Diagnosing Acute Bacterial Prostatitis

Which of the following clinical scenarios is most consistent with an older adult presenting with acute bacterial prostatitis?  

A. A 65  year old male who presents with a 6 month history of urinary frequency, occasional difficulty initiating urine stream, without dysuria or fever. GU exam within normal limits with the exception of prostate enlargement.  

B. A 50-year-old male with a 4 day history of increased urinary frequency, end-void dysuria, and intermittent fever. GU exam reveals suprapubic tenderness,  without  prostatic enlargement or scrotal abnormalities.  

C. A 70 year old man with a 3-day history of perineal pain, intermittent fever, dysuria, and difficulty initiating urine stream. Scrotal exam WNL and digital rectal exam reveals a tender, enlarged prostate.  

D. A 78 year old man with a 3 month history of intermittent gross hematuria and urinary frequency without dysuria. GU exam is WNL with the exam of a nontender enlarged prostate with multiple nodular lesions.  

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Transcript

Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question, so you can better understand how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: Which of the following clinical scenarios is most consistent with an older adult presenting with acute bacterial prostatitis?  

A: A 65-year-old male who presents with a 6-month history of urinary frequency, occasional difficulty initiating urinary stream without dysuria or fever. GU exam is within normal limits, with the exception of prostate enlargement.  

B: A 50-year-old male with a 4-day history of urinary frequency, end-void dysuria, and intermittent fever. GU exam reveals suprapubic tenderness without prostatic enlargement or scrotal abnormalities.  

C: A 70-year-old man with a 3-day history of perineal pain, intermittent fever, dysuria, and difficulty initiating urine stream. Scrotal exam within normal limits and digital rectal exam reveals a tender, enlarged prostate.  

D: A 78-year-old man with a 3-month history of intermittent gross hematuria and urinary frequency without dysuria. GU exam is within normal limits, with the exception of a non-tender enlarged prostate with multiple nodular lesions.  

The correct answer is C: A 70-year-old man with a 3-day history of perineal pain, intermittent fever, dysuria, and difficulty initiating urine stream. Scrotal exam within normal limits and digital rectal exam reveals a tender, enlarged prostate. 

Where do you start with a question like this? First, once again we're going to determine what kind of a question it is. Given we are provided with clinical presentation and now what we have to do is choose which one is most consistent with acute bacterial prostatitis. This of course, is a diagnosis question. A bit of background information. Acute bacterial prostatitis is a self-defining disease where the prostate is inflamed due to a bacterial infection. 

This condition is considered to be a complicated UTI as a structure adjacent to the urinary tract including the bladder is involved, so the prostate is involved, plus the bladder is involved. The contributing uropathogens causing this condition differ according to a number of clinical factors and adults, particularly males 35 years and under, and those at risk for STIs, gonorrhea and chlamydia, are contributing pathogens, and older men, particularly with BPH, are men at low risk for STIs. 

The infection is usually with gram negative organisms such as E. coli and pseudomonas species. Additional risk factors for acute bacterial prostatitis include a prior history of prostatitis, a history of bladder or urethral infection, pelvic trauma, dehydration, or the use of urinary catheter. Older men make up the majority of patients with acute bacterial prostatitis, and it's also important to keep in mind-that goes beyond the scope of this podcast-is acute prostatitis is not always bacterial in nature.  

However, we're focusing here on bacterial disease with suspected acute bacterial prostatitis. A midstream urine culture is used to identify the causative organisms with those with a suspected STI. A urine-based NAAT testing is recommended for the detection of gonococcal or chlamydia infection, regardless of the suspected bacterial pathogen. Urinalysis is usually one that will show positive leukocyte esterase. 

And you know what that is? That's the urine. That's the urine dip for WBCs. Usually it is called leukocyte esterase. And what it actually is, is when it's positive it's surrogate marker for neutrophils in the urine. Other diagnostic tests can include a CBC and electrolytes. This is generally done case-by-case based on severity of illness and presence of systemic symptoms. 

Blood cultures are usually obtained in more severe disease, as this condition carries a risk for bacteremia and resulting sepsis. With this is background information. And let's take another look at the questions and the answers. Which of the following clinical scenarios is most consistent with an older adult presenting with acute bacterial prostatitis? A: A 65-year-old man who presents with a 6-month history of urinary frequency, occasionally difficulty initiating urine stream without dysuria or fever. 

GU exam is within normal limits, with the exception of prostate enlargement. This is, of course, incorrect, and given the lack of fever, which is a near universal finding in prostatitis and lack of acute symptoms, this presentation is not consistent with the diagnosis in question. What this sounds a bit more like is a man in his mid-60s presenting with benign prostatic hyperplasia, a condition found in the majority of men in this age group. 

