A 25-year-old man comes to the office due to decreased force of the urinary stream and incomplete emptying of the bladder. He has no urgency, frequency, nocturia, dysuria, or fever. Bowel movements are regular. The patient has no chronic medical conditions and takes no medications. Vital signs are within normal limits. The abdomen is soft and nontender. External genitalia are normal; no penile discharge is noted. No inguinal lymphadenopathy is present. Neurologic examination shows no abnormalities. Urinalysis is normal. Postvoid residual volume is high. What is the most likely cause of this patient's current condition?

Question

A 25-year-old man comes to the office due to decreased force of the urinary stream and incomplete emptying of the bladder.  He has no urgency, frequency, nocturia, dysuria, or fever.  Bowel movements are regular.  The patient has no chronic medical conditions and takes no medications.  Vital signs are within normal limits.  The abdomen is soft and nontender.  External genitalia are normal; no penile discharge is noted.  No inguinal lymphadenopathy is present.  Neurologic examination shows no abnormalities.  Urinalysis is normal.  Postvoid residual volume is high.  What is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d960_817d_bc81_e5f38e0f69eb_MD0003_00 This patient has decreased urinary flow and a sensation of incomplete emptying. In a young man, this is consistent with a urethral stricture. Urethral stricture is a common disorder characterized by fibrotic narrowing of the urethra and occurs most frequently in the bulbar portion. Strictures are commonly idiopathic, but secondary causes include urethral trauma (eg, pelvic fracture, iatrogenic instrumentation), infection (eg, sexually transmitted urethritis), and radiotherapy. In some cases, the inciting cause is temporally remote and may not be immediately remembered by the patient. Urethral strictures can lead to acute urine retention, recurrent urinary tract infection, bladder stones, or, rarely, hydronephrosis and renal insufficiency. Patients typically have obstructive-type voiding symptoms (eg, weak urine stream, urinary spraying), although dysuria can occur. The diagnosis is suggested by an elevated postvoid residual volume. Urethrography (eg, voiding cystourethrogram) or cystourethroscopy can confirm the diagnosis. In addition to voiding problems, complications can include bladder stones, hydronephrosis, and fistulas. Mild strictures may be observed cautiously, but significant strictures typically require correction with either urethral dilation or surgical urethroplasty. (Choice A) Abnormal detrusor overactivity can cause similar symptoms but is more likely to cause urinary frequency and urgency, nocturia, or incontinence (storage-type symptoms related to bladder filling and urine storage), which are not seen in this patient. Obstructive symptoms (ie, decreased force of stream) and increased postvoid residual volume are more consistent with stricture. (Choice B) Benign prostatic hyperplasia causes similar obstructive-type voiding symptoms due to impedance of urine flow in the prostatic urethra. However, although symptomatic benign prostatic hyperplasia is very common in older men, it is rare at age <40. (Choice C) Although a stone in the lower ureter (eg, vesicoureteral junction) can cause symptoms of irritative voiding (eg, urgency, frequency), patients frequently have hematuria and severe, acute flank pain. Postvoid residual volume is normal. (Choice D) Urethral diverticulum is a rare condition characterized by lateral extension of urethral mucosa into the surrounding tissues. Usually seen in women, it often presents as a painful mass in the anterior vaginal wall. Other symptoms include hematuria, incontinence, and recurrent infection. Educational objective: Urethral stricture is a fibrotic narrowing of the urethra. Common causes include urethral trauma, infection, and radiotherapy. Symptoms include weak or spraying urine flow and incomplete emptying. Postvoid residual volume is increased. The diagnosis is confirmed on urethrography or cystourethroscopy; treatment includes urethral dilation or surgical urethroplasty. References: Urethral stricture: etiology, investigation and treatments. (http://www.ncbi.nlm.nih.gov/pubmed/23596502)

A 25-Year-Old Man Comes to the Office Due to Decreased