A 54-year-old man comes to the office due to 2 days of fever, chills, and perineal pain. He also has had frequent urges to urinate and pain on micturition but no penile discharge or testicular pain. The patient is not sexually active. He has no chronic medical problems and takes no medications. Temperature is 37.8 C (100 F), blood pressure is 120/70 mm Hg, and pulse is 94/min. Physical examination shows a circumcised penis with no urethral discharge. The testes are normal. Rectal examination reveals an edematous, tense, and tender prostate. Laboratory results are as follows: Dipstick urinalysis is positive for leukocyte esterase and nitrites. Which of the following is the most appropriate next step in management of this patient?

Question

A 54-year-old man comes to the office due to 2 days of fever, chills, and perineal pain.  He also has had frequent urges to urinate and pain on micturition but no penile discharge or testicular pain.  The patient is not sexually active.  He has no chronic medical problems and takes no medications.  Temperature is 37.8 C (100 F), blood pressure is 120/70 mm Hg, and pulse is 94/min.  Physical examination shows a circumcised penis with no urethral discharge.  The testes are normal.  Rectal examination reveals an edematous, tense, and tender prostate.  Laboratory results are as follows:  Dipstick urinalysis is positive for leukocyte esterase and nitrites.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d479_c605_bc81_8d5307ec3f47_MD0003_00 This patient's fever, dysuria, leukocytosis, and painful, edematous prostate indicate acute bacterial prostatitis (ABP). Most cases occur in young or middle-aged men when colonic flora (eg, Escherichia coli, Proteus) gain access to the urethra and subsequently enter the prostate through intraprostatic urinary reflux. Patients with ABP generally develop: A flulike illness with fever, chills, and malaise Lower urinary tract symptoms such as dysuria, frequency, urgency, hesitancy, and/or urine retention Perineal pain Laboratory evaluation usually reveals signs of systemic inflammation (eg, leukocytosis with bandemia), and urinalysis typically shows pyuria, nitrates, and bacteriuria. The diagnosis is confirmed when digital rectal examination reveals a tender, swollen prostate. Urine Gram stain and culture is then required to identify the underlying pathogen. Treatment with a prolonged course (6 weeks) of antibiotics (eg, trimethoprim-sulfamethoxazole, fluoroquinolone) ensures eradication of the organism and prevents complications such as prostatic abscess or chronic prostatitis. (Choices A and C) Imaging (eg, CT scan) is not generally required for ABP and should be reserved for patients who are likely to have a prostatic abscess (eg, prostatic fluctuance on digital rectal examination, failure to improve with antibiotics). Surgery is not needed for ABP because almost all cases resolve with prolonged antibiotic therapy. However, surgery or ultrasound-guided drainage is often required for prostatic abscess. (Choice B and D) Cystoscopy and urethral catheterization should generally be avoided in patients with ABP because passage of instruments through the urethra can cause septic shock (due to release of bacteria from prostate) or prostatic rupture. Patients who develop acute urinary retention due to prostatic swelling from ABP often require suprapubic (not urethral) catheterization. (Choice F) Chlamydia trachomatis and Neisseria gonorrhoeae are common causes of urethritis, which often presents with lower urinary symptoms (eg, dysuria) and urethral discharge. This patient is not sexually active and does not have urethral discharge. Testing for these pathogens would be low yield. Educational objective: Acute bacterial prostatitis often presents with lower urinary symptoms similar to a urinary tract infection. However, it is typically distinguished by the presence of perineal pain, pronounced systemic symptoms (eg, fever, chills, acute illness), and a tender, swollen prostate on digital rectal examination. Urine culture is required to establish the underlying pathogen. 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 2