What is the recommended treatment for cystitis in males?

Treatment of Cystitis in Males

Males with cystitis should receive a 7-day course of antibiotics, with fluoroquinolones (ciprofloxacin or levofloxacin) as the preferred first-line agents, as cystitis in men is considered a complicated UTI due to potential prostatic involvement. 1

Key Distinction: Males vs. Females

• Cystitis in males is fundamentally different from uncomplicated cystitis in women and should not be treated with the same short-course regimens 2
• The male urinary tract anatomy and potential for prostatic involvement necessitates longer treatment duration and agents with better tissue penetration 1
• Guidelines for "uncomplicated cystitis" (3-5 day regimens with nitrofurantoin or fosfomycin) apply only to premenopausal, non-pregnant women—not to men 3, 2

First-Line Treatment Approach

Fluoroquinolones are the preferred empiric choice:

• Ciprofloxacin 500 mg twice daily for 7 days OR
• Levofloxacin 500-750 mg once daily for 7 days 2, 4
• These agents achieve excellent prostatic penetration and cover the most common uropathogens (primarily E. coli) 4, 1
• Despite concerns about collateral damage in female uncomplicated cystitis, fluoroquinolones remain appropriate for male cystitis due to the complicated nature of the infection 3, 2

Alternative Options When Fluoroquinolones Cannot Be Used

If fluoroquinolones are contraindicated or the patient has allergies:

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7-14 days (only if local resistance <20% or susceptibility confirmed) 2, 5
• β-lactams with good urinary penetration (amoxicillin-clavulanate, cefdinir, cefpodoxime-proxetil) for 7-14 days 3, 2
• Consider obtaining urine culture before initiating therapy to guide antibiotic selection 6, 4

Agents to Avoid in Male Cystitis

Do NOT use short-course regimens designed for female uncomplicated cystitis:

• Nitrofurantoin 5-day courses are inadequate for male cystitis 2
• Fosfomycin single-dose therapy is insufficient 2
• Pivmecillinam short courses are not appropriate 3
• Amoxicillin or ampicillin monotherapy due to high resistance rates 3, 2

Risk Factors Requiring Special Attention

Assess for conditions that increase complication risk:

• Benign prostatic hyperplasia (BPH) is associated with increased risk of treatment failure and complications 1
• Urinary retention requires evaluation for underlying obstruction 1
• Diabetes mellitus may affect treatment response 1
• Prostate cancer or recent urologic procedures warrant longer treatment courses 1

Treatment Monitoring and Follow-Up

Clinical response assessment:

• Symptoms should improve within 48-72 hours of initiating appropriate therapy 2
• If symptoms persist or worsen, obtain urine culture with susceptibility testing 7
• Consider imaging or urologic evaluation if recurrent episodes occur, as this may indicate structural abnormalities 1

Complications to monitor:

• Prostatitis (0.5% of cases) 1
• Pyelonephritis (0.7% of cases) 1
• Need for hospitalization (0.7% of cases) 1
• Re-prescription rates are higher with narrow-spectrum agents in males compared to females 1

Common Pitfalls to Avoid

• Using 3-5 day treatment courses appropriate only for female uncomplicated cystitis will lead to treatment failure in men 2, 1
• Assuming all cystitis is "uncomplicated" when male cystitis is inherently complicated due to anatomical considerations 3, 1
• Failing to obtain cultures in recurrent cases or when initial therapy fails 6, 7
• Not evaluating for urologic abnormalities in men with recurrent cystitis, as structural issues are more common than in women 1