A prostate abscess is a rare but severe inflammatory reaction to an infectious process of the prostate gland that usually results as a complication of suboptimally treated acute prostatitis. Infections are typically introduced when infected urine is refluxed into the prostatic ducts or introduced through instrumentation transrectally via prostate biopsy.

• Prostate gland abscess
• Prostate abscess
• Acute prostatic abscess
• Abscess of prostate

• •Historically caused by complication of acute bacterial prostatitis via reflux of infected urine into the prostatic ducts during voiding. However, more recently associated with complications following introduction of instrumentation during prostate biopsy.
• •It is more likely to occur in patients with uncontrolled diabetes, compromised immune systems, and suboptimal treatment of acute prostatitis.
• •Associated with foreign body instrumentation such as intermittent self-catheterization and bladder outlet obstruction.
• •Escherichia coli is the most common cause followed by Klebsiella, Pseudomonas, Proteus, Enterobacter, Serratia, and Enterococcus species.
• •In young and/or sexually active patients (age <35 yr) consider Neisseria gonorrhoeae and Chlamydia trachomatis as the inciting organisms.

• •Acute prostatitis
• •Chronic prostatitis
• •Perirectal abscess
• •Perineal abscess
• •Chronic pelvic pain syndrome
• •Urethritis
• •Urinary tract infection

• •Largely based on clinical history and digital rectal examination (DRE)
• •DRE typically shows severe prostatic tenderness and focal areas of fluctuance. Of note, DRE is suspected to increase bacterial translocation from the urinary system to the bloodstream, but no data exists to support this
• •DREs
• •Patients who do not improve within 48 h of treatment for acute prostatitis are at increased risk of biofilm or prostatic abscess formation^1,2

• •Urinalysis with urine culture
• •Gonorrhea testing: First catch urine (or genital swab) nucleic acid amplification test (NAAT) for gonorrhea
• •CBC and complete metabolic panel (CMP)
• •Blood cultures

• •Transrectal ultrasound (TRUS) was the preferred imaging modality for diagnosing prostate abscess until MRI. Typical findings are irregular hypoechoic areas with ill-defined margins (Fig. E2) usually noted in the transition zone and central zone of the prostate.
• •MRI will show an abscess as hypointense on T1 and hyperintense on T2, which is now the preferred imaging modality due to due to its high sensitivity for abscess, which significantly informs treatment decisions.²
• •Computed tomography (CT) with and without contrast can be helpful in delineating extraprostatic collections and extent of spread of the abscess.

Surgical:

Includes ultrasound-guided drainage, transurethral drainage, and open drainage:

• •Surgical drainage depends on the size of the abscess; if it is >2 cm, it may benefit from surgical intervention.
• •Open drainage involves a transperineal incision and drainage for cases where the abscess has penetrated through the levator ani muscle.

Minimally invasive drainage techniques:

• •Transrectal ultrasound (TRUS)-guided drainage: This method has gained prominence due to efficacy and minimal invasiveness. TRUS-guided perineal drainage and transrectal placement of drainage tubes have been shown to be safe, well-tolerated, and effective in resolving abscesses, often shortening hospital stays and reducing the need for repeat interventions.³
• •Percutaneous transperineal drainage: This technique, often guided by TRUS, is increasingly used for larger abscesses or those not amenable to transrectal drainage. It involves the placement of a small-bore pigtail catheter, which allows continuous drainage and has been associated with favorable outcomes.⁴

• •Fluid resuscitation with intravenous (IV) fluid if systemic symptoms present such as sepsis
• •Antibiotic therapy is typically broad-spectrum, gram-negative coverage with parenteral preference due to limited prostatic penetrance of many oral antibiotics. Empirical antibiotic therapy was historically fluoroquinolone-based but has shifted to third-generation cephalosporins, aztreonam, or combinations including carbapenems (e.g., meropenem) to cover extended-spectrum beta-lactamase (ESBL)-producing organisms and other resistant pathogens, particularly Escherichia coli⁵
• •Incision and drainage of abscess
• •Debridement of necrotic tissue

Follow up with surgeon and infectious disease physician is often warranted.

• •General surgeon or colorectal surgeon for drainage
• •Endocrinologist or PCP may be needed if DM is uncontrolled
• •Infectious disease specialist
• •TRUS is needed for abscess drainage if conservative measures fail

A prostate abscess may be the first sign of a debilitating or chronic issue such as diabetes. Check the blood glucose to rule out the possibility of undiagnosed diabetes mellitus. Other immunosuppressive disorders may be associated with prostatic abscess such as HIV or immunosuppressive drugs.

Ensure optimal management of diabetes mellitus and other chronic conditions.

Advise patients with lower urinary tract infections/prostate infections to be vigilant of warning signs of abscess formation, especially patients who have just received a prostate biopsy or other instrumentation of the lower urinary tract.

• Prostatitis (Related Key Topic)