eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions

Acute Bacterial Prostatitis and Prostatic Abscess: Treatment

Author: Jonathan J Rhee, MD, Staff Physician, Department of Urology, University of Virginia
Coauthor(s): Michael Piesman, MD, Staff Physician, Department of Internal Medicine, Madigan Army Medical Center; Raymond A Costabile, MD, Jay Y Gillenwater Professor of Urology, University of Virginia Health System
Contributor Information and Disclosures

Updated: Dec 5, 2008

Treatment

Medical Therapy

The intense inflammation in acute bacterial prostatitis (ABP) makes the prostate gland highly responsive to antibiotics, which otherwise penetrate poorly into the prostate. Hospitalization is required for patients in whom acute urinary retention develops and in those who require intravenous antimicrobial therapy.

The choice of antibiotic is based on results of the initial culture and sensitivity. However, initial therapy should be directed at gram-negative enteric bacteria. Useful agents include fluoroquinolones, trimethoprim-sulfamethoxazole, and ampicillin with gentamicin. Antipyretics, analgesics, stool softeners, bed rest, and increased fluid intake provide supportive therapy. A Foley catheter can be inserted gently for drainage if severe obstruction is suspected. A punch suprapubic tube can be used if a catheter cannot be passed easily or is not tolerated by the patient. The catheter can be removed 24-36 hours later.

If the initial clinical response to therapy is satisfactory and the pathogen is susceptible to the chosen antibiotic, treatment is continued orally for 30 days to prevent sequelae such as chronic bacterial prostatitis and prostatic abscess formation.

For intravenous therapy, use trimethoprim-sulfamethoxazole (Bactrim), 8-10 mg/kg/d (based on the trimethoprim component) in 2-4 intravenous doses bid, tid, or qid until the culture and sensitivity results are known. An alternate regimen is gentamicin with ampicillin 3-5 mg/kg/d IV (gentamicin dose divided tid and 2 g ampicillin divided qid). After the patient is afebrile for 24 hours, an appropriate oral agent can be substituted for an additional 30 days.

For oral therapy, use trimethoprim-sulfamethoxazole (Bactrim), 160 mg of trimethoprim and 800 mg of sulfamethoxazole, PO bid for 30 days. Use levofloxacin (Levaquin) 500 mg PO bid; ciprofloxacin, 500 mg PO bid; norfloxacin, 400 mg PO bid; ofloxacin, 400 mg PO bid; or enoxacin, 400 mg PO bid for 30 days when clinical response is favorable.

Alpha-blocker therapy should also be considered. Because the bladder neck and prostate are rich in α receptors, alpha blockade may improve outflow obstruction and diminish intraprostatic urinary reflux (terazosin 5 mg/d PO for 4-52 wk).14 Tamsulosin (Flomax), alfuzosin (UroXatral) and doxazosin (Cardura) are acceptable alternatives.

Because of the limitation of alpha-blockers, clinical trials are ongoing using combination of alpha-blockers and 5-alpha-reductase inhibitors.15

Surgical Therapy

A prostatic abscess can be surgically drained with either transrectal or perineal aspiration, transurethral resection, or transrectal ultrasound–guided placement of a transrectal drainage tube.3 Drainage of some kind should be performed if the abscess is larger than 1 cm.16,17 Because of the potential for systemic infection and bacteremia, urethral instrumentation should be avoided in patients with acute bacterial prostatitis, especially if the patient is unstable or already showing signs of sepsis. In patients with sepsis, transurethral resection may be life-saving and should be considered if they are not responding to conservative therapy.

In patients with acute urinary retention, a Foley catheter may be attempted first as tolerated by the patient. However, it may cause extreme discomfort. In some cases, the transurethral catheter may obstruct drainage of an acutely inflamed prostate and cause bacteremia or prostatic abscess. If the catheter is not easy to pass, a suprapubic punch cystostomy is indicated.

Follow-up

For excellent patient education resources, visit eMedicine's Prostate Health Center. Also, see eMedicine's patient education articles Understanding the Male Anatomy and Prostate Infections.

