850996 URO Journal of Clinical UrologyRidgway et al.

Infection in Urology. Literature Review

Journal of Clinical Urology

Prostate abscess: A comprehensive review

1­–8
© British Association of
Urological Surgeons 2019
of the literature Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/2051415819850996
https://doi.org/10.1177/2051415819850996
journals.sagepub.com/home/uro

Alexander J Ridgway1 , Angus Chin-On Luk2 and Ian Pearce3

Abstract
Prostate abscess (PA) is a rare but serious infection of the prostate gland. Traditionally a complication of urethral
gonococcal infection, the majority of PAs are now seen in the older or immunosuppressed populations, in men with
existing prostatic disease, or those who have undergone recent instrumentation of the lower urinary tract. Aetiological
organisms are diverse, often with non-specific presentations posing a diagnostic challenge. Multiple management
options have been described, however no consensus exists on what is the best practice. This comprehensive review
examines the literature surrounding this condition in detail, with a focus on diagnostic and surgical treatment options.
Recommendations for practice are made where appropriate. This article aims to edge towards a national guideline for
the management of PA and inspire more research in the field.
Level of evidence - 3a

Keywords
Benign prostate disorders, infection in urology, basic science, radiology, other

Date received: 30 October 2018; accepted: 17 April 2019

Background outflow obstruction and/or immunocompromise. Causative

Prostate abscess (PA) is a rare clinical entity with a
potentially high mortality rate. It occurs from the focal
accumulation of pus in one or more lobes of the prostate
and is commonly thought to be a complication of acute
prostatitis.1
The majority of PAs are seen in the fifth and sixth dec-
ades of life,2 though may occur at any age with sporadic
instances in the paediatric population.3,4 Incidence data for
the condition is drawn from the 1990s when PA was esti-
mated to affect between 0.2–0.5% of men with urological
symptoms.5 Mortality, which was once as high as 50%, has
significantly reduced to as low as 3–16% with the intro-
duction of antibiotics, early identification and treatment of
urethral gonococcal infection.6,7
Two distinct mechanisms for the pathogenesis of PA
pathogens are usually enteric organisms such as
Escherichia coli and other coliform bacteria.8
The other less common mechanism is via bacterial
haematogenous spread from a distant focus of infection,
such as respiratory, digestive or urinary tracts and the skin.
This involves a smaller subgroup of patients (approxi-
mately 25% of cases) and a variety of causative microor-
ganisms, including Staphylococcus aureus,9 Mycobacterium
tuberculosis,10 Escherichia coli,11 Klebsiella pneumoniae,12
Pseudomonas aeruginosa,13 Burkholderia pseudomallei14
and Candida Spp.15
1West Middlesex University Hospital, London, UK
2Freeman Hospital, Newcastle-upon-Tyne, UK
3Manchester Royal Infirmary, Manchester, UK

