A 46-year-old man comes to the office due to dysuria and a dull, aching pain in the penis and perineal region. The symptoms began 6 months ago and prompted the patient to visit an urgent care center twice. Both times, he received a short course of antibiotics, which improved symptoms temporarily, but they returned within days. The patient has also had pain during ejaculation but no urethral discharge, back pain, abdominal pain, weakness, or incomplete voiding. He is married and monogamous with his wife and has 2 children. He does not use tobacco or illicit drugs but occasionally drinks 1 or 2 beers on weekends. He has no medication allergies and no family history of cancer. Temperature is 37.1 C (98.8 F) , blood pressure is 126/84 mm Hg, pulse is 72/min, and respirations are 14/min. Physical examination shows no abdominal or costovertebral angle tenderness. Digital rectal examination reveals a mildly tender prostate that is symmetric and not enlarged. The external genitalia are normal in size and appearance and are nontender to palpation. Item 1 of 3
Which of the following is the best next step in the diagnosis of this condition?

Question

Quizplus · Accepted Answer

Explanation: Chronic prostatitis is a common condition that affects 2%-10% of men. Manifestations include >3 months of dysuria, pain in the genitourinary region, and/or pain during ejaculation. Prostate examination is usually normal but may show hypertrophy, tenderness, or edema. Because some symptoms of chronic prostatitis resemble a urinary tract infection, patients often inappropriately receive short courses of antibiotic therapy. Although this may transiently improve symptoms, manifestations generally recur within days of antibiotic cessation. The diagnosis of chronic prostatitis typically requires urinalysis and urine culture before and after prostate massage. (Choice B) CT scan of the abdomen and pelvis is not typically indicated for patients with symptoms of chronic prostatitis unless abdominal pain is also present. Urinalysis and urine culture are easy to perform, low-cost, and not associated with radiation; they would almost always be done prior to consideration of CT scan. (Choice C) This patient has a normal genital examination and no testicular pain. Ultrasound of the scrotum would not be indicated at this time. (Choice D) Patients with urinalysis evidence of hematuria usually require urine cytology and referral for cystoscopy to evaluate for bladder cancer. This patient should receive a urinalysis prior to any other testing. (Choice E) This patient with a nonenlarged, symmetric prostate does not require prostatic biopsy at this time. Biopsy is not typically part of the diagnostic workup for chronic prostatitis. Educational objective: Chronic prostatitis is a common condition that usually presents with >3 months of dysuria, pelvic pain, and/or pain during ejaculation. Patients with suspected chronic prostatitis should receive a urinalysis and urine culture before and after prostate massage.

A 46-Year-Old Man Comes to the Office Due to Dysuria