Complications

Prostatic abscess is an uncommon but well-described complication of acute bacterial prostatitis (ABP). Although very rare, it usually occurs in patients who are immunocompromised, patients who have diabetes, patients with urethral instrumentation or prolonged indwelling urethral catheters, or patients on maintenance dialysis. Coliform bacteria, especially E coli, cause more than 70% of prostatic abscesses. A prostatic abscess should be suspected when worsening clinical symptoms follow an initial favorable response to treatment of acute bacterial prostatitis or a fluctuant mass is developing in the prostate gland. The presence of the abscess is confirmed with transrectal ultrasonography and noncontrast CT scanning of the pelvis.

Once an abscess is diagnosed, anaerobic antimicrobial therapy should be added to the treatment regimen. Clindamycin intravenously at 600-900 mg q8h or orally at 150-450 mg q8h is a good choice. However, medical management is often unsuccessful. Transrectal or perineal aspiration of the abscess is preferred and is often effective, especially if symptoms do not improve after 1 week of medical therapy. Transurethral resection of the prostate and drainage of the cavity is another approach. Recurrent abscesses are rare. The abscess should be allowed to drain and should be monitored closely if a spontaneous rupture occurs into the urethra.

Other potential sequelae of acute bacterial prostatitis include progression to chronic prostatitis, septicemia, pyelonephritis, and epididymitis.

More on Acute Bacterial Prostatitis and Prostatic Abscess

Overview: Acute Bacterial Prostatitis and Prostatic Abscess
Workup: Acute Bacterial Prostatitis and Prostatic Abscess
Treatment: Acute Bacterial Prostatitis and Prostatic Abscess
Follow-up: Acute Bacterial Prostatitis and Prostatic Abscess
Multimedia: Acute Bacterial Prostatitis and Prostatic Abscess
References
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References

  1. Nickel JC. 5 alpha reductase therapy for chronic prostatitis. In: Nickel JC, ed. Textbook of Prostatitis. Oxford, UK: ISIS Medical Media; 1999:333-7.

  2. Collins MM, Stafford RS, O'Leary MP, Barry MJ. How common is prostatitis? A national survey of physician visits. J Urol. Apr 1998;159(4):1224-8. [Medline].

  3. Nickel, JC. Inflammatory Conditions of the Male Genitourinary Tract: Prostatitis and Related Conditions, Orchitis, and Epididymitis. In: Wein, Kavoussi, Novick, Partin, Peters, eds. Campbell-Walsh Urology. 1. 9th ed. 2005:Chapter 9.

  4. Kanamaru S, Kurazono H, Terai A. Increased biofilm formation in Escherichia coli isolated from acute prostatitis. International Journal of Antimicrobial agents. 2006;28S:21-25.

  5. Bergman B. On the relevance of gram-positive bacteria in prostatitis. Infection. 1994;22 Suppl 1:S22. [Medline].

  6. Lomberg H, Cedergren B, Leffler H, et al. Influence of blood group on the availability of receptors for attachment of uropathogenic Escherichia coli. Infect Immun. Mar 1986;51(3):919-26. [Medline].

  7. Muller A, Mulhall JP. Sexual dysfunction in the patient with prostatitis. Curr Opin Urol. Nov 2005;15(6):404-9. [Medline].

  8. Barozzi L, Pavlica P, Menchi I. Prostatic abscess: diagnosis and treatment. AJR Am J Roentgenol. Mar 1998;170(3):753-7. [Medline].

  9. Nickel JC. The Pre and Post Massage Test (PPMT): a simple screen for prostatitis. Tech Urol. 1997;3(1):38-43. [Medline].

  10. Magri V, Cariani L, Bonamore R, et al. Microscopic and microbiological findings for evaluation of chronic prostatitis. Arch Ital Urol Androl. Jun 2005;77(2):135-8. [Medline].

  11. Meares EM, Stamey TA. Bacteriologic localization patterns in bacterial prostatitis and urethritis. Invest. Urology. 1968;5:492-518.

  12. Terrone C, Poggio M, Bollito E, et al. [Asymptomatic prostatitis: a frequent cause of raising PSA]. Recenti Prog Med. Jul-Aug 2005;96(7-8):365-9. [Medline].

