Primary melioidotic prostatic abscess: presentation,diagnosis and management

Introduction: In South‐East Asia and Northern Australia, melioidosis (infection with Burkholderia pseudomallei) is a known cause of severe community‐acquired sepsis. However, melioidosis presenting primarily as prostatic abscesses is very rare. Methods: The presenting features, investigations and management outcome of five patients who developed melioidotic prostatic abscesses from 1997 to 2000 were reviewed in the present study. Results: The mean age at presentation was 53 years (range: 29?69). Old age and diabetes mellitus were predisposing factors. All patients had a fever of at least 38.5°C and presented with obstructive urinary symptoms culminating in urinary retention. Presence of prostatic abscess was demonstrated by transrectal ultrasound in all cases. The abscesses were drained with transurethral resection of the prostate. One patient required re‐resection while another patient developed severe septic shock requiring intensive care and ­inotropic support. There was no mortality in our series. Conclusions: Elderly diabetic men presenting with fever and urinary tract obstruction in endemic areas may harbour an unusual but potentially life threatening melioidotic prostatic abscess. Transrectal ultrasound and bacteriological confirmation are mandatory. Prompt surgical drainage coupled with appropriate antibiotics are keys to a favourable outcome.     

Prostatic abscess caused by community‐acquired methicillin‐resistant Staphylococcus aureus

Prostatic abscess is uncommon and difficult to diagnose, because its clinical presentation mimics lower urinary tract symptoms. Prostatic abscess is often caused by gram‐negative organisms and occasionally by Staphylococcus aureus. Community‐acquired methicillin‐resistant S. aureus (MRSA) often causes skin and soft‐tissue infections, and rarely causes genitourinary infections. We report what we believe is the second case of a prostatic abscess as a result of MRSA in a healthy diabetic patient who was treated with transurethral resection of the prostate and intravenous administration of vancomycin.     

Early infectious complications with transponder placement for external beam radiation therapy for prostate cancer

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Little has been published related to transponders per se, but a number of studies relating to prostate biopsy‐related infections and the increased incidence of quinolone‐resistant Escherichia coli have been published. The study alerts the practising urologist to the risk of quinolone‐resistant E. coli in the setting of transrectally placed transponders. Furthermore, it proposes an antibiotic regimen that should reduce this risk.

OBJECTIVE

• ? To report our series of early infectious complications after placement of Calypso® transponders (Calypso Medical, Seattle, WA, USA) into the prostate.

PATIENTS AND METHODS

• ? Between February 2008 and October 2010, 50 consecutive patients underwent placement of Calypso® transponders into the prostate.
• ? Patients were administered ciprofloxacin 500 mg every 12 h, starting the night before the procedure and for 2 days after the procedure.
• ? Data were collected via chart review, and complications were classified according to the Clavien classification system.

RESULTS

• ? Of the 50 patients undergoing the procedure, five (10%) developed infectious complications, and three (6%) developed a grade II complication with a UTI requiring antibiotic therapy. One patient (2%) developed a grade IIIb complication with an epidural abscess and osteomyelitis of the lumbar vertebrae requiring open debridement and a lumbar fusion. One patient (2%) developed a prostatic abscess with methicillin‐resistant Staphylococcus aureus and subsequently died of an unrelated lower GI bleed.
• ? In 4/50 patients (8%), a culture confirmed the responsible bacteria, of which three cases were quinolone‐resistant Escherichia coli.

CONCLUSION

• ? As with prostate biopsy, the emergence of quinolone‐resistant E. coli remains a challenging infectious complication with transrectal prostate procedures. We propose an alternative strategy of double antibiotic coverage with one dose of oral ciprofloxacin 500 mg and gentamicin 80 mg i.m. before this procedure.

