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/lp/wolters-kluwer-health/periurethral-abscess-etiology-risk-factors-treatment-options-and-ouUPHnwpZz
- Publisher
- Wolters Kluwer Health
- Copyright
- Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc.
- ISSN
- 1661-7657
- eISSN
- 1661-7657
- DOI
- 10.1097/cu9.0000000000000159
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- See Article on Publisher Site
Abstract
Objectives: This study aimed to describe patterns of presentation, etiology, risk factors, management, and treatment outcomes of periurethral abscesses using a systematic review framework. Materials and methods: After prospective registration on the PROSPERO database (CRD42020193063), a systematic review of Web of Science, Embase, PubMed, and Cochrane scientific databases was performed. Articles published between 1900 and 2021 were considered. Extracted data included symptoms, etiology, medical history, investigations, treatment, and outcomes. Collated data were analyzed using univariate methods. Results: Sixty articles met the inclusion criteria reporting on 270 patients (211 male, 59 female) with periurethral abscess. The most common clinical features were pain (41.5%), pyuria (41.5%), dysuria (38.5%), urinary frequency (32.3%), fever (25%), and a palpable mass (23%). Predisposing risk factors included the presence of a sexually transmitted infection or urinary tract infection (55.0%), urethral strictures (39.6%), and recent urethral instrumentation (18.7%). Management approaches included open incision and drainage (64.3%), conservative management with antibiotics (29.8%), and minimally invasive techniques (needle aspiration, endoscopic drainage). Time trend analysis of etiology revealed a decreased incidence of infection (sexually transmitted infection/urinary tract infection, human immu- nodeficiency virus) and higher incidence of diabetes mellitus and periurethral bulking injections in recent years. Conclusions: Periurethral abscesses may display a wide range of clinical features. Presentation, risk factors and underlying etiology vary with sex. The optimal management technique is guided by abscess size. Open incision and drainage combined with antibiotics continues to be the mainstay of management. However, minimally invasive techniques are gaining favor. To the authors' knowledge, this is the first systematic appraisal and management algorithm for periurethral abscess. Keywords: Periurethral abscess; Sexually transmitted infection; Urethritis; Urinary tract infection 1. Introduction Periurethral abscesses may present in a similar fashion to other genitourinary pathology, including pain (scrotal, penile, pelvic, Periurethral abscess is a rare entity in contemporary urological prac- perineal, or suprapubic), fever, dysuria, pyuria, and acute urinary [2,3] tice with the potential for significant morbidity and mortality. Ab- retention. Accurate and timely diagnosis can be challenging, [2] scess formation occurs within paraurethral tissues, most commonly with many patients progressing to sepsis. Delayed detection related to the paraurethral glands (Littre's, Skene's, and Cowper's). and treatment may lead to complications such as urethral fistula, [4–6] The first published case was documented in 1901 of a 19-year-old stricture, and, rarely, extensive cellulitis, or necrotizing fasciitis. [1] man with underlying gonococcal urethritis. The abscess was suc- Historical mortality rates have been as high as 47% to 50% in the cessfully treated with open incision and drainage (I&D) along with context of delayed presentations and consequent phlegmon forma- [7] injection of tricresol (a mixture of 3 isometric methyl phenols) into tion. It has been proposed that abscess formation is preceded by [1] the abscess cavity. Given the rarity of this pathology, descriptions urethritis and associated with etiological factors such as urinary ob- regarding microbiology, risk factors, investigations, and outcomes struction, trauma (including surgery