Renal and Perinephric Abscess

Renal and perinephric abscess
Alain Meyrier, MD
Dori F Zaleznik, MD

UpToDate performs a continuous review of over 330 journals and other resources. Updates are
added as important new information is published. The literature review for version 12.3 is current
through August 2004; this topic was last changed on May 28, 2004. The next version of UpToDate
(13.1) will be released in February 2005.
RENAL ABSCESS
Pathogenesis - A renal abscess is now an uncommon infection of the urinary tract. It can
develop by one of two general mechanisms: hematogenous spread, which usually results in a
cortical abscess; and ascending infection from the bladder, which primarily involves the medulla in
most cases [1,2]. The latter mechanism is by far the most frequent.
Ascending infection - At present, ascending infection accounts for more than 75 percent of
renal abscesses [2]. Ascending infection, usually due to Gram negative organisms, begins in the
bladder and ascends to the renal parenchyma [1,3,4]. The resultant acute pyelonephritis is
followed by liquefaction which walls off the center of pyelonephritic area [2].
While most episodes of uncomplicated acute pyelonephritis occur in normal urinary tracts, a renal
abscess is a complication of an anatomic abnormality in the urinary tract in two-thirds of cases.
Such abnormalities include vesicoureteral reflux, renal stones, a neurogenic bladder, obstructive
tumors, or polycystic kidney disease [2,5]. (See "Urinary tract infection in polycystic kidney
disease"). Infection of a solitary benign renal cyst or of a hydatid cyst [6] is a rare form of renal
abscess. Diabetes mellitus is a risk factor for the development of renal abscess in association with
ascending infection.
Hematogenous spread - Hematogenous seeding from bacteremia most often causes a cortical
abscess. In the preantibiotic era, a renal abscess (also called a renal carbuncle) or multiple miliary
abscesses were a classic complication of Staphylococcus aureus septicemia that typically developed
one to eight weeks after the initial infection [4,7,8]. This form of renal abscess is now rare, since S.
aureus infections are generally treated early in their course. Renal abscess can, however, still be
seen in certain settings, such as an injection drug user with S. aureus infective endocarditis [3].
Hematogenous spread can also occur with bacteremia originating from the contralateral kidney [8]
or from extrarenal sources. It can, for example, arise in a bacteremic patient who suffered from a
seemingly minor skin lesion, such as staphylococcal pyoderma [9]. These patients may have had
no clinical evidence of systemic infection and no signs of overt sepsis.
Diagnosis - The initial clinical picture of a renal abscess due to ascending infection does not
fundamentally differ from that of uncomplicated acute pyelonephritis. In fact, clinical experience
indicates that in any form of pyelonephritis there is no correlation between the severity of clinical
ONLINE 12.3
2004 UpToDate

New Search Table of Contents Feedback Help
Official reprint from UpToDate
www.uptodate.com
Page 1 of 11 UpToDate: 'Renal and perinephric abscess'
19-Nov-04 http://www.utdol.com/application/topic/print.asp?file=uti_infe/4973
signs and symptoms and the lesions found by renal imaging. Typical presenting signs and
symptoms of a renal abscess include dysuria and frequency (although such signs of cystitis may be
absent) followed by the acute onset of fever, chills, unilateral flank pain, and leukocytosis. In
diabetics and malnourished alcoholics, renal infection may be indolent due to autonomic
neuropathy, and the diagnosis of renal infection may thereby be delayed [10].
Two findings should cast doubt on the diagnosis of simple acute pyelonephritis:
The patient appears acutely ill, with pallor, fatigue, sweats and general signs and symptoms of
deep-seated suppuration. In diabetics early ketoacidosis is common. Old age, lethargy and
elevation of blood urea nitrogen portend a poor prognosis [5].

Fever, pain and leukocytosis persist for more than five days despite appropriate antimicrobial
therapy. In comparison, patients with acute pyelonephritis should defervesce within three to four
days after therapy is begun [10].