     

Staphylococcus aureus prostatic abscess and subdural empyema: a case report

Introduction and objectivesTo report one case of prostatic abscess and subdural empyema by Staphylococcus aureusMethodsWe describe the case of a 51 year old male patient who was diagnosed of prostatic abscess and subdural empyema by Staphilococcus aureus. We use clinical presentation and physical exploration based on rectal digital examination, as diagnostic approach method. And computerized axial tomography and transrectal ultrasonography, which allows the guided needle drainage of the abscess, as diagnostic confirmation methodsResultsThe clinical picture resolved with the transrectal ultrasonography guided needle aspiration of the abscess and conservative treatment with antibiotics and urinary diversionConclusionsProstatic abscess is an uncommon entity nowadays. Provided the great variety of symptoms, a great degree of clinical suspicion is needed for the diagnosis, and once it is got it, immediate aggressive treatment must be initiated. Transrectal ultrasonography allows not only the diagnosis, but also the drainage of the abscess. The culture of the obtained material identifies the etiological agent and the most specific antibiotic therapy     

Decision making in the management of benign prostatic enlargement and the role of transabdominal ultrasound

Benign prostate enlargement (BPE) is a common disease affecting elderly men. It can present clinically in many ways including, but not exclusively, lower urinary tract symptoms (LUTS) and acute urinary retention (AUR). Therefore, in managing men with BPE, a correct diagnosis in the outpatient setting is important. Diagnosis of BPE in the clinic can be aided by simple, non‐invasive, transabdominal ultrasound (TAUS). In our practice, a normal prostate is generally defined as less than 20 mL, and shows no intravesical prostatic protrusion (IPP) to distort the normal funneling bladder neck on TAUS, with a maximum flow rate of more than 15 mL/s. The degree of IPP can be measured non‐invasively in the midsagittal plane, and can be graded accordingly. Studies have shown that the grade of IPP correlates well with the degree of bladder outlet obstruction (BOO). In addition, TAUS can also be used to measure prostate volume (PV) and post‐void residual urine (PVR). There is a good correlation between IPP and PV, but IPP is a better predictor for BOO. Patients with low‐grade IPP, no significant PVR (<100 mL) and no bothersome symptoms (low stage) can generally be watched; whereas those with high‐grade IPP, significant PVR (>100 mL) and bothersome symptoms (higher stage) will need more aggressive management. The final decision for management can then be tailored and individualized to achieve cost‐effectiveness.     

A broader role for 5ARIs in prostate disease? Existing evidence and emerging benefits

5ARIs are recommended for men who have moderate‐to‐severe lower urinary tract symptoms (LUTS) and benign prostatic enlargement (BPE) secondary to benign prostatic hyperplasia. Studies have confirmed the utility of combining 5ARIs with alpha‐blockers; the MTOPS study showed that risk of overall clinical progression was significantly reduced after 4.5 years with combination therapy (finasteride/doxazosin) in comparison with either monotherapy, while the ongoing CombAT trial (dutasteride/tamsulosin) has for the first time shown benefit in improving symptoms for combination therapy over monotherapies within 12 months of treatment. Data also suggest roles for 5ARIs in prostate cancer. Several studies indicate that treatment with a 5ARI improves the performance of PSA testing for identifying men with prostate cancer, while the PCPT showed a significant reduction in the risk of developing prostate cancer with finasteride. However, widespread use of finasteride in this setting has been tempered by an apparent increase in high‐grade disease observed in the study. The ongoing REDUCE study will provide further insight into prostate cancer prevention with 5ARIs. 5ARI‐containing regimens may have utility as less aggressive treatment options for patients who only have rising PSA after definitive local therapy, and in patients with disease resistant to androgen deprivation therapy who have PSA progression. Current evidence therefore shows that 5ARIs are effective in treating LUTS/BPE and preventing disease progression, and may also have a role in the prevention of prostate cancer. The overlap between BPE and prostate cancer may allow a more unified approach to managing these conditions, with 5ARIs having a central role. Prostate 69: 895–907, 2009. © 2009 Wiley‐Liss, Inc.     

Advanced prostate cancer presenting as a huge abscess

Prostatic abscess is a rare urological disease. It is not easily diagnosed based on the history, physical examination, laboratory data, and imaging studies. Patients with prostatic abscess and those with prostate cancer can have similar presenting signs and symptoms, such as lymphadenopathy and abnormal prostate-specific antigen values. A 67-year-old man without any underlying diseases presented with acute prostatitis. Transrectal ultrasonography was performed 14 days after initiation of antibiotic therapy revealed a fluid-containing irregular mass. Doppler ultrasonography showed high vascularity around the margin of the mass. Advanced prostate cancer with necrosis was found in tissue from transurethral resection of the prostate (TURP). His symptoms improved a lot after TURP and he accepted androgen deprivation therapy in the outpatient clinic. Although ultrasound-guided needle aspiration remains the mainstream treatment for prostatic abscess, TURP should be considered in patients with complicated prostate abscess or suspected prostatic carcinoma.     