and/or instrumentation), ure- [4,5] are sparse, with little consensus to guide contemporary management. thral diverticula, and urethral carcinoma. Reported management [8] techniques include conservative therapy (ie, antibiotics), needle as- *Corresponding Author: Dr Arsalan Tariq, Faculty of Medicine, The University of [9] [10] piration, and open I&D. Queensland, Herston, QLD 4029, Australia. E-mail address: a.tariq@uq.edu.au (A. Tariq). Despite being described intermittently in the literature for Supplemental Digital Content is available for this article. more than 120 years, the microbiology, demographics, risk fac- Current Urology, (2023) 17, 2, 100–108 tors, clinical manifestations, optimal treatment, and outcomes Received April 10, 2022; Accepted May 23, 2022. for periurethral abscesses remain poorly defined and are likely http://dx.doi.org/10.1097/CU9.0000000000000159 Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. This to have changed over time. Thus, the aim of this study was to sys- is an open-access article distributed under the terms of the Creative Commons tematically review the available literature concerning periurethral Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it abscesses and describe their etiology, risk factors, symptoms, in- is permissible to download and share the work provided it is properly cited. The vestigations, management techniques, and outcomes, including work cannot be changed in any way or used commercially without permission from the journal. temporal considerations. 100 Tariq et al. Volume 17 Issue 2 2023 www.currurol.org 2. Materials and methods presentation was 30.6 days (standard deviation, 71.2 days; n = 270). Delayed presentation to care was more common among fe- A systematic review was conducted in accordance with the Preferred male (28.2 ± 171.0 days, n = 59) than male patients (16.4 ± 9.9 Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) days, n = 211; p ≤ 0.01). Female patients were more likely to pres- [11] guidelines. The published study protocol was registered in the ent with a palpable mass than male patients (73% vs. 18%, p ≤ PROSPERO database (CRD42020193063). 0.01), and less likely to have a fever (7% vs. 30%, p =0.01).Ab- scess location in male patients included the penile (78%) and bul- 2.1. Data sources bar (22%) urethra, whereas the distribution among female pa- The EMBASE, Web of Science, and Cochrane databases were que- tients was highest in the distal (62%), followed by middle (21%) and proximal urethra (17%). Urinary retention was more com- ried in October 2021 for studies published in English, including mon in patients with concurrent urethral abnormality (eg, divertic- case reports and case series, from 1900 to 2021. All published lit- erature was reviewed for eligibility. Of note, abscess reports related ulum, stricture/stenosis, or previous instrumentation/injury) com- to the prostate and prostatic urethra were considered a separate pa- pared with those with no abnormality (59.8% vs. 0%, p ≤ 0.01; [12] thology and thus excluded from this review. The medical subject Table 2). heading search terms “urethral,”“urethra,”“periurethral,” “suburethral,”“paraurethral,”“Skene,”“Cowper,” and “Littre's” 3.2. Imaging along with text-search terms “abscess” or “abscesses” were used to Among 115 patients for whom imaging was reported, 124 imaging extract relevant articles. Reference lists of key articles were also ex- investigations comprised cystourethrography (61, 49.2%), mag- amined for additional relevant articles. Conference abstracts and netic resonance imaging (MRI; 31 [25.1%]), ultrasonography other unpublished accounts were excluded from this review because (USS; 19 [15.3%]), and computed tomography (CT; 13 [10.5%]; of insufficient detail to allow for appropriate assessment. Table 1). Nine patients underwent investigation with multiple im- aging modalities (CT and MRI, n =4;CT and USS, n =3; 2.2. Quality assessment urethrography and CT or US, n = 2). The abscess was