Prostatic Abscess: A Review and Update

Prostate abscess (PA) is a complication that ensues an acute infectious purulent process within the prostate gland which is typified by accumulation of purulent material within the prostate gland and this purulent material could be unilocular or multi-septated within the prostate gland. PA is a rare disease especially in the developed world where PA tends to be more commonly associated with patients who have diabetes mellitus, chronic kidney disease, chronic liver disease, immunosuppressive disease, HIV Infection, renal transplantation, and long-term urethral catheterisation. PA tends to be more commonly encountered in the developing world. PA could be an acute abscess or chronic abscess especially in association with chronic inflammatory conditions including tuberculosis or intravesical instillations of Bacillus Calmette Guerin (BCG). PA tends to constitute 0.5% of all urology disease and 6% of all acute cases of bacterial prostatitis. The mortality rate associated with PA has tended to be between 1% and 16% of all cases of prostate abscess. PA tends to be most commonly encountered in individuals who are in their fifth to sixth decade and could occur at any age. PAs that are due to sexually transmitted organisms tend to be more commonly encountered in younger males. PA tends to affect the central zone as well as the peripheral zones of the prostate gland. Haematogenous dissemination from a primary source of infection from a primary infection elsewhere have been reported and some of the reported sources included respiratory tract, digestive tract, urinary tracts, skin, and soft tissue are very rare. PA has also been reported to be associated with staghorn calculus. Some of the reported bacterial organisms that have caused acute prostate abscess (APA) include: Escherichia Coli, Klebsiella, Pseudomonas, Proteus, Enterobacter, Enterococcus, and staphylococcus. Other causes of prostate abscess have included other bacteria and fungal infection including: Brucellosis, Salmonella, Nocardia, Mycobacterium tuberculosis. Prostate abscess has also been reported in association with malignancy of the prostate gland. Manifestations of prostate abscess could include: (a) systemic symptoms including pyrexia, chills, headache, general malaise, low back ache and in some rare cases of prostate abscess, a history of treatment for tuberculosis or contact with a person who has tuberculosis, or travel to a salmonella endemic area may be obtained and in cases of Brucellosis PAs drinking of raw milk / contact with animals may be elicited and or rare occasions treatment of superficial urothelial carcinoma with Bacillus Calmette Guerin may be elicited. (b) perineal pain, dysuria, urinary frequency, urinary urgency, retention of urine, recent prostate biopsy, visible haematuria, urethral discharge of pus, lower urinary tract obstructive symptoms with poor flow, intermittent flow, hesitancy, and sensation of incomplete emptying of the urinary bladder, retention of urine, and tenderness over the prostate gland with a feeling of bogginess and soft fluctuation. The symptoms tend to be non-specific. Diagnosis of PAs tends to be established based upon a good clinical history taking, good clinical examination, urinalysis and urine culture, routine haematology and biochemistry blood tests with evidence of raised white blood cell count and CRP and at times lymphocytosis in cases of tuberculous prostate abscess, blood culture, urine culture, PCR detection of sexually transmitted organisms, radiology imaging including trans-rectal ultra-sound scan of the prostate, or CT) scan of abdomen and pelvis including the prostate, or MRI scan of the prostate. Treatment of PA depending upon the size of the abscess has been undertaken with various options including: Appropriate antibiotic treatment alone for small abscesses based upon the antibiotic sensitivity pattern of the cultured organism, Antibiotic treatment and radiology image-guided aspiration of the abscess. Antibiotic treatment plus radiology image-guided insertion of a drain into the prostate abscess, trans-urethral incision / resection / modified resection of the prostate gland to deroof and drain the abscess, open drainage of the abscess is only undertaken on rare occasions. Within remote district hospitals in developing countries in the absence of radiology imaging, the clinician would have no choice but to undertake finger guided aspiration / drainage of the prostate abscess plus antibiotic treatment. It is important to obtain the culture and sensitivity result of the aspirated and drained pus so that if there are fungi cultured or rare organisms cultured the choice of antibacterial / antifungal treatment would depend upon the microbiology results. It is important to treat all complications urgently and appropriately including provision of intensive care. Careful clinical follow-up, laboratory investigations and radiology imaging are necessitated to ensure good recovery and to quickly identify as well as appropriately treat any recurrent abscess and on rare occasions if there is an associated prostate cancer it would be detected. The prognosis associated with the treatment of PA depends upon a number of factors including: Timely diagnosis and adequate and appropriate treatment of the PA. The underlying associated medical conditions of the patient. The prognosis tends to be good if the PA is diagnosed early as well as treated early including utilization of the correct anti-microbial medicament and appropriate drainage of the abscess. Poor prognosis tends to be associated with individual patients who are older than 65 years, fever with a temperature higher than 100.4 degrees Fahrenheit, benign prostatic hyperplasia, chronic long-term urethral catheterisation. In the scenario of non-availability of bacterial culture report in a remote area in a developing country when there is delay in getting the culture results from the regional or national centre there would be the possibility of utilizing a broad spectrum and potent antibiotics but if the organism is a fungus then there would tend to be recurrence of the abscess and poor outcome and for this reason it would be recommended that every hospital in the world should have access to good laboratory services including haematology, biochemistry, microbiology, pathology, and radiology services including ultrasound scan, computed tomography scan as well as magnetic resonance imaging scan as well as well trained staff to operative the various equipment as well as high dependency units and intensive care units and staff should be available to provide support for all patients that need support.

