A 54-year-old man comes to the office due to 3 months of urinary frequency and urgency. He has also had discomfort in the pelvic region and pain during ejaculation. The patient's symptoms temporarily improved during a week-long course of trimethoprim-sulfamethoxazole for urinary tract infection but recurred shortly after treatment concluded. He has a history of hypertension well controlled with lisinopril. He also had a single episode of gonorrhea 20 years ago that was treated with penicillin. The patient has a 20-pack-year smoking history but quit 4 years ago. He drinks alcohol on social occasions and does not use illicit drugs. He is monogamous with his wife. Temperature is 37 C (98.6 F), blood pressure is 120/70 mm Hg, and pulse is 80/min. The abdomen is soft and nontender with no organomegaly. Genital examination shows a circumcised penis with no urethral discharge. Testicular examination shows no abnormalities. The prostate is slightly enlarged with minimal tenderness and no nodules. Urinalysis shows 20-30 leukocytes/HPF and moderate bacteruria but no erythrocytes. Prostate-specific antigen level is within normal limits. Which of the following is the most appropriate management of this patient?

Question

A 54-year-old man comes to the office due to 3 months of urinary frequency and urgency.  He has also had discomfort in the pelvic region and pain during ejaculation.  The patient's symptoms temporarily improved during a week-long course of trimethoprim-sulfamethoxazole for urinary tract infection but recurred shortly after treatment concluded.  He has a history of hypertension well controlled with lisinopril.  He also had a single episode of gonorrhea 20 years ago that was treated with penicillin.  The patient has a 20-pack-year smoking history but quit 4 years ago.  He drinks alcohol on social occasions and does not use illicit drugs.  He is monogamous with his wife.  Temperature is 37 C (98.6 F), blood pressure is 120/70 mm Hg, and pulse is 80/min.  The abdomen is soft and nontender with no organomegaly.  Genital examination shows a circumcised penis with no urethral discharge.  Testicular examination shows no abnormalities.  The prostate is slightly enlarged with minimal tenderness and no nodules.  Urinalysis shows 20-30 leukocytes/HPF and moderate bacteruria but no erythrocytes.  Prostate-specific antigen level is within normal limits.  Which of the following is the most appropriate management of this patient?

Quizplus · Accepted Answer

Explanation: This patient has a 3-month history of urinary symptoms and pelvic pain with evidence of urine leukocytes and bacteruria, suggesting chronic bacterial prostatitis. Chronic bacterial prostatitis is a common condition of young and middle-aged men due primarily to intraprostatic reflux of urine with microbial seeding of the prostate. Pathogens are similar to those that cause cystitis and include Escherichia coli (75%-80%), Enterococcus, Klebsiella, Proteus, and Pseudomonas. Risk is increased in patients with a history of diabetes mellitus, smoking, and urinary tract hardware or manipulation. Manifestations last >3 months and typically include recurrent urinary tract infection (eg, dysuria, frequency, peritoneal discomfort), pain in the genitourinary region, and/or pain with ejaculation. Prostate examination is often normal but may show hypertrophy, tenderness, or edema. Diagnosis requires urinalysis before and after prostatic massage (or examination of expressed prostate fluid), but patients with chronic/recurrent urogenital symptoms and bacteriuria are often treated presumptively. First-line treatment is 6 weeks of a fluoroquinolone (eg, ciprofloxacin) or trimethoprim-sulfamethoxazole; patients may have recurrent symptoms if treated for shorter duration (as in this patient who received a week of treatment) (Choice D). (Choice A) CT scan of the abdomen and pelvis may be useful in men with genitourinary symptoms if initial examination and testing reveal no abnormalities. This patient with chronic urogenital symptoms and bacteriuria would likely be treated presumptively for chronic bacterial prostatitis; imaging would not be required at this time. (Choice B) A transrectal biopsy of the prostate is primarily used to evaluate for prostate cancer in patients with abnormal prostate examinations (eg, nodules, induration, asymmetry) or elevated prostate-specific antigen. This patient has signs of genitourinary infection (eg, urine leukocytes, bacteriuria) and normal prostate-specific antigen; treatment of the infection is warranted at this time. (Choice E) Tamsulosin is an alpha-1 antagonist that relaxes the smooth muscle of the bladder neck and is often used as first-line therapy for benign prostatic hyperplasia. Although frequency and urgency may be signs of benign prostatic hyperplasia, patients typically do not have pain with ejaculation, urinary leukocytes, or bacteriuria. Educational objective: Chronic bacterial prostatitis typically presents with >3 months of urinary tract infection, pain in the genitourinary region, and/or pain with ejaculation. Examination of the prostate may be normal or show hypertrophy, tenderness, or edema. Urine leukocytes and bacteriuria are typically present, particularly after prostatic massage. Treatment requires 6 weeks of a fluoroquinolone (eg, ciprofloxacin) or trimethoprim-sulfamethoxazole.

A 54-Year-Old Man Comes to the Office Due to 3