successfully Quality assessment of included studies (Supplementary Tables 1 identified in all patients undergoing USS and CT and 93% of those and 2, http://links.lww.com/CURRUROL/A28 and http://links. who underwent cystourethrography ( p = 0.25). MRI was less suc- lww.com/CURRUROL/A29) was performed using the 8-item cessful in identifying abscesses in comparison to CT and USS (71% [13–15] Joanna Briggs Institute checklist, as recommended by the vs. 93%, 91%; p ≤ 0.01). However, these findings predominantly [16] Cochrane Collaboration guidelines. came from 1 study, and the role of MRI in diagnosis of urethral pa- thology is considered in the discussion hereinafter. 2.3. Outcome measures and data management After screening of abstracts, full-text publications were assessed for 3.3. Etiology inclusion by 2 reviewers (A.T. and A.G.S.). Extracted data in- A total of 102 (37.8%) patients had a predisposing factor for ab- cluded patient demographics (age, sex, ethnicity), symptoms, med- scess (diverticulum, strictures/stenosis, history of urolithiasis, or ical history, and, in particular, risk factors and precipitants, diag- previous instrumentation/surgery; Table 1). Urethral stricture/ stenosis (39.6%), previous instrumentation (18.7%), previous ure- nostic imaging, laboratory findings, management techniques, and follow-up information, if available. thral injury (16.4%), and urethral diverticuli (11.9%) were the most common etiological factors. Evidence of an underlying diver- 2.4. Statistical methods ticulum (60% vs. 9.2%, p = 0.01) or recent instrumentation (i.e., Descriptive statistical analysis was performed for continuous cystoscopic injection of bulking agents) was more common in fe- (mean, median, standard deviation, and interquartile ranges) and male patients (60% vs. 8.3% p ≤ 0.01), whereas urethral strictures categorical variables (frequencies, percentage distribution). Hy- (48.6% vs. 0%, p ≤ 0.01) were the most common predisposing factor pothesis testing was conducted using 2-tailed t test and Fisher exact in male patients (Table 1). Previous urethral injury or surgery pre- test using GraphPad QuickCalcs. A p value of <0.05 was desig- disposed male patients to penile abscesses (43.8%) (Supplementary nated as indicating statistical significance. Data tables, graphs, Table 3, http://links.lww.com/CURRUROL/A30). and figures were generated using Microsoft Excel. 3.4. Risk factors Risk factors were reported for 200 patients (74%), including a his- 3. Results tory of a sexually transmitted infection (STI) or urinary tract infec- tion (UTI) (55%), diabetes mellitus (6.6%), previous abscess Database searches identified a total of 1665 entries, of which 1585 (6.6%), human immunodeficiency virus (5.4%), and urethral car- were excluded based on title and abstract review (Fig. 1). Full-text ar- cinoma (1.6%) (Table 1). The rate of previous infection (STI/UTI) ticles (n = 80) were assessed for eligibility, of which 20 were excluded, was higher in male than female patients (58.3% vs. 11.1%, p ≤ resulting in 60 full-text articles with a total of 270 patients being 0.01). The incidence of diabetes mellitus was higher in female than included for analysis. Most studies originated in North America male patients (33.3% vs. 4.6%, p ≤ 0.01; Supplementary Table 3, (48.5%), Asia (36.3%), and Africa (7.7%). A majority of patients http://links.lww.com/CURRUROL/A30). were male (78.1%; Table 1). The median age was 49.0 years (range, 10 months–78 years), and 6 patients (2%) were children. 