Stesura Seveso Archivio Italiano di Urologia e Andrologia 2014; 86, 4344 ORIGINAL PAPER Diagnostic and therapeutic utility of transrectal ultrasound in urological office prostatic abscess management: A short report from a single urologic center Andrea Fabiani 1, Alessandra Filosa 2, Valentina Maurelli 1, Fabrizio Fioretti 1, Lucilla Servi 1, Mara Piergallina 1, Giovanni Ciccotti 1, Matteo Talle’ 1, Gabriele Mammana 1 1 Surgery Dpt, Section of Urology, ASUR Marche Area Vasta 3, Macerata Hospital, Macerata, Italy; 2 Section of Pathological Anatomy, Department of Clinical Pathology, Area Vasta 3, ASUR Marche, Macerata Hospital, Macerata, Italy. Objectives: Prostatic abscess (PA) is an infrequent condition in the modern antibiotic era. The everyday use of transrectal ultra- sound (TRUS) during diagnostic work-up and the widespread recurrence to prostatic biopsies may lead to an increase of PA diagnosis. In this short report we analyze the patients charac- teristics and the management of seven recent cases of PA diag- nosed in our institution. Materials and Methods: The records of 7 patients admitted to our Center for LUTS associated to septic fever or acute urinary retention, was prospectively collected. Suspect of PA was done on digital rectal examination (DRE) and confirmed by TRUS performed after urinary system ultrasound (UUS) evaluation. Patients were admitted to hospital only in case of septic signs. A sovrapubic (SPC) or urethral catheter (UC) was placed depending on symptoms. A TRUS-guided aspiration of PA was performed with patient in lithotomic position, using a 18 gauge two-part needle, side/end fire needle access. Patient was dis- charged with antibiotic therapy and followed up until complete resolution of the PA and symptoms. Results: Mean age was 62 years (range 24-82). Two patients were diabetics and one was affected by the immunodeficiency acquired syndrome (HIV). In one case, PA was detected after a persistent fever post TRUS guided prostate biopsy. Average prostate volume was 69 ml (range 19-118 ml). DRE was able to diagnose PA only in 2 cases (29%), UUS evaluation in 1 case (14%). All cases were confirmed by TRUS as hypo-anechoic areas with or without internal echoes in all patients. Mean PA dimension was 3.64 cm (range 1.5-8). SPC was placed in 3 cases (43%), UC in 3 patients (43%). Only 1 patient refused catheterization. Side fire needle aspiration was performed in all cases and in combination with end fire access in case of partic- ular location of abscess cavities. Second look was needed in 2 cases (29%). Antibiotics were administered in all cases. The aspirated pus showed a positive culture for Escherichia coli (43%), Klebsiella pneumoniae (29%), Pseudomonas aeruginosa (14%) and Enterococcus faecalis (14%). PA resolution time mean was 9 days (range 3-24). Conclusions: TRUS evaluation in case of persistent LUTS asso- ciated with fever or acute urinary retention is determinant in the diagnosis of PA. Office or institutional management with TRUS needle aspiration is a good option in these cases. KEY WORDS: Prostatic abscess; TRUS; End fire probe; Side fire access LUTS; Uroseptic fever. Submitted 3 October 2014; Accepted 31 October 2014 Summary No conflict of interest declared. INTRODUCTION Prostatic abscess (PA) is an infrequent condition in the modern antibiotic era. Nevertheless, the wide use of antibiotics in patients with lower urinary tract symptoms (LUTS) could be responsible of the growing PA incidence in the last years (1). The diagnosis may be difficult because at onset of the symptoms PA may mimic several other dis- eases of the lower urinary tract. Simple interpretation of the clinical symptoms and digital rectal examination (DRE) could be not able to make a diagnosis. The routine use of transrectal ultrasound (TRUS) evaluation in each case of LUTS associated to fever or predisposing factors for the development of PA may aid the clinician in the daily prac- tice (2). In this short report we present data about seven patients diagnosed with prostatic abscess, discussing clin- ical findings, diagnostic criticisms and treatment results obtained by TRUS guided needle aspiration. MATERIAL AND METHODS We prospectively collected the clinical and instrumental data of a short series of 7 patients admitted from Emergency Department to our Section of Urology in Macerata Hospital for LUTS associated to septic fever and/or acute urinary retention in a 12 months period. At the urologic evaluation, the patients underwent to DRE and systematically to TRUS after an urinary system ultra- sound (UUS) study. In case of confirmed suspect of PA, a sovrapubic (SPC) or urethral catheter (UC) was placed depending on symptoms. A TRUS-guided needle aspira- tion of PA was performed with patient in lithotomic posi- tion, using a 18 gauge two-part needle, with a probe B-K Type 8818 (BK Medical, Denmark), side/end fire needle access, without local anesthesia. All