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.
A 67-year-old man who is diagnosed with acute bacterial prostatitis presents with the chief complaint of a one-week history of constant perineal pain, arthralgia, irritative voiding symptoms, and intermittent fever. Which of the following is most consistent with the anticipated findings on prostatic digital rectal exam, DRE, with this condition?
A. An enlarged prostate with obliterating median sulcus.
B. A prostatic exam that reveals multiple firm non-tender nodular lesions.
C. A tender boggy prostate.
or
D. A firm non tender prostate.
And the correct option here is C, a tender boggy prostate.
Where should you start? First, assess what kind of question this is. Given we are told his diagnosis, yet we're being asked for anticipatory physical exam findings, this is an assessment question. Because what it's saying is, okay, here's the diagnosis. When you're gathering your subjective and objective information, what would you expect to find in this patient? Let's take a look at some background information.
The term prostatitis is used to describe inflammation of the prostate, whether caused by a pathogen
or other reasons. Acute bacterial prostatitis implies that the inflammation is caused by a bacterial infection. Select pathogens that cause bacterial prostatitis vary, often according to select patient characteristics and activities. In men who are insertive partners in anal intercourse, they're more likely to have infection caused by select coliforms. And whenever you see the word coliform, I'll always think lower GI organisms. IN individuals who have multiple sexual partners, regardless of age, STI, such as Chlamydia trachomatis, or Neisseria gonorrhea are more common. Infection with a gram-negative rod like E.coli or Pseudomonas species usually causes acute bacterial prostatitis in men who are at low risk for STI, particularly when aged 65 years and older. And the gentleman in this question is beyond age 65.
Regardless of the causative organism, the clinical presentation of bacterial prostatitis is similar. Acute bacterial prostatitis, the person presents acutely ill with fever, chills, malaise, and arthralgia, and as he reports, irritative voiding symptoms, supra-pubic and perineal pain are often reported. Sometimes what the man with bacterial prostatitis will tell you is, “My bottom always aches,” and that would be the perineum. And then he will often say, “If I sit down in a chair and kind of hit my bottom hard on the chair, a really bad pain comes up from my bottom up into my abdomen, takes a moment or two to go away.” And what that is, is the sitting in the chair, when the perineum actually hits the chair or any other solid surface, what ends up happening is the prostate gets jarred or jostled and that's what's causing the pain.
Often obstructive urinary tract symptoms, including urinary frequency, urgency, nocturia, difficulty initiating urine stream, along with the sensation of incomplete voiding, and a weak urinary stream is reported, particularly in an older guy like this, who you would anticipate has a component of benign prostatic hyperplasia. Digital rectal exam is part of the evaluation of the person with prostatitis, and is the focus of this question.
So back to the question.
A 67-year-old man who is diagnosed with acute bacterial prostatitis presents with the chief complaint of a one-week history of constant perineal pain, arthralgia, irritative voiding symptoms, and intermittent fever. Which of the following is most consistent with the anticipated findings on prostatic digital rectal exam with this condition?
Would it be: A. An enlarged prostate with an obliterated median sulcus? This is incorrect and this reflects the findings usually noted on DRE in benign prostatic hyperplasia. A really common condition in men of this age, and it's non-malignant as the name implies, and it's going to be noted in the majority of men aged 60 years and older. In fact, there is one, this is not a perfect set of numbers, but I find it very helpful when talking to men about their prostate and prostatic health as they get older, that if you examined a thousand 60-year-olds, 60% would have a degree of BPH. then go and examine a thousand 70-year-olds, 70% will have BPH. Now go and examine a thousand 80-year-olds, and guess what? 80% will have BPH, and it is considered to be a part of some age-related changes. In another question, we will deal with the management of BPH. Would it be option B. Prostatic exam that reveals multiple firm non-tender nodular lesions. This is also not correct. It is far more consistent with the prostate exam of a person with prostate cancer, whereas the malignancy yields these firm non-tender nodules. However, please note digital rectal exam fails to reveal prostate cancer until the disease is very advanced and certainly will be missed in earlier disease.
Option C. A tender boggy prostate. This is the correct answer. The prostate is usually quite firm on digital rectal exam. About as firm as what you can feel if you take your index finger and press straight in on your nose. Go to the tip of your nose, now press straight in with your index finger and you're going to feel that that quite firm, quite firm. It's compressible, but it's very firm. With prostatitis, the consistency of the prostate changes due to the tissue edema. So now that prostate is about as firm as pressing over your cheekbone with your fingertip. In addition, the prostate is quite tender on palpation with digital rectal exam in acute bacterial prostatitis, more tender beyond the general discomfort that is usually reported with a digital rectal exam.
Let's take a look at option D. A firm nontender prostate. This is of course incorrect because option C is our correct item. Could simply represent a normal prostate exam.
Key takeaway: Knowledge of the most common results of the physical exam for a given diagnosis is at the core of clinical practice and certification success.
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