Differential Diagnosis
- Single most likely diagnosis
- Chlamydia urethritis: This is considered the most likely diagnosis due to the patient's symptoms of dysuria, urgency, and whitish urethral discharge, despite denying any recent sexual intercourse. Chlamydia can have a prolonged incubation period, and the patient's past history of sexually transmitted infections (STIs) increases the likelihood.
- Other Likely diagnoses
- Trichomonas urethritis: Given the patient's past history of Trichomonas urethritis, it is possible that the patient has been re-infected, especially if the patient's sexual partners were not treated.
- Gonococcal urethritis: Although the patient denies recent sexual intercourse, gonococcal urethritis is still a possibility, especially if the patient has had unprotected sex in the past.
- Prostatitis: The patient's symptoms of dysuria, urgency, and occasional bilateral flank pain, along with the finding of a heterogeneous prostate on TRUS, suggest that prostatitis could be a contributing factor to the patient's symptoms.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Tuberculosis (TB) of the urinary tract: Although rare, TB of the urinary tract can present with similar symptoms, including dysuria, urgency, and flank pain. It is essential to consider this diagnosis, especially if the patient has a history of exposure to TB or has traveled to areas where TB is endemic.
- Urinary tract cancer: Although unlikely in a 36-year-old male, urinary tract cancer can present with similar symptoms, including dysuria, urgency, and flank pain. It is essential to consider this diagnosis, especially if the patient has a family history of cancer or has been exposed to carcinogens.
- Rare diagnoses
- Urethral stricture: Although the patient had a normal cystoscopy 4 months ago, it is possible that a new stricture has formed, causing the patient's symptoms.
- Interstitial cystitis: This condition can cause similar symptoms, including dysuria, urgency, and flank pain, although it is relatively rare in males.
- Schistosomiasis: This parasitic infection can cause urinary tract symptoms, including dysuria, urgency, and flank pain, although it is rare in the United States.