3.5. Microbiology There were 59 suspected pathogens isolated by urine culture and 3.1. Clinical features 205 suspected pathogens cultured directly from abscess fluid or tis- The most common clinical features included pain (43.3%; includ- sue (Table 1). Anaerobic organisms accounted for 96.6% of urine ing penile, scrotal, perineal, and suprapubic), pyuria (41.5%), dys- and 51.7% of abscess culture results. The most commonly identi- uria (38.5%), frequency (32.3%), fever (>38°C; 25%), and a pal- fied anaerobic organisms included Escherichia coli, Enterococcus, pable mass (23%; Table 1). Mean duration of symptoms before and Staphylococcus and Streptococcus species. Common aerobic 101 Tariq et al. Volume 17 Issue 2 2023 www.currurol.org Figure 1. PRISMA flowchart: data collection and selection of studies. pathogens included Neisseria gonorrhoeae and Corynebacterium successful), and endoscopic transurethral drainage in 8 patients species. Anaerobic (100% vs. 50.3%, p = 0.03) and gram-positive (3.1%; 62.5% successful; Table 1). Across all patients, no statisti- bacteria (100% vs. 23.6%, p ≤ 0.01) were more commonly identi- cally significant difference in treatment success was found between fied in samples from female than male patients. In male patients, a open I&D and needle aspiration; however, transurethral/endoscopic high proportion of anaerobic organisms were present across all loca- drainage was less likely to be successful (91.2% vs. 62.5%; p =0.03). tions (penile, 58.3%; bulbar, 91.7%; Supplementary Table 3, http:// Transurethral/endoscopic methods were more commonly successful in links.lww.com/CURRUROL/A30). However, aerobic organisms male than female patients (100% vs. 0%, p = 0.01), whereas the success were more commonly found in penile (41.7%) as compared with of needle aspiration was equivalent irrespective of sex. Treatment bulbar abscesses (8.3%, p = 0.02). The distribution of pathogens success was not affected by underlying pathology or location. based on Gram stain results stratified by abscess location in male pa- tients were 60% gram positive and 40% gram negative in penile ab- 3.7. Complications scesses versus 36.4% gram positive and 63.6% gram negative in Complications (eg, incomplete abscess resolution, secondary pa- bulbar abscesses (Supplementary Table 3, http://links.lww.com/ thology) were reported in 22 patients. Inadequate source control CURRUROL/A30). requiring further surgery was reported for 12 (7.2%), 2 (25%), and 1 (3.4%) patients who underwent I&D, endoscopic treatment, 3.6. Management and needle aspiration, respectively. Urethrocutaneous fistula (1 I&D Initial management included urinary diversion via suprapubic patient) and urethral stricture (1 I&D, 1 endoscopic treatment patient) catheter placement in 65 of 270 patients (24.1%) (Table 1). Defin- were uncommon. Abscess recurrence occurred in 1 patient each itive management included open I&D in 166 patients (64.3%; among the I&D and needle aspiration cohorts, and prolonged antibi- 91.6% successful), needle aspiration in 29 patients (11.2%; 89.7% oticswere requiredin1patient afterneedle aspiration(Table1). 102 Tariq et al. Volume 17 Issue 2 2023 www.currurol.org Table 1 Patient clinical features, male versus female. Total Male Female p No. patients, n (%) 270 (100) 211 (78.1) 59 (21.9) Age, median (IQR), yr 49 (35.8–62.3) 48 (34.8–63.5) 43.75 (38.0–59.0)* 0.01 Presenting symptoms, n (%) Acute urinary retention 26 (9.6) 21 (10.0) 5 (8.5) 1 Pain (penile, scrotal, perineal, suprapubic) 117 (43.3) 108 (51.2) 27 (45.8) 0.55 Difficulty voiding 13 (4.8) 8 (3.8) 5 (8.5) 0.17 Dysuria 104 (38.5) 85 (40.3) 19 (32.2) 0.29 Hematuria 4 (1.5) 2 (0.9) 2 (3.4) 0.21 Pyuria 112 (41.5) 104 (49.3) 27 (45.8) 0.66 Frequency 87 (32.2) 69 (32.7) 14 (23.7) 0.21 Other LUTS 17 (6.3) 8 (3.8) 13 (22.0)* ≤0.01 Mean symptom duration before presentation, d 30.6 16.4 28.2* ≤0.01 Physical examination, n (%) Palpable mass 62 (23.0) 37 (17.5) 43 (72.9)* ≤0.01 Fever 67 (24.8) 63 (29.9)* 4 (6.8) ≤0.01 Systemically unwell 18 (6.7) 14 (6.6) 4 (76.8) 1 Urethrocutaneous fistula 8 (3.0) 8 (3.8) 0 (0) 0.26 Imaging study, n (%) 124 84 40 Cystourethrography 61 (49.2) 59 (70.2)* 2 (5.0) ≤0.01 US 19 (15.3) 10 (11.9) 9 (22.5)* ≤0.01 CT 13 (10.5) 11 (13.1) 2 (5.0) 0.74 MRI 31 (25.0) 4 (4.7) 27 (67.5)* ≤0.01 Etiology, n (%) 134 109 25 History of urolithiasis (any) 6 (4.5) 5 (4.6) 1 (4.0) 1 Postprocedural/postinstrumentation 25 (18.7) 10 (9.2) 15 (60.0)* ≤0.01 Diverticulum 16 (11.9) 9 (8.3) 7 (28.0)* ≤0.01 Urethral stenosis/stricture 53 (39.6) 53 (48.6)* 0 (0) ≤0.01 Previous urethral injury/surgery? 