What is the appropriate workup for a man with recurrent Urinary Tract Infections (UTIs)?

Workup for Recurrent UTIs in Men

In men with recurrent UTIs, a thorough diagnostic evaluation is essential, including urine culture, imaging studies, and urological examination to identify underlying structural or functional abnormalities that are commonly present in male patients with recurrent infections.

Definition and Initial Assessment

• Recurrent UTIs are defined as ≥3 UTIs per year or ≥2 UTIs in the last 6 months 1
• UTIs in men are always considered complicated UTIs and require more extensive evaluation than in women 1
• Confirm diagnosis with urine culture for each symptomatic episode before initiating treatment 1
• Common causative organisms include E. coli (most common), Proteus mirabilis, Klebsiella, Enterococcus faecalis, and Staphylococcus saprophyticus 1, 2

Diagnostic Workup Algorithm

Step 1: Basic Evaluation

• Complete urinalysis including physical, chemical, and microscopic examination 3
• Urine culture with antimicrobial susceptibility testing for each symptomatic episode 1, 4
• Assessment for systemic symptoms suggesting pyelonephritis (fever, flank pain, costovertebral angle tenderness) 5, 6

Step 2: Identify Risk Factors

• Evaluate for urinary tract obstruction at any site 1
• Assess for presence of foreign bodies (catheters, stents) 1
• Check for incomplete bladder emptying with post-void residual measurement 1
• Evaluate for vesicoureteral reflux 1
• Review recent history of urinary tract instrumentation 1
• Screen for diabetes mellitus and immunosuppression 1, 6

Step 3: Advanced Imaging and Specialized Testing

• Abdominal/pelvic ultrasound to assess for structural abnormalities, stones, and post-void residual 1
• Consider CT urography if stone disease or anatomical abnormalities are suspected 1
• Cystoscopy to evaluate for bladder or urethral abnormalities 1
• Urodynamic studies if voiding dysfunction is suspected 1
• Prostate-specific evaluation (digital rectal examination, PSA testing) to assess for prostatitis or prostate enlargement 4

Treatment Approach

• Treat acute episodes with appropriate antibiotics based on culture results 1
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days is the recommended first-line treatment for men 1, 4
• Fluoroquinolones can be prescribed according to local susceptibility patterns 1
• Longer treatment duration (7-14 days) is recommended for men, especially when prostatitis cannot be excluded 1, 4
• Address underlying anatomical or functional abnormalities when identified 1

Prevention Strategies

• Correct underlying urological abnormalities when possible 1
• Consider continuous or post-coital antimicrobial prophylaxis when non-antimicrobial interventions have failed 1
• Ensure adequate hydration and regular bladder emptying 1, 4
• Consider methenamine hippurate for prevention in men without urinary tract abnormalities 1

Common Pitfalls and Caveats

• Failure to obtain urine culture before initiating treatment can lead to inappropriate antibiotic selection 1, 4
• Inadequate treatment duration (shorter than 7 days) often results in treatment failure in men 1, 4
• Overlooking prostate involvement can lead to persistent or recurrent infections 4
• Neglecting to evaluate for structural abnormalities, which are more common in men with recurrent UTIs 1
• Treating symptoms without confirming infection can contribute to antibiotic resistance 4, 2