procedures were per- formed in an ambulatory setting. Patients were admitted to hospital only in case of septic signs. The patients were discharged with antibiotic therapy and followed up with TRUS until complete resolution of the PA and symptoms. RESULTS Diagnostic and management data are presented in Tables 1 and 2. The figures show particular aspects of PA diag- DOI: 10.4081/aiua.2014.4.344 Presented at 19th National Congress S IEUN, Fermo 2014 345Archivio Italiano di Urologia e Andrologia 2014; 86, 4 Diagnostic and therapeutic utility of transrectal ultrasound in urological office prostatic abscess management nosis and treatment in same patients. Mean age was 62 years (range 24-82). Two patients were diabetics and one was affected by the immunodeficiency acquired syn- drome (HIV). In one case, PA was detected after a per- sistent fever post TRUS guided prostate biopsy (24 biop- sy cores). Average prostate volume was 69 ml (range 19- 118 ml). DRE was able to diagnose PA only in 2 cases (29%), UUS evaluation in 1 case (14%). PA was con- firmed by TRUS (both bi-plane and end-fire probe) as a hypo-anechoic areas with or without internal echoes in all patients. PA was located in transitional zone in 4 cases, peripheral zone was involved in 1 case. Combined localization was observed in 2 cases. PA dimension mean was 3.68 cm (range 1.5-8). SPC was placed in 3 case (43%), UC in 3 patients (43%). Only 1 patient refused catheterization. Side fire needle aspiration was per- formed in all cases. Combination with end fire needle access was performed in four cases (57%) due to the localization of abscess cavities. Second look was needed in 2 cases (29%). Intravenous parenteral antibiotics (Imipenem plus Teycoplanine) was administered only in case of hospitalization (43%). In cases managed at home, a combination of 3-rd generation Cephalosporine and Aminoglycoside was administered. The aspirated pus showed a positive culture in all patients (Escherichia coli n = 3, Klebsiella pneumoniae n = 2, Pseudomonas n = 1 and Enterococcus faecalis n = 1). Mean PA resolution time was 9 days (range 3-24). No patients died for this condition. DISCUSSION PA is a potential life threatening condition that, when not adequately treated, may progress to sepsis and death. Thus, an accurate diagnostic and an efficient treatment are both required. In available scientific literature data about PA consisted in cases reports and there is no stan- dardization of the diagnostic and therapeutic routine. In review articles, we found several reports discussing clin- ical presentation, diagnostic work up and therapeutic approach to PA. The summary of these individual expe- riences permitted to delineate some lines of action (3-4). First of all, we think that PA incidence will be increasing in the next years. In the modern antibiotic era incidence is estimated between 0.5% to 2.5% of diseases accompa- nying prostatic symptoms. We should expect a shift of the epidemiological profile of PA due to a widespread routine use of broad-spectrum antibiotics to patients with LUTS, without the investigation required (1), and to an increase in population longevity that lead to a fur- ther need to manage chronic illness, such as diabetes mellitus or chronic renal failure, promoting the infec- tious risk. Also others diseases altering the immune sys- tem could be responsible, e.g. immunodeficiency Patient Age Co-morbidities Clinical presentation DRE diagnostic + UUS diagnostic * Abscess location Pathogen 1 61 BPH Fever post TRUS biopsies + TZ K. Pneumoniae (24 cores)* 2 70 BPH LUTS and fever PZ Pseudomonas 3 68 DMNID Fever * TZ PZ K. Pneumoniae 4 24 Infertility AUR and fever after TZ E.Coli recurrent hematospermia 5 82 BPH Fever* TZ E.Coli 6 60 DMNID Fever and AUR TZ Enterococcus faecalis 7 69 HIV Fever* + TZ PZ E. Coli * Hospitalization. BPH: Benign prostatic hyperplasia. DMNID: Non insulin dependent diabetes mellitus. HIV: Immunodeficiency acquired syndrome. AUR: acute urinary retention. TRUS: transrectal ultrasound. DRE: digital rectal examination. UUS: urinary system ultrasound. TZ: transitional zone. PZ: peripheral zone. Table 1. Diagnostic findings of cases series. Patient Age Prostate volume (ml)/ Soprapubic catheter Urethral catheter Side fire (SF)/ Second look Time resolution abscess diameter (cm) positioned * positioned ° Side fire + end fire needle aspiration + (days) (SFEF) accesss 1 61 75 ml/3,9 cm * SF 7 2 70 71 ml/3,1 cm SF 5 3 68 69 ml/4,9 cm * SFEF + 9 4 24 19 ml/2,1 cm ° SF 9 5 82 118 ml/8 cm ° SFEF 6 6 60 68 ml/1,5 cm ° SFEF 3 7 69 61 ml/2,3 * SFEF + 24 SF: side fire access. SFEF: combined access- side fire and end fire. Table 2. Technical management of cases. Archivio Italiano di Urologia e Andrologia 2014; 86, 4 A. Fabiani, A. Filosa, V. Maurelli, F. Fioretti, L. Servi, M. Piergallina, G. Ciccotti, M. Talle’, G. Mammana 346 acquired syndrome (5). Then, if we recognize that the abscess is a result of