PANCE Blueprint Genitourinary (5%)

Prostatitis (Lecture)

Patient will present as → a 63-year-old man with a history of benign prostatic hyperplasia reports 3-days of fever, chills, and pain with urination. He was recently catheterized during an admission in the hospital. Physical exam reveals a tender and enlarged prostate on digital rectal exam. Urinalysis reveals pyuria and hematuria.

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Some patients are asymptomatic, but sudden onset of fever, chills, and low back pain combined with urinary frequency, urgency and dysuria are common in prostatitis.

  • Patients will have extreme tenderness on digital rectal exam (DRE)

Etiology is based on patient's age and risk factors

  • Chlamydia and Gonorrhea in men < 35
  • E coli in men > 35

**If you suspect acute prostatitis do not massage the prostate this can lead to sepsis!

Urinalysis will reveal pyuria and hematuria

  • Prostatic fluid may show leukocytosis with a culture typically positive for E Coli

Case presentation - 24 year old male complaining of blood in ejaculate after intercourse with girlfriend think prostatitis and treat appropriately

  • In this case and in men < 35 treat for Chlamydia and Gonorrhea - Ceftriaxone and Azithromycin (or Doxycycline).
  • In older men > 35 treat with fluoroquinolones or Bactrim for six weeks to ensure eradication of the infection.
    • Patient who cannot tolerate oral medication, demonstrate signs of severe sepsis, or have bacteremia should be hospitalized. In such cases, intravenous levofloxacin or ciprofloxacin may be given with or without an aminoglycoside (gentamicin or tobramycin).
"In men who have persistent fever and chills, inability to urinate, or low back pain despite initial treatment transrectal ultrasonography of the prostate gland is warranted and may help to detect prostate calculi or abcess."
  • Chronic prostatitis is treated with fluoroquinolones or bactrim x 6-12 weeks
Question 1
Which of the following can be used to treat chronic bacterial prostatitis?
A
Penicillin
Hint:
See D for explanation.
B
Cephalexin (Keflex)
Hint:
See D for explanation.
C
Nitrofurantoin (Macrobid)
Hint:
See D for explanation.
D
Levofloxacin (Levaquin)
Question 1 Explanation: 
Chronic bacterial prostatitis (Type II prostatitis) can be difficult to treat and requires the use of fluoroquinolones or trimethoprim-sulfamethoxazole, both of which penetrate the prostate.
Review Topic: Prostatitis
Question 2
When performing a rectal examination, prostatic massage is contraindicated in
A
prostatodynia
Hint:
Prostatodynia is an inflammatory disorder involving voiding dysfunction and pelvic floor musculature dysfunction. There is no bacterial involvement.
B
non-bacterial prostatitis
Hint:
Non-bacterial prostatitis is similar to chronic bacterial prostatitis, but no bacteria are cultured, and the cause is unknown.
C
acute bacterial prostatitis
D
chronic bacterial prostatitis
Hint:
Prostate massage can be performed in the absence of fever. Expressed prostatic secretions are cultured to help identify the organism.
Question 2 Explanation: 
Vigorous manipulation of the prostate during rectal examination may result in septicemia. This is contraindicated in the presence of fever, irritative voiding symptoms, and perineal/sacral pain.
Question 3
A male patient complains of chronic dysuria, frequency, and urgency with associated perineal pain. The most likely diagnosis is
A
cystitis
Hint:
Cystitis is characterized by dysuria without urethral discharge
B
gonococcal urethritis
Hint:
Initially there is burning on urination and serous or milky discharge in gonococcal urethritis.
C
epididymitis
Hint:
Epididymitis is characterized by dysuria, unilateral scrotal pain and swelling.
D
prostatitis
Question 3 Explanation: 
Some patients are asymptomatic, but low back or perineal pain, fever, chills, and irritative urinary symptoms are common in prostatitis.
Question 4
A male patient presents with hematuria. Upon further questioning the patient states that the hematuria occurs at the end of his urinary stream. Which of the following is the most likely source of blood?
A
renal pelvis
Hint:
Total hematuria, blood throughout the urinary stream, suggests a bladder or upper urinary tract source.
B
bladder neck
C
anterior urethra
Hint:
Presence of blood at the beginning of the urinary stream suggests an anterior (penile) urethral source.
D
ureter
Hint:
Hematuria from the kidneys or ureter may be present microscopically or throughout the stream.
Question 4 Explanation: 
Terminal hematuria, blood at the end of the urinary stream, suggests a bladder neck or prostatic urethral source.
Question 5
A 38-year-old male presents with fever, perineal pain, and dysuria. On physical examination, the patient is toxic- appearing, febrile, and his prostate is very tender to palpation. Laboratory testing reveals leukocytosis, pyuria, and bacteriuria. Which of the following is the treatment of choice for this patient?
A
Ciprofloxacin
B
Ceftriaxone and doxycycline
Hint:
Ceftriaxone and doxycycline are used in the treatment of acute epididymitis due to sexually transmitted infection.
C
Azithromycin + Ceftriaxone
Hint:
This is used in the treatment of chlamydia and gonorrhea
D
Nitrofurantoin
Hint:
Nitrofurantoin is used in the treatment of acute cystitis and not indicated in acute prostatitis.
Question 5 Explanation: 
Empiric antibiotic therapy should adequately treat gram-negative organisms unless a urine Gram stain is available and suggests an alternate bacterial cause. For patients with acute prostatitis who can take oral medications, trimethoprim-sulfamethoxazole (one double-strength tab orally every 12 hours) or a fluoroquinolone (ciprofloxacin 500 mg orally every 12 hours or levofloxacin 500 mg orally once daily) can be used as empiric therapy. Treat for six weeks to ensure eradication of the infection.
Question 6
A 23 year-old male being treated for an acute bacterial prostatitis has been taking antibiotics for less than 24 hours. He presents to the emergency room today with acute urinary retention for 12 hours. Which of the following is the most appropriate next step?
A
Insert a Foley catheter
Hint:
Urethral catheterization, or any form of instrumentation is contraindicated in the presence of acute bacterial prostatitis.
B
Initiate diuretic therapy
Hint:
Diuretic therapy is contraindicated in the treatment of acute urinary retention.
C
Schedule for cystoscopy
Hint:
See A for explanation.
D
Insert a percutaneous suprapubic tube
Question 6 Explanation: 
Inserting a percutaneous suprapubic tube is the treatment of choice in a patient with acute bacterial prostatitis who develops acute urinary retention.
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