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PsoasAbscess:APrimerfortheInternist
,DepartmentofInternalMedicine,LincolnHealthCenterandDurhamRegionalHospital,Durham,
NC
SouthMedJ.200194(1)

AbstractandIntroduction
Psoasabscessisarareconditionwithvagueclinicalpresentation.Inthisarticle,itsepidemiology,etiology,bacteriology,
diagnosis,andtreatmentarediscussed.Commondiseasesthatmaybeerroneouslydiagnosedinpatientswithpsoas
abscessarepresented.
Manyabdominalconditionsaresodramaticintheirpresentationthatpatientsmaygototheemergencyroom.Psoas
abscesshasaninsidiousonset,andpatientsmaybeseenbytheirprimarycarephysician.Becausepsoasabscessisrare
andisuncommonlydiscussedinprimarycaremedicalliterature,primarycarephysiciansmaymissthisdiagnosis.
Therefore,thesepractitionersneedtobefamiliarwithpsoasabscesstopreventdelayindiagnosisandtreatment.Psoas
abscessmaybeclassifiedasprimaryorsecondary,dependingonthepresenceorabsenceofunderlyingdisease.

PsoasMuscleAnatomy
Thepsoasmuscleisaretroperitonealorganthatoriginatesfromthelateralbordersofthe12ththoracictofifthlumbar
vertebraeandinsertsonthelessertrochanterofthefemur.In70%ofpeople,itisasinglestructure(psoasmajor),but30%
alsohaveasmallerpsoasminormuscle,whichliesanteriortothepsoasmajoralongthesamecourse.Itisinnervatedby
branchesofL2,L3,andL4,beforeformationofthefemoralnerve.Thepsoasmuscleliesincloseproximitytomanyother
organs,includingthesigmoidcolon,jejunum,appendix,ureters,aorta,renalpelvis,pancreas,iliaclymphnodes,andspine.
Thus,infectionsintheseorganscancontiguouslyspreadtothepsoasmuscle.Thepsoasmusclehasarichvascularsupply
thatisbelievedtopredisposeittohematogenousspreadfromsitesofoccultinfection.

Epidemiology
In1992,theworldwidereportedoccurrenceofpsoasabscesswas12casesperyear. [1]Thiswasasignificantincreasefrom
thecalculatedoccurrenceof3.9casesperyearbefore1985.Theincreasewasattributedtoimproveddiagnosiswiththe
widespreaduseofcomputedtomography(CT). [1,2]Itislikelythatincompletereporting,particularlyinthedevelopingworld,
spuriouslyloweredtheincidence.Upto1985,allthecasesofpsoasabscessreportedindevelopingcountrieswereprimary,
whereasintheUnitedStatesandCanadanearly50%ofcasesweresecondary. [1]Earlierreportssuggestedthatprimary
psoasabscesswasmorecommoninyoungerpatients,with83%ofcasesdiagnosedinpatientslessthanage30.In
contrast,upto40%ofsecondarypsoasabscesseswerediagnosedinpatientsmorethan40yearsold.Primaryand
secondarypsoasabscesseswererelativelyrareintheelderly. [1]Thisagedistributionisdifferentfromthefindingsina
recentseriesof18patientsfromJohnsHopkinsUniversitySchoolofMedicine.Inthisseries,researchersfoundsecondary
psoasabscess(agerange,2to78years)tobemoreprevalent(61%)thanprimarypsoasabscess(agerange,27to81
years).Itisnotablethat28%ofthepatientswereovertheageof65.Ofthepatientswithprimarypsoasabscess,86%
wereintravenousdrugusers,and57%wereinfectedwiththehumanimmunodeficiencyvirus(HIV).Noneofthepatients
withsecondarypsoasabscesshadHIVinfectionorahistoryofintravenousdrugabuse.Itispossiblethattheincidenceof
primarypsoasabscesswillincreasewiththeHIVpandemic. [3]Otherpredisposingconditionsincludediabetes,
immunosupression,andrenalfailure. [4]Underlyingdiseasesinpatientswithsecondarypsoasabscessareshownin.
Table1.ConditionsAssociatedWithSecondaryPsoasAbscess

DiseaseSite

Conditions

Gastrointestinal Diverticulitis,appendicitis,Crohn'sdisease,colorectalcarcinoma,appendicealtumor
Genitourinary

Urinarytractinfection,extracorporealshockwavelithotripsy,cancer

Musculoskeletal Vertebralosteomyelitis,lumbarspondylodiskitis,infectioussacroiliitis,septicarthritis
Other

Endocarditis,femoralarterycatheterization,infectedabdominalaorticaneurysm,hepatocellular
carcinoma,trauma,intrauterinecontraceptivedevice,acupuncture,spinalsurgerysepsis,
suppurativeadenitis,longtermhemodialysisorperitonealdialysis

