Transrectal ultrasound-guided aspiration of a prostatic abscess

Author(s)

Livanos A. Vougiouklis N. Chartabilas E. Malandri M.

Patient

male, 80 year(s)

Clinical History

An 80-year-old male was referred with dysuric disturbances. A TRUS and a CT examination revealed a large prostate gland with most of its parenchyma having been replaced by fluid, suggesting an abscess. The TRUS-guided aspiration confirmed the diagnosis and contributed to the therapy of the patient.

Imaging Findings

An elderly Caucasian male, aged 80, presented reporting dysuric symptoms. On clinical examination, a tenderness of the perineum and an enlarged, tender and warm prostate were found. The results of the laboratory analysis showed high blood glucose levels and the presence of numerous leukocytes in his urine. The plain abdominal radiograph of the abdomen was found to be negative. On the abdominal US scan (Fig. 1), the prostate was found to be enlarged, thick-walled and hypoechoic with areas of different echogenicity. An abdominal CT scan was taken, which confirmed the US findings. The prostate was enlarged, with interior fluid-density material and a thick, ragged wall (Figs. 2, 3). During a transrectal ultrasound it was found that most of the gland had been replaced by an ill-defined mass with cystic areas which were filled with an isoechoic material (Fig. 4). These contents were seen to swirl during the manipulation of the probe. The power color-Doppler examination did not show any vessels with flow. The radiological findings and the clinical impression suggested a prostatic abscess. At first a single prostate tissue sample was obtained from the periphery of the suspected parenchyma, however, this proved to be the intestinal wall. Using an 18G-diameter canulla of the biopsy needle, 60 ml of a yellowish-green purulent fluid were extracted and sent for laboratory analysis. During the following days, the patient’s condition was complicated by a local infection of perineum which was treated uneventfully with surgical drainage and antibiotics. On follow up, no signs of an active abscess were present.

Discussion

A prostatic abscess is an infrequent entity. The causative organisms are usually Gram-negative rods but Gram-positive and anaerobic bacteria can also be found. The patients present with pain on digital examination, along with dysuria, urinary frequency, perineal pain, acute urinary retention, and hematuria, and may also be febrile. When the symptoms persist despite therapy, a prostatic abscess should be suspected. On the US scan, the presence of a movable, gravity-dependent content at the center of the gland is typical . These findings can be confirmed on the CT scan and one would see loculated fluid-density material centrally, which does not enhance, contrary to the solid component of the gland which shows increased contrast enhancement. The therapeutic options include a transrectal or a transperineal US guided aspiration, a transurethral resection or a transurethral drainage. The transrectal US guided aspiration carries a small possibility of bleeding and spreading of the infection. The transperineal US guided aspiration is recommended in older patients, in emergency situations such as sepsis and in patients with a high risk for surgery. The latter method is more painful and the draining catheter has to remain longer.

Final Diagnosis

References

Citation

Livanos A. Vougiouklis N. Chartabilas E. Malandri M. (2005, Oct 29).

Transrectal ultrasound-guided aspiration of a prostatic abscess, {Online}.

URL: http://www.eurorad.org/case.php?id=3342

DOI: 10.1594/EURORAD/CASE.3342

ISSN: 1563-4086

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Published 29.10.2005
DOI 10.1594/EURORAD/CASE.3342
Section Uroradiology & Genital Male Imaging
Case Type Clinical Cases
Difficulty Resident
Views 4640
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Figure 1
An abdominal US

A transabdominal ultrasound of the prostate gland, with the longitudinal and transverse sections, revealing the enlargement of the gland, with a few highly reflective internal echoes. Its volume is estimated to be 78...
Figure 2
A CT of the prostate gland

An axial CT at the upper level of the prostate gland after IV contrast administration confirming the enlargement of the prostate protruding into the bladder and showing an enhancing ring.
Figure 3
Post-contrast CT at the center of the prostate gland

An axial CT scan taken at the center of the prostate gland showing that the gland is enlarged and most of its parenchyma is replaced by low density lobulated material. The gland abuts the obturator internus muscle...

Area of Interest: unknown; Imaging Technique: ww,ww;
Figure 4

a. A TRUS of the prostate gland in transverse section, showing that most of the gland has been replaced by an ill-defined mass with cystic areas filled with an intermediate echogenic material. These contents were seen...

Area of Interest: unknown;