the retrograde flow of contaminated urine during micturition into prostatic ducts that pro- motes the formation of microabscesses that coalesce and form prostatic abscesses (6-7), the rate of this disease is certainly more important than what reported in the sci- entific literature. Differential diagnosis between acute bacterial prostatitis and PA is difficult if based only on clinical symptoms and digital rectal examination (DRE) (2) or lower abdominal ultrasound evaluation. The rou- tine use of TRUS evaluation in each case of LUTS associ- ated to fever or predisposing factors for the development of PA may aid the clinician in the daily practice (3). At DRE prostatic abscess could be appreciate as a painful fluctuating area (4). In our short report this findings was observed in 2 cases. Similarly, prostate lower abdominal ultrasound evaluation was able to pose the PA suspect only in 1 case in which the exam revealed an hypoechoic irregular area within prostate parenchyma suggesting the diagnosis confirmed by TRUS (Figures 1a, 1b). In the other cases, abdominal ultrasound was unremarkable. In our experience TRUS showed to be an excellent tool in making the diagnosis. The most common finding is the presence of one or more hypo-anechoic areas, of several sizes, containing thick liquid and located in the transi- tion zone and/or in central zone of the prostate, perme- ated by hyperechogenic areas and anatomical gland dis- tortion. In our series these findings were variably observed in 100% of the cases. Although other condi- tions could have a similar TRUS appearance, as neoplas- tic process, cystic lesions and granulomas (8-10), the TRUS appearance of PA is quite characteristic and can be differentiated on the basis of determined criteria (11). As reported in the literature, TRUS should also be consid- ered the diagnostic study of choice to assist the treatment and follow-up of patients with prostatic abscess (12). Figures 2a-2b show the results of TRUS guided needle aspiration at follow up of one patient. As observed in our cases, clinicians need to suspect PA in case of fever with LUTS especially in patients presenting with fever and persistent LUTS despite antibiotics use, for diabetics or immune-deficient men with protracted symptoms, for those with LUTS and fever progressing to urinary reten- tion and after the performance of prostatic biopsy. In all scientific reports, diabetes mellitus and HIV infection are invariably referred as risk factors for the development of PA. In our series, a peculiarity was represented by case 4 (Figure 3) that was a young patient (24 years old) who developed AUR due to infectious enlargement of a mid- line cyst and was symptomatic for recurrent hematosper- mia, as revealed by clinical history taken at the moment of emergency evaluation. These results highlight the importance to investigate with TRUS younger patients with genito-urinary symptoms (13). In reference to prostate biopsy as risk factor of PA, it should be under- lined that data from European Randomized Study of Screening for Prostate Cancer (Rotterdam section) (ERSPC) revealed growing evidence of increasing hospitalizations for serious infectious complications within 2 week of prostate biopsy (14). Specifically, the Authors found a 10% increase in the frequency of hospital admissions and most of these were for infectious complications Figure 1a. Bladder ultrasound: 68 years old, presented at our attention for persistent fever and prostatic abscess (*). Figure 1b. Transrectal ultrasound (end-fire probe) view of the figure 1a confirm a multisided prostatic abscess (*). Figure 2a-b. TRUS evaluation (endfire probe) at follow up of patient in figures 1a-b, axial (A) and longitudinal (B). 347Archivio Italiano di Urologia e Andrologia 2014; 86, 4 Diagnostic and therapeutic utility of transrectal ultrasound in urological office prostatic abscess management probably related to rising antimicrobial resistance. It is well known that men with prostatic enlargement and diabetes or major co-morbidities had an increased risk of febrile complications after prostate biopsy (15). These results highlight the importance of judicious patient selection for PSA screening because these men may be less likely to benefit from early prostate cancer detection and also have a greater risk of complications from the diagnostic work-up. However, we considered that in case of patient number 1 of our series, neither prostate vol- ume (57 ml) neither co-morbidities predicted PA onset, due to a multi resistant Klebsiella pneumoniae. In our local experience with TRUS guided biopsies, on 1382 procedures performed in the last 6 years, we found only thissingle case of PA (0.07%) and 10 cases of hospital- izations for septic fever (0.72%) with 1 admission to intensive care unit. No deaths from this complication was observed (unpublished data). We can confirm that the frequency of hospital admission for septic