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.