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. Urine microscopy after prostate massage reveals 30 leukocytes/hpf, and subsequent culture is negative. What is the most likely diagnosis?

Question

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. Urine microscopy after prostate massage reveals 30 leukocytes/hpf, and subsequent culture is negative.  What is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: The diagnosis of chronic prostatitis is generally made when urinalysis after prostate massage reveals >20 leukocytes/hpf. Urine culture results then differentiate patients as having either: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) - urine culture results are aseptic Chronic bacterial prostatitis - urine culture results show bacteriuria (>10 fold increase after prostate massage) CP/CPPS occurs far more commonly than chronic bacterial prostatitis. (Choice A) Patients with acute prostatitis are typically ill with high fever, dysuria, pelvic/perineal pain, and cloudy urine. Rectal examination usually reveals a warm, edematous, and very tender prostate. Urine culture usually reveals a gram-negative organism such as Escherichia coli or Proteus. (Choice B) Chronic bacterial prostatitis is diagnosed when urine culture after prostate massage shows bacteriuria at a >10-fold concentration compared with urinalysis prior to prostate massage. This patient with an aseptic urine culture has CP/CPPS. (Choice D) Interstitial cystitis can also be associated with long-standing dysuria and aseptic pyuria but is usually characterized by discomfort that is worse when the bladder is full and improved with voiding. In addition, most cases occur in women. (Choice E) Overactive bladder is usually characterized by urinary frequency and urgency. Pelvic pain, dysuria, and pyuria would be atypical. Educational objective: Chronic prostatitis/chronic pelvic pain syndrome is characterized by >3 months of dysuria and pelvic pain. Urine studies following prostate massage usually show pyuria (>20 leukocytes/hpf) with no microorganisms.

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