42-year-old man presents to ED with 2-day history of dysuria, low back pain, inability to fully empty his bladder, severe perineal pain along with fevers and chills. He says the pain is worse when he stands up and is somewhat relieved when he lies down. Vital signs T 104.0 F, pulse 138, respirations 24. PaO2 96% on room air. Digital rectal exam (DRE) reveals the prostate to be enlarged, extremely tender, swollen, and warm to touch.
Based on the patient’s symptoms, vital signs, and physical examination findings, it is highly suggestive of acute bacterial prostatitis (ABP). ABP is an infection of the prostate gland, usually caused by bacteria, and can present with a variety of symptoms including dysuria, low back pain, urinary retention, perineal pain, and systemic signs of infection such as fever and chills.
The patient’s dysuria (painful urination) can be attributed to the inflammation and infection in the prostate gland, which can cause irritation of the urinary tract. This can also contribute to the feeling of incomplete bladder emptying. The low back pain may be related to the inflammation and swelling of the prostate gland, which can radiate to the surrounding structures.
The presence of fever, chills, and elevated pulse suggests a systemic inflammatory response to the infection. The elevated pulse rate could be a compensatory response to the fever and increased metabolic demand. The PaO2 of 96% on room air indicates an adequate oxygenation level and suggests the absence of significant respiratory compromise.
The findings on the digital rectal exam (DRE) further support the diagnosis of ABP. The enlarged prostate, tenderness, swelling, and warmth to touch are consistent with acute inflammation and infection of the prostate gland. The prostate gland normally has a firm consistency and is not tender or warm to touch. The combination of these findings in the DRE is highly specific for ABP.
To confirm the diagnosis of ABP and identify the causative organism, further investigations may be performed. These can include a urine culture and sensitivity test, which will help identify the specific bacteria causing the infection and guide antibiotic therapy. It is important to note that the urine culture may not always yield positive results in cases of ABP, as the infection is primarily localized to the prostate gland rather than the urinary tract. Therefore, additional tests such as a prostate fluid culture or a prostate-specific antigen (PSA) test may be considered. PSA levels may be elevated in cases of prostatic inflammation or infection.
Treatment for ABP typically involves antibiotic therapy, analgesics for pain relief, and adequate hydration. Empirical antibiotic therapy is often initiated while awaiting culture results, and the choice of antibiotics should cover the likely causative pathogens such as Escherichia coli, Klebsiella spp., or Enterobacter spp. The duration of antibiotic treatment is typically 4-6 weeks, with the initial treatment duration depending on the severity of symptoms and the response to therapy.
Supportive measures such as pain management with nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids may be necessary to alleviate the patient’s symptoms. Adequate hydration is essential to help flush out the bacteria and maintain urinary flow. If urinary retention is severe, urinary catheterization may be required to relieve the obstruction and facilitate drainage.
In some cases, hospitalization may be necessary for patients who are severely ill, unable to tolerate oral intake or medications, have significant urinary retention, or are at risk of complications such as sepsis. Close monitoring of vital signs, urine output, and response to treatment is essential in these patients.
In conclusion, the patient’s presentation is consistent with acute bacterial prostatitis. Prompt diagnosis and treatment are crucial in preventing complications and ensuring a favorable outcome. Early initiation of appropriate antibiotic therapy, analgesics, and supportive measures can help alleviate symptoms and resolve the infection. Follow-up evaluation is essential to ensure resolution of the infection and to address any potential complications or chronic sequelae.