A 72-year-old man comes to the office due to increased urinary frequency and pain during urination. The patient has had mild urinary hesitancy and frequent nocturia for several years but was not bothered until he began experiencing intermittent burning pain during urination 3 months ago. The patient has also been urinating several times during the day as well as at night and has had urgent need to urinate. He has had no fever, abdominal or back pain, or hematuria. The patient was given oral trimethoprim-sulfamethoxazole a month ago after testing revealed a urinary tract infection. His symptoms improved while taking the antibiotics but recurred after finishing the 1-week course of treatment. Medical history is notable for hypertension and gout. He is a former smoker with a 30-pack-year history and does not drink alcohol. The patient worked in a petroleum refinery for many years before retiring at age 65.
Temperature is 36.7 C (98 F) , blood pressure is 130/84 mm Hg, and pulse is 72/min. The abdomen is soft and nontender with no masses or hepatosplenomegaly. There is no costovertebral angle tenderness. Digital rectal examination shows a diffusely enlarged and moderately tender prostate.
Leukocyte count is 9,200/mm³. Urinalysis results are as follows:
Which of the following is the most likely cause of this patient's current urinary symptoms?

Question

A 72-year-old man comes to the office due to increased urinary frequency and pain during urination. The patient has had mild urinary hesitancy and frequent nocturia for several years but was not bothered until he began experiencing intermittent burning pain during urination 3 months ago. The patient has also been urinating several times during the day as well as at night and has had urgent need to urinate. He has had no fever, abdominal or back pain, or hematuria. The patient was given oral trimethoprim-sulfamethoxazole a month ago after testing revealed a urinary tract infection. His symptoms improved while taking the antibiotics but recurred after finishing the 1-week course of treatment. Medical history is notable for hypertension and gout. He is a former smoker with a 30-pack-year history and does not drink alcohol. The patient worked in a petroleum refinery for many years before retiring at age 65.
Temperature is 36.7 C (98 F) , blood pressure is 130/84 mm Hg, and pulse is 72/min. The abdomen is soft and nontender with no masses or hepatosplenomegaly. There is no costovertebral angle tenderness. Digital rectal examination shows a diffusely enlarged and moderately tender prostate.
Leukocyte count is 9,200/mm³. Urinalysis results are as follows:

Which of the following is the most likely cause of this patient's current urinary symptoms?

Quizplus · Accepted Answer

11ec193a_986d_9ae2_853d_23869ed37ea4_MD0002_00 This patient has lower urinary tract symptoms (LUTS), pyuria, and an enlarged, tender prostate consistent with chronic bacterial prostatitis (CBP). CBP can be asymptomatic or present with dysuria and increased urinary frequency. However, unlike in acute prostatitis, systemic symptoms (eg, fever, chills) are typically absent. It is usually caused by enteric gram-negative bacilli, and is a potential cause of recurrent symptoms in patients receiving an inadequate course of antibiotics for acute prostatitis. Although symptoms may be temporarily alleviated by short courses of antibiotics, the same organism can often be isolated when symptoms recur. The diagnosis of CBP should be suspected in men with persistent or recurrent LUTS, especially if the same organism is repeatedly found on culture. Culture of prostatic secretions or urine culture following prostatic massage can confirm the diagnosis, but most patients are treated empirically. Prolonged antibiotic therapy (4-6 weeks) is recommended; fluoroquinolones (eg, ciprofloxacin) are preferred in most cases (alternate: trimethoprim-sulfamethoxazole). Treatment failure is common, and complications include prostatic abscess, bacteremia, and epididymitis. (Choice B) Interstitial cystitis (ie, painful bladder syndrome) is more common in women and usually presents with suprapubic pain (made worse with either bladder filling or emptying), increased urinary frequency, urgency, and nocturia. It would not cause prostatic tenderness or bacteriuria. (Choice C) Benign prostatic hyperplasia can cause chronic LUTS, but obstructive voiding symptoms (eg, dribbling, decreased force of stream) are usually more prominent, and this patient's pyuria and dysuria are more consistent with CBP. (Choice D) Bladder stones are an uncommon cause of irritative voiding symptoms. They are typically seen in patients with incomplete bladder emptying, recurrent infection, or foreign bodies in the bladder. Although patients with gout can occasionally form urate bladder stones, this patient's prostatic tenderness is more consistent with CBP. (Choice E) Urothelial (transitional cell) carcinoma of the bladder usually presents with painless gross hematuria, and sometimes with urinary frequency, urgency, and dysuria. Smoking is a major risk factor, but this patient's pyuria, lack of significant hematuria, and previous response to antibiotics make bladder cancer less likely. Educational objective: Chronic prostatitis is characterized by recurrent or persistent lower urinary tract symptoms, prostatic tenderness, and repeated identification of the same organism on urine culture. A prolonged (4-6 weeks) course of antibiotics is recommended, and fluoroquinolones (eg, ciprofloxacin) are preferred for most patients. __________ References: Chronic prostatitis: management strategies. (http://www.ncbi.nlm.nih.gov/pubmed/19192937) Common questions about chronic prostatitis. (http://www.ncbi.nlm.nih.gov/pubmed/26926816)

A 72-Year-Old Man Comes to the Office Due to Increased