Periurethral abscess: an unusual source of sepsis

Abstract

A 34-year-old male presented with a 3-day history of perianal pain and fever. There was no history of urinary symptoms or urethral discharge and the patient denied sexual contact or exposure to sexually transmitted diseases. Temperature was elevated at 38°C. There were no perianal or scrotal skin changes and digital rectal examination revealed a tender prostate without clinical evidence of prostatic abscess. C-reactive protein (CRP) was 117 (range <9 mg/L) and white cell count (WCC) 17.82 ¥ 10 9 (range 4-11 ¥ 10 9 /L). Urinalysis showed sterile pyuria. A diagnosis of acute prostatitis was made and he was commenced on intravenous Augmentin™ (amoxicillin and clavulanic acid, GlaxoSmithKline Plc, Middlesex, UK) and gentamicin. Temperature settled, inflammatory markers normalized and the patient was discharged 4 days after admission on a further 14-day course of oral ciprofloxacin. He was however readmitted the following day systemically unwell with fever, rigours, hypotension and tachycardia. CRP was now 274 mg/L and WCC 13 ¥ 10 9 /L. He was recommenced on IV Augmentin and gentamicin. Blood cultures grew a peptostreptoccus species while urinalysis again showed sterile pyuria. Magnetic resonance imaging (MRI) of the pelvis was performed and showed a loculated periurethral abscess lying posterior and inferior to the membranous urethra (Figs. 1-3). The abscess cavity extended to the anterior aspect of the rectum but was separated from it by a distinct tissue plane (Fig. 3). The prostate was radiologically normal. Rigid cystoscopy revealed a dense bulbomembranous urethral stricture 2 cm in length. Optical urethrotomy was performed and a urethral catheter was placed. Following this, a large multi-loculated abscess was incised and drained through a separate perineal incision. The abscess cavity was found to be behind and beneath the bulbar urethra and as was demonstrated on the MRI (Fig. 3), extended posteriorly to, but did not involve the anterior wall of the rectum. A suprapubic urinary catheter was inserted and he continued on a course of IV gentamicin and Augmentin. Oral doxycycline was added while awaiting intraoperative microbiology results. These grew a heavy mixed growth of anaerobic organisms. Chlamydia polymerase chain reaction and gonococcal cultures were subsequently negative. Urethral and suprapubic catheters were removed prior to discharge on day 5. He remains in follow-up and when last seen, 9 months after initial presentation, was asymptomatic with a normal flow test and no significant post void residual on ultrasound. Fig. 1. Contrast enhanced axial T1-weighted magnetic resonance imaging of the pelvis showing abscess cavity (A) lying anterior to the anus (An) and posterior and inferior to the bulbo-membranous urethra (U).Fig. 2. Contrast enhanced coronal T1-weighted magnetic resonance imaging of the pelvis showing abscess cavity (A) lying inferior to the bulbar urethra (U).

Periurethral abscess etiology, risk factors, treatment options, and outcomes: A systematic review

“…Imaging modalities (CT, USS, and cystourethrography) can accurately confirm a clinical diagnosis of periurethral abscess. [2,3,18] Therefore, in current practice, early utilization of CT or USS is prudent to ensure timely treatment. The sensitivity of MRI to identify a periurethral abscess was inferior to CT/USS in this review; however, these results were attributable largely to 1 study.…”

“…Periurethral abscesses may present in a similar fashion to other genitourinary pathology, including pain (scrotal, penile, pelvic, perineal, or suprapubic), fever, dysuria, pyuria, and acute urinary retention. [2,3] Accurate and timely diagnosis can be challenging, with many patients progressing to sepsis. [2] Delayed detection and treatment may lead to complications such as urethral fistula, stricture, and, rarely, extensive cellulitis, or necrotizing fasciitis.…”

“…[2,3] Accurate and timely diagnosis can be challenging, with many patients progressing to sepsis. [2] Delayed detection and treatment may lead to complications such as urethral fistula, stricture, and, rarely, extensive cellulitis, or necrotizing fasciitis. [4][5][6] Historical mortality rates have been as high as 47% to 50% in the context of delayed presentations and consequent phlegmon formation.…”