Treatment of Prostate Abscess
Prostate abscess requires mandatory drainage combined with antimicrobial therapy—antibiotics alone are insufficient and should never be used as monotherapy. 1
Immediate Drainage Approach
Percutaneous drainage under transrectal ultrasound guidance is the first-line intervention due to lower complication rates and shorter hospital stays compared to surgical alternatives. 1
Drainage Technique Options:
- Transrectal needle aspiration or small-bore pigtail catheter placement is preferred as it shortens hospital stay and provides a viable alternative to transurethral drainage 1
- The choice between transrectal versus transperineal routes depends on abscess location, size, patient anatomy, and operator preference—both are superior to conservative management alone 1
- Transurethral drainage is specifically indicated for periurethral prostatic abscesses 2, 3
- For large (>1 cm) or loculated abscesses, surgical drainage is generally required if percutaneous drainage fails 2, 3
Size-Based Treatment Algorithm:
- Microscopic abscesses (<1 cm): May be treated with antibiotics alone for 4-6 weeks 2
- Larger abscesses (≥1 cm): Require drainage in addition to antibiotics 2, 4
Antimicrobial Therapy
First-Line IV Antibiotics:
- Piperacillin-tazobactam 4.5 g every 6-8 hours IV is the recommended first-line option for E. coli prostatic abscess 1
- For multidrug-resistant E. coli, consider carbapenems: Ertapenem 1 g once daily, Meropenem 1 g every 8 hours IV, or Imipenem-cilastatin 1 g every 6-8 hours IV 1
- Fluoroquinolones are effective for smaller abscesses due to good prostatic diffusion 2
- Adjust antibiotics based on culture sensitivities once available 1, 5
Diagnostic Confirmation Before Treatment
Essential Pre-Treatment Studies:
- Transrectal ultrasound is the imaging modality of choice to identify prostatic abscess and guide drainage 1
- Obtain urine culture and blood cultures before starting antibiotics to guide targeted therapy 1
- Complete blood count should be obtained to aid in diagnosis 1
- Culture the abscess fluid at the time of drainage to confirm pathogen and antibiotic sensitivities 1
Critical Pitfalls to Avoid
- Never rely on antibiotics alone for prostate abscess treatment—abscesses require drainage for source control 1
- Never attempt prostatic massage in suspected abscess, as this risks bacteremia and sepsis 1, 6
- Do not delay drainage in favor of prolonged antibiotic trials for abscesses ≥1 cm 2, 4
Multidisciplinary Management
- Collaborative treatment involving urologists, intensive care, and infectious disease specialists is recommended for optimal patient care, particularly in septic or complicated cases 1
- Evaluate for urinary retention or obstruction that may have predisposed to abscess formation 1
Expected Outcomes
- Mean hospitalization time ranges from 6-11 days with appropriate drainage and antibiotics 7, 4
- Post-drainage imaging should confirm abscess resolution 5
- Most common pathogens are E. coli (currently) and S. aureus, though historically Neisseria gonorrhoeae and Mycobacterium tuberculosis were more common 2, 7, 4