A 59 y.o. male presents with fever, nausea and groin pain

What do you see in his bladder?

Our patient had a prostate abscess.  Prostate abscesses are uncommon because of the use of broad-spectrum antibiotics in patients with lower urinary tract symptoms. When it does occur, it is difficult to distinguish from acute bacterial prostatitis but the distinction is important since the treatment differs.

 Typical symptoms of abscess include dysuria, fever, and perineal and lower back pain which can mimic prostatitis. The prostatic abscess requires drainage, traditionally requiring an open perineal incision or transurethral resection.  Currently minimally invasive treatment with TRUS(trans rectal ultrasound) or drainge via a transperineal aspiration is carried out.

Risk factors for prostate abscess include obstructive uropathy, straddle injury and urethral foreign bodies. HIV, immune suppression, diabetes  and chronic indwelling foleys are also risk factors.   The most common pathogens are gram negative with E coli and Klebsiella being involved in most cases.  Pseudomonas, staph aureus and Strep agalactiea have also been implicated.  More recently MRSA prostatic abscesses have been reported. In 2000, a new strain of community acquired MRSA, USA300 Panton-Valentine leucocidin (PVL) positive MRSA was reported.  This PVL confers greater virulence increasing the likelihood of necrotizing pneumonia , endocarditis, osteo renal  abscesses and prostate abscesses.

prostate abscess in a 19 yo healthy male

Our patient had obstructive uropathy and a MRSA abscess of the prostate. A transrectal ultrasound was used to localize the abscess but it could not be aspirated because of a high bladder neck.  Using the rectal US as a guide an 18 gauge needle was used to aspirate the abscess trans perineally.  Purulent material was obtained and cultured positive for MRSA.  Blood cultures were also positive. The pt was treated with IV antibiotics and recovered without further incident.

Jang K, Lee D, Lee S, Chung B. Treatment of prostatic abscess: cass collection and comparison of treatment methods. 2012 Korean J Urology  53(12): 860-864.

Bhagat SK, Kekre NS, Gopaladrishnan G, et al. Changing profile of prostatic abscess. Int Braz J Urol. 2008;34:164-179.

Lachant D, Apostolakos, Pietropaoli A. Methicillin resistant staph aureus prostatic abscess with bacteremia. 2013  Case reports in Infectious Diseases. Article ID 613961.