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A 62-year-old man presents to your clinic complaining of four days of dysuria, frequency, and urgency. He feels slightly feverish and has had dull, lower-back pain for the past few months. He has had several episodes of the dysuria over the last several months. Each time he was given antibiotics for one week, and the symptoms resolved. Currently his temperature is 100.4 F. The genital examination is unremarkable, and the digital rectal examination reveals a nontender prostate, which is normal in size and consistency, with no palpable masses. After gentle massage of the prostate, a small amount of purulent discharge is extruded from the urethral meatus. The urine culture grows 100,000 colonies/mL of E. coli. Urine cultures from his prior symptomatic episodes also grew E. coli but only 10,000 colonies/mL. Which of the following is most appropriate?
(A) Cystoscopy
(B) Ciprofloxacin and azithromycin orally once now
© Trimethoprim/sulfamethoxazole for one week
(D) Renal ultrasound
(E) Ciprofloxacin for 4 to 6 weeks
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VANCO IS ON HIS WAY NOW TO HERE
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Answer:
(E) Ciprofloxacin for 4 to 6 weeks
Explanation:
This patient has chronic bacterial prostatitis. Chronic prostatitis can present with lower abdominal pain, perineal pain, or low back pain. There is usually no dysuria unless there is accompanying cystitis. On physical examination, the prostate usually feels normal and is nontender. As in this patient, chronic prostatitis may manifest as a recurrent urinary tract infection (UTI). The key to the diagnosis is culture of urine or urethral discharge. Pathogens for chronic prostatitis in older men are the same as for a UTI, with E. coli being the most common organism identified. One may extrude purulent discharge by massaging the prostate, which will grow the offending organism. One can also culture the urine post massage of the prostate, which should grow ten times more colonies than premassage urine. This patient cultured 10,000 colonies of E. coli in prior cultures, and currently he grew 100,000 colonies postprostatic massage. Ciprofloxacin for 7 days would be appropriate treatment if this were just a UTI. Therapy for one week is not long enough to clear chronic bacterial prostatitis. Most antibiotics don't have good penetration into the prostate, and it takes at least four weeks of therapy with ciprofloxacin to clear the infection. Ciprofloxacin and azithromycin for a single dose would be the treatment for urethritis. This patient does have a urethral discharge, which may be confused with urethritis. However, since the discharge is extruded only on palpation of the prostate, this strongly suggests that the prostate is the source of infection. Cystoscopy would be useful in a patient with recurrent UTIs in whom you suspected a structural malformation of the genitourinary tract. This patient's UTIs are originating from his chronically infected prostate. Trimethoprim/sulfamethoxazole for 12 weeks is an acceptable alternative for treating chronic prostatitis