Emphysematous prostatic abscess: diagnosis and treatment

We report an unusual case of an emphysematous prostatic abscess. Prostatic abscess is a difficult clinical diagnosis associated with lower urinary tract symptomatology and frequently diabetes mellitus. Computerized axial tomography and transrectal or transurethral ultrasonography can assist in making a specific diagnosis. Definitive treatment is complete surgical drainage, which is achieved by transurethral resection of the prostate. Wide spectrum, adjuvant antibiotic therapy should be given to assure coverage of anaerobic bacteria.     

Prostatic abscess: imaging with transrectal ultrasound. Case report

A 50-year-old man presented with acute urinary retention and urosepsis. Transrectal ultrasonography (TUS) of the prostate demonstrated an abscess. Transperineal US-guided aspiration of pus, urinary bladder catheterization together with systemically administered antibiotics led to an uneventful recovery. TUS was a rapid diagnostic aid for differentiation between prostatitis and prostatic abscess; the appearance of an hypoechoic process within the prostate suggests an abscess.     

Gas-forming infections in genitourinary tract.

Diabetes mellitus associated with urinary tract infections and ureteral obstruction can be predisposing factors leading to emphysematous pyelonephritis. Fever, flank pains, and a palpable renal mass, associated with dehydration and hyperglycemia, were the most frequent presenting symptoms associated with emphysematous pyelonephritis. Computerized tomography (CT) scan is the best method to identify a renal or perirenal abscess and its ramifications. Intravenous antibiotic therapy is determined by blood and urine cultures. Mortality was zero in patients treated by nephrectomy. One patient who had incision and drainage of a renal abscess died of sepsis, and 1 patient died of sepsis following incision and drainage of a prostatic abscess. Patients with cystitis emphysematosa require antibiotic therapy and relief of bladder outlet obstruction. Prostatic abscess is best treated by perineal incision and drainage. Periurethral scrotal abscesses should be incised, drained, and the overlying necrotic skin debrided. Early diagnosis and aggressive medical and surgical management of gas-forming infections of the genitourinary tract are vital.     

Have the Organisms that Cause Breast Abscess Changed With Time?––Implications for Appropriate Antibiotic Usage in Primary and Secondary Care

Abstract: Many patients with breast abscess are managed in primary care. Knowledge of current trends in the bacteriology is valuable in informing antibiotic choices. This study reviews bacterial cultures of a large series of breast abscesses to determine whether there has been a change in the causative organisms during the era of increasing methicillin‐resistant Staphylococcus aureus (MRSA). Analysis was undertaken of all breast abscesses treated in a single unit over 2003 – 2006, including abscess type, bacterial culture, antibiotic sensitivity and resistance patterns. One hundred and ninety cultures were obtained (32.8% lactational abscess, 67.2% nonlactational). 83% yielded organisms. Staphylococcus aureus was the commonest organism isolated (51.3%). Of these, 8.6% were MRSA. Other common organisms included mixed anaerobes (13.7%), and anaerobic cocci (6.3%). Lactational abscesses were significantly more likely to be caused by S. aureus (p < 0.05). Methicillin‐resistant Staphylococcus aureus rates were not statistically different between lactational and nonlactational abscess groups. Appropriate antibiotic choices are of great importance in the community management of breast abscess. Ideally, microbial cultures should be obtained to institute targeted therapy but we recommend the continued use of flucloxacillin with or without metronidazole (or amoxicillin‐clavulanate as a single preparation) as initial empirical therapy.     

