What is the appropriate treatment for a patient with suspected urethritis, urinary tract infection, prostatitis, or overactive bladder?

Treatment for Suspected Urethritis, UTI, Prostatitis, and Overactive Bladder

For patients with suspected urological infections, treatment should be pathogen-directed based on the specific condition, with empiric therapy guided by the most recent European Association of Urology guidelines. 1

Urethritis Treatment

Gonococcal Urethritis

• First-line: Ceftriaxone 1g IM or IV single dose + Azithromycin 1g PO single dose 1
• Alternative regimens (for cephalosporin allergy):
  • Gentamicin 240mg IM single dose + Azithromycin 2g PO single dose
  • Gemifloxacin 320mg PO single dose + Azithromycin 2g PO single dose
  • Spectinomycin 2g IM single dose
  • Fosfomycin trometamol 3g PO on days 1,3, and 5

Non-gonococcal Urethritis (Unidentified Pathogen)

• First-line: Doxycycline 100mg PO twice daily for 7 days 1
• Alternative: Azithromycin 500mg PO on day 1, then 250mg PO for 4 days

Pathogen-Specific Treatment

• Chlamydia trachomatis:

  • Azithromycin 1.0-1.5g PO single dose, OR
  • Doxycycline 100mg PO twice daily for 7 days

• Mycoplasma genitalium:

  • Azithromycin 500mg PO on day 1
  • For macrolide resistance: Moxifloxacin 400mg daily for 7-14 days

• Ureaplasma urealyticum:

  • Doxycycline 100mg PO twice daily for 7 days
  • Alternative: Azithromycin 1.0-1.5g PO single dose

• Trichomonas vaginalis:

  • Metronidazole/Tinidazole 2g PO single dose
  • Alternative: Metronidazole 500mg PO twice daily for 7 days

Persistent Non-gonococcal Urethritis

• After first-line doxycycline: Azithromycin 500mg PO on day 1, then 250mg PO for 4 days
• After first-line azithromycin: Moxifloxacin 400mg PO daily for 7-14 days + Metronidazole 400mg PO twice daily for 5 days

Important: Sexual partners should be treated while maintaining patient confidentiality 1

Urinary Tract Infection Treatment

Complicated UTI with Systemic Symptoms

• First-line (one of the following combinations): 1

  • Amoxicillin plus an aminoglycoside
  • Second-generation cephalosporin plus an aminoglycoside
  • IV third-generation cephalosporin

• Oral therapy (when appropriate):

  • Ciprofloxacin (only if local resistance <10% AND patient doesn't require hospitalization)
  • Avoid fluoroquinolones if patient has used them in the last 6 months

Catheter-Associated UTI

• Treat according to complicated UTI recommendations
• Replace or remove indwelling catheter before starting antimicrobial therapy
• Duration of catheterization should be minimal
• Use hydrophilic coated catheters to reduce CA-UTI

Caution: Do not treat asymptomatic bacteriuria except before traumatic urinary tract interventions 1

Prostatitis Treatment

Acute Bacterial Prostatitis

• Duration: 30-day therapy with appropriate antibiotics 2
• Preferred agents: Fluoroquinolones (e.g., ciprofloxacin) or trimethoprim-sulfamethoxazole 3
• These agents penetrate prostatic tissue and secretions effectively

Chronic Bacterial Prostatitis

• Duration: Low-dose therapy for 6-12 months 2
• Preferred agents: Fluoroquinolones or trimethoprim-sulfamethoxazole 3
• Long-term suppressive antibiotic therapy may be useful in selected patients with recurrent bacteriuria or persistent symptoms 3

Overactive Bladder Treatment

Overactive bladder is characterized by urge urinary incontinence, urgency, and frequency.

Pharmacological Options

• Antimuscarinic agents:
  • Tolterodine (Detrol LA): Extended-release capsules for adults with overactive bladder symptoms 4
  • Oxybutynin: Available in extended-release formulation, shown to be effective in reducing urge incontinence episodes 5

Note: These medications are not antimicrobials but are indicated specifically for overactive bladder symptoms

Important Clinical Considerations

1. Diagnostic Approach:

   • For urethritis: Perform Gram stain of urethral discharge and NAAT testing before treatment 1
   • For UTI: Obtain urine culture before initiating antimicrobial therapy 1

2. Treatment Pitfalls to Avoid:

   • Do not use ciprofloxacin and other fluoroquinolones for empirical treatment of complicated UTI when patients have used fluoroquinolones in the last 6 months 1
   • Do not attempt to eradicate infection unless foreign bodies (stones, catheters) are removed and correctable urological abnormalities are addressed 2
   • Do not routinely use antibiotic prophylaxis to prevent catheter-associated UTI 1

3. Special Populations:

   • For men with epididymitis: Treatment should target the likely pathogens (Enterobacterales, C. trachomatis, or N. gonorrhoeae) 1
   • For Fournier's gangrene: Broad-spectrum antibiotics with surgical debridement and urinary diversion via suprapubic catheter 1

By following these evidence-based treatment recommendations, clinicians can effectively manage urethritis, UTI, prostatitis, and overactive bladder while minimizing complications and reducing the risk of antimicrobial resistance.