Management of Recurrent UTIs in a 68-Year-Old Man
Surgery is recommended for men with recurrent urinary tract infections (UTIs) due to benign prostatic hyperplasia (BPH) when refractory to other therapies. 1
Diagnostic Evaluation
- Confirm diagnosis with positive urine cultures for each symptomatic episode before initiating treatment 2
- Recurrent UTIs are defined as ≥3 UTIs per year or ≥2 UTIs in the last 6 months 2
- UTIs in men are always considered complicated and require more extensive evaluation than in women 2
- Obtain urinalysis and urine culture with sensitivity for each symptomatic acute cystitis episode 1
Required Workup for Men with Recurrent UTIs
- Evaluate for urinary tract obstruction, particularly BPH, which is a common cause of recurrent UTIs in older men 2
- Assess for presence of foreign bodies such as catheters or stents 2
- Check for incomplete bladder emptying with post-void residual measurement 2
- Evaluate for vesicoureteral reflux and review recent history of urinary tract instrumentation 2
- Screen for diabetes mellitus and immunosuppression 2
- Consider cystoscopy and upper tract imaging if anatomical abnormalities are suspected 2
Treatment Approach
Acute Episode Management
- Treat with appropriate antibiotics based on culture results 2
- First-line treatment: Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days 2, 3
- Alternative: Ciprofloxacin, but should be avoided if local resistance rate is >10% or if the patient has used them in the last 6 months 4, 5
- Consider patient-initiated treatment (self-start) for select patients while awaiting urine cultures 1
Addressing Underlying Causes
- If BPH is identified as the cause of recurrent UTIs, surgical intervention is recommended 1
- Surgery is particularly indicated when recurrent UTIs are clearly due to BPH and refractory to other therapies 1
- Correct any identified anatomical or functional abnormalities 2
Prevention Strategies
- Consider continuous or post-coital antimicrobial prophylaxis when non-antimicrobial interventions have failed 2
- Increase fluid intake to reduce risk of recurrent UTI 4
- Consider methenamine hippurate for reducing recurrent UTI episodes 4
- Probiotics containing strains proven for urogenital health may help prevent UTIs 4
Special Considerations for Older Men
- Elderly patients may present with atypical UTI symptoms such as altered mental status, functional decline, fatigue, or falls 4
- Negative results for both nitrite and leukocyte esterase on dipstick tests often suggest absence of UTI 4
- Avoid fluoroquinolones if local resistance rate is >10% or if the patient has used them in the last 6 months 4
- Nitrofurantoin should be avoided if creatinine clearance <30 mL/min 4
Importance of Antimicrobial Stewardship
- Adhere to antimicrobial stewardship principles to reduce inappropriate treatment and decrease broad-spectrum antibiotic use 1
- Tailor treatment to the shortest effective duration to mitigate increasing antibiotic resistance 1
- Consider local antibiogram patterns when selecting antimicrobial agents 1