What are the diagnosis and next steps for a 60-year-old male with a history of hyperlipidemia and varicose veins, presenting with dysuria and incomplete voiding, who has been taking Ciprofloxacin (ciprofloxacin) 500mg every 12 hours and Celecoxib (celecoxib) 200mg twice a day, with urinalysis showing positive nitrite, elevated red blood cell count, and many bacteria, and imaging showing an enlarged prostate gland with calcifications and a hard, non-tender structure near the scrotum?

Diagnosis and Management of 60-Year-Old Male with Dysuria, Incomplete Voiding, and Enlarged Prostate

Primary Diagnosis

This patient has complicated urinary tract infection (UTI) with benign prostatic hyperplasia (BPH) and requires immediate antibiotic adjustment, urological evaluation for the scrotal mass, and consideration of alpha-blocker therapy for obstructive symptoms. 1, 2

Critical Diagnostic Considerations

Confirmed Diagnoses

• Bacterial UTI with incomplete treatment response: Positive nitrite, elevated RBC (90/uL), and many bacteria on urinalysis confirm active infection despite 3 days of ciprofloxacin 3
• Benign prostatic hyperplasia with obstruction: Enlarged prostate with calcifications and 16% residual urine volume indicates significant BPH with incomplete bladder emptying 3
• Undiagnosed scrotal mass: Hard, non-tender structure near scrotum requires urgent evaluation to exclude testicular malignancy, epididymal pathology, or inguinal hernia 3

Red Flags Present

• Persistent dysuria despite 3 days of appropriate antibiotic therapy suggests either resistant organism, inadequate treatment duration, or prostatic involvement 1, 2
• Hematuria (RBC 90/uL) in setting of UTI and prostatic calcifications warrants PSA testing and consideration of prostate cancer 3
• Hard scrotal mass requires immediate ultrasound evaluation regardless of tenderness 3

Immediate Management Steps

1. Antibiotic Management - Critical Adjustment Needed

Continue ciprofloxacin 500mg every 12 hours but extend duration to complete 14 days total (not just the initial prescription), as male UTIs are classified as complicated infections requiring longer treatment, especially when prostatitis cannot be excluded. 1, 2, 4

Rationale for continuing ciprofloxacin:

• Already started and showing partial response (lessened dysuria) 1
• Excellent prostatic penetration for potential prostatic involvement 5
• Evidence shows 7-day courses are inferior to 14-day courses in men (86% vs 98% cure rate) 1, 2

If no improvement within 48-72 hours, obtain urine culture and switch to:

• Trimethoprim-sulfamethoxazole 160/800mg twice daily for 14 days (if local resistance <20%) 1, 4
• OR cefpodoxime 200mg twice daily for 14 days if TMP-SMX contraindicated 1, 4

2. Discontinue Celecoxib Immediately

Stop celecoxib 200mg BID now - this medication is contraindicated in this patient for multiple reasons:

• Significant nephrotoxicity risk with pre-existing renal cysts 6, 7
• Can cause acute renal failure even in patients with normal baseline function 6, 7
• Increased risk of peripheral edema and hypertension, particularly problematic with his hyperlipidemia 8
• Not indicated for BPH-related pain; dysuria is from infection, not inflammation 3

Alternative for pain management if needed:

• Acetaminophen 650-1000mg every 6 hours as needed (safer renal profile) 6

3. Urgent Diagnostic Workup Required

Within 48 hours:

• Scrotal/testicular ultrasound: Hard scrotal mass must be evaluated urgently to exclude testicular cancer, which presents as painless hard mass 3
• Prostate-specific antigen (PSA): Hematuria, prostatic calcifications, and age >60 warrant PSA testing 3
• Post-void residual (PVR) measurement: 16% residual suggests significant obstruction; formal PVR measurement needed 3
• Urine culture with sensitivities: Should have been obtained before starting antibiotics; obtain now if symptoms not improving 1, 2, 4

Within 1-2 weeks:

• Digital rectal examination (DRE): Evaluate prostate size, consistency, nodularity, and tenderness to assess for prostatitis or malignancy 3, 2, 4
• Renal function panel: Assess creatinine given renal cysts and recent celecoxib exposure 3, 6

4. Initiate BPH-Specific Therapy

Start alpha-blocker therapy immediately to address obstructive symptoms:

• Tamsulosin 0.4mg once daily (preferred due to uroselective profile and once-daily dosing) 3
• OR Alfuzosin 10mg once daily (alternative with similar efficacy) 3

Expected timeline:

• Symptom improvement within 2-4 weeks 3
• Reassess at 4 weeks; if inadequate response, consider adding 5-alpha reductase inhibitor (finasteride 5mg daily) for long-term prostate volume reduction 3

Follow-Up Algorithm

Week 1-2 (During Antibiotic Treatment)

• Monitor for symptom resolution: dysuria should improve within 48-72 hours 1, 2
• If worsening fever, chills, or systemic symptoms develop → hospitalize for IV antibiotics (ceftriaxone 1-2g daily) 2, 4
• Complete scrotal ultrasound and PSA testing 3

Week 2-4 (Post-Antibiotic Completion)

• Repeat urinalysis 1-2 weeks after completing antibiotics to confirm microbiologic cure 4
• Assess alpha-blocker response: improvement in incomplete voiding and urinary stream 3
• Review scrotal ultrasound and PSA results; refer to urology if abnormal 3

Month 1-3

• Mandatory urology referral for: 3
  • Scrotal mass evaluation and management
  • Persistent obstructive symptoms despite alpha-blocker
  • Elevated PSA or abnormal DRE
  • Recurrent UTIs (≥2 episodes in 6 months)
  • Consideration of surgical intervention if medical management fails

Long-Term Management

• Annual DRE and symptom assessment with AUA Symptom Index 3
• Monitor for acute urinary retention risk (higher with enlarged prostate and elevated PSA) 3
• Renal ultrasound every 2 years to monitor cysts 3

Critical Pitfalls to Avoid

Do not:

• Treat for <14 days: Male UTIs require full 14-day course when prostatitis cannot be excluded; shorter courses have 12% higher failure rate 1, 2
• Continue celecoxib: Serious nephrotoxicity risk outweighs any theoretical benefit 6, 7
• Delay scrotal mass evaluation: Hard masses require urgent imaging regardless of symptoms 3
• Ignore incomplete voiding: 16% residual urine indicates significant obstruction requiring treatment 3
• Use amoxicillin or ampicillin empirically: High worldwide E. coli resistance rates make these ineffective 4
• Assume asymptomatic bacteriuria: This patient has symptomatic infection requiring treatment 2

Common error: Attributing all symptoms to BPH and missing concurrent UTI or malignancy. This patient has multiple pathologies requiring simultaneous management. 3, 1

Medication Reconciliation

Continue:

• Atorvastatin (no interaction with antibiotics or alpha-blockers) 3
• Daflon/Diosmin (no contraindications) 3

Adjust:

• Ciprofloxacin 500mg Q12: Continue to complete 14 days total 1, 2

Discontinue:

• Celecoxib 200mg BID: Stop immediately due to nephrotoxicity risk 6, 7

Add:

• Tamsulosin 0.4mg once daily for BPH symptoms 3
• Acetaminophen 650mg Q6H PRN for pain (if needed) 6