I am not dismissing this guy's symptoms at all, but it's just not germane to answering the question. B: A 50-year-old male with a 4-day history of increased urinary frequency, end-void dysuria, and intermittent fever. GU exam reveals suprapubic tenderness without prostatic enlargement or scrotal abnormalities. Again, not correct given the lack of prostatic findings and the presence of suprapubic tenderness, this is clinical presentation is more consistent with a lower UTI. 

I have to say, I'm a little bit out on the limb with even saying that I need more clinical information, but it doesn't sound like a prostatitis. Well, much less common in men. Lower UTI or cystitis needs to be part of the differential diagnosis in men with new-onset urinary symptoms. You'll also notice in this there was no prostatic enlargement in this 50-year-old man. 

And that's one of the most potent risk factors for a bacterial prostatitis in older men. Plus 50 isn't that old. Option C: A 70-year-old man with a 3-day history of perineal pain, intermittent fever, dysuria, and difficulty initiating urine stream. Scrotal exam is within normal limits. Digital rectal exam reveals tender and enlarged prostate. This is, of course, the correct answer. 

Acute bacterial prostatitis presents just as its name suggests, acute. Late, usually with fever, chills, malaise, and often with arthralgia. Irritated voiding symptoms, suprapubic pain, and perineal pains are typically reported, and one report of men with acute bacterial prostatitis are, I dare say, any acute prostatitis will be as follows. The person will say to you, when I go to sit down and my bottom hits the chair, I get a sharp pain that goes from my bottom up through my abdomen. 

And what that is, you know, when you sit down, you jar your internal organs a bit, you know, damage them, but you do jar them a little bit. And now you've got this tender, inflamed prostate. And when it gets injured like that, there is rather acute pain that can go along with it. Often obstructive urinary tract symptoms, including urinary frequency, urgency, nocturia, and difficulty initiating urine stream along with the sensation of incomplete voiding and weak urine stream are reported. 

And I know that you can read that go like, it sounds like a lot of guys have taken care of who just have BPH. And you're absolutely right. And I bring this up so that you can start conceptualizing more differentials here. You're right. But digging a little bit further into this guy's history, you probably would find that if he has some obstructive symptoms, chronically, all of a sudden they've gotten much worse over the last like 3 or 4 days. 

Objective findings usually include fever in the general rectal exam. You will have that notation of that tender, boggy or sponge-like prostate. And if you want to try something that will give you an idea of how firm the prostate in health usually feels, take your index finger, press on the tip of your nose and press straight in. Straight in to your fingers on the tip of your nose. 

Now press straight in like you're trying to push your nose into your face. And what will happen is that that will give you the idea of how firm a healthy prostate is. And now let's get an idea of what the prostate feels like in prostatitis. Take your index finger, put it right over your cheekbone, and press it. And do you get the idea? 

Because you're pressing straight in over your cheekbone that you've got a little bit more give than you did when you're pressing over the tip of your nose and kind of a boggy feeling. And that's what the prostate feels like with prostatitis. Let me add just one more part here. The digital rectal exam and a man with a healthy prostate is usually not a comfortable exam to have done. 

And if you say, is this uncomfortable when you're doing a rectal exam on a man with a healthy prostate, he probably will say, yes, that is uncomfortable. And what I will usually do is say, is it when I'm palpating in the prostate-through the digital rectal exam, I'll say, is it the tip of my finger where it's really uncomfortable? 

Or is it the presence of my entire finger or the base of my finger that's uncomfortable, and they'll be able to differentiate that and they'll say, oh, it's just kind of the whole thing is uncomfortable if they're prostate is normal. Okay. So, C was our correct answer. D: A 78-year-old man with a 3-month history of intermittent gross hematuria and urinary frequency without dysuria. 

GU exam is within normal limits with the exception of a non-tender enlarged prostate with multiple nodular lesions. Again, obviously not the correct answer, but the lack of dysuria is really something that should make you lean away from a diagnosis associated with infection and inflammation, such as acute bacterial prostatitis or a lower urinary tract infection. Now, the gross hematuria finding, that is a finding where blood is visible in the urine. 

This is alarming, particularly in the absence of UTI symptoms. The prostate exam with multiple nodules is suggestive of prostate cancer. One more time, it's suggestive of and the next stop for this man should be urology because he needs to have evaluation done above and beyond what you can do in primary care. And that's how you need to be thinking to get through these boards like a primary care provider. 

One more comment I need to make about this option D. A prostate with multiple nodular lesions. If this ends up being prostate cancer, it's a very advanced disease. So just keep that in mind. Very often the prostate in a man with earlier prostate cancer will actually be perfectly normal. Key takeaway: as with any other diagnosis, keep in mind what groups are greatest risk for the condition. 

Couple this with the most likely clinical presentation of the disease and you have the keys to accurate diagnosis. 

Voiceover: Thank you for listening to NP certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast, and for more NP resources, visit FHEA.com.