Case Presentation: A 50-year-old male with a history of poorly controlled type II diabetes (recent A1c: 11.2%), hypertension, and recurrent urinary symptoms presented with frequency, urgency, subjective fever, and dysuria one week after Foley catheter removal. The patient was first seen in the emergency department (ED) two weeks prior with dysuria, hematuria, retention with a high post void residual, and urinalysis (UA) showing 2+ blood. A Foley catheter was placed and he was started on tamsulosin and referred to outpatient urology. One week later, the patient presented with penile pain at the catheter site and trace hematuria. He received 1g IM ceftriaxone, the Foley was removed, and he was discharged from the ED with a seven-day course of cefpodoxime. The UA was notable for 3+ blood, trace leukocytes, many bacteria, and the urine culture eventually grew Staphylococcus aureus, Pseudomonas aeruginosa and Klebsiella pneumoniae. Initial labs for the current presentation revealed leukocytosis of 16.8 cells/µL, normal lactic acid, and UA showing 2+ leukocytes, 3+ blood, positive nitrites, and many bacteria. Urine and blood cultures grew pan-sensitive Pseudomonas aeruginosa and CT abdomen/pelvis revealed a 1.7 x 1.5 x 2.4 cm peripherally enhancing fluid collection in the prostate concerning for abscess. He received a 750mg IV dose of levofloxacin, was started on finasteride, and discharged on a four-week course of 750mg oral levofloxacin daily with outpatient urology follow up and repeat imaging.
Discussion: A prostate abscess is a focal accumulation of purulent material within the prostate and often secondary to acute bacterial prostatitis. Risk factors include urinary retention due to voiding dysfunction, indwelling catheters, neurogenic bladder as well as comorbid conditions such as poorly controlled diabetes, renal failure, cirrhosis, and immunocompromised states [1]. Recurrence of symptoms or minimal improvement despite antibiotic therapy should warrant further workup and is especially important in men, given that recurrent UTIs are far less common in males. While prostate abscesses are not necessarily rare, our case does demonstrate a few important points. First, our patient had uncontrolled diabetes and did not receive imaging until his third presentation despite having had recurrent symptoms for many weeks. Second, our patient was previously discharged with cefpodoxime which does not cover Pseudomonas aeruginosa. Additionally, treatment of prostate abscess requires a longer course of antibiotics which differs from treatment for UTIs. Management generally involves either conservative treatment with antibiotics alone for small abscesses (< 1-2 cm) for a minimum of four weeks or surgical intervention with adjunct antibiotic therapy for larger abscesses (>2 cm) [1-4]. Antibiotics commonly used with good prostate penetration are fluroquinolones, 3rd generation cephalosporins, aztreonam, or ampicillin + aminoglycoside [1].
Conclusions: Symptoms for prostate abscess can often mimic those of UTIs, prostatitis, and BPH. More prompt recognition and imaging should be considered especially in patients who have comorbid conditions with recurrent symptoms and/or refractory to antibiotic treatment as in our patient. Delayed care may lead to sepsis and increased morbidity. It is paramount for clinicians to consider further imaging in male patients who have persistent urinary symptoms despite treatment especially in those with risk factors.