Antibiotic prophylaxis for transurethral prostatic resection in men with preoperative urine containing less than 100,000 bacteria per ml: a systematic review

PURPOSE: We determined whether antibiotic prophylaxis can reduce the risk of postoperative infective complications in men undergoing transurethral resection of the prostate (TURP) who have preoperative urine with less than 100,000 bacteria per ml. MATERIALS AND METHODS: MEDLINE, EMBASE (Elsevier B.V., Amsterdam, The Netherlands) and the Cochrane Library were searched for randomized and quasi-randomized controlled trials that compared the effects of antibiotic prophylaxis with placebo or active controls for men undergoing TURP with preoperative sterile urine. Two reviewers independently extracted patient characteristic and outcomes data based on a prospectively developed protocol. RESULTS: A total of 28 trials, 10 placebo controlled and 18 no treatment controlled, involving 4,694 patients, met the inclusion criteria. The mean age of the subjects was 69 years and the majority underwent TURP for prostatic hyperplasia (85%). Antibiotic prophylaxis was significantly more effective than placebo in reducing postoperative TURP complications. The risk differences for post-TURP bacteriuria, high degree fever, bacteremia and use of additional antibiotic treatment were -0.17 (95% CI 0.20, -0.15), -0.11 (-0.15, -0.06), -0.02 (-0.04, 0.00) and -0.20 (-0.28, -0.11), respectively. The results were observed consistently across all classes of antibiotics assessed. There was no difference in the duration of postoperative catheterization or hospitalization. Adverse events were rare, generally mild, and included allergic reactions, pyrexia and abdominal complaints. CONCLUSIONS: Prophylactic antibiotics decrease the incidence of post-TURP bacteriuria, high fever, bacteremia and additional antibiotic treatment. Additional research should evaluate the optimal antibiotic regimen, and whether the cost and possibility of the development of resistant strains of organisms justify the routine use of prophylactic antibiotics.     

Examining the ‘gold standard’: a comparative critical analysis of three consecutive decades of monopolar transurethral resection of the prostate (TURP) outcomes

What's known on the subject? and What does the study add? Transurethral resection of the prostate (TURP) remains the dominant and definitive treatment for lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS‐BPH), but the widespread use of medical therapies (particularly monotherapies) for rapid symptom improvement has meant that the most common indication for TURP has shifted to moderate–severe medical therapy refractory LUTS to, coupled with abnormal objective parameters, or when complications arise. Patients undergoing TURP as part of contemporary randomised controlled trials are not older but have a larger preoperative prostate volume and reduced major morbidity compared with large cohort studies from successive past eras. Delayed surgery because of prolonged medical monotherapy may explain a higher reported failure to void rate, possibly because of negative impact on detrusor function from unrelieved obstruction. This study examined contemporary TURP for significant changes, specifically regarding prostate size, operative parameters, and outcomes, compared with two preceding decades. Electronic databases PubMed, EMBASE & Cochrane collaboration were searched for English literature on prospective randomized controlled trials, published between 1997 and 2007 using keywords “transurethral resection” and “prostate”. Monopolar TURP (M‐TURP) cohort data of each study were selectively pooled for analysis, weighting studies according to patient numbers. Where possible, pooled post‐operative outcomes data were compared with two large cohort landmark studies of successive preceding decades. A total of 3470 patients from 67 studies were included. Mean patient age (67 years) was unchanged, while mean pre‐operative prostate volume of 47.6 g was greater than previously reported. Mean resected prostate tissue (25.8 g) with a resection time of 38.5 minutes suggested improved resection efficiency. A statistically significantly reduced transfusion rate and increased urinary tract infection (UTI) rate were reported. Hospital stay (3.6 days) and initial catheterisation duration (2.5 days) were similar, but post‐operative urinary retention rate was slightly higher (6.8%). Contemporary RCTs of M‐TURP showed larger prostate volume, and reduced major morbidity, compared with large cohort studies from successive past eras. The higher reported failure to void rate, may possibly reflect worse detrusor function at time of TURP. Delaying surgery by prolonged medical monotherapy may compound this. Trials methodology in this area requires quality improvement and standardisation in future.     

