doc_clotaire
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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
(C) Trimethoprim/sulfamethoxazole for one week
(D) Renal ultrasound
(E) Ciprofloxacin for 4 to 6 weeks
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| admin
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E - Chronic Baterial Prostatitis.
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| Justice
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I would suggest (E)
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| doc_clotaire
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(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.
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| rakmay
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what would be the treatment if the pt with same symptoms and culture was negative and no history of UTI?
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