretion represents dead microorganisms that were attacked by the body's immune defenses. Septicopyemia can happen for various reasons - for example, due to purulent tonsillitis, or other similar diseases. Predisposing factors in this situation are hypothermia, weakened immunity, etc. This path of development of an abscess is possible, but it is not so common. [3]

A much more common is the secondary process associated with prostatitis. If statistics believes, about 5% of men with prostatitis experience a complication such as prostate abscess. In this case, the absence of treatment, or improper therapy (self-medication) of acute inflammation, becomes the basis for the development of this complication. As a result, the inflammatory reaction is aggravated, fluid accumulates in the tissues, and blood circulation is disturbed. In the area of the prostate gland, metabolic products accumulate, abscesses begin to form - at first small ones, which then combine into large elements - abscesses. [4]

Specialists most often call such causes of pathology:

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

Risk factors

Most representatives of the strong half of humanity who have crossed the 40-year frontier are to some extent predisposed to the development of disorders of the prostate gland. You can conditionally distinguish these risk groups:

• Men who have an irregular or excessively violent sex life, often changing partners, or not having sex at all, have an increased risk of prostate diseases. Adverse factors are:

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

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

• Men who lead an inactive, sedentary lifestyle, which contributes to circulatory disorders in the pelvic area.
• Motorcyclists, cyclists, and horse riding enthusiasts are more prone to injuries to the groin and circulatory disorders in the genitals.
• Fans of plentiful feasts, eating fatty, salty, spicy foods, abusing alcohol, smoking people also have a tendency to develop disorders of the prostate gland.

All men who are in a particular risk group should regularly visit a urologist (preferably every year), as well as observe all necessary preventive measures. [5]

The following factors predispose to the development of prostate abscess:

• immunosuppressive diseases or immunodeficiency syndromes (e.g. HIV); [6]
• some instrumental procedures (for example, prostate biopsy);
• continuous catheterization of the urethra;
• endocrine diseases (for example, diabetes mellitus);
• chronic kidney disease requiring prolonged hemodialysis.

Pathogenesis

The prostate gland plays a crucial role in the male body, because it is not without reason that it is called the “second heart” for the man. The prostate is responsible for erectile function, sperm quality and its production, etc. The main purpose of the body is secretory.

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

To delve into the process of infection of an organ, you first need to learn about its anatomical features. The prostate gland includes two lobes, and each, in turn, consists of two dozen smaller lobes, opening into a single duct. [7]

The development of a prostate abscess occurs after infection penetrates in one of three ways:

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

An inflammatory reaction in the prostate is associated with a massive release of white blood cells and bacteria. In the future, when the immune defense is triggered or against the background of adequate therapy, the focus of inflammation is delimited.

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

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

The inflammatory reaction causes stagnant processes and accumulation of fluid in the tissues, an increase in the concentration of metabolic products, which generally negatively affects the work of the body. Purulent foci are gradually formed - initially small, which then join together to form a large abscess.

The excretory ducts of the prostate are clogged by tissue decay products. At this point, the diagnosis can show positive results, however, in fact, an abscess can already be considered formed.

In some men, a purulent focus is formed in response to certain medical procedures that affect the gland or bladder. A causative factor may also be clogging of the excretory canals with formed organic and inorganic formations - usually calcite stones .

Symptoms of the prostate abscess

Over the past few decades, antibiotic therapy has occupied one of the leading places in the treatment of many diseases. Antibiotics are prescribed often and not always justified, which led to a change in the course of some pathologies. That is why certain diseases - in particular, an abscess of the prostate - can "mask" under other disorders, for example, mimic inflammation of the lower genitourinary tract.

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

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

Many patients have symptoms of a urological nature:

• frequent urination;
• urination disorders (decrease in stream, pain, etc.);
• less often - an acute form of urinary retention , the presence of blood elements in the urinary fluid.

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

Pain can be described as follows: severe, sharp, throbbing, radiating to the lower back and / or rectal area. Sometimes problems with urination and defecation join, bloating is possible (impossibility of gas removal).

The specified symptomatology is observed when the prostate abscess is at the infiltration stage. Then follows a purulent-destructive stage, during which there is a period of "imaginary improvement":

• pain is relieved;
• temperature indicators are reduced.

But soon the picture is significantly deteriorating, which is associated with a breakthrough of the purulent element in the perurethral or paravesical cell structures. The next stage is characterized by the appearance of dangerous complications.

