A 56-year-old man comes to the physician with fever, chills, and painful urination for 3 days. He has also experienced decreased force in his urinary stream, urinary frequency, and nocturia. The patient was diagnosed with benign prostatic hyperplasia 2 years ago. His other medical problems include hypertension, hyperlipidemia, and type 2 diabetes mellitus. His medications include saw palmetto, metformin, enalapril, and lovastatin. He is sexually active with his wife of 35 years.
His temperature is 38.3° C (101° F), blood pressure is 127/84 mm Hg, and pulse is 98/min. There is no costovertebral angle tenderness bilaterally. His genitalia and testes are normal. His prostate is enlarged and very tender to palpation on digital rectal examination.
Laboratory results are as follows:

Urine and blood cultures are sent. Urine Gram stain shows no organisms.
Which of the following would be the best next step in management of this patient?

Question

A 56-year-old man comes to the physician with fever, chills, and painful urination for 3 days.  He has also experienced decreased force in his urinary stream, urinary frequency, and nocturia.  The patient was diagnosed with benign prostatic hyperplasia 2 years ago.  His other medical problems include hypertension, hyperlipidemia, and type 2 diabetes mellitus.  His medications include saw palmetto, metformin, enalapril, and lovastatin.  He is sexually active with his wife of 35 years.
His temperature is 38.3° C (101° F), blood pressure is 127/84 mm Hg, and pulse is 98/min.  There is no costovertebral angle tenderness bilaterally.  His genitalia and testes are normal.  His prostate is enlarged and very tender to palpation on digital rectal examination.
Laboratory results are as follows:

Urine and blood cultures are sent.  Urine Gram stain shows no organisms.
Which of the following would be the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9908_c96d_853d_c5a59ed560ce_MD0002_00 This patient's presentation is most consistent with acute bacterial prostatitis (ABP). Most cases are due to Gram-negative (eg, Escherichia coli, Proteus mirabilis, Klebsiella, Enterobacter) organisms. Gram-positive (eg, Staphylococcus aureus, Streptococci, Enterococci) infections are less common and are usually due to remote infection elsewhere, prolonged catheterization, or recent prostatic surgery. Patients typically present with acute urinary complaints (eg, frequency, urgency, urge incontinence), pelvic/perineal pain, cloudy urine, and systemic symptoms (eg, fever, chills, malaise, myalgia). Digital examination shows an exquisitely tender prostate that is warm and edematous. Prostate massage is not recommended, however, due to pain and increased risk of bacteremia. In addition, prostate fluid is not necessary for diagnosis (Choice D). Evaluation includes urine Gram stain and culture. Empiric antibiotics that effectively penetrate the prostate (eg, oral trimethoprim-sulfamethoxazole [TMP-SMX] or fluoroquinolone) are recommended. Intravenous antibiotics are recommended for septic-appearing patients. Oral antibiotics are usually continued for prolonged periods (eg, 4 weeks) and tailored to culture results. After the infection resolves, patients usually need urologic evaluation to determine the underlying cause. Chronic bacterial prostatitis (CBP) can be a complication of ABP due to inadequate duration of treatment. CBP tends to present with less severe urinary symptoms and without significant systemic findings. Most urologists obtain urine and prostate fluid specimens after prostate massage for diagnosis. Fluoroquinolones are the preferred first-line agent. Patients usually require a prolonged course of antibiotics ranging from 6 weeks to 6-12 months in some cases. (Choice A) Acute urinary retention is an infrequent complication of acute prostatitis, and bladder drainage must be done by suprapubic catheterization. Catheter insertion through the inflamed urethra into the bladder is contraindicated in acute prostatitis. (Choice B) Doxycycline is effective against Chlamydia trachomatis, which is more common in sexually active men and chronic bacterial prostatitis. It does not penetrate the prostate as well as fluoroquinolones or TMP-SMX and is not considered first-line therapy for ABP. (Choice E) Transrectal ultrasound can evaluate for suspected prostatic abscess or cancer. Prostate abscess can present similarly to prostatitis but usually has significant fluctuance on digital examination or persistent symptoms despite antibiotics. Educational objective: Management of acute prostatitis involves obtaining a urine culture followed by empiric treatment with fluoroquinolones or oral trimethoprim-sulfamethoxazole. Prostate massage is not recommended. If bladder drainage is required, the suprapubic route should be used. __________ References: Approach to urinary tract infections. (http://www.ncbi.nlm.nih.gov/pubmed/20535247) Treatment of bacterial prostatitis. (http://www.ncbi.nlm.nih.gov/pubmed/20459324)

A 56-Year-Old Man Comes to the Physician with Fever, Chills