fever after prostate biopsy is low (< 1%) (15). The problem is rep- resented by the high level of antimicrobial resistance. We must take into consideration the use of a combination of 3-rd generation Cephalosporine and Aminoglycoside or Imipenem and Teicoplanine as better antibiotic therapy than traditional fluorquinolones. TRUS-guided needle aspiration is the method of choice for treatment of PA (16). The treatment options included also surgical inter- vention such as transurethral prostate incision (TUIP), transurethral de-roofing (TURP) or transperineal tube placement. TURP is a more invasive approach and it is associated with several risks such as hemorrhage, retro- grade ejaculation and sepsis. An alternative to simple aspiration could be the continuous drainage with a tube placed under TRUS guidance either by transperineal or transrectal route. However, this approach is fraught with a serious risk of developing a prostate-rectal fistula for- mation and prolonged hospitalization (17-18). Tiwari et al. (19) reported 24 patients treated with transurethral de-roofing in 17 cases, transperineal needle aspiration TRUS guided in 3 cases. The remnants patients was man- aged conservatively. Invasive treatment was applied in case of dimension of cavities abscess > 1 cm or multi-loc- ulated. Vias et al. (3) published one of the largest series of PA managed with TRUS-guided needle aspiration. Of 48 patients, they report a 100% of diagnostic accuracy by TRUS and a success treatment rate of 85.42%, avoid- ing the risk of potential disadvantages of TUR. The diam- eter “cut off” of cavities considered eligible for aspiration was 2 cm. In our short report, we confirm the high diag- nostic accuracy (100%) of TRUS with a similar success rate. Applying the dimensional cut-off proposed by Vias, only two patient needed a second look aspiration due to the persistence of cavities within the prostate. No TUR de-roofing was performed. In all cases, our TRUS follow up revealed a complete resolution of PA. Technically, our TRUS guided needle aspiration consisted in the use of a biplane probe (6-12Mhz, Type 8818, BK Medical, Denmark) with a side fire needle access in all patients (Figure 4). When PA was multifocal (four patients), espe- cially in two cases in which cavities was located in the anterior zone of the prostate, we resorted to an end fire access (Figure 5) in view of the potential increased capacity of this configuration, showed during prostate biopsies, to sample this anatomical area of the gland (20). We approached all cases with catheterization. Suprapubic catheter was placed in three case. In one case, patient refused catheterization both urethral and suprapubic. Also in this case the evolution of treatment was positive without need of ancillary procedures. Figure 3. A midline prostatic utricle cyst after TRUS guided needle aspiration in young men with acute urinary retention. Wall cyst presents small calcification. The surrounding right seminal duct is shown in figure 5. Figure 4. TRUS guided aspiration with a biplane probe, side fire needle access. Archivio Italiano di Urologia e Andrologia 2014; 86, 4 A. Fabiani, A. Filosa, V. Maurelli, F. Fioretti, L. Servi, M. Piergallina, G. Ciccotti, M. Talle’, G. Mammana 348 CONCLUSIONS The diagnosis of prostatic abscess should be warranted for patients presenting with fever and persistent LUTS despite antibiotics use, for diabetics or immune-deficient patients with protracted symptoms and for those with LUTS and fever progressing to urinary retention and after the performance of prostatic biopsy. TRUS evalua- tion is determinant and mandatory for the diagnosis.. In our experience, office or institutional management with TRUS needle aspiration is a good option in all cases. REFERENCES 1. Granados EA, Riley G, Salvador J, Vicente J. Prostatic abscess: Diagnosis and treatment. J Urol. 1992; 148:80-2 2. Oliveira P, Andrade JA, Porto HC, et al Diagnosis and treatment of prostatic abscess Int Braz J Urol. 2003; 29:30-4. 3. Vias BJ, Ganpule SA, Ganpule AP, et al. 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Correspondence Andrea Fabiani, MD (Corresponding Author) andreadoc1@libero.it Valentina Maurelli, MD valentinamaurelli@hotmail.it Fabrizio Fioretti, MD, PhD fa.fioretti@libero.it Lucilla Servi, MD lucilla.servi@sanita.marche.it Mara Piergallina, MD mara.piergallina@tiscali.it Giovanni Ciccotti, MD giovanni.ciccotti@sanita.marche.it Matteo Talle’, MD matteo.talle@gmail.com Gabriele Mammana, MD gabriele.mammana@sanita.marche.it Surgery Dpt, Head of Section of Urology ASUR Marche Area Vasta 3, Macerata Hospital, Macerata, Italy Alessandra Filosa, MD, PhD alessandrafilosa@yahoo.it Section of Pathological Anatomy, Department of Clinical Pathology, Area Vasta 3, ASUR Marche, Macerata Hospital, Macerata, Italy Figure 5. Longitudinal view of patient in figure 3: TRUS guided aspiration with an endfire probe, endfire needle access.