A 54-year-old man comes to the office due to a day of fever, chills, malaise, and low back pain. This morning, he also noticed urinary frequency and urgency. The patient has had no urethral discharge and is not sexually active. Medical history is significant for type 2 diabetes mellitus and hypertension. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 38.9 C (102 F), blood pressure is 130/78 mm Hg, and pulse is 90/min. The patient appears acutely ill. Cardiopulmonary examination is normal. Abdomen is soft and nontender. There is no tenderness over the costovertebral angle or spine. The lower extremities have no edema or rash. Digital rectal examination reveals marked anterior tenderness. Which of the following is the most likely diagnosis of this patient?

Question

A 54-year-old man comes to the office due to a day of fever, chills, malaise, and low back pain.  This morning, he also noticed urinary frequency and urgency.  The patient has had no urethral discharge and is not sexually active.  Medical history is significant for type 2 diabetes mellitus and hypertension.  The patient does not use tobacco, alcohol, or illicit drugs.  Temperature is 38.9 C (102 F), blood pressure is 130/78 mm Hg, and pulse is 90/min.  The patient appears acutely ill.  Cardiopulmonary examination is normal.  Abdomen is soft and nontender.  There is no tenderness over the costovertebral angle or spine.  The lower extremities have no edema or rash.  Digital rectal examination reveals marked anterior tenderness.  Which of the following is the most likely diagnosis of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d28f_8315_bc81_0f8d72671c52_MD0003_00 This patient with fever, malaise, chills, and marked anterior tenderness on digital rectal examination likely has acute bacterial prostatitis (ABP). Most cases arise in young or middle-aged men when enteric pathogens (eg, Escherichia coli) contaminate the urethra and enter the prostate via the intraprostatic reflux of urine. Patients with ABP are generally acutely ill and frequently present with ≥1 of the following: Flu-like illness with malaise, fever, chills, and myalgia (eg, back pain) Lower urinary tract symptoms such as dysuria, frequency, urgency, and pelvic/suprapubic pain Acute urinary retention due to prostatic swelling (compresses the urethra) The diagnosis is generally confirmed when digital rectal examination reveals a markedly swollen, tender prostate (anterior tenderness), but urine culture is required to establish the infecting organism. Treatment with 6 weeks of trimethoprim-sulfamethoxazole or levofloxacin (based on urine culture sensitivities) ensures eradication and limits risk of complications (eg, prostatic abscess, chronic prostatitis). (Choices A and C) Acute cystitis usually causes lower urinary symptoms (eg, dysuria, frequency, urgency, suprapubic pain) with no systemic manifestations (eg, fever, chills, malaise). Acute pyelonephritis usually causes lower urinary symptoms and systemic symptoms, but examination frequently reveals costovertebral tenderness. Prostatic edema and tenderness are not generally seen. (Choice D) Acute urethritis is usually caused by sexually transmitted pathogens (eg, Neisseria gonorrhoeae, Chlamydia trachomatis); symptomatic cases are generally marked by dysuria and urethral discharge. Prostatic swelling and pain are not typically seen. Furthermore, because this patient is not sexually active, he is unlikely to have a sexually transmitted pathogen. (Choice E) Acute flares of inflammatory bowel disease (eg, ulcerative colitis) can cause systemic symptoms (eg, fever, malaise) but are almost always associated with diarrhea and abdominal pain. (Choice F) Retrocecal appendicitis may not cause the classic right lower quadrant pain and tenderness associated with acute appendicitis. Although rectal tenderness can occur, it is usually more prominent at the right lateral, rather than the anterior, rectal wall. In addition, passive range of motion at the right hip often causes pain due to approximation of the retrocecal appendix and psoas muscle (psoas sign). Educational objective: Acute bacterial prostatitis usually manifests with a flu-like illness and lower urinary symptoms. The diagnosis is generally confirmed when digital rectal exam reveals exquisite prostatic tenderness and swelling. References: Acute bacterial prostatitis: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/26926407)

A 54-Year-Old Man Comes to the Office Due to a Day