From the Guidelines
The diagnostic workup for a suspected male Urinary Tract Infection (UTI) should begin with a thorough history and physical examination, followed by urinalysis and urine culture, as recommended by the European Association of Urology guidelines on urological infections 1. The initial diagnostic test is urinalysis, which may show pyuria (>10 white blood cells per high-power field), bacteriuria, leukocyte esterase, or nitrites.
- A urine culture should be obtained before starting antibiotics to identify the causative organism and guide therapy.
- For uncomplicated UTIs in men, empiric treatment with trimethoprim-sulfamethoxazole (160/800 mg twice daily for 7-14 days), fluoroquinolones like ciprofloxacin (500 mg twice daily for 7 days), or nitrofurantoin (100 mg four times daily for 7 days) is appropriate while awaiting culture results, as suggested by the European Association of Urology guidelines on urological infections 1. Some key points to consider in the diagnostic workup include:
- Patients typically present with dysuria, frequency, urgency, suprapubic pain, or hematuria.
- Men with fever, flank pain, or systemic symptoms should be evaluated for pyelonephritis or prostatitis, which may require longer treatment courses (2-6 weeks) and possibly imaging studies such as renal ultrasound or CT scan.
- Recurrent UTIs in men warrant urologic evaluation with cystoscopy and possibly imaging to identify anatomical abnormalities, stones, or other underlying conditions, as recommended by the European Association of Urology guidelines on urological infections 1. It is essential to note that UTIs in men are less common than in women because of their longer urethra and antibacterial properties of prostatic fluid, so when they do occur, they often indicate an underlying abnormality that requires further investigation, as highlighted by the European Association of Urology guidelines on urological infections 1. The European Association of Urology guidelines on urological infections also emphasize the importance of antimicrobial stewardship to combat the rising threat of antimicrobial resistance, providing recommendations for antibiotic selection, dosing, and duration based on the latest evidence 1. In cases where urosepsis is suspected, urine and paired blood specimens should be obtained, if feasible, for culture and antimicrobial susceptibility testing, and a Gram stain of uncentrifuged urine should be requested, as recommended by the Infectious Diseases Society of America 1.
From the Research
Diagnostic Workup for Suspected Male Urinary Tract Infection (UTI)
- The initial workup for suspected male UTI should consist of a careful history and physical examination, with or without simple adjunctive tests such as uroflowmetry, post-void residual, and frequency volume charts 2.
- Urinalysis is useful mainly for excluding bacteriuria, while urine culture may not be necessary for outpatients with uncomplicated UTIs, but is necessary for outpatients with recurrent UTIs, treatment failures, or complicated UTIs, as well as for inpatients who develop UTIs 3.
- A patient's prior urine culture results are useful in predicting the identity and susceptibility of a current positive urine culture, and can inform empiric antibiotic therapy 4.
- Diagnostic tests such as urine dipstick test and urine culture are not always performed, with urine dipstick test done in only 1.8% of consultations and urine culture positive for Escherichia coli in 50.4% of bacteriological tests 5.
Additional Considerations
- The definition and treatment of male UTIs are imprecise, and there is a need for new guidelines 5.
- Male UTIs are rare in general practice and have different presentations, with undifferentiated UTIs, prostatitis, cystitis, and pyelonephritis being the most commonly identified 5.
- Fluoroquinolones are the most prescribed antibiotics for male UTIs, followed by beta-lactams, trimethoprim-sulfamethoxazole, and nitrofurantoin 5.
- High resistance to commonly used antibiotics such as Cefalexin, Ampicillin, and Ciprofloxacin has been found, highlighting the need for appropriate antibiotic selection 6.