What is the treatment for recurrent urinary tract infections (UTIs) in men?

Treatment for Recurrent Urinary Tract Infections in Men

Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 7-14 days is the recommended first-line treatment for recurrent UTIs in men, with treatment duration and approach tailored based on underlying causes. 1

Diagnostic Evaluation

• Recurrent UTIs in men are defined as ≥3 UTIs per year or ≥2 UTIs in the last 6 months 1
• UTIs in men are always considered complicated and require more extensive evaluation than in women 1
• Confirm diagnosis with urine culture for each symptomatic episode before initiating treatment 1, 2
• Common causative organisms include E. coli (most common at 50.4%), Proteus mirabilis, Klebsiella, Enterococcus faecalis, and Staphylococcus saprophyticus 1, 2

Essential Diagnostic Workup

• Evaluate for urinary tract obstruction at any site (crucial step) 1
• Assess for presence of foreign bodies such as catheters or stents 1
• Check for incomplete bladder emptying with post-void residual measurement 1
• Evaluate for vesicoureteral reflux and review recent history of urinary tract instrumentation 1
• Screen for diabetes mellitus and immunosuppression 1
• Consider prostate evaluation, as chronic bacterial prostatitis often presents with recurrent UTIs 3

Treatment Approach

Acute Episode Treatment

• Base antibiotic selection on culture results whenever possible 1, 4
• First-line treatment: TMP-SMX 160/800 mg twice daily for 7-14 days 1, 5
• Alternative options when resistance is a concern or allergies exist:
  • Nitrofurantoin (if lower UTI only) 6, 4
  • Fosfomycin (for uncomplicated lower UTI) 6, 4
  • Fluoroquinolones (second-line due to resistance concerns and FDA warnings) 7, 6

Treatment Duration

• Acute uncomplicated cystitis: 7 days 5, 4
• Complicated UTI or mild prostatitis: 10-14 days 5, 3
• Chronic bacterial prostatitis: 6-12 weeks of therapy 3

Management of Underlying Conditions

• Address and correct underlying anatomical or functional abnormalities when identified 1
• Consider surgical management for men with recurrent UTIs due to benign prostatic hyperplasia (BPH) when refractory to other therapies 1
• For chronic bacterial prostatitis causing recurrent UTIs, use antibiotics that penetrate prostatic tissue (TMP-SMX or fluoroquinolones) 3

Prevention Strategies

• Consider continuous or post-coital antimicrobial prophylaxis when non-antimicrobial interventions have failed 1, 8
• Implement antibiotic stewardship principles:
  • Use short-duration therapy with narrow-spectrum antibiotics when possible 1
  • Consider local antibiogram patterns when selecting antimicrobial agents 1, 4
  • Avoid treating asymptomatic bacteriuria 9
• Non-antimicrobial interventions:
  • Increase fluid intake 9
  • Urge-initiated and post-coital voiding 9
  • Consider immunoactive prophylaxis 9, 8

Common Pitfalls to Avoid

• Using fluoroquinolones as first-line therapy (FDA warns against this due to unfavorable risk-benefit ratio) 7
• Using beta-lactam antibiotics as first-line (associated with collateral damage and more rapid recurrence) 7
• Treating asymptomatic bacteriuria, which increases risk of resistance 9
• Failing to evaluate for underlying structural or functional abnormalities 1
• Using broad-spectrum antibiotics when narrower options are available 9

Special Considerations

• For men with recurrent UTIs related to prostatitis, longer antibiotic courses are necessary (6-12 weeks) 3
• For catheter-associated recurrent UTIs, focus on reducing frequency and duration of catheterization 8
• For multidrug-resistant organisms, treatment should be guided by susceptibility testing 6, 4