The patient shows signs of systemic toxicity (fever, tachycardia, hypotension), combined with suprapubic tenderness and a
4. OTHER INFECTIVE UROLOGICAL EMERGENCIES 49
palpable bladder if in urinary retention. On digital rectal examination the prostate is extremely tender.
Treatment consists of intravenous antibiotics, pain relief and relief of retention if present. Traditional teaching recommended a suprapubic catheter be inserted, rather than a urethral catheter, to avoid the potential obstruction of prostatic urethral ducts by a urethral catheter with retention of infected secretions and pus. However, in-and-out catheterisation or short periods with an indwelling catheter probably do no harm, and this is certainly an easier way of relieving retention than suprapubic catheterisation.
Failure to respond to the treatment regimen outlined above (persistent symptoms and persistent fever while on antibiotic therapy) suggests the development of a prostatic abscess. A transrectal ultrasound, or computed tomography (CT) scan if the former proves too painful, is the best way of diagnosing a pro-static abscess (Fig. 4.1). This may be drained by a transurethral incision or deroofing using a resectoscope.
Fournier's gangrene (Fig. 4.2) is a necrotising fasciitis affecting the genitalia and perineum. It primarily affects males. Necrosis
FIGURE 4.1. A computed tomography scan of a prostatic abscess.
50 H. HASHIM AND J.REYNARD
FIGURE 4.2. Fournier's gangrene. (See this figure in full color in the insert.)
and subsequent gangrene of infected tissues occurs. Culture of infected tissue reveals a combination of aerobic (e.g., E. coli, enterococcus, Klebsiella) and anaerobic organisms (Bacteroides, Clostridium, microaerophilic streptococci), which are believed to grow in a synergistic fashion. Conditions that predispose to the development of Fournier's gangrene include diabetes, local trauma to the genitalia and perineum (e.g., zipper injuries to the foreskin), and surgical procedures such as circumcision.