Differential Diagnosis

• Single most likely diagnosis
  • Infection of the prostate: The patient's symptoms of urinary hesitancy and frequency, along with the presence of many leukocytes and gram-negative rods in the urine, are consistent with a diagnosis of prostatitis, which is an infection of the prostate gland. The rectal examination finding of an enlarged, rubbery, and nontender prostate further supports this diagnosis.
• Other Likely diagnoses
  • Outflow obstruction of the bladder: The patient's symptoms of urinary hesitancy and frequency could also be due to an outflow obstruction of the bladder, which is often caused by benign prostatic hyperplasia (BPH) in older men. However, the presence of leukocytes and gram-negative rods in the urine suggests an infectious component.
  • Infection of the urethra: While the patient does not have urethral discharge, it is possible that he has a urethral infection, especially given the presence of gram-negative rods in the urine. However, the rectal examination findings and the patient's symptoms are more suggestive of prostatitis.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Neurogenic bladder: Although less likely, a neurogenic bladder could cause urinary hesitancy and frequency. This condition is often associated with neurological disorders, such as spinal cord injuries or multiple sclerosis, and can lead to serious complications, such as urinary retention and kidney damage, if left untreated.
• Rare diagnoses
  • Infection of the epididymis: Epididymitis is an infection of the epididymis, which is a rare cause of urinary symptoms in older men. The patient's testicular examination shows no abnormalities, making this diagnosis less likely.
  • Other rare causes of urinary symptoms, such as bladder cancer or stones, could also be considered, but are less likely given the patient's presentation and laboratory findings.