What is the recommended treatment for a 78-year-old male with recurrent cystitis, mild prostatomegaly, and no other comorbidities?

Treatment for Recurrent Cystitis in a 78-Year-Old Male with Mild Prostatomegaly

Fluoroquinolones (levofloxacin 500 mg daily or ciprofloxacin 500 mg twice daily) are the recommended first-line treatment for this 78-year-old male with recurrent cystitis and prostatomegaly, with a 7-day course being appropriate for uncomplicated lower UTI/cystitis. 1

Initial Antibiotic Therapy

The treatment approach should follow these steps:

1. First-line antibiotic options:

   • Levofloxacin 500 mg once daily for 7 days
   • Ciprofloxacin 500 mg twice daily for 7 days 1

2. Dosage considerations:

   • Adjust dosage based on renal function:
     • For creatinine clearance ≥50 mL/min: Levofloxacin 500 mg once daily
     • For creatinine clearance 26-49 mL/min: Levofloxacin 500 mg once daily
     • For creatinine clearance 10-25 mL/min: Levofloxacin 250 mg once daily 1

3. Alternative antibiotics if fluoroquinolones are contraindicated:

   • TMP/SMX 160/800 mg twice daily (if local resistance rates <20%)
   • Note: Nitrofurantoin and fosfomycin are not appropriate choices for this patient as they are only recommended for uncomplicated cystitis without prostatic involvement 1

Addressing Prostatomegaly

The mild prostatomegaly noted on ultrasound may be contributing to recurrent infections and should be addressed:

1. Consider finasteride therapy:

   • Finasteride 5 mg daily can reduce prostate volume and improve symptoms
   • In clinical trials, finasteride reduced prostate volume by 17.9% over 4 years compared to a 14.1% increase in the placebo group 2
   • Finasteride has been shown to improve maximum urinary flow rate by 1.9 mL/sec compared to 0.2 mL/sec in placebo groups 2
   • This improvement in urinary flow may help reduce the risk of recurrent UTIs by improving bladder emptying

2. Monitor for finasteride side effects:

   • Sexual function-related adverse effects (impotence, decreased libido, ejaculation disorders) are most common
   • Breast enlargement and tenderness may occur 2

Monitoring and Follow-up

1. Short-term follow-up:

   • Clinical improvement should be expected within 48-72 hours of antibiotic initiation 1
   • Follow-up urine culture to confirm eradication of infection

2. Long-term management:

   • If finasteride is initiated, assess symptom improvement using standardized symptom scores
   • A therapeutic trial of at least 6 months is generally necessary to assess whether a beneficial response to finasteride has been achieved 2

Prevention Strategies for Recurrent UTIs

1. Increase fluid intake to reduce the risk of urinary tract infections 1

2. Consider prophylactic antibiotics for frequent recurrences after initial treatment success

3. Address any urinary retention that may be contributing to recurrent infections

Important Caveats

• Chronic bacterial prostatitis may be underlying the recurrent cystitis in this patient with prostatomegaly and would require a longer course of antibiotics (6-12 weeks) 3
• If symptoms persist despite appropriate antibiotic therapy, further evaluation with urological consultation may be necessary
• Avoid catheterization if possible, as it increases the risk of introducing new infections

By addressing both the acute infection with appropriate antibiotics and the underlying prostatomegaly with finasteride, this approach targets both immediate symptom relief and long-term prevention of recurrent infections.