Bacteriology
Staphylococcusaureusisthepathogenin80%ofcasesofprimarypsoasabscess. [2,3]OtherpathogensincludeSerratia
marcescens, [3]Pseudomonasaeruginosa, [3]Haemophilusaphrophilus, [5]andProteusmirabilis. [1]Secondarypsoasabscess
isusuallycausedbyentericbacteria.TheseincludeEscherichiacoli,Streptococcusspecies,Enterobacterspecies,and
Salmonellaenteritidis. [3]MethicillinresistantSaureusisalsoaknownpathogen. [3]Mycobacteriumtuberculosisasacause
ofpsoasabscessiscurrentlyrareintheUnitedStates.Inareasoftheworldwheretuberculosisisstillacommondisease,
itcontinuestobeanimportantcauseofpsoasabscess.Nontuberculousmycobacteriaarealsoimportant,asevidencedby
recentcasereportsofpsoasabscesscausedbyMkansasii[6]andMxenopi. [7]

Diagnosis
Symptomsareoftennonspecific.Patientsmaypresentwithfever,flankpain,abdominalpain,orlimp.Becauseofthe
innervationofthepsoasmusclebyL2,L3,andL4,painduetoitsinflammationsometimesradiatesanteriorlytothehip
andthigh.Othersymptomsarenausea,malaise,andweightloss.Thesesymptomsbringtomindotherclinicalsyndromes
thataremorecommonlyseenbyprimarycarephysicians().
Table2.ClinicalSyndromesWithPainSimilartoThatDuetoPsoasAbscess

Clinical
Syndrome

Differentiating
Findings

Musclestrain

Usuallyattributedtomuscleinjurybythepatient.Thepatternofpainradiationseeninpsoas
abscessisabsent.Nosystemicsymptoms.

Meralgia
paresthetica

Oftencausesonlyparesthesiabutcanalsocauseshootingpaintotheanteriorandlateralsurface
ofthethighduetocompressionoflateralfemoralcutaneousnerve(originatesfromL2andL3)
aroundthegroin.

Sciatica

Backpainduetoirritationoflumbarorsacralnerverootstypicallyradiatestotheposterioror
lateralsurfaceofthethigh,knee,orleg.Thissometimesinvolvesthedorsumofthefoot,firstor
secondandthirdtoes(L5root),orplantarsurfaceofthefootandforthorfifthtoes(S1root).The
presenceofparesthesiainthedistributionofpainissuggestiveofsciatica.Rarely,irritationofL3
orL4rootcanleadtobackpainthatradiatestotheanteriorthighandknee,butthekneejerkis
usuallydiminishedorabsentandthereisassociatedparesthesia.

Renal
Characteristicallycausesflankpain,whichradiatestothegroin.Nauseaandvomitingare
colic/pyelonephritis common.Feverandmalaiseunusualexceptwhenthereisassociatedkidneyinfection.
Agoodphysicalexaminationiscriticalforthepromptdiagnosisofpsoasabscess.Thediagnosismaybegivenaway,ifthe
patientisnotedtofavorthepositionofgreatestcomfort.Thisisthesupineposition,withthekneemoderatelyflexedand
thehipmildlyexternallyrotated.Rarely,psoasabscessisassociatedwithpainlesssubinguinalmass.Therearewell
describedsignsofpsoasinflammation, [8]whichtheclinicianshouldlookforineverypatientsuspectedofhavingpsoas
abscess().Thepremiseofthesetestsisthatthepsoasmuscleistheprimaryhipflexor.Flexionandstretchingor
contractionoftheinflamedpsoasmuscleresultsinpain.
Table3.TestsforIliopsoasInflammation

* Thesemaneuversmayalsoyieldpositiveresultsinconditionssuchasappendicitisinwhichthereisinflammation
oftheiliopsoaswithouttheformationofpsoasabscess.

Laboratorytestsarehelpfulintheevaluationofsuspectedpsoasabscess.Leukocytosis(meancount,15,900/mm3),
elevatederythrocytesedimentationrate(ESR)(mean,90mm/hr),andelevatedbloodureanitrogen(BUN)(mean,30.5
mg/dL)werereportedin100%ofpatientsintheseriesfromJohnsHopkins. [3]Thesearenotuniversalfindings.Pyuriais
sometimespresent. [9]Asinmostclinicalproblems,diagnosisisaidedbyappropriateradiologictesting.Beforethe
availabiltyofultrasonographyandCT,manycasesofretroperitonealabscesswerediagnosedatautopsy.Wheneverpsoas
abscessissuspected,CTshouldbedonefordefinitivediagnosis.Thishassupercededultrasonographyastheradiologic
testofchoice.Ultrasonographyisdiagnosticinonly60%ofcasesofpsoasabscess, [9]comparedwith80%to100%forCT.

testofchoice.Ultrasonographyisdiagnosticinonly60%ofcasesofpsoasabscess, [9]comparedwith80%to100%forCT.
[10]Sensitivityandspecificityofdiagnosingpsoasabscessisnotimprovedbymagneticresonanceimaging(MRI),andwith
itshighercostandgreaterpatientdiscomfort,MRIhasnoroleinthediagnosisofpsoasabscess.