22 (16.4) 20 (18.3) 2 (8.0) 0.37 No lower urinary tract disease 32 (23.9) 31 (28.4) 1(4.0) 0.02 RF, n (%) 258 240 18 T2DM 17 (6.6) 11 (4.6) 6 (33.3)* ≤0.01 HIV 14 (5.4) 14 (5.8) 0 (0.0) 0.61 STI/UTI 142 (55.0) 140 (58.3)* 2 (11.1) ≤0.01 Other RF 6 (2.3) 5 (2.1) 1 (5.6) 1 Previous abscess 17 (6.6) 16 (6.7) 1 (5.6) 0.36 Urethral carcinoma 4 (1.6) 3 (1.3) 1 (5.6) 0.25 No RF 58 (22.5) 51 (21.3) 7 (36.9) 0.14 Urinary pathogens, n (%) 59 36 23 Aerobic 2 (3.4) 5 (13.9) 0 (0) 0.15 Anaerobic 57 (96.6) 31 (86.1) 23 (100.0) 0.15 Gram positive 19 (32.2) 9 (25.0) 9 (39.1) 0.27 Gram negative 40 (67.8) 27 (75.0) 14 (60.9) 0.27 Abscess pathogens, n (%) 205 199 6 Aerobic 99 (48.3) 99 (49.7) 0 (0) 0.03 Anaerobic 106 (51.7) 100 (50.3) 6 (100) 0.03 Gram positive 53 (25.9) 47 (23.6) 6 (100)* ≤0.01 Gram negative 152 (74.1) 152 (76.4)* 0 (0.0) ≤0.01 Urinary diversion, n (%) 65 (24.1) 63 (23.3) 2 (0.7) ≤0.01 Definitive management, n (%) Attempt Successful Attempt Successful Attempt Successful Open I&D 166 (64.3) 152 (91.6) 114 (47.5) 108 (94.7) 52 (83.4) 42 (81) 0.12 Needle aspiration 29 (11.2) 26 (89.7) 25 (10.4) 22 (88.0) 4 (6.5) 4 (100) 0.61 Transurethral/endoscopic 8 (3.1) 5 (62.5) 5 (2.1) 5 (100) 3 (4.8) 0 (0) 0.11 Conservative 77 (29.8) 75 (97.4) 74 (30.8) 72 (97.3) 3 (4.8) 3 (100) ≤0.01 Bold are the statistically significant p values. CT = computed tomography; HIV = human immunodeficiency virus; I&D = incision & drainage; IQR = interquartile range; LUTS = lower urinary tract symptoms; MRI = magnetic resonance imaging; RF = risk factors; STI = sexually transmitted infection; surgery? = previous lower urinary tract surgery; T2DM = type 2 diabetes mellitus; US = ultrasound; UTI = urinary tract infection. *p ≤ 0.05; p value assessed through 2-tailed t test (age and symptom duration before presentation only) and Fisher exact test (all other variables). p value comparing male versus female cohorts. 3.8. Time-trend analysis reports published from 2000 to the present were generally older than Patients were stratified according to 2 time periods, 1900–2000 those from 1900 to 2000 (50.3 vs. 43.2 years, p ≤ 0.01). Urinary reten- (112 patients) and 2000–present (158 patients; Table 3). Patients from tion (16.1% vs. 5.1%, p ≤ 0.01) and pain (69.6% vs. 24.7%, p ≤ 0.01) 103 Tariq et al. Volume 17 Issue 2 2023 www.currurol.org Table 2 Patient clinical features by presence versus absence of urethral abnormality. Any urethral abnormality No urethral abnormality p No. patients, n (%) 102 (85) 18 (15) Age, median (IQR), yr 56.7 (30.0–56.7) 38 (24.88–59.3) ≤0.01 Presenting symptoms, n (%) Acute urinary retention 61 (59.8) 0 (0) ≤0.01 Pain (penile, scrotal, perineal, suprapubic) 85 (83.3) 13 (72) 0.32 Difficulty voiding 11 (10.8) 2 (11.0) 1 Dysuria 21 (20.6) 6 (33.0) 0.23 Hematuria 3 (2.9) 1 (6.0) 0.48 Pyuria 30 (29.4) 8 (44.0) 0.27 Frequency 9 (8.9) 0 (0) 0.35 Other LUTS 9 (8.8) 2.0 (11) Mean symptom duration before presentation, d 35 9 0.19 Physical examination, n (%) Palpable mass 46 (45.1) 13 (72) 0.041 Fever 57 (55.9) 0.798 0.42 Systemically unwell 11 (10.8) 0.021 0.53 Urethrocutaneous fistula 4 (3.9) 1 0.18 Imaging study, n (%) Cystourethrography 59 (57.8) 1 (6) ≤0.01 US 13 (12.7) 6 (33) 0.04 CT 9(8.8) 4(22) 0.1 MRI 9 (8.8) 2 (11.1) 0.67 Etiology, n (%) 102 History of urolithiasis (any) 6 (5.9) - - - Diverticulum 16 (15.7) - - - Urethral stenosis/stricture 53 (52.0) - - - Previous urethral injury/surgery? 