have been asserted. The first is via the retrograde flow of

Corresponding author:
contaminated urine through the prostatic ducts and accu- Alexander J Ridgway, West Middlesex University Hospital,
mulation and subsequent infection within the prostate. Twickenham, London, TW7 6AF, UK.
This typically occurs in men with pre-existing bladder Email: alexjridgway@doctors.org.uk
2 Journal of Clinical Urology 00(0)
Abscesses may be simple or loculated, unifocal or mul-
tifocal and may be found in any zone of the gland.6 Whilst
abscess encapsulation prevents infected material from
reaching neighbouring structures, it also reduces pene-
trance of host immune cells and mediators. As a conse-
quence abscesses rarely resolve without any medical or
surgical intervention.
Risk factors and association
Diabetes mellitus is the most commonly cited predispos-
ing co-morbidity for the development of prostatic abscess
with a reported co-prevalence of up to 63%.16 Other causes
of immunosuppression including liver cirrhosis, renal fail-
ure and haemodialysis also predispose to PA. The reported
incidence of PA in men living with HIV is 3%, and as high
as 14% in those who have progressed to AIDS.10 This con-
sidered, clinicians should have a high index of suspicion
for such underlying conditions in a previously healthy
male presenting with PA.
Indwelling catheters, bladder outlet obstruction and
recent instrumentation of the lower urinary tract are also
risk factors for the development of PA with previous cross-
sectional studies reporting that 8–11% of patients present-
ing with PA had recently undergone prostatic biopsy.1 There
have been case reports of PA caused by M. tuberculosis
after intravesical bacillus Calmette-Guérin immunother-
apy17 and following cryotherapy for prostate cancer.18,19
Presentation and work up
Dysuria and urinary frequency are the most common
symptoms of PA (71–77%), with acute urinary retention
and fever also occurring in a third of cases.20,21 Patients
may rarely complain of perineal or lower back pain, pain
on defaecation, and haematuria.
Such symptoms do not easily differentiate PA from
other diseases of the lower urinary tract, potentially result-
ing in delayed diagnosis with PA often being misdiagnosed
as acute prostatitis, only to be correctly diagnosed with
failure to respond to medical treatment.
Digital rectal examination (DRE) is the cornerstone of
PA clinical diagnosis with fluctuance or ‘bogginess’ being
almost pathognomic of PA. One study found that fluctua-
tion on DRE was present in 83% of patients with PA con-
firmed by ultrasound,22 though other studies put the figure
much lower at between 29–43%.23–25 Prostate-specific
antigen (PSA) values are also likely to be raised.
Based on its location, a PA may spontaneously fistulate
and drain into one of the surrounding pelvic structures.
Abscesses located near the base of the gland fistulate into
the bladder or proximal prostatic urethra, whilst those near
the apex may lead to rectal or perianal fistulas.6 Drainage
may be reported by the patient. Severe cases of PA may
also extend to the seminal vesicle and spermatic cord.
PA represents a significant diagnostic challenge and a
high index of suspicion is required. It should be considered
as a differential diagnosis in men with persistent fever and
lower urinary tract symptoms despite antibiotic use, par-
ticularly in patients with diabetes or following prostatic
biopsy. Delay in diagnosis is associated with poor out-
comes, resulting from complications such as abscess rup-
ture and overwhelming sepsis.26,27
Microbiology
Gram-negative bacilli (predominantly E. coli) are the most
common causative pathogens, responsible for between
60–80% of infections.2 Other organisms may also be
implicated depending upon patient characteristics and co-
morbidities, for example methicillin-resistant S. aureus
(MRSA) among patients with diabetes and intravenous
drug users28 and M. Tuberculosis and Mycobacterium
avium in patients with HIV.10
In the 1970s approximately 75% of infections were sus-
ceptible to first-generation antibiotics but with time this
figure has now fallen to approximately 20%.16 Quinolones
such as ciprofloxacin, which have traditionally been used
in the UK owing to their broad spectrum of cover and good
penetration into the prostate, are demonstrating declining
efficacy due to increasing resistance.29 Alarmingly, there
have now been more than 30 reported cases of MRSA PA
in the literature.30 A low threshold for changing antibiotic
therapy is imperative when patients do not respond ade-
quately to initial treatment.
Imaging
Prostatic abscesses may be difficult to differentiate from
other urinary tract or prostate pathologies on the basis of
history and examination alone. Thus, radiological imaging
becomes vital to confirm the diagnosis and at times, assess
treatment outcome. Ultrasound, computed tomography
(CT) and magnetic resonance imaging (MRI) form the
mainstay of PA imaging.
Trans-rectal ultrasound
The availability of trans-rectal ultrasound (TRUS) has
made it the most commonly used imaging tool for PA. It
has the benefit of offering both diagnostic and therapeutic
