The 5 Minute Urology Consult 3rd Ed.

URETHRA, ABSCESS (PERIURETHRAL ABSCESS)

H. Henry Lai, MD, FACS

Gerald L. Andriole, MD, FACS

 BASICS

DESCRIPTION

• Urethral abscess is best defined based on the sex of the patient

– Men: Infection of the male urethra and periurethral tissues, usually associated with urinary infection and urethra stricture disease.

– Women: Infection of Skene’s glands located on the anterior vaginal wall, usually associated with a chronically infected urethral diverticulum.

 Diagnosis and management of female urethral abscess are discussed in Section I “Urethra, diverticulum, female (Urethral diverticulum)”.

EPIDEMIOLOGY

Incidence

Can occur at any age.

Prevalence

• The exact prevalence is not known.

• More likely in diabetics or those with sexually transmitted diseases.

• Recurrent abscess in up to 19% of patients.

RISK FACTORS

• Diabetes mellitus

• Urethral stricture disease

• Frequent urethral instrumentation

• Periurethral bulking agent injection

• Gonorrhea

• HIV

• Previous periurethral abscess

Genetics

N/A

PATHOPHYSIOLOGY

• Periurethral extravasation of infected urine (1).

• Urine extravasation may be caused by:

– High-pressure voiding behind a stricture

– Difficult dilation of a stricture, false passage

– Traumatic urethral instrumentation

• Often localized to the bulbar urethra or spongiosum.

• Once eroded through Buck’s fascia, may cause extensive necrosis of the fascia and adjacent tissues, leading to Fournier gangrene.

• Three potential sources of Fournier gangrene:

– Periurethral

– Perirectal

– Subcutaneous

• Fistula may develop in delayed cases following spontaneous abscess rupture

• Common organisms:

– Neisseria gonorrhea

– Chlamydia trachomatis

– Gram-negative rods

– Enterococci

– Anaerobes

ASSOCIATED CONDITIONS (2)

• Diabetes mellitus

• Immunosuppression (eg, HIV)

• Sexually transmitted disease

• Urethral stricture disease

• Urinary tract infection

GENERAL PREVENTION

• Eradicate and prevent sexually transmitted disease

• Sterilize the urine and defer instrumentation if the urine is infected

• Diversion of urine away from the urethra

• Adequate management of urethral stricture:

– Dilation

– Internal urethrotomy

– Urethroplasty and reconstruction

– Perineal urethrotomy

 DIAGNOSIS

ALERT

Failure to recognize and treat a localized periurethral abscess in a male can result in life-threatening necrotizing fasciitis (fournier gangrene), or septic shock.

HISTORY

• Symptoms may include urethral discharge, dysuria, pain, swelling of penis or scrotum, foul smelling urine, fever, chills, weak urine stream, incomplete emptying, urinary frequency, urgency.

• History of urethral stricture and treatment

• Recent history of urethral instrumentation, dilation, catheterization, bulking agent, sling, or other surgery

• History of sexually transmitted disease, pelvic radiation, trauma (risk factors of stricture)

• History of recurrent UTI

• Diabetes, including glycemic control

• Immunosuppression (eg, HIV)

• Prior periurethral abscess and treatment

– Maintain an index of suspicion for neoplasm for recurrent periurethral abscess and stricture

PHYSICAL EXAM

• Evaluate for urosepsis: fever, tachypnea, tachycardia, hypotension, mental status change.

• Palpate penile shaft and perineum for mass, induration, tenderness, fluctuance, or crepitus.

• Fournier gangrene may involve the penis, scrotum, perineum, extending around the rectum, inner thighs, or up the abdominal wall.

• Palpate for a distended bladder (retention).

• Rectal exam to exclude perirectal abscess.

DIAGNOSTIC TESTS & INTERPRETATION

Lab

• Urinalysis of the initial urine stream

• Urine culture and sensitivity

• Wound culture, including anaerobic

• Blood culture (sepsis workup)

• BUN, creatinine (renal function, dehydration)

• WBC with differential

• Coagulation profile (sepsis-induced coagulopathy)

Imaging

• CT (look for subcutaneous air, abscesses)

• Retrograde urethrogram:

– Not recommended during acute phase

– Look for extravasation, stricture, fistula

• Transrectal ultrasound imaging of prostate: not recommended during acute phase

Diagnostic Procedures/Surgery

• Post-void residual volume (bladder scanner)

• Aspiration of pus when diagnosis is in doubt

Pathologic Findings

• Tissue inflammation, necrosis, fasciitis

• Biopsy may be used to rule out urethral or perianal cancer in rare cases

DIFFERENTIAL DIAGNOSIS (3,4)