After a sudden breakthrough of the abscess in the perurethral tissue, the following clinical signs are possible:

• pyuria (pus in the urinary fluid);
• cloudy sediment and flakes in urine;
• deterioration in the smell of urinary fluid.

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

It is important to understand that a breakthrough of a purulent element is not accompanied by its complete purification from pus. This suggests that after some time a re-growth of the prostate abscess is possible.

In HIV-infected patients, against the background of immunodeficiency, the clinical picture may slightly differ, in the direction of the prevalence of intoxication signs:

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

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

If the prostate abscess opens into the pelvic or abdominal cavity, then in the absence of medical care there is a rapid development of peritonitis, septic complications, after which the patient dies.

Stages

An abscess of the prostate is an infectious-inflammatory reaction that proceeds in several stages, accompanied by purulent tissue fusion and the formation of cavity formations with purulent contents.

There are two main stages of the disease:

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

The clinical picture during the first infiltration stage is quite bright, 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 and the subsequent aggravation of the pathology, up to the onset of complications.

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

Forms

An abscess of the prostate can be of several types:

• primary, proceeding 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 root cause of the development of an abscess, it is often necessary to know the classification of this disease based on symptoms and analytical characteristics.

• The acute form of bacterial prostatitis is a clinically pronounced inflammatory process.
• The chronic form of bacterial prostatitis is a long-term and periodically recurring inflammatory process.
• Chronic pelvic pain syndrome - characterized by long-existing discomfort, without a clear inflammatory reaction.
• Inflammatory syndrome of chronic pelvic pain is a painful condition in which it is possible to detect factors of inflammation in the urinary fluid, semen and prostate secretion.
• A latent inflammatory process in the prostate gland is detected by chance, only during an organ biopsy.

Complications and consequences

With an abscess of the prostate, you should act quickly, otherwise extremely unfavorable complications may soon develop. Any delay with medical help will contribute to the aggravation of the process: 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.

To prevent the development of complications is possible only with the help of early access to medical care, timely diagnosis and further competent treatment of the disease. [10]

Complications develop in the following circumstances:

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

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

Diagnostics of the prostate abscess

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

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

• increased white blood cell count;
• increased ESR.

A general urinary fluid test helps determine:

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

Backseeding of urine or a urethral smear allows you to assess the affiliation of pathogenic microorganisms.

Instrumental diagnostics is the basis for making the correct diagnosis:

• Transrectal ultrasound is considered an accurate way to determine prostate abscess. Often, this procedure alone is enough to correctly identify the disease. The nature of the image on ultrasound can be different, depending on what stage the inflammatory reaction is at. For example, the initial stage of development of an abscess looks like a hypoechoic formation in the edema zone, with the formation of anechogenic areas of necrosis, in accordance with the pathology. The subsequent stages are characterized by the appearance of an encapsulated formation with a pyogenic wall. At the same time, there is a decrease in edema and normalization of the size of the gland. In individual patients, cysts and granulomas are visualized by ultrasound.
• Finger diagnostics of the prostate is carried out very carefully so as not to provoke the development of an infectious toxic shock. During the procedure, there is a sharp pain, hypersensitivity and an increase in the volume of the prostate gland. Digital rectal examination in 80% of cases helps to detect softening of tissues and fluid fluctuation (fluctuation) of the formation.
• CT and MRI are especially informative diagnostic procedures that help to examine tissue nearby from the lesion and to find distant lesions of the abscess. Magnetic resonance imaging visualizes destructive zones - these are spherical fluid foci, the boundaries of which are smoothed and uneven. Pus inside the capsule is detected by an intermediate type of magnetic resonance impulse, as for a high-protein substance.
• Puncture of an abscess of the prostate is performed to identify the pathogen that caused the inflammatory process, as well as to remove purulent contents from the focus. Identification of the pathogen will help the doctor prescribe appropriate antibacterial drugs. However, this procedure is relatively rare, due to its invasiveness and the risk of infection of healthy tissue.
• If complications in the form of fistula formation are suspected, urethroscopy, an ultrasound examination of the bladder, and anoscopy are additionally prescribed.

