Having tough time with a Dx and proper TX for patient (uro. clinical)

[neurolorurodoc]

Hello bright minds, I am a med student on my uro clinical and had this difficult Dx, any ideas?

Hx:
30/m complaining of progressive urethral pain, no other major health problems, pain started 4 years ago as sporadic pain and progressed over time into constant “extremely painful” burning pain. 14 visits to clinic for same reason with no relief. Complains new joint pain in knees with burning throbbing pain their as well, itching and burning in penis, around penis, around anus, and newly attributed neurological pain in his fingers and hands. Patient claims pain started after unprotected sex with female 4 years ago and insists symptoms resemble or mimic exact symptoms of late stage syphilis.

Tx/Dx thusfar:
- for STDs, - for 2 cystoscopies, - for Hep A, B, C, HIV, urine test normal xray for kidney stones negative..
- Treatment included rocephin shot, deoxy antib, cipro antib, given different times to eliminate variables (no + results, pain progressed).

Dx of attending thusfar
Chronic pros. as hunch, but really just out of process of elimination. Attending asked me for other Dx, causes of symptoms, and ideas for treatment.
All I can think of for causes Trauma to the urinary tract; PID, STDs, Chronic/acute bac or non bac prost., cancer, autoimmune disorders?
And for Tx:
I don’t know, seems like patient tried every antib with no positive change. Should I recommend trial of penicillin since every other STI seemed to be treated eventhough no + result shown? Other tests I really don’t know. Patient seems in extreme pain and to be honest I don’t think the Attending really knows what the exact Dx is and what the exact Tx should go from here.
Any ideas?

---

Members don't see this ad.

 

[mdfirst]

im not doc or anything, but it just sounds like an STD or infection to me.

 

[neurolorurodoc]

im not doc or anything, but it just sounds like an STD or infection to me.

I totally thought the same thing. But patient got tested for all STDs 2 times with a 2 month absence from sex to solidify the results. So what STD goes undetected and causes this type of symptoms? Also no rashes, sores, any skin abnormality present on penis or surrounding skin... Attending seemed to rule STDs out and focused on Chronic Prost. but even patient is convinced the symptoms are something else and has something transmitted from sex and has some type of STI, it is an interesting case.

 

[Trinity12]

Patients like that guy can be tough and frustrating to deal with. One of the good things about uro is that you usually know what's going on (not trying to solve a medical mystery), but chronic urethral pain and orchitis can be trying. Maybe look into something like Sjogren's and some sort of autoimmune d/o? Or consider a psych consult (I'm half joking with that)... could be conversion d/o due to some weird guilt over that sexual encounter.

 

[neurolorurodoc]

Patients like that guy can be tough and frustrating to deal with. One of the good things about uro is that you usually know what's going on (not trying to solve a medical mystery), but chronic urethral pain and orchitis can be trying. Maybe look into something like Sjogren's and some sort of autoimmune d/o? Or consider a psych consult (I'm half joking with that)... could be conversion d/o due to some weird guilt over that sexual encounter.

Interested about Sjogren's , thought of it and mentioned it, attending said Sjogren's is seen in women 90% of the time and Sjogren's still doesnt explain 70% of the Sx and Hx of patient. This is a fustrating case and honestly I never knew Urology can be so complex and not be able to provide answers after so many years and visits.

 

[Dimoak]

Reiter's Syndrome via chlamydia?

 

[neurolorurodoc]

Reiter's Syndrome via chlamydia?

But how is this even an option when the patient never had Hx of STDs?

 

[Dimoak]

But how is this even an option when the patient never had Hx of STDs?

I read the -for STDs in your post as a bullet, instead of as negative. AFAIK, that was the only dx not mentioned earlier in this thread that could cause symptoms similar to those described. Perhaps a psych consult really is in order?

 

[neurolorurodoc]

I read the -for STDs in your post as a bullet, instead of as negative. AFAIK, that was the only dx not mentioned earlier in this thread that could cause symptoms similar to those described. Perhaps a psych consult really is in order?

Actually a psych consult was in the order which made me wonder, can a pysch problem such as depression or anxiety manifest itself in such real localized and very specific pain? Patient shows no symptoms or Hx of anxiety, depression or other pysch health issues.

 

[umean2tellme]

Patient could be lying about not having STD's.

 

[pincheeric]

Could be something like a mycobacterial chronic prostatitis. The fact, though, that he has genital pain, anal pain, and hand pain points to something more system than a simple STD. Could be somatization, factitious, or malingering. Could think of a zebra like multiple sclerosis or lupus.

Don't just throw PCN at it, it's a waste.

Nice try with the PID. That's a creative answer for a man!

 

[neurolorurodoc]

Could be something like a mycobacterial chronic prostatitis. The fact, though, that he has genital pain, anal pain, and hand pain points to something more system than a simple STD. Could be somatization, factitious, or malingering. Could think of a zebra like multiple sclerosis or lupus.

Don't just throw PCN at it, it's a waste.

Nice try with the PID. That's a creative answer for a man!

Nice angle, yes males do get PID too, not as common as females but they do. To the person above this post, how can he lie about having STDs when we tested him in our clinic. Tests dont lie.