Summative Cases

Summative Case #2

Kelly E. Cumella, DNP, RN, FNP-C

Case Study

Patient Profile

Name: James Smith

Age: 40 years old

Gender: male

History of Present Illness

J.S. is a 40-year-old man who presents to the office with a five-day history of worsening perineal pain 9/10 (worsening the past two days especially), fever (up to 102°F), chills, difficulty urinating.

General Appearance: Ill-appearing, mildly diaphoretic, febrile.

Medical History

Generally healthy, no significant medical history. Non-smoker, no alcohol use, no drug use.

Surgical: no surgical history

Medications

Daily men’s multivitamin, Tylenol per bottle instructions (PRN).

Social History

Patient is married to his wife, Sarah, of 15 years. He has 3 children, ages 10, 6, and 2. He works as a police officer in the local jail. He has strong family and social support.

Family History

Patient is adopted and unaware of family history.

Review of Systems

  • Constitutional: Reports fever, chills, body aches, and generalized fatigue worsening over the past two days.
  • HEENT: Denies trouble swallowing, denies blurred vision, denies sore throat, denies post nasal drip, denies recent URI.
  • Respiratory: Denies shortness of breath, denies cough, denies wheezing.
  • Cardiovascular: Denies palpitations, denies chest pain, denies lower extremity edema.
  • Gastrointestinal: Reports mild, lower abdominal discomfort, denies nausea, denies emesis, denies constipation, denies diarrhea, denies appetite changes.
  • Genitourinary: Reports pain in perianal area 9/10, worsening over the past two days, reports mild burning with urination and sensation of incomplete bladder emptying. Denies hematuria. Denies any new sexual partners, denies any recent trauma. Denies penile discharge.
  • Derm: Denies any rashes, lesions, or skin changes.
  • Neurological: Denies headaches, tremors, dizziness, or weakness.
  • Psych: Denies any confusion, denies changes in mentation.

Physical Exam

Vital Signs

  • Temperature: 101.3°F
  • Heart rate: 92 bpm
  • Blood pressure: 128/75 mm Hg
  • Respiratory rate: 18 bpm

General Survey

  • Abdominal examination: No palpable masses. Mild suprapubic tenderness without rebound or guarding. No CVA tenderness.
  • Genitourinary examination:
    • Rectal examination: Very gentle DRE performed. The prostate is tender, uniformly swollen. It is boggy, and the patient experiences significant pain during palpation. There is no indication of rectal bleeding or abnormal discharge.
    • No inguinal lymphadenopathy noted.
  • Other systems: No significant findings on the respiratory, cardiovascular, or neurological systems.

Diagnostic Testing Ordered

  1. Urinalysis (UA) with Microscopy, Urine dip positive for WBCs, +1 blood, leukocyte esterase, and nitrites
  2. Urine Culture and Sensitivity to identify causative organism
  3. Complete Blood Count to assess for systemic infection and inflammation (leukocytosis and neutrophilia).
  4. Blood cultures x2 to assess for bacteremia due to fever and chills.
  5. Basic Metabolic Panel (BMP) to assess renal function.
  6. Nucleic acid amplification tests for Gonorrhea and Chlamydia from first catch urine is offered to the patient but he declines.
  7. Transrectal ultrasound if not improved after 48-72 hours of antibiotics.

Pathophysiology of the Disorder

Fill in the blanks with the correct term: enterobacterales, E. Coli, Staphylococcus, bladder, lymphatic, biopsy, cholecystectomy

The prostate can be subject to inflammatory disorders. Acute bacterial prostatitis is an acute infection of the prostate gland, most commonly by gram-negative organisms. The most common being _____________________, which includes Escherichia coli, Proteus spp and Klebsiella pneumonia, and Pseudomonas species. In over 50% of cases, the causative organism is _____________________(“Prostatitis Treatment & Management: Approach Considerations, Acute Bacterial Prostatitis, Chronic Bacterial Prostatitis and Pelvic Pain,” 2023).

The entry of these organisms to the prostate gland can occur from three different routes. Most often, bacteria travel from the urethra or _____________________ through the prostatic ducts with the intraprostatic reflux of urine. Another route would be direct manipulation of the prostate from a transrectal prostate _____________________ or transurethral manipulation, such as a catheterization or cystoscopy procedure. Finally, _____________________ and hematogenous spread is possible but less frequent (UpToDate, 2025).

Pharmacology Plan

Treatment of acute prostatitis will depend on the clinical picture of the patient. Treatment can range from hospitalization of intravenous antibiotic therapy to outpatient management dependent on clinical presentation.

Indications for hospitalization include: sepsis, inability to tolerate oral medication, and history of resistant urinary tract infection for a pathogen in which oral antibiotics are not an option.

For treatment of outpatients, a fluoroquinolone or trimethoprim-sulfamethoxazole dependent on local resistance is recommended. Two options would be: Ciprofloxacin 500 mg orally twice daily or Trimethoprim-sulfamethoxazole (TMP-SMX) DS 1 tablet orally twice daily.