Differential diagnosis

Pathology	Distinctive symptoms	Differential diagnostic methods
Prostate adenoma (hyperplasia)	Gradual decrease in the urinary stream, 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 lesion.	Study of the level of prostate-specific antigen, histology of the prostate gland.
Urethral infection	No signs of obstruction of the outflow of urine.	Bacteriological analysis of urine with the exception of acute prostatitis.
Colorectal cancer	Change in intestinal function, sometimes rectal bleeding, weight loss.	Rectal and colonic endoscopy, imaging methods (barium enema).
Epididymitis	Scrotal pain, signs of impaired urination.	With the help of duplex color sonography, the expansion and redness of the epididymus is detected.

Treatment of the prostate abscess

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

If, during the diagnosis, an already formed prostate abscess was revealed, then it is necessary to open the abscess with the subsequent installation of drainage. In order to avoid damage to the urethra, bougienage is done: first, metal bougie is introduced into the urethra.

In most cases, an autopsy is performed in the perineum, which allows you to perform extensive operations without the risk of relapse or the formation of fistulas. In the postoperative stage, antibacterial and detoxification treatment is prescribed. [12]

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

Medication

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 with purulent destruction, drainage of the purulent focus is performed in stationary conditions.

At the stage of infiltration, the following actions are appropriate:

• the introduction of antibiotics with a wide spectrum of antibacterial activity (cephalosporin or fluoroquinolone preparations, aminoglycosides);
• intravenous infusion of detoxification solutions, as well as immunostimulation.

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

Detoxification therapy includes:

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

Treatment is carried out under the control of the sensitivity of the body: when allergic reactions or other side effects occur, the appointment is reviewed.

The main analgesics used are:

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

Possible side effects in the treatment of analgesics: allergic reactions, irritability, sleep disturbances, tachycardia.

Recommended antibiotic 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.

With the appearance of allergic reactions, dyspepsia, severe headaches and other severe side effects, the appointment may be reviewed by your doctor.

Surgery

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

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

An autopsy of the prostate abscess is performed with the minimum possible tissue trauma, using local anesthesia.

The procedure is performed using transrectal ultrasound, which allows full control of the process. With a deep location of the foci, they resort to percutaneous drainage with control computed tomography. [13]

The standard open method of surgery involves performing a transperineal opening with drainage of the capsule and further antibiotic therapy. Most surgeons prefer performing perineal access technique, due to the possibility of extensive manipulations, minimal risk of secondary infection and the development of postoperative complications.

In the postoperative phase, antibiotic therapy is prescribed against a background of detoxification infusion treatment.

Prevention

An abscess of the prostate is a relatively infrequent disease. However, in general, pathologies of the prostate gland are considered very common, which indicates the need for their prevention, early detection and timely quality therapy.

A regular prophylactic visit to the urologist helps to identify most of the problems of the male genitourinary sphere, and start treatment on time. Such periodic examinations are very important; it is extremely undesirable to ignore them.

Experts advise all men who have crossed the 40-year-old threshold, even with good health and the absence of painful symptoms, to check their health with a urologist at least once every 2 years. A standard preventative visit usually includes:

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

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

Every male patient should understand:

• any man always has a risk of developing pathologies of the prostate gland;
• A routine preventive visit to the doctor reveals many problems at an early stage;
• if you find painful symptoms in yourself, you should not look for options for self-medication, you should immediately go to the doctor.

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

• you need to eat properly and efficiently, with the exception of heavy fatty foods, alcohol and convenience foods;
• it is important to carefully observe the rules of intimate hygiene, regularly take a shower and change clothes;
• during sexual intercourse, we should not forget about the means of barrier contraception;
• it is necessary to lead an active lifestyle, since physical inactivity contributes to the development of many diseases of the genitourinary sphere;
• should be careful about your health, avoid genital injuries;
• it is impossible to supercool;
• it is necessary to regulate your intimate life, as too rare and too frequent sexual contacts can cause blood flow disorder in the prostate gland;
• it is important to treat any inflammatory or urological pathologies in time, regularly contact a specialist for a routine examination.

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

Forecast

Modern medical methods for the treatment of 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 of small prevalence, there are no dysfunctions 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 treating doctor are observed.

Of course, without a prompt timely medical assistance, the prognosis will not be favorable: here it is already worth talking about the threat to the life of the patient. If the treatment was complete and competent, then they speak of a positive outcome. Nevertheless, it must be taken into account that the transferred prostate abscess almost always affects the further functional ability of the prostate gland. The possibility of complications in the form of a re-development of an abscess, erectile dysfunction and a man’s reproductive ability cannot be ruled out. It is wise to carry out possible preventive measures, comply with all the instructions of doctors, in general, monitor your health.