EP.TU.317Assessing the competency of foundation doctors in urethral catheterisation

Aim Our aim was to assess FY1/FY2 doctors’ experiences and confidence in performing urethral catheterisation in a teaching hospital. Methods This was a single centre, survey based study. An anonymous online questionnaire was circulated to all foundation doctors at the trust. The survey contained 18 questions. The domains included the number of catheterisations performed, confidence levels and whether they had been signed off as competent. This was followed by a series of knowledge questions. Results The survey was sent to 71 email addresses and the response rate was 53%. The results showed that respondents’ lacked experience and confidence in urethral catheterisation. We also found that 32% trainees had not inserted a female catheter during foundation training, and 55% had failed to insert a catheter in the last year. The vast majority (71%) of respondents did not feel confident in female catheterisation. Conclusions This study shows that knowledge and competency in urethral catheterisation (which is an essential GMC requirement) amongst junior doctors is still inadequate.

356 An Unfortunate Case of Spinal Injury and Bladder Dysfunction During the Covid-19 Pandemic

There is no doubt that COVID-19 has had a profound impact on every medical and surgical speciality. In the height of the pandemic many non-emergency services were shut down, including dental services, with unexpected consequences. We present a case which highlights the unexpected and indirect consequences of a national lockdown on a Urology patient and discuss learning points. A 54-year-old male, previously fit and well suffered with a small dental abscess, media outlets were reporting that dental surgeries were closed, and he therefore attempted to drain the abscess himself. The infection spread to his epidural space, causing compression via a collection at L2 and consequently spinal cord injury. This was managed with urgent lumbar decompression and antibiotics. A specialist functional urology team were involved after his transfer to the tertiary spinal unit 3 months after his first presentation. He was catheterised but suffered with recurrent catheter blockages. Video urodynamics demonstrated a stable bladder with a low-pressure leak point, managed with urethral catheterisation. A repeat video urodynamics demonstrated a loss of compliance and stress incontinence. Unclear as to whether he would regain function rehabilitation techniques are currently being attempted prior for definitive operative management with an artificial sphincter. This case highlights the indirect impact of COVID-19 on UK urology services, and this has not been widely reported.