If a sexually transmitted infection is suspected based on sexual history or presence of discharge, the chosen antibiotic regimen also needs to cover N. gonorrhoeae and C. trachomatis.

Treatment duration is uncertain. It is generally recommended to treat for two weeks and extend to four weeks if symptoms are not fully resolved after two weeks (UpToDate, 2025).

Patient Education

  • Fever should resolve within two to six days of antibiotic treatment.
  • Monitoring for worsening fever, chills, lethargy, lightheadedness, nausea, vomiting, hematuria. These symptoms warrant further follow-up and evaluation.
  • Urgent consultation with a urologist is recommended if urinary retention develops.

Review Questions

Click the arrow to expand the section and view the correct answers.

  1. Which of the following is NOT a typical symptom of acute prostatitis?
    1. Fever
    2. Perineal pain
    3. Abdominal bloating
    4. Dysuria
Answer:

C. Abdominal bloating. Acute prostatitis typically presents with fever, perineal pain, and urinary symptoms. Abdominal bloating is not characteristic and suggests a gastrointestinal rather than genitourinary etiology.

  1. Which of the following is a potential complication of severe acute prostatitis if not treated promptly?
    1. Chronic prostatitis
    2. Prostate cancer
    3. Sepsis
    4. Urethral stricture
Answer:

C. Sepsis. Untreated acute prostatitis can lead to bacteremia and sepsis due to infection with virulent gram-negative organisms and the prostate’s rich vascular supply.

  1. Which of the following imaging studies is most commonly used in the diagnosis of acute prostatitis if abscess formation is suspected?
    1. X-ray of the abdomen
    2. Transrectal ultrasound
    3. MRI of the pelvis
    4. Abdominal CT scan
Answer:

B. Transrectal ultrasound. Transrectal ultrasound is the most commonly used imaging study when a prostatic abscess is suspected, particularly in patients who do not respond to antibiotics.

  1. True or False: The diagnosis of acute prostatitis can be made clinically.
Answer:

True. Acute prostatitis is primarily a clinical diagnosis based on symptoms and physical exam findings; laboratory studies support but are not required for diagnosis.

  1. During a Digital Rectal Examination (DRE) of a patient with suspected acute bacterial prostatitis, which of the following findings would most likely be present?
    1. A soft, smooth, non-tender prostate.
    2. A boggy, tender, swollen prostate.
    3. A hard, nodular prostate.
    4. A prostate with normal size and consistency.
Answer:

B. A boggy, tender, swollen prostate. A boggy, tender prostate on gentle DRE is characteristic of acute bacterial prostatitis and reflects acute inflammation.

  1. Which organism is most commonly associated with acute bacterial prostatitis?
    1. Staphylococcus aureus
    2. Escherichia coli
    3. Pseudomonas aeruginosa
    4. Klebsiella pneumoniae
Answer:

B. Escherichia coli. E. coli is the most common causative organism due to ascending infection from the urinary tract.

  1. First-line empirical antibiotics for acute bacterial prostatitis typically include:
    1. Amoxicillin-clavulanate
    2. Trimethoprim-sulfamethoxazole or fluoroquinolones
    3. Nitrofurantoin
    4. Metronidazole
Answer:

B. Trimethoprim-sulfamethoxazole or fluoroquinolones. These antibiotics are first-line because they have reliable activity against common pathogens and achieve adequate prostatic tissue penetration.

  1. How long is the typical duration of antibiotic therapy in acute bacterial prostatitis?
    1. 3–5 days
    2. 7 days
    3. 14–28 days
    4. 6 months
Answer:

C. 14–28 days. Prolonged antibiotic therapy is required to fully eradicate infection from prostatic tissue and prevent chronic prostatitis.

  1. Which of the following is the most common route of infection in acute bacterial prostatitis?
    1. Hematogenous spread
    2. Lymphatic spread
    3. Ascending urethral infection
    4. Direct extension from the rectum
Answer:

C. Ascending urethral infection. The most common route of infection is ascending spread from the urethra or bladder via intraprostatic reflux.

  1. Why are fluoroquinolones effective in treating prostatitis?
    1. They inhibit beta-lactamase enzymes.
    2. They have good penetration into prostatic tissue.
    3. They are bacteriostatic agents.
    4. They neutralize prostate secretions.
Answer:

B. They have good penetration into prostatic tissue. Fluoroquinolones are effective because they achieve high concentrations within prostatic tissue, making them well-suited for treatment.

References

Microsoft. (2024). Copilot [AI assistant]. Microsoft Corporation.

Prostatitis Treatment & Management: Approach Considerations, Acute Bacterial Prostatitis, Chronic Bacterial Prostatitis and Pelvic Pain. (2023). EMedicine. https://emedicine.medscape.com/article/785418-treatment?form=fpf

UpToDate. (2025). Uptodate.com. https://www.uptodate.com/contents/acute-bacterial-prostatitis

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Be Prepared for Your Nurse Practitioner Clinical Readiness Exam Copyright © 2026 by Elizabeth Heavey, Renee Biedlingmaier, Colleen Burgoyne and Carnel C. Jackson is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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