Ultrasound-guided needle aspiration in prostatic abscess

OBJECTIVES: To review the clinical presentation of prostatic abscess and to assess the usefulness of ultrasound-guided needle aspiration as a treatment option for this condition. METHODS: Between October 1984 and November 1997, prostatic abscess was diagnosed in 31 patients. The average age was 60 years (range 29 to 79). Prostate ultrasound was performed using either a hypogastric or transrectal approach. Initial therapy included ultrasound-guided needle aspiration in 24 (77.4%), transurethral resection of prostate (TURP) in 5 (16.1%), or conservative management with antibiotic therapy. During follow-up, ultrasound examinations and urine cultures were performed on an outpatient basis. RESULTS: Past medical history most often included previous urinary infection (15 patients, 48%) and bladder outlet obstruction (13 patients, 42%). Sixty-one percent of patients presented with irritative voiding symptoms at the time of diagnosis. Ultrasound-guided needle aspiration resolved 83.3% of cases; 2 patients needed a second procedure. Three patients required TURP for drainage and 2 to remove an obstruction after abscess resolution. CONCLUSIONS: A high degree of suspicion is needed to diagnose prostatic abscess clinically. Transrectal ultrasound is necessary for the differential diagnosis. Transrectal ultrasound-guided needle aspiration is a technically simple and effective therapeutic procedure with no morbidity and, in case of failure, may be repeated or a drainage TURP may be undertaken.     

Comparison of the response to treatment between Asian and Caucasian men with benign prostatic hyperplasia: Long‐term results from the combination of dutasteride and tamsulosin study

The Combination of Avodart and Tamsulosin study was a 4‐year, randomized, double‐blind study of the efficacy and safety of dutasteride and tamsulosin, alone or in combination, in men with moderate‐to‐severe benign prostatic hyperplasia. In this post‐hoc investigation, we analyzed primary and secondary end‐points from the Combination of Avodart and Tamsulosin study in Asian (n = 325) and Caucasian men (n = 4259). The incidence of acute urinary retention or benign prostatic hyperplasia‐related surgery did not differ significantly between treatment groups in the Asian subpopulation. In Caucasian men, the incidence of acute urinary retention/benign prostatic hyperplasia‐related surgery was significantly lower in the combination therapy group compared with the tamsulosin monotherapy group (P < 0.001), but not compared with dutasteride monotherapy. Combination therapy significantly increased the time to benign prostatic hyperplasia clinical progression and resulted in improved International Prostate Symptom Score, maximum urinary flow rate, quality of life, and reduced prostate volume in Asian and Caucasian men who received combination therapy compared with tamsulosin monotherapy. Combination therapy also significantly improved (P < 0.05) time to benign prostatic hyperplasia clinical progression, International Prostate Symptom Score, maximum urinary flow rate and quality of life versus dutasteride in the Caucasian subpopulation. The adverse‐event profile was comparable between subpopulations. In conclusion, Asian and Caucasian men respond similarly to these treatments, despite apparent racial differences in 5α‐reductase activity.     

Diabetes mellitus and health-related quality of life in prostate cancer: 5-year results from the Prostate Cancer Outcomes Study

Study Type – Therapy (outcomes research)
Level of Evidence 2b What’s known on the subject? and What does the study add? Comorbid diabetes can affect prostate cancer treatment decision‐making and outcomes. Few longitudinal studies have investigated the effect of comorbid diabetes on general and cancer‐specific health‐related quality of life (HRQL) in prostate cancer. Our study found that men with prevalent diabetes (pre‐prostate cancer diagnosis) generally had the poorest general HRQL, urinary control and sexual function scores over time, independent of treatment. Non‐diabetic men had the best scores and men with incident diabetes (post‐prostate cancer diagnosis) reported intermediate scores. OBJECTIVE ? To investigate the association between prostate cancer, diabetes, and long‐term general and cancer‐specific health‐related quality of life (HRQL) in a cohort of men with non‐metastatic prostate cancer. PATIENTS AND METHODS ? We used data from self‐administered surveys to assess the HRQL of men with localized or locally advanced disease at 6 (baseline), 12, 24, and 60 months after initial diagnosis. ? We examined changes in general and cancer‐specific HRQL with repeated measures analyses using a mixed‐model approach. RESULTS ? In total, we evaluated 1811 men, including 13% with prevalent (pre‐prostate cancer diagnosis) diabetes, 12% with incident (post‐prostate cancer diagnosis) diabetes, and 75% who never reported being diagnosed with diabetes. ? Generally, men with prevalent diabetes had the poorest scores on general HRQL and non‐diabetic men the best scores, independent of treatment. ? Similarly, men with prevalent diabetes had the lowest urinary control and sexual function scores over time, while men without diabetes had the highest scores. Men with incident diabetes reported intermediate scores. CONCLUSION ? Prostate cancer survivors with comorbid diabetes have poorer general and cancer‐specific HRQL than those without diabetes.     