530 An Audit of Appropriate Documentation Following Urethral Catheterisation

Introduction Urethral catheterisation is a procedure frequently done in the hospital by medical personnel. Appropriate documentation is necessary to ensure safe clinical care and to reduce the risk of litigation. Method We randomly reviewed electronic notes of patients seen by the on-call urology team who had a urethral catheter inserted in September 2020. Reviewing the trust’s guidelines, we considered that appropriate documentation should include reference to the following 10 items; indication, chaperone present, consent obtained, groin examination, catheter size, catheter type, insertion process, urine colour, water in balloon and residual volume were reviewed. Results A total of 50 patients were included. 72%(36/50) were inserted by a member of the urology team. Only 28%(14/50) had all 10 items documented. Indication for catheterisation was best documented at 94%(47/50) while presence of a chaperone and groin examination (i.e. presence of a foreskin and its replacement post-catheterisation) were the lowest at 44%(22/50). Conclusions This study shows there is low compliance to adequate documentation of urethral catheterisation. A ‘smart phrase’ has been developed for use with our Trusts electronic medical records system to assist clinicians with appropriate documentation. Clinicians that use the phrase ‘.icat’ are prompted to document all 10 requisite items. This uses the mnemonic i-CATHETAR [indication, Chaperone and consent, groin Assessment, Tube (catheter size and type), insertion process (Hard/Easy), urine Tint, Aqua in balloon, Residual volume]. A second audit cycle is currently being done to review the effectiveness of this intervention.

Comparative evaluation of modified proximal perineal urethrostomy with direct guided urethral catheterisation and tube cystostomy for the management of obstructive urolithiasis in male goats

Twelve clinical cases of chronic obstructive urolithiasis in male goats were selected for the study with the objective to evaluate two surgical techniques - modified proximal perineal urethrostomy (MPPU) with direct guided urethral catheterisation (Group I) and tube cystostomy (Group II) for the surgical management. Ultrasonography was effective in assessing the urinary bladder and detection of uroliths. Functional patency of normal urethra was regained in five out of six animals of each group by third post-operative week. Direct access to the perineal urethra providing quick relief to the turgid bladder was identified as the major advantage of modified proximal perineal urethrostomy technique. Tube cystostomy technique provided direct visual assessment of urinary bladder, precise fixing of Foley’s catheter and retrieval of uroliths. Even though this technique was found to be more invasive, it was identified as an effective approach for correcting cystorrhexis resulted from obstructive urolithiasis

Prostate-specific antigen increase after urethral catheterisation: fact or myth

Background To find out any association of urethral catheterisation with rise in serum PSA. Methods This study was conducted in 80 patients of BPH who had to undergo catheterisation because of acute urinary retention. Patients were divided into two groups: Group A (n = 43 patients), age group 40–60 years, and Group B (n = 47 patients), age group 60–75 years. Values of PSA, free/total PSA and PSA density were recorded in both age groups before catheterisation and one and three days after catheterisation. Results PSA, PSA density and free/total PSA were not statistically different before and after urethral catheterisation. Conclusions In the absence of urinary tract infection, urethral catheterisation does not elevate serum PSA. PSA, PSA density and free/total PSA were not statistically different before and after urethral catheterisation.

Iatrogenic bladder injury from port insertion during laparoscopic appendicectomy

A 26-year-old man underwent laparoscopic appendicectomy for acute appendicitis that was carried out uneventfully after initial urethral catheterisation to empty the bladder. Postoperatively, he developed oliguria associated with high drain output and elevated drain fluid creatinine. A contrast-enhanced computed tomography urography scan showed a small amount of contrast in the intraperitoneal space. A diagnostic laparoscopy performed for a suspected bladder injury revealed that the drain (inserted via the suprapubic port) had traversed the bladder. The drain was removed, and the bladder defects were repaired. The catheter was removed 2 weeks later uneventfully. It is important to recognise and avoid the urinary bladder during suprapubic port insertion during laparoscopic appendicectomy. This complication can be minimised via initial bladder decompression and introduction of the suprapubic port lateral to the umbilical ligaments. A high index of suspicion is required to diagnose a small bladder injury.