opportunities and has been found to be the most reliable
method to diagnose the condition, providing an accurate
diagnosis in between 80–100% of cases.16,23–25
Abscesses are hypoechoic and well defined on ultra-
sound scans. There may be internal septa or heterogeneous
solid portions.21 A peri-lesional hypoechoic halo may be
present and colour-doppler may demonstrate increased
peri-lesional flow, reflecting hyperaemia.6 Several classifi-
cation systems for the ultrasonographic appearance of PA
Ridgway et al. 3
have been suggested although none of these has gained
widespread clinical acceptance.21,31,32
Although current data indicates that CT and MRI offer
no advantage over TRUS in terms of diagnosis,7,16,23 this
imaging method is limited by its ability to estimate the
extension of abscesses that have penetrated the confines of
the prostate gland.22 Patients may also find TRUS too
painful to tolerate and alternative imaging may be required.
CT
Unlike the intrusive, often uncomfortable and two-
dimensional TRUS, CT offers non-invasive cross-sec-
tions of internal structures, which can be built up to a 3D
image. CT scanning is acceptable to most patients and
a good alternative in those who cannot tolerate the
trans-rectal approach, or those who require further extra
-glandular imaging. The appearance of low-attenuation,
well-demarcated regions within one or more lobes of the
prostate is suggestive of PA.33
MRI
MRI offers similar benefits to CT scanning, whilst being
radiation-free. The imaging modality functions at a molec-
ular level and offers unparalleled resolution and tissue
contrast.34 It has been lauded for its ability to distinguish
between tissue of the prostate and the seminal vesicle.35
Additionally, it may pick up abscesses in the initial stages
of formation where TRUS may be inconclusive. PAs
appear hypointense on T1 weighted MR and hyperintense
on T2 weighted images.36
There is no standardisation for the diagnostic assess-
ment for PA, though TRUS is widely accepted to be the
gold standard. Although CT and MRI have undeniable
clinical value, they do not offer the same one-step real-
time approach to assessment and treatment of PA.
Management
PA requires prompt recognition and initiation of treatment.
Antibiotics are the mainstay of medical management for
PA and can offer an alternative to surgical intervention in
the case of smaller abscesses.
Given the range of potential pathogens there is a lack of
uniformity and guidance in relation to therapeutic antimi-
crobial prescription. Microbiological consultation is vital,
taking into account geographical location, patient co-
morbidities and environmental exposures. Blood cultures,
mid-stream specimen urine (MSSU), surgical aspirates
and semen samples, though difficult and painful to obtain
from patients with PA, have a high clinical value in deter-
mining the causative organism and corresponding sensi-
tivities. It should be noted, however, that initial urine
samples have grown wholly different pathogens to those
isolated from the more reliable surgical aspirates.10,16
Prolonged parenteral antibiotic courses of at least 2 weeks,
followed by 2–4 weeks of oral treatment are usually
required.
Traditionally, only abscesses smaller than 1 cm were
deemed suitable for non-operative management.15,37,38 In
the largest study to date examining the outcomes of PA
with different treatment modalities, all 16 patients in their
series with abscesses <2 cm made full recovery without
surgical drainage; whilst these patients required longer
courses of antibiotics, there was no significant difference
in length of hospital stay.39 Case reports point to very poor
outcomes for patients with abscesses >2 cm managed
medically.8,39
Opinion regarding surgical approach also varies, with
the previously favoured perineal incision now seldom used
due to high morbidity including erectile dysfunction from
damage to local nerves.38
Surgical options broadly fall within three categories:
trans-perineal, trans-rectal and trans-urethral.
Trans-perineal approach
Trans-perineal aspiration allows rapid assessment and
drainage of the abscess under ultrasound guidance, usually
without the need for general anaesthetic, though it is less
well tolerated by patients than the trans-rectal approach
(See Table 1 for full comparison).40
A number of low volume series examine trans-perineal
drainage for PA and report encouraging success rates.
Oliveira et al. found that of the four PAs drained in their
study period, three were successful whilst one went on to
have further surgery.7 Elwagdy et al. prospectively exam-
ined 18 men with PA. All underwent trans-perineal aspira-
tion and only 11.1% of patients required further surgical
intervention. In all patients, drainage produced rapid clini-
cal improvement and resolved pain and fever.22 El-Shazly
et al. describe trans-perineal drainage for two cases in
which PA had extended into the ischiorectal fossa, both
with good effect.41
Trans-rectal approach
Trans-rectal aspiration is very similar to a TRUS biopsy
and is favoured by many urologists who are already com-
fortable with this approach. Lim et al. reported a success
rate of 85.7% in their case series of 14 patients, though