Urinalysis - Pyuria and bacteriuria are seen in almost all cases of ascending infection. Even
though the medullary abscess may not directly communicate with the collecting system, the whole
kidney is pyelonephritic resulting in the appearance of the offending organism in the urine. The
urinalysis may be normal and the urine culture may be negative if the abscess does not
communicate with the collecting system. This is more common with hematogenous spread,
although staphylococcal bacteriuria is present in some cases [9]. This may also be true in case of
infection within a cyst.
Radiologic evaluation - Lack of clinical improvement should be followed by a radiologic
examination, looking for a renal abscess. (See "Indications for radiologic evaluation in acute
pyelonephritis"). The abscess can be seen with each of the major imaging modalities:
An intravenous pyelogram should show a space-occupying mass (show radiograph 1). This is
not an obligatory investigation as ultrasonography and computed tomographic (CT) scanning are
the best means to establish the diagnosis of renal abscess.

Renal ultrasonography reveals a thick-walled cavity filled with fluid (show radiograph 2). In
some cases, echoes due to necrotic debris result in a picture difficult to distinguish from that of
necrosis within a renal cancer. Pus is often difficult to distinguish from sterile urine or blood in the
case of infection within a cyst. In a patient examined after resting in the supine position,
ultrasonography is strongly suggestive of suppuration when it shows a horizontal separation
between an upper level of low-density fluid (urine) and an underlying level of more dense fluid
(pus).

Considering the importance in atypical cases of distinguishing an abscess from another cause of
febrile, space occupying lesion, especially carcinoma, CT scan guided percutaneous fine needle
aspiration may be performed to obtain fluid for Gram stain and culture. In 91 of 108 cases in which
the material so obtained was adequate, 4 yielded abundant clusters of neutrophils which led to the
diagnosis of renal abscess [11].

The findings on CT scan vary with the stage of the disease. The initial focus is a focal bacterial
nephritis (also known as acute lobar nephronia or focal pyelonephritis) which is manifested by a
focal, mass-like lesion which is hypodense after contrast medium injection, indicating
vasoconstriction and ischemia. This is followed by liquefaction, which walls off the center of the
pyelonephritic area [12]. CT scan reveals the typical findings of a renal abscess in which a
hyperdense rim of contrast surrounds the walled-off abscess cavity (called the "ring sign"), an
image that appears late after contrast medium injection [12] (show radiograph 3).

