A male patient with dysuria, dribbling pain localized to the testicles and pelvis, and chills and fever for four days—what is the most likely diagnosis?

Diagnosis: Acute Bacterial Prostatitis

This 50-year-old male presenting with dysuria, post-void dribbling, testicular and pelvic pain, along with chills and fever for four days most likely has acute bacterial prostatitis. 1

Clinical Reasoning

The constellation of symptoms points away from isolated epididymo-orchitis and toward prostatic involvement:

• Dysuria combined with pelvic pain suggests urethral/bladder pathology with prostatic extension, which is characteristic of bacterial prostatitis rather than isolated epididymal infection 1
• Post-void dribbling indicates bladder outflow obstruction or prostatic inflammation affecting urinary flow—a hallmark of prostatitis that would not occur with simple epididymitis 2
• Systemic symptoms (chills and fever for 4 days) indicate significant bacterial infection with systemic involvement 1
• Testicular/pelvic pain distribution reflects referred pain from prostatic inflammation rather than primary testicular pathology 1

Key Differentiating Features from Epididymo-Orchitis

While epididymo-orchitis remains in the differential, several features make it less likely as the primary diagnosis:

• Epididymo-orchitis typically presents with gradual onset of scrotal pain and swelling with a palpably enlarged, tender epididymis starting at the lower pole 2, 3
• The absence of described scrotal swelling in this patient argues against primary epididymal pathology 4, 2
• Post-void dribbling is not a feature of epididymitis but rather suggests prostatic involvement with bladder outflow issues 2
• In men over 35 years, coliform bacteria (especially E. coli) are the predominant pathogens for both prostatitis and epididymitis, typically ascending from urinary tract sources 3, 5

Immediate Diagnostic Workup

Confirm the diagnosis with targeted testing:

• Digital rectal examination to assess for prostatic tenderness, warmth, and boggy consistency characteristic of acute prostatitis 2
• Urinalysis and urine culture to identify pyuria, bacteriuria, and the causative organism (most commonly E. coli in this age group) 1, 3
• Avoid vigorous prostatic massage during acute infection as it can precipitate bacteremia 1
• Scrotal ultrasound with Doppler only if significant scrotal symptoms develop to exclude concurrent epididymitis or abscess formation 1, 6

Empiric Antibiotic Therapy

Start treatment immediately while awaiting culture results:

• Fluoroquinolones are first-line for acute bacterial prostatitis in men over 35: Levofloxacin 500 mg orally daily or ofloxacin 200 mg orally twice daily 1, 3
• Alternative if fluoroquinolone resistance suspected: Third-generation cephalosporin plus aminoglycoside for severe cases 1
• Treatment duration: Minimum 2-4 weeks for acute bacterial prostatitis (longer than the 7-10 days used for simple epididymitis) 1, 3
• Adjust antibiotics based on culture sensitivities once available 1

Supportive Management

• Analgesics and anti-inflammatory medications for pain control 1, 3
• Adequate hydration to maintain urine flow 3
• Alpha-blockers may be considered if significant voiding symptoms persist, though evidence is limited in acute settings 1

Critical Pitfalls to Avoid

• Do not dismiss this as simple UTI—the combination of systemic symptoms, pelvic pain, and voiding dysfunction requires prostatic-penetrating antibiotics for adequate duration 1
• If the patient appears septic or has severe systemic symptoms, hospitalize for IV antibiotics (fluoroquinolone or third-generation cephalosporin) and close monitoring 1
• Failure to improve within 48-72 hours warrants imaging (CT or MRI) to exclude prostatic abscess, which would require drainage 1
• In patients with indwelling catheters or recent urologic procedures, consider broader coverage including third-generation cephalosporin due to higher risk of resistant organisms 7

Follow-Up Considerations

• Reassess at 48-72 hours to confirm clinical improvement (defervescence, reduced pain, improved voiding) 4
• If symptoms persist beyond 3 months, reclassify as chronic prostatitis/chronic pelvic pain syndrome requiring different management approach 1
• Evaluate for underlying structural abnormalities (BPH, bladder outlet obstruction) once acute infection resolves, as these predispose to recurrent infections 2