22 (21.6) - - Other 5 (4.9) - - - RF, n (%) T2DM 11 (10.8) 2 (11.1) 1 HIV 0 (0) 1 (5.6) 1 STI/UTI 40 (39.2) 5 (27.8) 0.79 Other RF 3 (2.9) 3 (16.7) 0.04 Prior abscess 21 (20.6) 1 (5.6) 0.19 Urethral carcinoma 4 (3.9) 0 (0) 1 No RF 55 (53.9) 9 (50) 0.8 Definitive management, n (%) Attempts Successes Attempts Successes Open I&D 102 (83.6) 92 (90.2) 1 9 (42.9) 8 (88.9) 0.01 Needle aspiration 4 (3.3) 4 (100) 1 5 (23.8) 5 (100) ≤0.01 Transurethral/Endoscopic 5 (4.1) 3 (60.0) 1 2 (9.5) 1 (50) 0.29 Conservative 11 (9.0) 8 (72.3) 1 5 (23.8) 4 (80) 0.07 Bold are the statistically significant p values. CT = computed tomography; HIV = human immunodeficiency virus; I&D = incision & drainage; IQR = interquartile range; LUTS = lower urinary tract symptoms; MRI = magnetic resonance imaging; RF = risk factors; STI = sexually transmitted infection; surgery? = previous lower urinary tract surgery; T2DM = type 2 diabetes mellitus; US = ultrasound; UTI = urinary tract infection. p <0.05; p value assessed through 2-tailed t test (age and symptom duration before presentation only) and Fisher exact test (all other variables). were reported more often among patients from 1900 to 2000. Dysuria 4. Discussion (57.6% vs. 11.6%, p ≤ 0.01), pyuria (52.5% vs. 25.9%, p ≤ 0.01), and frequency (53.8% vs. 1.8%, p ≤ 0.01) were more commonly Diagnosis and management of periurethral abscess continue to be reported in publications from 2000 to the present. a challenging aspect of urological practice. Patients often have vague [5] Urethral stricture/stenosis was less common (9.5% vs. 53.3%, p presentations and broad symptoms. In addition, pathophysiology ≤ 0.01), whereas a history of urolithiasis was more common can be multifactorial and inadequate treatment can cause significant [17] (14.3% vs. 0%, p ≤ 0.01) in reports from 2000 to the present than morbidity. Given the scarcity of the literature on this topic, we before 2000, respectively. A higher incidence of human immunodefi- sought to provide an evidence base to guide clinicians. This system- ciency virus was reported before than after 2000 (10.6% vs. 0.7%, p = atic review highlights that periurethral abscess continues to be a 0.01), whereas STI/UTI incidence remained high across both time periods rare pathology and is often accompanied by concurrent urethral [10,18] (43.1% vs. 65.9%). Open I&D was more commonly attempted as pri- pathology. We also demonstrate that differences in clinical mary treatment modality before 2000 (69.1% vs. 48.8%; p =0.01), presentation, etiology, risk factors, and microbiology exist be- whereas needle aspiration was used more frequently from 2000 tween sexes. Furthermore, successful management is underpinned [4] to the present than before 2000 (27.6% vs. 17.1%, p =0.01). by surgical source control and antimicrobial therapy. 104 Tariq et al. Volume 17 Issue 2 2023 www.currurol.org [19] 4.1. Sex and urethral pathology nary incontinence represents a contemporary risk factor. It is The presence of underlying urethral pathology in periurethral ab- likely that correct injection technique is of paramount importance [20] scess patients was common, particularly among those with a previ- in reducing the potential for such presentations. In addition, ous abscess and/or those presenting with acute urinary retention urethral diverticuli were often present in female patients in this re- (Table 2). In the latter cohort, it is important for clinicians to sus- view, with subsequent urinary stasis predisposing these women to [21] pect the possibility of concurrent urethral pathology (eg, diverticu- infection and calculus formation. Therefore, careful physical ex- lum, stricture/stenosis, or previous urethral injury), which could amination is important to assess for urethral abnormalities (eg, make urethral catheterization difficult and require suprapubic diverticuli) in people presenting with suspected periurethral ab- [4] catheter placement. The incidence of periurethral abscess is scess. In particular for female patients, a palpable diverticulum or higher in men (Table 1), potentially because of a longer, more tor- sterile abscess may be targeted for transvaginal needle aspiration [22] tuous urethra, along with higher rates of stricture/stenosis, which as a minimally invasive management option. may cause higher intraurethral pressure and subsequent epithelial disruption allowing progression of infection into the periurethral 4.2. Infectious and diagnostic issues [6] glands. In women, an emerging trend