One study of 61 consecutive patients with renal abscesses found that CT scan and ultrasonography
detected 96 and 92 percent of abscesses, respectively [1].
Recommendations - A renal abscess should be entertained in patients with presumed
pyelonephritis whose symptoms and fever do not respond after five days of appropriate antibiotic
therapy. Elderly patients or those with diabetes may lack localizing symptoms. Ultrasonography or
CT are the two modalities used to detect or exclude a renal abscess. Aspiration of the abscess
should be performed to determine the etiologic organism(s) and to exclude a tumor.
Treatment - Prior to therapy, the abscess may continue to grow, rupture into the perinephric
space, or drain by rupturing into the collecting system. The two major components of treatment
are long-term antimicrobial therapy and catheter drainage [13-16]. Medical therapy is most
effective if begun before the infection has spread beyond the renal capsule. Catheter drainage is an
alternative which is considered when the abscess diameter is greater than 3 cm [15]. Rescue
nephrectomy may be indicated in case of large abscesses in an immunocompromised host,
especially in diabetics.
Antimicrobial therapy - In case of ascending infection, mostly due to Enterobacteriaceae, the
choice of antimicrobials depends in part upon the stage at which the diagnosis is made. If, for
example, a patient has already been started on an appropriate antibiotic for presumed cystitis or
pyelonephritis, then this agent may be continued if aspirate of the abscess reveals the same
organism or is already sterile. In comparison, two drugs are recommended in the untreated patient
to more rapidly reduce the bacterial inoculum and possibly to minimize the emergence of resistant
strains. We usually begin with an aminoglycoside plus a fluoroquinolone (such as ciprofloxacin or
levofloxacin) if the organism is sensitive to both drugs [10]. In general, the aminoglycoside is
given for 10 to 14 days (but not longer due to the risks of nephrotoxicity and ototoxicity), whereas
the fluoroquinolone is continued for several weeks. The total duration of antimicrobial therapy is
determined by the response, as assessed in part by CT scan (see below).
Changes in the antimicrobial regimen are necessary in some cases. In one report, for example, a
change was required in 10 of 33 patients [14]. This reflected a difference between the results of
urine and blood cultures and direct culture of the contents of the abscess.
Treatment efficacy and duration are based upon clinical, laboratory, and radiologic studies. The
patient who responds typically feels better within four to five days and is afebrile within one to two
weeks. The erythrocyte sedimentation rate and C-reactive protein level return more slowly toward
normal. Repeat ultrasound and/or CT examinations demonstrate progressive reduction in the size
of the abscess cavity.
The total duration of antimicrobial therapy is determined by the clinical response and ranges from
one to two months in most patients. The criteria for abscess cure include resolution of pain, fever,
and malaise, normalization of the erythrocyte sedimentation rate, and disappearance of the
abscess cavity on CT scan, which usually shows a permanent cortical scar. Antimicrobial therapy
can be discontinued when the clinical and laboratory parameters have been stable for ten days.
The absence of recurring signs and symptoms of infection and inflammation after cessation of
antimicrobials is the best indicator of bacteriologic cure. Thus, the patient should be monitored at
two week intervals for two to three months after the end of therapy.
Treatment of a renal staphylococcal carbuncle is based upon the same principles. However the
choice of antibiotics is different, guided by antibiotic sensitivity tests and taking into account the
possible toxicity of some of these antimicrobial agents, such as aminoglycosides and vancomycin.
In case of methicillin resistant S. aureus (MRSA) infection, guidance from an infectious diseases
specialist is frequently helpful in selecting appropriate antibiotics.
Percutaneous drainage - Although many patients will respond to antimicrobial therapy alone
[4,17], insertion of a percutaneous catheter into the abscess under ultrasound or CT guidance is a
safe and minimally invasive procedure to obtain a specimen for culture and to drain the pus-filled
cavity in an attempt to hasten recovery and shorten the duration of antimicrobial therapy [1,4,16].
In one study, for example, 57 of 61 renal abscesses were drained; all of the patients improved and
survived [1]. Percutaneous drainage is particularly beneficial when the abscess is large (diameter
of 3 cm) or when surgery is indicated in a high-risk patient who is not a good surgical candidate.
In a series of 52 patients, 92 percent of medium abscesses (3 to 5 cm) resolved with drainage
alone. Abscesses greater than 5 cm often required more than one percutaneous drainage
procedure (33 percent) or adjunct open surgical intervention (37 percent) [15].
Surgery - Surgical drainage of a renal abscess should be considered when the abscess is
secondary to an anatomic abnormality (such as renal stones or vesicoureteral reflux) or when its
