A 60-year-old man comes to the emergency department due to fever, burning on urination, generalized body aches, and lower abdominal discomfort.  The dysuria began 3 days ago, and the remainder of the symptoms developed within the last 24 hours.  The patient also has been unable to urinate for the past 18 hours.  He has a history of hypertension, hyperlipidemia, coronary artery disease, and benign prostatic hyperplasia.  Medications include aspirin, metoprolol, atorvastatin, lisinopril, and tamsulosin.  He is not sexually active.  The patient does not use tobacco, alcohol, or illicit drugs and has no medication allergies.  Temperature is 38.3 C (100.9 F), blood pressure is 130/75 mm Hg, pulse is 105/min, and respirations are 16/min.  Abdominal examination reveals mild lower abdominal tenderness with no costovertebral angle tenderness.  The urinary bladder is palpable in the hypogastric area.  Rectal examination reveals a swollen, tender, and enlarged prostate with no palpable nodules.  The genitals are normal in appearance and nontender to palpation.  Laboratory testing shows a leukocyte count of 12,500/mm³ with 85% neutrophils and an elevated serum creatinine at 1.3 mg/dL (last known value: 0.9 mg/dL).  Microscopic urinalysis results are as follows:

Which of the following is the best next step in management of this patient?

A 20-year-old man comes to the office due to penile lesions, which began several months ago.  The lesions have not enlarged, and the patient has had no fever, pain, discomfort, dysuria, or urethral discharge.  He says, “These spots appeared after I had unprotected sex with a woman I met at a party.  I am worried that I may have a sexually transmitted disease.”  The patient has not had sexual intercourse since then but masturbates regularly.  He has no medical problems, takes no medications, and does not use tobacco, alcohol, or illicit drugs.  The patient is a college student and works part time as a restaurant server.  Vital signs are within normal limits.  No lymphadenopathy or other skin rashes are present.  External genitalia examination findings are shown below.

Which of the following is the most appropriate next step in management of this patient’s current condition?

A 46-year-old man comes to the office due to dysuria and a dull, aching pain in the penis and perineal region.  The symptoms began 6 months ago and prompted the patient to visit an urgent care center twice.  Both times, he received a short course of antibiotics, which improved symptoms temporarily, but they returned within days.  The patient has also had pain during ejaculation but no urethral discharge, back pain, abdominal pain, weakness, or incomplete voiding.  He is married and monogamous with his wife and has 2 children.  He does not use tobacco or illicit drugs but occasionally drinks 1 or 2 beers on weekends.  He has no medication allergies and no family history of cancer.  Temperature is 37.1 C (98.8 F), blood pressure is 126/84 mm Hg, pulse is 72/min, and respirations are 14/min.  Physical examination shows no abdominal or costovertebral angle tenderness.  Digital rectal examination reveals a mildly tender prostate that is symmetric and not enlarged.  The external genitalia are normal in size and appearance and are nontender to palpation.

Item 1 of 3

Which of the following is the best next step in the diagnosis of this condition?

Item 2 of 3

Urine microscopy after prostate massage reveals 30 leukocytes/hpf, and subsequent culture is negative.  What is the most likely diagnosis?

Item 3 of 3

The most likely diagnosis is discussed with the patient, and he asks what can be done to relieve his symptoms.  Which of the following is the most appropriate response to this patient?