Emphysematous Prostatitis in a Diabetic Patient

Abstract

A 64-year-old male with a history of end stage renal disease and diabetes mellitus presented with generalized abdominal pain, fever, chills, sweats and difficulty urinating. Temperature was 101.9F and physical examination revealed a diffusely tender but not distended abdomen without rebound, guarding or rigidity. On genitourinary examination perineal tenderness was noted and digital rectal examination was deferred based on computerized tomography findings. Multiphasic computerized tomography of the abdomen and pelvis demonstrated copious amounts of gas in the prostate (4.4 3.6 cm, see figure), which is consistent with emphysematous prostatitis. A suprapubic tube was placed with drainage of approximately 400 ml of concentrated purulent urine. The white blood cell count was 19,200 at presentation and increased to 29,000. The patient was started empirically on antibiotics and subsequent urine cultures were positive for Citrobacter species. Transurethral drainage/unroofing of the prostatic abscess was performed. Approximately 300 ml of purulent fluid were exposed during transurethral resection. A Foley catheter was placed and the suprapubic tube was left in position. The patient was kept in the intensive care unit for several days requiring pressor support and culture specific antibiotic therapy, which improved the hemodynamic status. After complete convalescence he was discharged home on postoperative day 14. Emphysematous prostatitis is a rare entity with few cases reported, and diagnosis is a challenge since patients present with nonspecific symptoms. Most patients are treated for urinary tract infection and emphysematous prostatitis is considered only after infections recur. Imaging of the prostate by computerized tomography and/or transrectal ultrasound should be performed in all patients with the suspected diagnosis. Gas forming bacterial infections of the urine are the culprits behind the illness and are typically seen in diabetic patients. The most commonly reported organisms are Klebsiella pneumoniae, Pseudomonas aeruginosa and Candida albicans. 1‐3 Mortality from emphysematous prostatitis is high and, thus, immediate drainage of the abscess is eminent.