of “sterile abscess” forma- Male patients presenting with periurethral abscess more com- tion after transurethral injections of bulking agents for stress uri- monly develop serious infections (ie, febrile illness; Table 1), with Table 3 Patient clinical features, by time period (1900–2000 vs. 2000–present). Total 1900–2000 2000–2021 p No. patients, n (%) 270 (100) 112 (41.5) 158 (58.5) Age, median (IQR), yr 49 (35.8–62.3) 43.2 (36.1–56.7) 50.29 (38.4–49.3)* ≤0.01 Presenting symptoms, n (%) Acute urinary retention 26 (9.6) 18 (16.1)* 8 (5.1) ≤0.01 Pain (penile, scrotal, perineal, suprapubic) 117 (43.3) 78 (69.6)* 39 (24.7) ≤0.01 Dysuria 104 (38.5) 13 (11.6) 91 (57.6)* ≤0.01 Pyuria 112 (41.5) 29 (25.9) 83 (52.5)* ≤0.01 Frequency 87 (32.2) 2 (1.8) 85 (53.8)* ≤0.01 Other LUTS 17 (6.3) 3 (2.7) 14 (8.9) 0.04 Mean symptom duration before presentation, d 30.6 18.3 15.3* 0.33 Physical examination, n (%) Palpable mass 62 (23.0) 25 (22.3) 37 (23.4) 0.88 Fever 67 (24.8) 51 (45.5)* 16 (10.1) ≤0.01 Systemically unwell 18 (6.7) 7 (6.3) 11 (7.0) 1 Urethrocutaneous fistula 8 (3.0) 6 (5.4) 2 (1.3) 0.07 Imaging study, n (%) 124 61 63 Cystourethrography 61 (49.2) 55 (90.2)* 6 (9.5) ≤0.01 US 19 (15.3) 3 (4.9) 16 (25.4) 0.74 CT 13 (10.5) 2 (3.3) 11 (17.4) 0.08 MRI 31 (25.0) 1 (1.6) 30 (47.6)* ≤0.01 Etiology, n (%) 134 92 25 History of urolithiasis (any) 6 (4.5) 0 (0) 6 (14.3)* ≤0.01 Postprocedural/postinstrumentation? 25 (18.7) 19 (20.7) 6 (14.3) 0.48 Diverticulum 16 (11.9) 9 (9.8) 7 (16.7) 0.26 Urethral stenosis/stricture 53 (39.6) 49 (53.3)* 4 (9.5) ≤0.01 Previous urethral injury/surgery? 22 (16.4) 14 (15.2) 8 (19.0) 0.62 No lower urinary tract disease 32 (23.9) 21 (22.8) 11 (26.2) 0.69 RF, n (%) 258 123 135 T2DM 17 (6.6) 8 (6.5) 5 (3.7) 0.40 HIV 14 (5.4) 13 (10.6)* 1 (0.7) ≤0.01 STI/UTI 142 (55.0) 53 (43.1) 89 (65.9)* 0.001 Other RF 6 (2.3) 6 (4.9)* 0 (0) 0.01 Prior abscess 17 (6.6) 0 (0) 17.0 (12.6)* ≤0.01 Urethral carcinoma 4 (1.6) 1 (0.8) 3 (2.2) 0.62 No RF 58 (22.5) 38 (30.9)* 20 (14.8) ≤0.01 Management, n (%) Attempts Successes Attempts Successes Attempts Successes Open I&D 166 (59.3) 152 (91.6) 85 (72.6)* 78 (91.8) 81 (49.7) 69 (85) 0.01 Needle aspiration 29 (10.4) 26 (89.7) 21 (17.9) 17 (81.0) 8 (4.91)* 8 (100) ≤0.01 Transurethral/endoscopic 8 (2.9) 5 (62.5) 4 (3.4) 2 (50.0) 4 (2.4) 3 (75) 0.72 Conservative 77 (27.5) 75 (97.4) 7 (6.1) 5 (71.4) 70 (42.9)* 69 (99) ≤0.01 Bold are the statistically significant p values. CT = computed tomography; HIV = human immunodeficiency virus; I&D = incision & drainage; IQR = interquartile range; instrumentation? = urethral catheterization; LUTS = lower urinary tract symptoms; MRI = magnetic resonance imaging; RF = risk factors; STI = sexually transmitted infection; surgery? = previous lower urinary tract surgery; T2DM = type 2 diabetes mellitus; US = ultrasound; UTI = urinary tract infection. *p <0.05; p value assessed through 2-tailed t test (age and symptom duration before presentation only) and Fisher exact test (all other variables). 105 Tariq et al. Volume 17 Issue 2 2023 www.currurol.org [7] [28] a higher risk for phlegmon formation and sepsis. Fortunately, reflecting the greater prevalence of multiresistant organisms. however, male patients seem to present for care earlier (Table 1), Nonetheless, detailed microbiological data were scarce in the stud- allowing for prompt assessment and investigation. Imaging modal- ies included in this review. Among patients who had cultures performed, ities (CT, USS, and cystourethrography) can accurately confirm a many either demonstrated no growth or only described pathogens [2,3,18] clinical diagnosis of periurethral abscess. Therefore, in current at the genus level. A majority of pathogens were identified from di- practice, early utilization of CT or USS is prudent to ensure timely rect cultures of the abscess fluid. Given these findings, importance treatment. The sensitivity of MRI to identify a periurethral abscess should be placed on obtaining a sample of abscess fluid early and