four of these needed at least one further attempt at drain-
age giving a primary success rate of 57%. Failures were
due to either small volume aspirate or subsequent perirec-
tal abscess.21 Gogus et al. reported a success rate of 83.3%;
the abscess recurred in one out of six patients and this
patient went on to have a trans-urethral resection of the
prostate (TURP).42 Collado et al. reported a success rate of
83.3% in 24 patients who underwent trans-rectal aspiration
4 Journal of Clinical Urology 00(0)
Table 1.  Comparing trans-perineal with trans-rectal aspiration.
Pros
Trans-perineal Simple procedure
Trans-rectal Shorter needle trajectory
More comfortable for patient
Less chance of bleeding and damage to local structures
Familiar approach to urologists
as the initial therapy,15 whilst Goyal et al. submitted three
patients, all with multifocal PAs, to trans-rectal aspiration
with treatment ultimately failing in all cases,31 presumably
due to the multifocal nature of the abscesses. Vyas et al.
reported a success rate of 85.4% out of their 48 patients
with PA, however, complete resolution after one aspiration
was only observed in 20 patients; an average of 4.1 (range
1–7) aspirations was required for abscess clearance in 41
patients, with seven ultimately requiring TURP/
deroofing.25
Some advocate leaving an indwelling catheter in the
abscess following drainage to allow complete evacuation.
Aravantinos et al. reported a 100% success rate with trans-
rectal aspiration and continuous drainage, 29% of whom
had multifocal PA.43
Trans-urethral approach
The major disadvantage of both trans-perineal and trans-
rectal approaches is the risk of incomplete abscess drain-
age. Trans-urethral drainage offers a more definitive and
efficacious treatment of PA. Indeed, in larger published
studies up to one third of patients with PA ultimately
required TURP.44,45
Procedures range from limited interventional tech-
niques such as trans-urethral incision (TUI) and trans-
urethral deroofing (TUD) to the more invasive and stand-
ard TURP. Although these are described as three distinct
procedures in the literature, the techniques enjoy signifi-
cant overlap.
In a case series by Tiwari et al., 17 out of 19
patients underwent TUD (one of which followed
failed aspiration). All abscesses were successfully
cleared, including those with multi-focal abscesses. 2
Trauzzi et al. and El-Shazly et al. each performed
TUD for seven patients, all of which were successful
at clearing the abscess. 10,43
Lee et al. proposed a novel method for TUD using
Holmium laser. In their prospective case series of eight
patients, all abscesses were cleared successfully without
recurrence with a mean length of stay post-surgery of 11.6
days.46
Many authors advocate TURP for the treatment of PA.
Dong Sup Lee et al. treated 14 patients with TURP
with successful abscess clearance being reported in all
Cons
More painful than trans-rectal approach
Risk of recto-urethral fistula, faecal
contamination of abscess cavity, perirectal
abscess
patients.39 In addition Jang et al. found that 23 patients
having TURP had a significantly shorter hospital stay
compared to 18 patients who underwent aspiration (aver-
age of 10.2 days and 23.2 days, respectively).8 Since older
patients with PA may already have a degree of prostate
hyperplasia, this makes TURP an attractive option in this
age group.
The risks of transurethral procedures include direct
haematogenous spread of the organism, retrograde ejacu-
lation, urethral stenosis and incontinence.38 Reporting of
these varies among studies, perhaps due to the transient
nature and underreporting of symptoms.
Only three studies have reported retrograde ejacula-
tion following trans-urethral drainage. This occurred in
6–28% of patients.16,31,41 This risk, however, may be
unacceptable to a younger patient wanting to retain
fertility.
It should be noted that whilst the above procedures
carry risks, delays in treatment may have similar conse-
quences. Progression of disease may lead to seeding via
direct haematogenous spread, abscess enlargement and
compression of surrounding structures, fistulation and
rupture, leading to more complicated and invasive sur-
gery with increased mortality and morbidity. Table 2
summarises surgical interventions and outcomes across
included studies.
Discussion
PA remains a rare but serious condition that requires
prompt identification and management. Given its rarity the
burden of disease is difficult to estimate in the UK.
Historically a disease of the young and promiscu-
ous, the most common risk factor is now diabetes,
though the diagnosis should be considered in all immu-
nocompromised patients with lower urinary tract
symptoms who fail to respond to initial therapy. Those
who have undergone instrumentation of the lower uri-
nary tract including long-term catheter, and patients
with storage and/or voiding problems are also at
increased risk.
Fluctuance on digital rectal exam is pathognomonic for
PA, though is not always present clinically. Blood cultures,
MSSU and surgical aspirates are indispensable in an era of
increasing levels of antimicrobial resistance and atypical
Ridgway et al. 5

