Prostatic abscesses

Gonococci or coliforms can infect a patient's prostate. To begin with they cause a prostatitis, and later a frank abscess. He presents with urgency, frequency, and dysuria, or with retention. He has fever, rigors, and severe rectal or perineal pain, sometimes with tenesmus. His prostate is enlarged, usually more so on one side than the other, and is exquisitely tender. Untreated, his abscess may burst into: (1) his urethra, (2) his perirectal tissues, where it can present as an ischiorectal abscess, (3) his perineum, or (4) his rectum, forming a rectourethral fistula.

PROSTATIC ABSCESSES DIFFERENTIAL DIAGNOSIS. Extreme prostatic tenderness should make the diagnosis clear. Don't confuse a prostatic abscess with: (1) An ischiorectal abscess[md]the swelling is to one side of the midline. (2) An abscess in a seminal vesicle[md]rectally, the site of maximum swelling and tenderness will be higher and more to one side.

SPECIAL TESTS. Test his urine for sugar, and culture it.

ANTIBIOTICS. Give him a broad-spectrum antibiotic, such as ampicillin or chloramphenicol, until you know the results of culture.

MANAGEMENT. If his prostate is not fluctuant, see what antibiotics alone will do in 48 hours.

If antibiotics fail to cause a marked improvement in 48 hours, or his abscess is fluctuant, refer him to an expert urologist, who will drain his abscess into his urethra with a resectoscope.

If you cannot refer him, drain the abscess yourself, as follows. Fortunately, this is very rarely necessary.

DRAINAGE. Anaesthetize him, and put him in an exaggerated lithotomy position. Start by passing a rubber Jacques catheter. If this passes easily, leave it in place. If you cannot pass it, do a suprapubic cystotomy.

To drain his abscess, pass a metal sound, and cut down on to this through a 5 cm midline incision immediately in front of his anus.

Remove the sound and control bleeding. Put your finger through the incision into his prostatic urethra, and then through its posterior wall into the abscess cavity. If this contains several loculi, break down the septa between them.

Pack the wound loosely with a dry dressing and leave it open, or suture the skin edges loosely over it. Remove the catheter about the 7th day.

Alternatively, make an oblique lateral incision, as when removing the prostate by Ghadvi's method (23.21).