Treatment
Treatmentinvolvestheuseofappropriateantibiotics,aswellasdrainageoftheabscess.Knowledgeofcommon
pathogensshouldguideinitialchoiceofantibiotics.Adjustmentsshouldbebasedonreportofabscessfluidcultureand
sensitivitytesting.Ithasbeensuggestedthatincasesofpsoasabscessbelievedtobeprimary,antistaphylococcal
antibiotictherapyshouldbestartedbeforefinalbacteriologicdiagnosis. [1]However,theidentificationofnonstaphylococcal
organismsinsomepatientswithprimarypsoasabscessandtheidentificationofstaphylococcusinpatientswithsecondary
psoasabscess[3]makeitprudentinallcasesofpsoasabscesstostarttreatmentwithbroadspectrumantibioticspending
finalbacteriologicdiagnosis.Coverageshouldincludestaphylococcalandentericorganisms,forwhichagentssuchas
clindamycin,antistaphyloccocalpenicillin,andanaminoglycosidemaybeused. [11]Lesscumbersomeregimenscanbe
easilyformulated.DrainageoftheabscessmaybedonethroughCTguidedpercutaneousdrainageorsurgicaldrainage.
Percutaneousdrainageismuchlessinvasiveandiseffectivefordraininguniloculatedandmultiloculatedpsoasabscesses.
[12]Itistechnicallysimilartoopensurgicaldrainage,andithasbeenadvocatedasthedrainagemethodofchoice. [13]
Surgicaldrainageisassociatedwithshorterhospitalstay(15.9vs28.5days). [3]Surgicaldrainagemaybeidealforpatients
withunderlyingCrohn'sdiseaseorothergastrointestinaldiseases.Inthesepatients,performingasingleoperationtodrain
abscessandresectdiseasedbowelisdesirable. [15]Anoccasionalpatientwillrequiremultipleoperations[15]orrepeated
percutaneousdrainagebeforetheabscessresolves.Abscessdrainageneedstobecontinueduntilobliterationofthe
abscesscavityoccursandthereisevidenceofclinicalimprovement.Parametersthatcanbeusedtodetermineclinical
recoveryincludedefervescenceandnormalizationofthewhitebloodcell(WBC)count,aswellassubjectiveimprovement.
Thedurationofantibiotictherapyshouldbeindividualized.Antibioticsaresometimescontinuedupto2weeksafter
completeabscessdrainage.
ThefollowingreportdescribesacaseofpsoasabscessinapatientwhowasalsofoundtohaveHIVinfection.

CaseReport
A51yearoldmanwithoutahistoryofurologicdiseasewenttohisprimarycarephysicianafter4daysofrightflankpain
associatedwithurinaryfrequency.Hedenieddysuria,fever,chills,nausea,orvomiting.Physicalexaminationrevealeda
temperatureof97.8Fandbloodpressureof127/67mmHg.Therewasmildtendernessintherightflankbutnopulsatile
abdominalmass,bruit,orsignificantabdominaltenderness.Prostateexaminationwasunremarkable.Whitebloodcell
countwas9,400/mm3.Urinalysisshowed5to10WBCs.A10daycourseoftrimethoprim/sulfamethoxazolewasstartedfor
presumedurinarytractinfection,andthepatientwastoldtoreturnuponcompletionofthetreatment.
Aweekafterinitiatingantibiotictherapy,hewenttoanurgentcareclinicbecauseofrighthippainandnausea.Hehadlost
about4pounds.Findingsonradiographyofthehipwerenegative.Nodefinitediagnosiswasmade.Hewasgiven
ibuprofenanddischargedhome.Threedayslater,thepatientreturnedtohisprimarycarephysicianforfollowup.Bythen,
hehadsevererighthippainwithradiationtotheanteriorthigh.Temperaturewas98.7F,andtotalweightlosswas7
pounds.Hehadphysicalsignsofpsoasinflammationinadditiontotendernessintherightlowerquadrant.Computed
tomographyoftheabdomenandpelvisshowedalargerightpsoasabscess(Figure).TheWBCwas7,800/mm3.Liver
enzyme,creatinine,andBUNvalueswerenormal.TheESRwas87mm/hr.Broadspectrumantibiotictherapywasstarted,
andpercutaneousdrainageofthepsoasabscessyielded210mLofpurulentmaterial,whichgrewEcoliandStreptococcus
viridans.UrineculturefromtheinitialpresentationtohisprimarycarephysicianalsogrewEcoli.ColonoscopyandupperGI
serieswithsmallbowelfollowthroughdidnotrevealanygastrointestinaldisease.Multiplebloodcultureswerenegative,
andresultsofechocardiographywerenormal.TestforHIVwaspositive.Thepatientrecoveredfullyfromtheabscessafter
drainageandantibiotictreatment.HeiscurrentlyreceivingcareforHIVinfection.

Figure1.

Largerightpsoasabscess
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ReprintAddress
ReprintrequeststoBabafemiTaiwo,MD,LincolnHealthCenter,1301FayettevilleSt,Durham,NC27707.
SouthMedJ.200194(1)2001LippincottWilliams&Wilkins
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