Antibiotic compared with antiseptic prophylaxis for prostatic surgery

Two different regimens of cephalosporin antibiotic prophylaxis were compared with antiseptic lubricating jelly to try to prevent infection and complications in 196 men after prostatic surgery. Pre-operative urine was cultured and prostatic chips (170 cases) were also cultured to define the source of any infection. The use of antibiotics was associated with a reduced risk of postoperative bacteriuria. No serious complications occurred, although 1 patient in the antiseptic treated group developed rigors; 79 of 170 patients (46%) had positive prostatic chip cultures, of whom 74 had sterile pre-operative urine. There was no association between the result of chip culture and the presence of a pre-operative catheter. Culture positive patients had an increased risk of post-operative urine infection, although the same organism was found in the prostate and urine in only 36% of cases of post-operative bacteriuria and in 43 (54%) the organism cultured from the prostate was Staphylococcus albus. This study provides further evidence of the benefit of true prophylactic antibiotic therapy for transurethral prostatic surgery and the prostatic chip data suggest that some of the risk is due to pre-operative contamination of the prostate in the absence of per-operative urinary infection or catheterisation.     

Spectrum of mitochondrial genomic variation and associated clinical presentation of prostate cancer in South African men

BACKGROUND

Prostate cancer incidence and mortality rates are significantly increased in African–American men, but limited studies have been performed within Sub–Saharan African populations. As mitochondria control energy metabolism and apoptosis we speculate that somatic mutations within mitochondrial genomes are candidate drivers of aggressive prostate carcinogenesis.

METHODS

We used matched blood and prostate tissue samples from 87 South African men (77 with African ancestry) to perform deep sequencing of complete mitochondrial genomes. Clinical presentation was biased toward aggressive disease (Gleason score >7, 64%), and compared with men without prostate cancer either with or without benign prostatic hyperplasia.

RESULTS

We identified 144 somatic mtDNA single nucleotide variants (SNVs), of which 80 were observed in 39 men presenting with aggressive disease. Both the number and frequency of somatic mtDNA SNVs were associated with higher pathological stage.

CONCLUSIONS

Besides doubling the total number of somatic PCa‐associated mitochondrial genome mutations identified to date, we associate mutational load with aggressive prostate cancer status in men of African ancestry. Prostate 76:349–358, 2016. © 2015 The Authors. The Prostate published by Wiley Periodicals, Inc.     

Prophylactic cefuroxime in transurethral resection

Summary 65 men undergoing elective transurethral resection of the prostate under the care of one urologist entered a randomised controlled trial using Cefuroxime. Patients were excluded if they had received antibiotics in a 2 week period before surgery, if they had positive pre-operative urine cultures or if they had been catheterised. 58 patients completed the study. One patient in the antibiotic group and 2 in the control group developed urinary infection. The overall infection rate was 5.17%. The control and antibiotic groups were comparable as regards age and the duraction of resection. One patient in the antibiotic group developed an allergic reaction. It is felt that routine antibiotic prophylaxis in patients with sterile urine undergoing elective TUR is unnecessary.     

Periurethral abscess

From 1963 to 1985, 63 periurethral abscesses were treated in 47 men. The records were reviewed to characterize the natural course of the disease. The most common predisposing factors were a history of gonorrhea, previous periurethral abscess and urethral stricture disease. Treatment consisted of abscess drainage, suprapubic urinary diversion and intravenous antibiotic therapy, consisting of an aminoglycoside and a cephalosporin. Mortality was 1 of 63 patient hospitalizations (1.6 per cent). Improved survival over historical cohorts is attributed to the availability of better antibiotics and medical support.