size and associated lesions make it unlikely that medical treatment alone or with catheter drainage
will be effective.
Rescue nephrectomy is occasionally performed in patients with a complicated renal abscess. Such a
patient might be diabetic with marked destruction of renal tissue by pyelonephritis.
Recommendations - The therapy of a renal abscess usually involves continuing the antibiotics
selected for the treatment of pyelonephritis (or modifying antibiotics based upon the culture of the
abscess contents) and percutaneous drainage of the abscess. Surgical drainage is usually reserved
for patients with an accompanying anatomic abnormality, such as renal stones.
PERINEPHRIC ABSCESS
Etiology - Abscesses can also arise in the perinephric region. These abscesses involve the
perirenal fat and begin as a diffuse infection with necrosis of the perirenal fat. After a delay of
several days, a pus containing cavity is formed.
Perirenal, like renal abscesses, can develop as a complication of pyelonephritis or can result from
hematogenous spread of infection. In the former, pyelonephritic infection/suppuration can rupture
across the renal capsule into Gerota's space. Extracorporeal shock-wave treatment of renal stones
can also cause perinephric abscess. These infections often arise in patients with urinary tract
obstruction, such as a staghorn or other calculus, or in patients with a cortical abscess [2].
When the abscess arises from hematogenous spread, S. aureus is the usual pathogen. However,
these types of infections are now rare. Most perinephric abscesses today complicate pyelonephritis
and are caused by aerobic Gram negative bacilli. Gas may occasionally be produced by some of
these organisms.
Clinical presentation - Perinephric infection differs from intrarenal infection in several ways. The
onset of pain, fever and leukocytosis is typically more progressive in those with perinephric
collections. Flank and abdominal tenderness are more superficial in these cases, and inflammation
of the skin may be observed on the flank.
Imaging - Plain abdominal and chest films may assist in suggesting the diagnosis [18]. Plain
abdominal films can show radioopaque renal stones. The outline of the ipsilateral psoas muscle
may be blurred. Extraintestinal gas may be seen around the kidney in case of gas forming
organisms. A pleural and lung parenchymal reaction is observed on chest radiographs in
approximately one-half of the cases, with pleural effusion, ipsilateral pneumonia, atelectasis and/or
an elevated hemidiaphragm.
The diagnosis of perinephric suppuration is essentially based upon CT scan imaging. It shows the
site and extent of the abscess (show radiograph 4 and show radiograph 5). In one contemporary
series of 25 patients with perinephric abscess, CT scan detected the abscess in 22 of 24 patients
(92 percent) in whom the study was performed [13]. Occasionally, CT scan detects metastatic or
contiguous abscesses in other organs, such as the liver in a right-sided perinephric abscess or the
spleen in the case of left-sided suppuration [19]. For patients with possible urologic obstruction, an
intravenous pyelogram may indicate the cause, such as renal calculi.
Prognosis and treatment - When diagnosis and treatment are delayed, perinephric abscess is a
severe condition with a 40 percent mortality. Conversely early diagnosis and treatment are credited
with a good prognosis. In the series of 25 patients with the availability of CT scanning and
percutaneous drainage procedures, mortality was reduced to 12 percent [13].
The principles of therapy for perinephric abscesses are the same as for renal abscesses. Treatment
is based upon choosing appropriate antibiotics, guided by identification of the offending organisms
and antibiotic susceptibility testing. Urine cultures, blood cultures, or percutaneous sampling of the
pus may all yield the responsible pathogen(s). Criteria of cure are similarly based upon clinical,
laboratory and CT scan surveillance [17]. Percutaneous catheter or surgical drainage may be
indicated in case of large pus containing cavities [16].
Early urologic treatment of obstruction, when responsible for perirenal infection, is mandatory. In
the case of staghorn stones with severe pyelonephritic renal atrophy, nephrectomy is the best
choice to eliminate the cause of the abscess, the abscess itself, and the risk of relapse. In the
retrospective series of 25 perinephric abscesses cited above, all were treated with antibiotics; 11
patients were additionally treated with percutaneous drainage, 3 with urinary drainage, and 1 with
exploratory surgery [13]. Of the 10 patients treated with antibiotics alone, two had a postmortem
diagnosis; the 8 remaining patients had a mean abscess size of 1.8 cm and mean hospitalization of
10 days. In contrast, the 11 patients undergoing percutaneous drainage as adjunctive therapy had
mean abscess sizes of 11 cm and mean hospitalization of 30 days; four of these patients
underwent nephrectomy for persistent infection and none died.
Recommendations
Perinephric abscess like a renal abscess should be considered in patients with presumed
pyelonephritis who fail to respond to five days of appropriate antibiotics or initially respond and
then develop further symptoms or recurrent fevers.

