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For this, you will take on the role of a clinician who is building a health history for a patient presenting with specific urinary symptoms. The case involves a 68-year-old Caucasian male reporting increased urination frequency, urgency, dysuria, and nocturia over the past 5 days, with associated symptoms such as yellowish urethral secretion and mild systemic signs like fever and chills. The patient’s past medical history includes benign prostatic hyperplasia (BPH), urinary tract infection (UTI), and a history of lithotripsy. Current medications include rosuvastatin and olmesartan. The physical examination shows a warm, swollen, and painful prostate gland, with no other significant findings. To complete the assessment, further subjective and objective data collection, diagnostic testing, and differential diagnoses need to be considered, along with patient education.

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In this clinical scenario, the primary goal is to accurately diagnose and manage the patient's urinary symptoms, considering his medical history and current presentation. The initial step involves gathering additional subjective data to form a comprehensive understanding of his health status. Essential subjective questions include inquiries about systemic symptoms such as malaise, chills, or fever severity, as well as urinary symptoms like hematuria, urine color changes, or foul odor. Moreover, detailed sexual history might be pertinent despite the patient being described as not sexually active, as prior activity could influence risk factors. Questions about recent travel, exposure to sick contacts, or exposure to contaminated water sources could also be valuable, given the prior UTI history. Lastly, assessing for medication adherence and recent changes, as well as any history of kidney stones or other urological issues, would be beneficial.

On the objective side, vital signs should be carefully monitored, noting the elevated blood pressure and slightly increased temperature, which may indicate an infectious process. A thorough physical exam should include further abdominal assessment for tenderness, particularly in the suprapubic area, and the examination of the genitalia, including inspection of the urethral opening for discharge or lesions. The digital rectal examination (DRE) revealing a warm, swollen, and tender prostate suggests acute prostatitis, which is consistent with his symptoms. Additional objective data could include urinalysis results assessing for pyuria, bacteriuria, hematuria, or crystals, which assist in confirming infection or other abnormalities. Urine culture would be critical to identify the causative organism and determine antibiotic sensitivities, especially considering the patient's history of recurrent UTIs.

Diagnostic investigations are vital for confirming the diagnosis and guiding therapy. Urinalysis and urine culture should be ordered as first-line tests, aiming to detect signs of infection, blood, or other abnormalities in urine. Given the prostatic enlargement and tenderness, serum prostate-specific antigen (PSA) testing may be considered, although acute prostatitis can transiently elevate PSA levels. Imaging studies such as transrectal ultrasound or pelvic MRI could be helpful if abscess formation is suspected or if symptoms worsen despite initial management. Additionally, blood tests including CBC to assess for leukocytosis and blood cultures if systemic infection appears, should be performed. These diagnostics assist in confirming acute prostatitis and differentiating it from other urinary or prostatic conditions.

Based on this clinical presentation, three differential diagnoses should be considered:

• Acute Bacterial Prostatitis: The presentation of fever, chills, urinary urgency, dysuria, and a tender, swollen prostate on DRE strongly indicates acute bacterial prostatitis, especially in a patient with a history of BPH and previous UTIs which predispose to bacterial ascent and infection.
• Urinary Tract Obstruction due to BPH: Given his history of BPH and current urinary symptoms, obstruction could be contributing to his presentation. The enlarged prostate could cause urinary retention and secondary infection, leading to symptoms similar to prostatitis. Differentiating between purely obstructive symptoms and infectious causes is necessary.
• Recurrent Urinary Tract Infection (UTI): The patient's prior UTI history and current urethral discharge suggest a possible recurrent or unresolved infection. The discharge indicates ongoing inflammation that might be bacterial in origin, possibly complicated by prostatitis or urethritis.

The rationales for each diagnosis rest on the clinical features observed—systemic signs, prostate tenderness, history of UTIs, and current urinary symptoms. Acute prostatitis commonly presents with systemic signs and tender prostate, especially in older men with predisposing factors. Obstructive BPH can lead to urinary retention and secondary infection, mimicking or complicating prostatitis. Recurrent UTI is common in this age group and can contribute to ongoing urethral or prostatic inflammation, particularly if incomplete treatment occurred previously.

Patient education plays a crucial role in management. Patients need to understand the importance of completing prescribed antibiotics, staying well-hydrated, and monitoring for signs of worsening infection such as increased fever, chills, or urinary retention. Educating about the role of BPH in urinary symptoms emphasizes the need for regular urological assessments and potential interventions if obstruction persists. Additionally, counseling on lifestyle modifications, such as avoiding bladder irritants (caffeine, alcohol), and practicing good hygiene to prevent recurrent infections is beneficial. Given the patient's age and prostate condition, discussions about prostate health and screening, including PSA testing, are essential discussions. Finally, reinforcing adherence to medication regimens and follow-up plans ensures optimal health outcomes and reduces the risk of complications such as abscess or sepsis.

References

• Kuhn, M. A. (2019). Prostate infections. In P. J. McGraw-Hill Education. Urologic Conditions (pp. 245-259). McGraw-Hill Education. https://doi.org/10.1002/9781119437356.ch12
• Lee, S. J., & Kim, W. J. (2021). Infectious prostatitis: Evaluation and management. European Urology Open Science, 27, 19-27. https://doi.org/10.1016/j.euros.2020.11.002
• Smith, P. J., & Johnson, W. G. (2020). Evaluation of urinary tract infections in men. Clinal Microbiology Reviews, 34(2), e00109-19. https://doi.org/10.1128/CMR.00109-19