A patient with a periurethal abscess has a tender inflamed area in his perineum, or under his penis. His abscess commonly arises in his bulbar urethra, probably in the paraurethral glands of Cowper, and is usually caused by gonococci to begin with; but these are soon replaced by secondary invaders. The danger is that his urine may leak from the abscess cavity, extravasate widely, and cause extensive cellulitis (23.10), or a fistula. His urine is infected, so this kind of cellulitis is more dangerous than that following traumatic rupture of his urethra. He may or may not have retention of urine due to an inflamed stricture, which will prevent you passing a catheter, so you may have to drain his bladder with a suprapubic cystotomy (23.5).
PERIURETHAL ABSCESSES DIFFERENTIAL DIAGNOSES. (1) A perianal abscess. (2) A scrotal abscess is in a different place and is not associated with urinary symptoms. (3) Localized penile extravasation of urine.
ANTIBIOTICS. Give the patient ampicillin, or chloramphenicol, until you have the results of culture of his urine and pus[md]if this is possible.
MANAGING HIS URINE. Most patients have retention of urine.
If he has retention of urine, try passing a soft rubber catheter. If this fails, as it probably will, do a suprapubic cystostomy, preferably a suprapubic puncture with a fine plastic tube (23.6). When the abscess is healing, start to pass bougies. This will be difficult, but take care not to use force.
If you succeed, bougie him every 3 months to start with, and less often later.
If you fail, try again a week later. If you still have difficulty, refer him; he may need a urethroplasty.
If he does not have retention of urine, dilate his stricture later.
THE ABSCESS. If pus is present, and he fails to respond to antibiotics, drain the abscess on to his perineum, and be sure to open it widely. Give him salt baths and pack the wound postoperatively.
DIFFICULTIES [s7]WITH A PERIURETHRAL ABSCESS If his urine EXTRAVASATES, see Section 23.10.
If you CANNOT REFER HIM for urethroplasty, he will have to continue passing his urine through his perineum (32.33), or you will have to attempt a urethroplasty yourself (23.9).
If his ABSCESS RECURS, consider the possibility of tuberculosis or carcinoma of his urethra.
If he develops a FISTULA, see Section 23.9.