Table 2.  Comparison of surgical interventions and outcomes for management of Prostate Abscess.

Study N Method Abscess character- Success rate Other information

istics

Aravantinos 7 Trans-rectal drainage All >1.5cm, 2 All successful BOO in 2 patients.

200843 + indwelling catheter multi-focal Average hospitalization
10 days

Bhagat 200816 35 14 TURP, 17 TUR 3 had retrograde

drainage, 4 aspiration ejaculation following
TUR drainage

Collado 199915 29 24 aspiration, 5 TURP 2 failed aspiration and

needed repeat, 3 required
TURP

Dajani and 25 9/25 required full TURP

O’Flynn, 196845 for PA

Dong Sup Lee 15 TURP All successful

201639

El-Shazly 11 7 TUR deroofing, 2 3 of the 7 TUR patients 2 of 7 TURs had

201241 TRUS aspiration, 2 previously had attempted retrograde ejaculation
perineal drainage and failed aspiration

Elwagdy 201522 18 TRSS + trans-perineal Mean pus drained 16 complete resolution

needle aspiration 15.1ml +/- 1.5 2 recurrence – TUR
(3.6–29.3)

Gogus 200442 6 TRUS-guided trans- Mean 31.6ml 5/6 success (1 recurrence No serious
rectal aspiration (17–65) + BOO – had TUR) complications

Goyal 201331 17 3 aspiration, 3 TURP All abscesses All aspirations failed –

in first instance (+ 3 multi-loculated or underwent TURP
redos), 11 TUR multi-focal

Jang 20128 41 18 TRUS aspiration, 23 Abscess size mean 4 failed aspiration. LOS 10.2 days
TURP 3.88cm (2–6) in TURP, 23.2 in
aspiration

Lee 201546 8 Holmium laser TUD Mean pus drained All successful, no Mean LOS post-
83.5ml (42–162) recurrence surgery 11.6 days
(5–32)

Lim 200021 14 TRUS guided Mean 12ml 12/14 success (4/12 needing Failures due to
aspiration, no drain (2–28ml) repeat drainage) perirectal abscess/small
aspirate

Morse 200944 57 51 aspiration, 28 open 20 needed retreating

drainage

Oliveira 20037 7 4 aspiration (1 failed), 1 failed aspiration, needed

3 TURP TURP

Tiwari 20112 19 16 TRUS deroofing; 3 1/3 needle aspirations had  

trans-perineal needle recurrence – underwent
aspiration TUD

Trauzzi 199410 7 TUR deroofing All successful  

Vyas 201325 48 48 TRUS aspiration Mean 10.2ml 20 successful initially,  

(2.5–30) average of 4.1 (1–7)
aspirations. 7 required
TURP/deroofing

BOO: bladder outlet obstruction; LOS: length of stay; PA: prostate abscess; TRUS: trans-rectal ultrasound; TUD: trans-urethral deroofing; TUR:
transurethral resection; TURP: transurethral resection of prostate.
6 Journal of Clinical Urology 00(0)

Figure 1.  Suggested treatment algorithm for prostate abscess.

DRE: digital rectal exam; PA: prostate abscess; MSU: mid-stream urine; TRUS: trans-rectal ultrasound scan; CT: computed tomography; MRI: magnetic
resonance imaging; TURP: transurethral resection of prostate.

causative organisms. TRUS is the gold-standard diagnosis
and offers a one-step approach to aspiration and drainage. CT
and MRI should be reserved for those in whom TRUS is not
tolerated or contraindicated, or when there is diagnostic
uncertainty.
Broad-spectrum parenteral antibiotics and analgesia are
the mainstay of initial therapy for those with suspected PA.
Microbiological consultation is always recommended and
clinicians should keep a low threshold for switching antibi-
otic if a patient fails to improve clinically. Those with small
abscesses (<2 cm) may respond well to antibiotics alone,
their progress monitored clinically or with serial scans.
Aspiration and drainage should be reserved for patients with
a simple abscess in a clinically-stable condition, and
Ridgway et al. 7
particularly those of a younger age for whom fertility is
more of an issue. For septated or multiple abscesses, and in
those who are very unwell, TUD or TURP is perhaps more
suitable. Whilst these procedures have a higher rate of post-
operative complications, they have been shown to be the
more definitive methods for abscess clearance and may be
expedient in the elder patient with a degree of existing pros-
tate hyperplasia. We therefore suggest the treatment algo-
rithm for PA as shown in Figure 1.
Conclusion
PA presents a diagnostic and therapeutic challenge to clini-
cians. Diversifying aetiological organisms and increasing
antimicrobial resistance means there is little scope for anti-
biotic standardisation in practice. Similarly, the rarity of
the condition leaves us without any large-scale trials com-
paring surgical techniques. Treatment choices are largely
made on a patient-by-patient basis and according to patient
and surgeon preference. This article aims to edge towards
a national guideline for the management of PA and inspire
more research in the field.
Conflicting interests
IP is the editor of JCU.
Funding
This research received no specific grant from any funding agency
in the public, commercial, or not-for-profit sectors.
Ethical approval
Not applicable.
Informed consent
Not applicable.
Guarantor
Not applicable.
Contributorship
AR and AL researched literature and conceived the study. AR
wrote the first draft of the manuscript. All authors reviewed and
edited the manuscript and approved the final version of the
manuscript.
Acknowledgements
We would like to thank IP for his assistance and guidance in this
research.
ORCID iD
Alexander J Ridgway https://orcid.org/0000-0003-4767-1322
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