Diagnosis: Chronic Bacterial Prostatitis or Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)
This patient most likely has chronic bacterial prostatitis or CP/CPPS, given the constellation of right groin pain radiating to lower abdomen, penile tip to anus pain, urinary burning, nocturia, and fever—despite a negative urinalysis. 1
Clinical Reasoning
The symptom pattern is highly characteristic of prostatitis:
Pain distribution: The American Urological Association identifies that CP/CPPS characteristically causes pain at the tip of the penis, perineum, suprapubic region, or testicles, with pain often exacerbated by urination 1, 2. This patient's pain from penile tip to anus with groin and lower abdominal radiation fits this classic distribution perfectly.
Urinary symptoms: Burning with urination and nocturia are core features of both chronic bacterial prostatitis and CP/CPPS 1, 2. The American Urological Association notes that nocturia and urinary urgency are common symptoms of CP/CPPS 1.
Fever with negative urinalysis: This is a critical diagnostic clue. The presence of fever (38.1°C) suggests bacterial prostatitis, yet the negative urinalysis does not rule out prostatitis because midstream urine may not capture prostatic infection 3. The European Association of Urology recommends taking midstream urine culture in patients with acute bacterial prostatitis symptoms to guide diagnosis, but acknowledges that accurate microbiological evaluation for atypical pathogens such as Chlamydia trachomatis and Mycoplasma species is crucial in chronic bacterial prostatitis 3.
Duration: The one-month history suggests chronic rather than acute bacterial prostatitis, though the fever indicates possible acute exacerbation 1, 2.
Critical Diagnostic Steps Required
Do NOT perform prostatic massage in this patient if acute bacterial prostatitis is suspected, as this risks bacteremia 3, 1.
The diagnostic workup should include:
Blood cultures and complete blood count given the fever, as recommended by the European Association of Urology for patients presenting with acute bacterial prostatitis 3
Midstream urine culture (not just urinalysis) to guide antibiotic treatment 3
Testing for atypical pathogens: The European Association of Urology suggests performing accurate microbiological evaluation for Chlamydia trachomatis and Mycoplasma species in patients with chronic bacterial prostatitis 3. This can be done via nucleic acid amplification test on first-void urine 1.
Meares and Stamey 2- or 4-glass test if chronic bacterial prostatitis is confirmed after acute phase resolves 3
Alternative Diagnoses to Exclude
While prostatitis is most likely, two life-threatening conditions must be urgently excluded:
Fournier's Gangrene: The World Society of Emergency Surgery guidelines describe this as necrotizing fasciitis with perineal/genital pain that can radiate to the abdomen, fever, and systemic features 3. However, this patient lacks the hallmark findings of intense pain disproportionate to examination findings, purulent discharge, crepitus, or visible necrotic tissue 3. Physical examination must carefully inspect the perineum for any signs of skin changes, crepitus, or necrosis 3.
Appendicitis: The ACR Appropriateness Criteria note that right lower quadrant pain with fever could represent appendicitis 3. However, the penile tip to anus pain distribution, urinary symptoms, and month-long duration make this unlikely. The absence of nausea/vomiting further argues against appendicitis 3.
Immediate Management
Empiric antibiotic therapy should be initiated immediately given the fever and clinical presentation:
The European Association of Urology suggests fluoroquinolones (levofloxacin or ciprofloxacin) for a minimum of 4 weeks as first-line therapy for chronic bacterial prostatitis 3
Consider parenteral therapy if severe infection is present, given the fever 3
If sexually transmitted infection is suspected (age <35 years, sexual history), consider adding coverage for Chlamydia and Gonorrhea with ceftriaxone 1000 mg IM/IV plus doxycycline 3, 1
Common Pitfalls
Don't dismiss the diagnosis because urinalysis is negative: Prostatic infections may not show in midstream urine 3, 1
Don't perform prostatic massage acutely: This is contraindicated in acute bacterial prostatitis due to bacteremia risk 3, 1
Don't overlook IC/BPS overlap: The American Urological Association notes that CP/CPPS and interstitial cystitis/bladder pain syndrome have overlapping presentations, and some patients meet criteria for both conditions 1, 2. If symptoms persist despite antibiotic therapy, consider this overlap.
Address the hypertension: BP 173/80 requires management, though this may be pain-related 1