Skip to content

Urinary Tract Infection (UTI) in Males

BASICS

DESCRIPTION

CystitisĀ is an infection of theĀ lower urinary tract, usually due toĀ gram-negative enteric bacteriaĀ (see alsoĀ Prostatitis, Pyelonephritis, Urethritis). In healthy males agedĀ 15ā€“50 years, UTI isĀ uncommon and considered uncomplicated. InĀ newborns, infants, and elderly men, UTIs areĀ complicated, often associated withĀ functional or structural abnormalities.

System(s):Ā Genitourinary

Synonym(s):Ā UTI, cystitis

EPIDEMIOLOGY

  • Incidence:
    • Uncommon in men <50 years
    • 6ā€“8 infections per 10,000 men aged 21ā€“50
  • Prevalence:
    • Lifetime prevalence ~14%

ETIOLOGY AND PATHOPHYSIOLOGY

Common Pathogens:

  • Escherichia coliĀ (majority)
  • Klebsiella spp.
  • Enterobacter
  • Enterococcus
  • Proteus
  • Citrobacter, Providencia
  • Streptococcus faecalis, Staphylococcus spp.
  • Pseudomonas, MorganellaĀ (elderly/catheterized patients)

Pathogenesis:

  • Ascending infection or viaĀ bladder instrumentation

Genetics:Ā Not applicable

RISK FACTORS

  • Age, Obesity, Prior UTI
  • BPHĀ (33% incidence in UTI cases)
  • Urethral stricture, Calculi
  • Fecal/urinary incontinence
  • Recent urologic surgery
  • Catheterization/instrumentation
  • Prostate/kidney infections
  • Immunocompromised, Diabetes
  • Bladder diverticula, Neurogenic bladder
  • Cognitive impairment, Institutionalization
  • Uncircumcised males
  • Anal intercourse or infected female partner

GENERAL PREVENTION

  • Prompt treatment of predisposing conditions
  • Limit catheter use; if necessary, useĀ aseptic techniqueĀ and remove early
  • Cranberry products not recommended

COMMONLY ASSOCIATED CONDITIONS

  • Acute/chronic pyelonephritis
  • Urethritis, Prostatitis
  • Prostatic hypertrophy, Prostate cancer

Geriatric Considerations:

  • ASB (asymptomatic bacteriuria)Ā common in elderly; 5ā€“10% in men >65
  • Do not treat ASB

Pediatric Considerations:

  • Often due to obstruction; special criteria for evaluation

DIAGNOSIS

HISTORY

  • Dysuria, urgency, frequency, hesitancy, nocturia
  • Dribbling, slow stream
  • Suprapubic/perineal pain, low back pain
  • Fever, chillsĀ (suggests pyelonephritis/prostatitis)
  • Hematuria, constipation

PHYSICAL EXAM

  • Suprapubic tenderness, CVA tenderness
  • Digital rectal exam: check forĀ prostate tenderness

DIFFERENTIAL DIAGNOSIS

  • Urethritis, STIs, epididymitis, prostatitis

  • 90% of febrile male UTIs haveĀ prostate involvement

DIAGNOSTIC TESTS

Urinalysis:

  • Pyuria (>10 WBCs),Ā Bacteriuria
  • Leukocyte esterase: sensitivity 78%, PPV 71%, NPV 67%
  • Nitrite: sensitivity 47%, specific for gram-negative rods

Culture:

  • >10āµ CFU/mLĀ for positive result
  • >10Ā³ CFU/mLĀ may be significant if pyuria present
  • Infants/children <24 months: ā‰„50,000 CFU + pyuria

Other Investigations:

  • STI testing (NAAT)Ā if dysuria or STI risk
  • Further evaluation inĀ recurrent/febrile UTIs:
    • Ultrasound, Cystoscopy, Urodynamics, IVP

Blood culturesĀ only if suspectĀ sepsis

TREATMENT

Catheter Management

  • Avoid prolonged catheterization
  • Intermittent catheterization preferred
  • Exchange Foley if infection suspected

General Measures

  • Hydration,Ā Analgesia
  • Prevent constipationĀ (psyllium, wheat germ)

Antibiotics

First Line

  • Uncomplicated UTI:Ā Empirical for 5ā€“7 days
    • ConsiderĀ local resistance,Ā nitrite positivity,Ā culture & sensitivity
    • Avoid Fosfomycin/nitrofurantoin in prostatitis (poor tissue penetration)
  • Complicated or recurrent infection:
    • 10ā€“14 days therapy
    • Repeat culture after treatment
    • ConsiderĀ prostatic involvement

Second Line

  • Based onĀ culture/sensitivityĀ andĀ patient history

Symptomatic Catheter Patients:

  • Treat if symptomatic
  • Do not treat asymptomatic bacteriuria

ISSUES FOR REFERRAL

  • Recurrent UTIs, febrile UTIs, pyelonephritis
  • Male infantsĀ with UTI

ADDITIONAL THERAPIES

  • Probiotics
  • PEG 3350Ā for constipation
  • PhenazopyridineĀ (limit to 48 hrs)

ADMISSION/INPATIENT CONSIDERATIONS

  • Cannot tolerate oral meds
  • Acute renal failure
  • Sepsis suspected

ONGOING CARE

Follow-Up

  • IfĀ persistent/worsening symptomsĀ after 48ā€“72 hrs
  • Evaluate forĀ recurrent UTI or underlying pathology

Diet

  • EncourageĀ adequate hydration

Patient Education

PROGNOSIS

  • Excellent withĀ appropriate antimicrobial therapy

COMPLICATIONS

  • Pyelonephritis,Ā Ascending infection
  • Recurrent UTI,Ā Prostatitis

CLINICAL PEARLS

  • UTI in males <50 isĀ uncommon and usually uncomplicated
  • Risk factors: BPH, incontinence, catheter use, sexual exposure
  • STI testingĀ is essential in any male with dysuria
  • Always considerĀ prostatitis in febrile male UTIs

REFERENCES

  1. Wagenlehner FME, Weidner W, Pilatz A, et al.Ā Urinary tract infections and bacterial prostatitis in men. Curr Opin Infect Dis. 2014;27(1):97ā€“101.
  2. Drekonja DM, Rector TS, Cutting A, et al.Ā Urinary tract infection in male veterans: treatment patterns and outcomes. JAMA Intern Med. 2013;173(1):62ā€“68.
  3. Coupat C, Pradier C, Degand N, et al.Ā Selective reporting of antibiotic susceptibility data improves the appropriateness of intended antibiotic prescriptions in urinary tract infections: a case-vignette randomized study. Eur J Clin Microbiol Infect Dis. 2013;32(5):627ā€“636.
  4. Foxman B.Ā Urinary tract infection syndromes: occurrence, recurrence, bacteriology, risk factors, and disease burden. Infect Dis Clin North Am. 2014;28(1):1ā€“13.

See Also:Ā Prostate Cancer, BPH, Prostatitis, Pyelonephritis, Urethritis ICD-10 Codes: - N39.0: Urinary tract infection, unspecified site - N30.90: Cystitis, unspecified - N30.91: Cystitis, with hematuria