Prostatic Abscess: A Review and Update
Authors: Venyo Anthony Kodzo-Grey 
Published: January 2022

Prostate abscess (PA) is a complication that ensues an acute infectious purulent process within the prostate gland which is typified by accumulation of purulent material within the prostate gland and this purulent material could be unilocular or multi-septated within the prostate gland. PA is a rare disease especially in the developed world where PA tends to be more commonly associated with patients who have diabetes mellitus, chronic kidney disease, chronic liver disease, immunosuppressive disease, HIV Infection, renal transplantation, and long-term urethral catheterisation. PA tends to be more commonly encountered in the developing world. PA could be an acute abscess or chronic abscess especially in association with chronic inflammatory conditions including tuberculosis or intravesical instillations of Bacillus Calmette Guerin (BCG). PA tends to constitute 0.5% of all urology disease and 6% of all acute cases of bacterial prostatitis. The mortality rate associated with PA has tended to be between 1% and 16% of all cases of prostate abscess. PA tends to be most commonly encountered in individuals who are in their fifth to sixth decade and could occur at any age. PAs that are due to sexually transmitted organisms tend to be more commonly encountered in younger males. PA tends to affect the central zone as well as the peripheral zones of the prostate gland. Haematogenous dissemination from a primary source of infection from a primary infection elsewhere have been reported and some of the reported sources included respiratory tract, digestive tract, urinary tracts, skin, and soft tissue are very rare. PA has also been reported to be associated with staghorn calculus. Some of the reported bacterial organisms that have caused acute prostate abscess (APA) include: Escherichia Coli, Klebsiella, Pseudomonas, Proteus, Enterobacter, Enterococcus, and staphylococcus. Other causes of prostate abscess have included other bacteria and fungal infection including: Brucellosis, Salmonella, Nocardia, Mycobacterium tuberculosis. Prostate abscess has also been reported in association with malignancy of the prostate gland. Manifestations of prostate abscess could include: (a) systemic symptoms including pyrexia, chills, headache, general malaise, low back ache and in some rare cases of prostate abscess, a history of treatment for tuberculosis or contact with a person who has tuberculosis, or travel to a salmonella endemic area may be obtained and in cases of Brucellosis PAs drinking of raw milk / contact with animals may be elicited and or rare occasions treatment of superficial urothelial carcinoma with Bacillus Calmette Guerin may be elicited. (b) perineal pain, dysuria, urinary frequency, urinary urgency, retention of urine, recent prostate biopsy, visible haematuria, urethral discharge of pus, lower urinary tract obstructive symptoms with poor flow, intermittent flow, hesitancy, and sensation of incomplete emptying of the urinary bladder, retention of urine, and tenderness over the prostate gland with a feeling of bogginess and soft fluctuation. The symptoms tend to be non-specific. Diagnosis of PAs tends to be established based upon a good clinical history taking, good clinical examination, urinalysis and urine culture, routine haematology and biochemistry blood tests with evidence of raised white blood cell count and CRP and at times lymphocytosis in cases of tuberculous prostate abscess, blood culture, urine culture, PCR detection of sexually transmitted organisms, radiology imaging including trans-rectal ultra-sound scan of the prostate, or CT) scan of abdomen and pelvis including the prostate, or MRI scan of the prostate. Treatment of PA depending upon the size of the abscess has been undertaken with various options including: Appropriate antibiotic treatment alone for small abscesses based upon the antibiotic sensitivity pattern of the cultured organism, Antibiotic treatment and radiology image-guided aspiration of the abscess. Antibiotic treatment plus radiology image-guided insertion of a drain into the prostate abscess, trans-urethral incision / resection / modified resection of the prostate gland to deroof and drain the abscess, open drainage of the abscess is only undertaken on rare occasions. Within remote district hospitals in developing countries in the absence of radiology imaging, the clinician would have no choice but to undertake finger guided aspiration / drainage of the prostate abscess plus antibiotic treatment. It is important to obtain the culture and sensitivity result of the aspirated and drained pus so that if there are fungi cultured or rare organisms cultured the choice of antibacterial / antifungal treatment would depend upon the microbiology results. It is important to treat all complications urgently and appropriately including provision of intensive care. Careful clinical follow-up, laboratory investigations and radiology imaging are necessitated to ensure good recovery and to quickly identify as well as appropriately treat any recurrent abscess and on rare occasions if there is an associated prostate cancer it would be detected. The prognosis associated with the treatment of PA depends upon a number of factors including: Timely diagnosis and adequate and appropriate treatment of the PA. The underlying associated medical conditions of the patient. The prognosis tends to be good if the PA is diagnosed early as well as treated early including utilization of the correct anti-microbial medicament and appropriate drainage of the abscess. Poor prognosis tends to be associated with individual patients who are older than 65 years, fever with a temperature higher than 100.4 degrees Fahrenheit, benign prostatic hyperplasia, chronic long-term urethral catheterisation. In the scenario of non-availability of bacterial culture report in a remote area in a developing country when there is delay in getting the culture results from the regional or national centre there would be the possibility of utilizing a broad spectrum and potent antibiotics but if the organism is a fungus then there would tend to be recurrence of the abscess and poor outcome and for this reason it would be recommended that every hospital in the world should have access to good laboratory services including haematology, biochemistry, microbiology, pathology, and radiology services including ultrasound scan, computed tomography scan as well as magnetic resonance imaging scan as well as well trained staff to operative the various equipment as well as high dependency units and intensive care units and staff should be available to provide support for all patients that need support.