A 78-year-old male patient, diabetic on treatment with oral antidiabetics, with a history of renal lithiasis and repeated nephritic colic, and with malignant neoplasia of the neck treated with RT two months earlier, who came to the emergency department for an irritative micturition syndrome with pollakiuria, bladder tenesmus and dysuria of two months' evolution. Two days earlier he had been in the emergency department where he was diagnosed with UTI and antibiotic treatment with Amoxicillin-clavulanic acid was started without improvement.
Physical examination showed an axillary temperature of 38.2º C. The rest of the examination was completely normal, including a rectal examination which revealed a prostate of size III/IV, not indurated and slightly painful on palpation. The blood test showed a significant leukocytosis of 41800 with neutrophilia (93%), a blood glucose of 337 mg/dl, a platelet count of 394000, a fibrinogen of 771 and a decrease in Quick's Index (68%). Urine sediment showed pyuria and microhaematuria and plain chest and abdominal X-rays showed no pathology. An ultrasound scan of the abdomen was also performed at the emergency department and showed no pathology.
With suspicion of UTI, she was admitted to the Urology Department and intravenous antibiotic treatment was started after obtaining a urine culture. The treatment regimen chosen in this case was a combination of ceftriaxone 1 g plus tobramycin 100 mg every 12 hours. On the third day of admission and in view of the patient's clinical and analytical improvement, it was decided to switch from intravenous to oral antibiotherapy, continuing with cefuroxime-axetil. On the seventh day, coinciding with the arrival of the blood and urine cultures taken on admission, which were reported as negative, the patient presented a fever peak of 39ºC and a new rise in the leukocyte count. We decided to reinstate intravenous antibiotherapy and to perform a vesico-prostatic ultrasound scan in which the patient's large prostate (400 cc) was striking.
In view of the suspicion that it could be an acute prostatitis in the context of BPH, it was decided to continue with intravenous antibiotherapy and to schedule a Millin-type adenomectomy when the infectious symptoms had subsided. Despite antibiotic therapy, the evolution continued to be unfavourable, with persistent febrile peaks, so the treatment regimen was changed and levofloxacin i.v. was introduced instead of ceftriaxone, and a fractionated urine culture was requested. Despite the change in antibiotic treatment, the patient continued to present fever and worsening general condition, so it was decided to perform a transrectal ultrasound to rule out the presence of any complications, in which a poorly defined area appeared in the medial and cranial periphery of the right lobe, with heterogeneous echogenicity, although predominantly hypoechogenic, and with an absence of flow in the Doppler method suggestive of prostatic abscess.
In view of the ultrasound findings, it was decided to perform a transrectal ultrasound-guided puncture of the abscess, obtaining about 20 ml of purulent material which was sent to microbiology. The culture of the prostatic exudate and pus were positive for E. coli. Despite the puncture, the patient continued with septic symptoms and reported no improvement, so it was decided to perform a CT scan to confirm the diagnosis and rule out complications of the abscess. The CT scan showed an increase in the size of the prostate gland with a multi-tabular liquid collection, located caudally to the gland itself.
In view of the CT findings, and transrectal puncture having failed, it was decided to perform a transvesical prostatectomy. During the operation, after opening the capsule, we were able to appreciate the total destructuring of the gland, with the presence of multiloculations and purulent material inside it, as well as extensive areas of tissue necrosis involving the entire prostatic urethra at the apical level.
Pathological anatomy showed two small foci of microacinar adenocarcinoma, far from the limits of resection, with a Gleason 2 + 3 and chronic and acute abscessed prostatitis with extensive areas of necrosis together with nodular hyperplasia.
The postoperative evolution was satisfactory, with a rapid clinical and analytical improvement, and the patient was discharged from hospital 21 days after the operation. Fifteen days after discharge, the patient was seen in our outpatient clinic with stress urinary incontinence. Six months after the operation, the patient continues to have mild to moderate incontinence and requires absorbent pads for daily hygiene.
