E2460. Transperineal Prostate Abscess Drainage
  1. Samir Yezdani; Zucker School of Medicine at Hofstra/Northwell
  2. Edward Colombo; Zucker School of Medicine at Hofstra/Northwell
  3. Christopher Yeisley; Zucker School of Medicine at Hofstra/Northwell
Prostatic abscesses (PA) are rare but can cause serious clinical illness. Though typically managed conservatively, drainage, especially for larger abscesses, can be used as a therapeutic adjunct. There are two typical minimally invasive approaches, transrectal and transperineal. Historically, both approaches have been utilized by urology whereas interventional radiology has opted for the transrectal approach. Our goal is to show that given the knowledge of imaging modalities, particularly ultrasound, and procedural abilities during training, the transperineal approach is also a viable option for interventional radiology.

Educational Goals / Teaching Points
Briefly review the anatomy, pathology, and pathophysiology of the prostate and PA. Briefly review the clinical diagnosis of PA. Discuss the imaging characteristics of PA, particularly on ultrasound, computed tomography, and magnetic resonance imaging. Discuss transrectal ultrasound (TRUS) and its role in diagnosis. Compare the TRUS w/ transrectal drainage and TRUS with transperineal drainage.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
PA usually develops in individuals with a history of acute and chronic bacterial prostatitis. Predisposing factors include longer symptom duration, immunocompromising conditions such as diabetes mellitus, and voiding disturbances. Escherichia coli is the most common causative organism isolated in PA; however, other commonly identified organisms include Klebsiella pneumonia, Pseudomonas aeruginosa, and polymicrobial infections. The preferred way to diagnose prostatic abscess is TRUS, which is more specific than digital rectal examinations and abdominal ultrasound, providing an accurate diagnosis in up to 100% of individuals with PA. CT can also be used to diagnose PA and better evaluate spread of infection to adjacent organs. MRI, while typically used to evaluate prostate carcinoma, may be useful in the evaluation of early abscess where TRUS findings are equivocal. The high sensitivity, low cost, and ability to perform therapeutic intervention at the time of TRUS make it the preferred diagnostic modality in the majority of patients. While small abscess can be managed conservatively with antibiotic therapy, percutaneous drainage of PA is associated with shorter duration of antibiotics and shorter hospital stays with one study recommending drainage of PA via TRUS-guided aspiration for PA greater than 2 cm with severe lower urinary tract symptoms and/or leukocytosis. In interventional radiology, the typical approach for treatment of PAs is TRUS-guided aspiration which is a widely accepted and safe procedure except in the case of patients with severe hemorrhoids, anal fistulas, or fissures. This poster serves to highlight the value of the transperineal approach for drainage which has been described as early as 1986 but has not been universally adopted.

The transperineal approach is minimally invasive and allows for the easy placement of a drainage tube to ensure the complete drainage of the PA over the course of multiple days, which may lead to less recurrent PAs than the traditional transrectal approach.