• Anasarca (generalized edema) from liver or renal failure

• Carcinoma of perianal glands

• Fournier gangrene

• Perirectal abscess

• Pneumoscrotum after laparoscopy

• Subcutaneous abscess

• Urethral carcinoma

• Urethral diverticulum (in female)

 TREATMENT

GENERAL MEASURES

Supportive treatment of other medical issues: diabetes, hypotension, septic shock, or organ failures

MEDICATION

First Line

• Board spectrum antibiotics coverage

– Cephalosporin and aminoglycoside

 Such as ceftriaxone 2g IV q24 plus gentamicin 1.5–2 mg/kg loading dose, followed by 5–7 mg/kg IV q24

– Consider vancomycin (15–20 mg/kg IV q12)

Second Line

Antibiotics are adjusted based on culture sensitivity

SURGERY/OTHER PROCEDURES

• Incision and drainage of abscess with debridement and excision of necrotic tissue.

• May require repeated exploration and debridement as the margin between necrotic tissue and viable tissue becomes more apparent.

• Needle aspiration or endoscopic transurethral incision may be considered in selected cases.

• Wet to dry dressing change twice a day.

• Wound vac placement after debridement if the wound is clean and if wound location permits.

• Exposed testicle may be placed in the scrotum or thigh pouch.

• Skin grafting may be needed to cover skin loss, alternatively secondary closure of wound.

• Biopsy to exclude urethral or perianal cancer.

• Urinary diversion:

– Suprapubic tube initially

– Avoid urethral Foley catheter

– Perineal urethrotomy as a secondary option in patients with severe bladder spasm or when adequate urine drainage has not been achieved.

• Cystoscopy to evaluate urethral stricture disease after complete resolution of infection.

• Definitive management of stricture should be deferred for 6 mo after resolution of abscess.

ADDITIONAL TREATMENT

Radiation Therapy

N/A

Additional Therapies

N/A

Complementary & Alternative Therapies

N/A

 ONGOING CARE

PROGNOSIS

• Variable based on diagnosis and treatment

• Failure to recognize and treat a periurethral abscess in a male can result in life-threatening necrotizing fasciitis (Fournier gangrene) and septic shock.

COMPLICATIONS

• Sepsis, acute renal failure, death (1%) (5)

• Necrotizing fasciitis: Progression to Fournier gangrene

• Extensive genital skin loss

• Recurrent abscess and urinary infection

• Necrosis of corpora spongiosum

• Urethrocutaneous fistula

FOLLOW-UP

Patient Monitoring

• Frequent wound check until healed.

• Monitoring for recurrent stricture (eg, uroflow)

• Periodic evaluation of urine for infection.

• Testing for sexually transmitted disease.

Patient Resources

Urology Care Foundation: Benign urethral lesions http://www.urologyhealth.org/urology/index.cfm?article=93

REFERENCES

1. Sanders CJ, Mulder MM. Periurethral gland abscess: Aetiology and treatment. Sex Transm Infect. 1998;74(4):276–278.

2. Walther MM, Mann BB, Finnerty DP. Periurethal abscess. J Urol. 1987;138:1167–1170.

3. Blaschko SD, et al. Proximal bulbar urethral abscess. Int Braz J Urol. 2013;39(1):137–138.

4. Kenfak-Foqoena A, Zarkik Y, Wisard M, et al. Periurethral abscess complicating gonocococcal urethritis: Case report and literature review. Infection. 2010;38(6):497–500.

5. Malatinsky E. Sepsis caused by periurethral abscess. Int Urol Nephrol. 1991;23(5):485–488.

ADDITIONAL READING

Butler JM, Bennetsen D, Dias A. An unusual cause of pelvic pain and fever: Periurethral abscess from an infected urethral diverticulum. J Emerg Med. 2011;40(3):287–290.

See Also (Topic, Algorithm, Media)

• Fournier Gangrene

• Urethra, Carcinoma, General Considerations

• Urethra, Discharge

• Urethra, Diverticulum, Female (Urethral Diverticulum)

• Urethra, Mass

• Urethral Stenosis/Stricture, Female

• Urethra, Stricture, Male

 CODES

ICD9

• 597.0 Urethral abscess

• 598.9 Urethral stricture, unspecified

• 599.2 Urethral diverticulum

ICD10

• N34.0 Urethral abscess

• N35.9 Urethral stricture, unspecified

• N36.1 Urethral diverticulum

 CLINICAL/SURGICAL PEARLS

• In men, urethral abscess is associated with urinary infection, urethral stricture, diabetes, and immunosuppression. In women, it is associated with urethral diverticulum.

• Incision and drainage of abscess may include exploration and debridement of necrotic tissues.

• Board spectrum antibiotics coverage and supportive care.

• Urinary diversion with suprapubic tube are important in the treatment of urethral abscess.

• Early recognition and treatment is key to prevent progression to life-threatening Fournier gangrene and septic shock.



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