  13. Granados EA, Riley G, Salvador J, Vincente J. Prostatic abscess: diagnosis and treatment. J Urol. Jul 1992;148(1):80-2. [Medline].

  14. Barbalias GA, Nikiforidis G, Liatsikos EN. Alpha-blockers for the treatment of chronic prostatitis in combination with antibiotics. J Urol. Mar 1998;159(3):883-7. [Medline].

  15. Wyllie MG. Promise for prostatitis?. BJU Int. Nov 2005;96(7):1137-8. [Medline].

  16. Aravantinos E, Kalogeras N, Zygoulakis N, Kakkas G, Anagnostou T, Melekos M. Ultrasound-Guided Transrectal Placement of a Drainage Tube as Therapeutic Management of Patients with Prostatic Abscess. Journal of Endourology. 2008;22:1751-1754.

  17. Chou YH, Tiu CM, Liu JY. Prostatic abscess: transrectal color Doppler ultrasonic diagnosis and minimally invasive therapeutic management. Ultrasound Med. Biol. 2004;30:719-724.

  18. Meares EM Jr. Prostatitis. Med Clin North Am. Mar 1991;75(2):405-24. [Medline].

  19. Hennenfent B. The economics of urological care in the 21st century. Urology. Feb 1996;47(2):285-6. [Medline].

  20. Lipsky BA. Prostatitis and urinary tract infection in men: what's new; what's true?. Am J Med. Mar 1999;106(3):327-34. [Medline].

  21. Ludwig M, Schroeder-Prentzen I, Schiefer HG, Weidner W. Diagnosis and therapeutic management of 18 patients with prostatic abscess. Urology. 1999;53:340-345.

  22. Nickel JC. Prostatitis: myths and realities. Urology. Mar 1998;51(3):362-6. [Medline].

  23. Pewitt EB, Schaeffer AJ. Urinary tract infection in urology, including acute and chronic prostatitis. Infect Dis Clin North Am. Sep 1997;11(3):623-46. [Medline].

  24. Procopiou M, Genne D, Abbet P. Acute prostatitis with prostatic abscess caused by group B Streptococcus. Clin Infect Dis. Aug 1998;27(2):403-4. [Medline].

  25. Roberts RO, Lieber MM, Bostwick DG. A review of clinical and pathological prostatitis syndromes. Urology. Jun 1997;49(6):809-21. [Medline].

  26. Schaeffer AJ. Clinical practice. Chronic prostatitis and the chronic pelvic pain syndrome. N Engl J Med. Oct 19 2006;355(16):1690-8. [Medline].

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Further Reading

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Keywords

acute bacterial prostatitis, prostatic abscess, ABP, acute prostatitis, prostatitis, prostate disease, bladder outlet obstruction, benign prostatic hyperplasia, chronic bacterial prostatitis, nonbacterial prostatitis, abacterial prostatitis, prostatodynia, male urinary tract infection, Escherichia coli, Proteus mirabilis, Klebsiella species, Enterobacter species, Pseudomonas aeruginosa, Serratia species, acute infection of the prostate, recurrent urinary tract infection, chronic infection of the prostate, chronic abacterial prostatitis, chronic pelvic pain syndrome, inflammatory chronic pelvic pain syndrome, noninflammatory chronic pelvic pain syndrome, asymptomatic inflammatory prostatitis, intraprostatic urinary reflux

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Contributor Information and Disclosures

Author

Jonathan J Rhee, MD, Staff Physician, Department of Urology, University of Virginia
Jonathan J Rhee, MD is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Nothing to disclose.

Coauthor(s)

Michael Piesman, MD, Staff Physician, Department of Internal Medicine, Madigan Army Medical Center
Michael Piesman, MD is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Raymond A Costabile, MD, Jay Y Gillenwater Professor of Urology, University of Virginia Health System
Raymond A Costabile, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society of Andrology, American Urological Association, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Edmund S Sabanegh, MD, Director, Center for Male Fertility, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation
Edmund S Sabanegh, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Society for the Study of Male Reproduction, Society of Reproductive Surgeons, and Southwest Oncology Group
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

 
 
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