A 56-year-old man comes to the office due to progressive urinary frequency, urgency, and hesitancy for the past several months. The patient also reports new-onset low back pain and perineal pain during ejaculation. He has had no dysuria or hematuria. The patient has smoked a pack of cigarettes daily for 30 years. Temperature is 37 C (98.6 F), blood pressure is 130/76 mm Hg, and pulse is 80/min. There is no suprapubic or costovertebral angle tenderness. Examination of the external genitalia is normal. Rectal examination shows increased anal sphincter tone and a smooth, slightly enlarged prostate. Deep tendon reflexes are normal. Urinalysis shows many leukocytes and no erythrocytes. Urine culture grows no organisms. Serum prostate-specific antigen is 2 ng/mL (age-specific reference value is

Question

A 56-year-old man comes to the office due to progressive urinary frequency, urgency, and hesitancy for the past several months.  The patient also reports new-onset low back pain and perineal pain during ejaculation.  He has had no dysuria or hematuria.  The patient has smoked a pack of cigarettes daily for 30 years.  Temperature is 37 C (98.6 F), blood pressure is 130/76 mm Hg, and pulse is 80/min.  There is no suprapubic or costovertebral angle tenderness.  Examination of the external genitalia is normal.  Rectal examination shows increased anal sphincter tone and a smooth, slightly enlarged prostate.  Deep tendon reflexes are normal.  Urinalysis shows many leukocytes and no erythrocytes.  Urine culture grows no organisms.  Serum prostate-specific antigen is 2 ng/mL (age-specific reference value is <3.5 ng/mL).  Which of the following is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d0f4_4993_bc81_f58ae2b18121_MD0003_00 Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), typically defined as chronic pelvic pain (including pain in the perineum and testes, which can radiate to the back) for >3 months without an identifiable cause, can present as voiding difficulties, irritative voiding symptoms (eg, frequency, urgency, hesitancy), pain with ejaculation, or blood in the semen. Patients are generally afebrile and have little or no prostate tenderness (despite the term "prostatitis"), with a normal urinalysis and negative urine culture results. Prostate-specific antigen levels are often normal. There is usually no history of urinary tract infection. CP/CPPS can be categorized as inflammatory or noninflammatory based on the presence of leukocytes in urine and prostatic secretions, but this distinction has uncertain clinical significance. The exact etiology of CP/CPPS is unclear, but it is thought to be due to noninfectious chronic prostate inflammation. > CP/CPPS is a diagnosis of exclusion, and additional testing (eg, scrotal ultrasound, cystoscopy) is individualized based on the patient's particular clinical features. Even though a bacterial cause is not known, antibiotics (eg, fluoroquinolones) are often helpful in symptom relief. Other interventions include alpha-adrenergic inhibitors (eg, tamsulosin) and 5-alpha-reductase inhibitors (eg, finasteride). (Choice A) Epididymitis can also present with irritative voiding symptoms, but patients usually have scrotal pain, swelling, and tenderness as well as a purulent urethral discharge. (Choice B) Benign prostatic hyperplasia may cause irritative voiding symptoms, but patients more typically have slowly progressive bladder outlet obstruction (eg, decreased force of stream, incomplete voiding, dribbling, nocturia) and do not typically have back pain. (Choice C) Prostate cancer is unlikely in a young patient with a normal prostate-specific antigen level and no nodules or asymmetry on prostate examination. Elevated prostate-specific antigen levels should not be attributed to CP/CPPS. (Choice E) Chronic bacterial prostatitis (not to be confused with CP/CPPS) presents with dysuria and urinary frequency, but patients often have a history of urinary tract infection, prostatic tenderness or induration, and a positive urine culture. Acute bacterial prostatitis is characterized by fever, perineal pain, and severe tenderness on prostate examination. (Choice F) Bladder cancer most commonly presents with painless gross hematuria, with or without irritative voiding symptoms. Educational objective: Chronic prostatitis/chronic pelvic pain syndrome is a common disorder of uncertain etiology, characterized by irritative voiding symptoms (eg, frequency, urgency, hesitancy); perineal or genital pain; and pain or blood on ejaculation. Urine culture is sterile. Treatment includes antibiotics, alpha blockers, and 5-alpha-reductase inhibitors. References: Contemporary management of chronic prostatitis/chronic pelvic pain syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/26411805)

A 56-Year-Old Man Comes to the Office Due to Progressive