A 55-year-old man comes to the office due to 2 weeks of urinary urgency, frequency, dysuria, and perineal pain. He had a similar episode 3 months ago, and a short course of antibiotic therapy completely resolved his symptoms. The patient has a history of type 2 diabetes mellitus and hyperlipidemia. He has smoked a pack of cigarettes daily for 20 years. Temperature is 37.5 C (99.5 F), blood pressure is 120/80 mm Hg, and pulse is 80/min. Examination shows suprapubic tenderness. There is no urethral discharge, and testicles are normal without tenderness. There is no costovertebral angle tenderness. Digital rectal examination reveals a symmetrically enlarged, smooth, and tender prostate. Complete blood count is normal. Urinalysis shows pyuria, many bacteria, and no red blood cells. Urine culture will most likely reveal which of the following organisms?

Question

A 55-year-old man comes to the office due to 2 weeks of urinary urgency, frequency, dysuria, and perineal pain.  He had a similar episode 3 months ago, and a short course of antibiotic therapy completely resolved his symptoms.  The patient has a history of type 2 diabetes mellitus and hyperlipidemia.  He has smoked a pack of cigarettes daily for 20 years.  Temperature is 37.5 C (99.5 F), blood pressure is 120/80 mm Hg, and pulse is 80/min.  Examination shows suprapubic tenderness.  There is no urethral discharge, and testicles are normal without tenderness.  There is no costovertebral angle tenderness.  Digital rectal examination reveals a symmetrically enlarged, smooth, and tender prostate.  Complete blood count is normal.  Urinalysis shows pyuria, many bacteria, and no red blood cells.  Urine culture will most likely reveal which of the following organisms?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d28e_e6d4_bc81_3fe2f5025f17_MD0003_00 This patient's recurrent urinary symptoms (eg, urgency, frequency, dysuria), prostatic tenderness, and pyuria/bacteriuria suggest chronic bacterial prostatitis (CBP). Most cases arise when coliform organisms contaminate the urethra and subsequently enter the prostate via intraprostatic reflux of urine. Escherichia coli is the leading pathogen, causing >75% of cases; other enteric organisms such as Enterococcus faecalis, Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa are also common. Risk is greatest in those with diabetes mellitus, tobacco abuse, and recent urinary tract procedure. CBP manifestations are often subtle, but patients generally have: Symptoms of recurrent urinary tract infections (eg, dysuria, frequency, urgency, perineal tenderness, pyuria, bacteriuria) that transiently resolve with a short course of antibiotics An enlarged, swollen, and tender prostate The diagnosis is generally made presumptively, but confirmation requires prostatic massage and examination of prostatic fluid (levels of bacteria in prostatic fluid are greater than those in urine prior to prostatic massage). Prolonged antibiotic therapy (4-6 weeks) is necessary to prevent recurrence; fluoroquinolones are considered first-line therapy because they achieve high concentration in prostatic tissue and provide good coverage for enteric pathogens. (Choice A) Chlamydia trachomatis generally causes nongonococcal urethritis with painful urination and mucoid urethral discharge. It is an infrequent cause of CBP and cannot be identified on urinalysis gram-stain because the cell wall lacks peptidoglycan. (Choice C) Mycobacterium tuberculosis primarily causes pulmonary infection; the prostate is not a frequent site of bacterial spread. (Choice D) Gram-positive skin flora such as Staphylococcus aureus primarily cause urinary infections in the setting of bacteremia or indwelling urinary hardware (eg, long-standing Foley catheter). S aureus is a less common cause of CBP. (Choice E) Ureaplasma urealyticum is often a urinary commensal organism but may occasionally cause CBP. However, Ureaplasma is not associated with bacteriuria on urinalysis because the pathogen lacks a cell wall. Educational objective: Chronic bacterial prostatitis generally causes recurrent urinary tract infection symptoms and prostatic swelling and tenderness. Most cases arise when coliform pathogens enter the prostate from the urethra; Escherichia coli is the leading pathogen. References: Common questions about chronic prostatitis. (http://www.ncbi.nlm.nih.gov/pubmed/26926816)

A 55-Year-Old Man Comes to the Office Due to 2