before was inferior to CT/USS in this review; however, these results were at- commencement of antimicrobials for therapeutic and diagnostic pur- [23] tributable largely to 1 study. This finding seems counterintuitive poses in patients without features of systemic illness. In addition to ab- because MRI is generally well suited to identification of soft tissue scess drainage, this strategy will maximize the chance of clinical cure by [24] pathology and has been used in urethral imaging along with facilitating the choice of antimicrobial therapy with optimal coverage. [25] imaging of prostatic abscesses, highlighting that there may still be a role for MRI in periurethral abscess characterization. 4.3. Management considerations Men with periurethral abscesses demonstrated higher rates of pre- Open I&D continues to the most commonly used method of surgi- vious STI and penile urethral abscess, consistent with the natural pro- cal source control of periurethral abscess and is effective (91.6% gression of gonoccocal urethritis and associated higher rates of success rate in this study) in patients with primary and recurrent [18,26] STIs. Targeted antimicrobial therapy in men requires disease. However, needle aspiration or conservative management consideration of abscess location. For penile urethral abscesses, (targeted antimicrobials and supportive care) can also be consid- antibiotics with gram-positive and aerobic organism coverage ered as an initial treatment option in appropriate patients (97.4% should be selected, whereas anaerobic coverage is required for bul- success rate). In the 21st century, treatment with needle aspiration has bar abscesses (Supplementary Table 3, http://links.lww.com/ increasingly been reported, presumably because of wider adoption by CURRUROL/A30). All pathogens reported in the microbiology test- clinicians and greater availability of imaging guidance (ie, USS, CT, or ing of female patients were anaerobic organisms (Table 1), highlight- MRI). Interestingly, similar trends have also been reported in the [29,30] ing the likely role of local flora in abscess formation and the need to contemporary treatment of prostatic abscesses. Furthermore, consider appropriate antibiotic coverage for Bacteroides species, the available literature demonstrates that long-term complications Gardnerella vaginalis, Ureaplasma species, and Streptococcus spe- of periurethral abscess are relatively uncommon. Nonetheless, [27] cies. The reportedUTI andSTI ratesinperiurethralabscesspa- follow-up after treatment is prudent because failure of appropriate tients were higher in reports from 2000 to the present than those be- healing after surgical treatment may precipitate urethrocutaneous [22,31,32] fore 2000 (Table 3) despite advances in antibiotics, potentially fistulae or strictures requiring intervention. Failure of healing Figure 2. Periurethral abscess management algorithm. CT = computed tomography; DM = diabetes mellitus; Gram +ve = gram positive; Gram -ve = gram negative; IDC = indwelling urinary catheter; IV = intravenous; I&D = incision and drainage; MRI = magnetic resonance imaging; PU = periurethral; SPC = suprapubic catheter; STI = sexually transmitted infection; USS = ultrasonography. 106 Tariq et al. Volume 17 Issue 2 2023 www.currurol.org may also be a harbinger for underlying urethral carcinoma as a pre- References [18,33–35] cipitant for recurrent and/or prolonged abscess occurrence. [1] Heidingsfeld ML. Trikresol in para-urethral abscess. Boston Med Surg J To aid clinicians in navigating the assessment and management 1903;148:418–421. of this rare but serious pathology, we present a novel management [2] Galvin SD, Sampangi NR, Wilson BK, Samalia KP. Periurethral abscess: algorithm for periurethral abscess in Figure 2. An unusual source of sepsis. ANZ J Surg 2010;80(9):653–654. [3] Garg G, Goel A, Sharma D, Pandey S. 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Journal
Current Urology – Wolters Kluwer Health
Published: Jun 12, 2023