A 30-year-old man comes to the office due to 3 days of dysuria and urinary frequency. He had similar symptoms twice over the past 4 months; both times, he was told he had a urinary tract infection and had complete resolution of symptoms following short courses of antibiotic therapy. He is sexually active and has pain with ejaculation but no urethral discharge or fever. The patient smokes a pack of cigarettes daily and does not use alcohol or illicit drugs. He has no other chronic medical issues. Temperature is 37.2 C (99 F), blood pressure is 120/80 mm Hg, and pulse is 78/min. Abdomen is soft and nontender. There is no costovertebral angle tenderness. External genitalia are normal without any focal tenderness, rashes, or ulcerations. Rectal examination reveals a smooth, nontender prostate. Urinalysis is as follows: Which of the following is the most likely cause of this patient's current symptoms?

Question

A 30-year-old man comes to the office due to 3 days of dysuria and urinary frequency.  He had similar symptoms twice over the past 4 months; both times, he was told he had a urinary tract infection and had complete resolution of symptoms following short courses of antibiotic therapy.  He is sexually active and has pain with ejaculation but no urethral discharge or fever.  The patient smokes a pack of cigarettes daily and does not use alcohol or illicit drugs.  He has no other chronic medical issues.  Temperature is 37.2 C (99 F), blood pressure is 120/80 mm Hg, and pulse is 78/min.  Abdomen is soft and nontender.  There is no costovertebral angle tenderness.  External genitalia are normal without any focal tenderness, rashes, or ulcerations.  Rectal examination reveals a smooth, nontender prostate.  Urinalysis is as follows:  Which of the following is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d92b_405f_bc81_2f393d14419e_MD0003_00 This patient's recurrent symptoms of urinary tract infection, pain with ejaculation, and pyuria/bacteriuria raise strong suspicion for chronic bacterial prostatitis. Most cases arise in young or middle-aged men who smoke or have diabetes mellitus. Coliform bacteria (eg, Escherichia coli) cause the majority of cases and generally gain access to the prostate from the urethra via the intraprostatic reflux of urine. Manifestations are often subtle, but many patients have ≥1 of the following: Symptoms of recurrent urinary tract infections (eg, dysuria, frequency, suprapubic tenderness, pyuria, bacteriuria) that transiently improve with short courses of antibiotic therapy Pain with ejaculation (discharge of prostatic fluid is irritative) Prostatic swelling and tenderness; however, notably, the prostate examination is often normal The diagnosis is generally made clinically, but confirmation requires prostatic massage followed by examination of prostatic fluid (prostatic fluid bacteria > urine bacteria prior to prostatic massage). Eradication of the pathogen usually requires at least 6 weeks of antibiotic therapy (eg, fluoroquinolone). (Choice B) Chronic epididymitis is usually caused by infectious (eg, Neisseria gonorrhoeae, Chlamydia trachomatis) or autoimmune conditions. Chronic infectious epididymitis can lead to painful ejaculation and a small amount of pyuria. However, focal tenderness over the epididymis (posterior testis) would be expected; in addition, bacteriuria and transient improvement with antibiotics (as seen in this patient) make chronic epididymitis unlikely. (Choice C) Chronic urethritis is primarily due to insufficient treatment of N gonorrhoeae or C trachomatis or the presence of an atypical sexually transmitted organism (eg, Trichomonas vaginalis). The lack of urethral discharge makes this diagnosis less likely. (Choice D) Chronic pyelonephritis can cause recurrent lower urinary tract symptoms (eg, dysuria, pyuria, bacteriuria) but most patients have fever, flank pain, and costovertebral tenderness. Furthermore, painful ejaculation would be uncommon. Most cases of chronic pyelonephritis occur with structural abnormalities in the urinary tract (eg, ureteral obstruction, struvite stones). (Choice E) Interstitial cystitis occurs mostly in women and usually causes suprapubic pain that worsens with bladder filling and improves with voiding. Patients sometimes have lower urinary tract symptoms (eg, urgency, frequency) and hematuria, but pain on ejaculation, pyuria, and bacteriuria indicate an alternate diagnosis. Educational objective: Chronic bacterial prostatitis often presents with symptoms of recurrent urinary tract infection, painful ejaculation, and/or prostatic tenderness in young or middle-aged men. Patients often have transient improvement of symptoms with short courses of antibiotics. Six weeks of a fluoroquinolone is generally required for eradication. References: Common questions about chronic prostatitis. (http://www.ncbi.nlm.nih.gov/pubmed/26926816)

A 30-Year-Old Man Comes to the Office Due to 3