A 60-year-old man comes to the emergency department due to fever, burning on urination, generalized body aches, and lower abdominal discomfort. The dysuria began 3 days ago, and the remainder of the symptoms developed within the last 24 hours. The patient also has been unable to urinate for the past 18 hours. He has a history of hypertension, hyperlipidemia, coronary artery disease, and benign prostatic hyperplasia. Medications include aspirin, metoprolol, atorvastatin, lisinopril, and tamsulosin. He is not sexually active. The patient does not use tobacco, alcohol, or illicit drugs and has no medication allergies. Temperature is 38.3 C (100.9 F), blood pressure is 130/75 mm Hg, pulse is 105/min, and respirations are 16/min. Abdominal examination reveals mild lower abdominal tenderness with no costovertebral angle tenderness. The urinary bladder is palpable in the hypogastric area. Rectal examination reveals a swollen, tender, and enlarged prostate with no palpable nodules. The genitals are normal in appearance and nontender to palpation. Laboratory testing shows a leukocyte count of 12,500/mm³ with 85% neutrophils and an elevated serum creatinine at 1.3 mg/dL (last known value: 0.9 mg/dL). Microscopic urinalysis results are as follows: Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: This patient with fever, dysuria, leukocytosis, and lower abdominal pain has urinalysis evidence of pyuria and bacteriuria. Although this constellation of findings is consistent with a urinary tract infection, the presence of a tender, swollen prostate makes acute bacterial prostatitis more likely. One of the most common complications of acute bacterial prostatitis is acute urinary retention, which is due to urethral impingement from prostate swelling. Manifestations typically include an inability to void, suprapubic fullness/discomfort, and renal insufficiency. A bladder scan can confirm the diagnosis (>300 mL residual volume). Treatment involves urgent bladder decompression with suprapubic catheterization (urethral catheterization is occasionally attempted by urologists who are experienced with this procedure but may increase the risk of septic shock) and empiric antibiotics (eg, trimethoprim-sulfamethoxazole, ciprofloxacin). (Choice A) 5-alpha-reductase inhibitors are useful in chronic bladder outlet obstruction secondary to benign prostatic hyperplasia. This patient has pyuria and bacteruria with a tender, swollen prostate indicating his bladder outlet obstruction is due to an acute prostate infection; urgent bladder decompression and antibiotics are required. (Choices C and E) Patients with signs and symptoms of acute bacterial prostatitis do not generally require imaging. CT scan of the abdomen and pelvis and transrectal ultrasound of the prostate are usually reserved for those who have persistent symptoms and laboratory abnormalities despite appropriate antimicrobial therapy. (Choice D) Prostatic massage with prostatic fluid analysis is often used to diagnose chronic bacterial prostatitis. This test should be avoided in patients with acute bacterial prostatitis as it offers no additional diagnostic benefit, is quite uncomfortable, and increases the risk of bacteremia. Educational objective: Patients with acute bacterial prostatitis usually have fever, dysuria, urinary frequency, and cloudy urine. Rectal examination typically reveals a warm, edematous, and very tender prostate (unlike urinary tract infection). Prostatic swelling can lead to bladder outlet obstruction with acute urinary retention; treatment with urgent bladder decompression (eg, suprapubic catheter) and antibiotics is required. References: Ultrasound-guided transrectal placement of a drainage tube as therapeutic management of patients with prostatic abscess. (http://www.ncbi.nlm.nih.gov/pubmed/18673079) Urinary retention in adults: diagnosis and initial management. (http://www.ncbi.nlm.nih.gov/pubmed/18350762)

A 60-Year-Old Man Comes to the Emergency Department Due to Fever