CT scan is the imaging modality of choice for perinephric collections.

Antibiotics should be directed at pathogens recovered from the abscess. Small abscesses may
be treated with antibiotics alone.

Larger collections or those associated with renal stones should be drained, either percutaneously
or via surgery. Nephrectomy may be necessary in some cases.

Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Fowler, JE Jr, Perkins, T. Presentation, diagnosis and treatment of renal abscesses: 1972-
1988. J Urol 1994; 151:847.
2. Hutchison, FN, Kaysen, GA. Perinephric abscess: The missed diagnosis. Med Clin North Am
1988; 72:993.
3. Hoverman, IV, Gentry, LO, Jones, DW, Guerriero, WG. Intrarenal abscess. Report of 14 cases.
Arch Intern Med 1980; 140:914.

4. Dembry, LM, Andriole, VT. Renal and perirenal abscesses. Infect Dis Clin North Am 1997;
11:663.
5. Yen, DH, Hu, SC, Tsai, J, et al. Renal abscess: early diagnosis and treatment. Am J Emerg Med
1999; 17:192.
6. Angulo, JC, Lera, R, Santana, A, Sanchez-Chapado, M. Hydatid renal abscess: a report of two
cases. BJU Int 1999; 83:1065.
7. Fair, WR, Higgins, MH. Renal abscess. J Urol 1970; 104:179.
8. Siroky, MB, Moylan, RA, Austen, G, Olsson, CA. Metastatic infection secondary to genito-
urinary sepsis. Am J Med 1976; 61:351.
9. Lee, BK, Crossley, K, Gerding, DN. The association between Staphylococcus aureus,
bacteremia and bacteriuria. Am J Med 1978; 65:303.
10. Meyrier, A, Guibert, J. Diagnosis and drug treatment of acute pyelonephritis. Drugs 1992;
44:356.
11. Truong LD, Todd TD, Dhurandar B, Ramzy I. Fine-needle aspiration of renal masses in adults:
analysis of results and diagnostic problems in 108 cases. Diagn Cytopathol 1999; 20:339.
12. Huang, JJ, Sung, JM, Chen, KW, et al. Acute bacterial nephritis: A clinicoradiologic correlation
based on computed tomography. Am J Med 1992; 93:289.
13. Meng, MV, Mario, LA, McAninch, JW. Current treatment and outcomes of perinephric
abscesses. J Urol 2002; 168:1337.
14. Lang, EK. Renal, perirenal and pararenal abscesses: Percutaneous drainage. Radiology 1990;
174:109.
15. Siegel, JF, Smith, A, Moldwin, R. Minimally invasive treatment of renal abscess. J Urol 1996;
155:52.
16. Deyoe, LA, Cronan, JJ, Lambiase, RE, Dorfman, GS. Percutaneous drainage of renal and
perirenal abscesses: Results in 30 patients. AJR Am J Roentgenol 1990; 155:81.
17. Dalla Palma, L, Pozzi-Mucelli, F, Ene, V. Medical treatment of renal and perirenal abscesses:
CT evaluation. Clin Radiol 1999; 54:792.
18. Haddad, MC, Hawary, MM, Khoury, NJ, et al. Radiology of perinephric fluid collections. Clin
Radiol 2002; 57:339.
19. Reese, JH, Anderson, RU, Friedland, G. Splenic abscess arising by direct extension from a
perinephric abscess. Urol Radiol 1990; 12:91.
GRAPHICS




2004 UpToDate
- www.uptodate.com - customerservice@uptodate.com

New Search Table of Contents Feedback Help

Renal and Perinephric Abscess

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Renal and Perinephric Abscess

Uploaded by

Copyright:

Available Formats

Renal and perinephric abscess

You might also like