What is the treatment for cystitis in males?

Treatment of Cystitis in Males

First-line treatment for cystitis in males should be nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) due to its high efficacy and minimal resistance patterns. 1, 2

First-Line Treatment Options

• Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) is the preferred first-line antibiotic with clinical cure rates of 88-93% and bacterial cure rates of 81-92% 1
• Fosfomycin trometamol (3 g single dose) is an appropriate alternative first-line option, though it may have slightly lower microbiological cure rates (78%) compared to nitrofurantoin (86%) 1, 2
• Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days) can be used if local resistance rates are known to be <20% or the specific isolate is confirmed susceptible 1, 2
• Pivmecillinam (400 mg twice daily for 3-7 days) is recommended in regions where available (primarily European countries) 1, 3

Second-Line Treatment Options

• Fluoroquinolones (ciprofloxacin, levofloxacin, ofloxacin) should be reserved for situations where first-line agents cannot be used due to concerns about promoting resistance 1, 2
• β-Lactams (amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil) can be used for 3-7 days when other recommended agents cannot be used, but generally have inferior efficacy and more adverse effects 4, 1
• Other β-lactams like cephalexin are less studied but may be appropriate in certain settings 4

Treatments to Avoid

• Amoxicillin or ampicillin should not be used for empirical treatment due to poor efficacy and high prevalence of antimicrobial resistance worldwide 4, 1

Special Considerations for Male Patients

• Male urinary tract infections are less common than in females and may indicate underlying structural or functional abnormalities that require further evaluation 3
• In a nationwide study from Norway, narrow-spectrum antibiotics (particularly pivmecillinam) were effective first-line treatments for cystitis in men, with more than 75% of episodes not requiring re-prescription or leading to complications 3
• Complications (prostatitis, pyelonephritis, or hospitalization) occurred in only 1.8% of all male cystitis episodes treated with appropriate antibiotics 3

Treatment Algorithm for Male Cystitis

1. First choice: Nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5 days) 1, 2
2. Second choice: Fosfomycin trometamol (3 g single dose) 1, 5
3. Third choice: Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days) if local resistance <20% 1, 2
4. Fourth choice: Fluoroquinolones or β-lactams only when first-line options cannot be used 4, 1

Risk Factors and Complications

• Benign prostatic hyperplasia (BPH) is associated with increased risk of complications and need for re-prescription 3
• Prostate cancer and urinary retention are associated with a lower risk of both complications and re-prescriptions, possibly due to more aggressive initial management 3
• Diabetes is associated with a lower risk of re-prescriptions but requires careful monitoring 3

Monitoring and Follow-up

• Urine culture should be performed if symptoms do not resolve by the end of treatment or recur within 2-4 weeks 2, 6
• Retreatment with a 7-day regimen using another agent should be considered if symptoms persist or recur 5
• Consider urologic evaluation for men with recurrent infections to identify any underlying structural abnormalities 7