From the Guidelines
The diagnostic workup for recurrent Urinary Tract Infections (UTIs) in a young male should prioritize a thorough urological evaluation, including a detailed history, physical examination, laboratory testing, and imaging studies, with a focus on identifying underlying anatomical or functional abnormalities. The initial assessment should involve a detailed history focusing on risk factors such as sexual practices, hygiene habits, and previous genitourinary procedures. A complete physical examination, including a digital rectal examination to assess prostate size and tenderness, is essential. Laboratory testing should include urinalysis, urine culture with sensitivity testing, and possibly blood tests to check renal function and inflammatory markers.
Imaging studies are typically warranted, starting with renal ultrasound to evaluate for structural abnormalities, as there is no relevant literature to support the use of CT abdomen and pelvis with or without IV contrast, CTU, MRI abdomen and pelvis with or without IV contrast, or MRU in the evaluation of a child assigned male at birth (AMB) for the initial imaging of a first febrile UTI 1. A voiding cystourethrogram (VCUG) may be necessary to assess for vesicoureteral reflux or urethral strictures, although the literature on VCUG has mixed recommendations, and recent data have shown that in children <3 months of age with first febrile UTI, the presence of E coli in urine, and normal renal and bladder US, VCUG can be safely avoided 1.
In some cases, a DMSA renal scan can be done for the initial imaging, close to the time of febrile UTI to evaluate for the presence of pyelonephritis, and if the DMSA scan is normal, VCUG may be avoided in >50% of individuals 1. Cystoscopy may be necessary to directly visualize the urethra and bladder for anatomical abnormalities, stones, or foreign bodies. In some cases, urodynamic studies might be indicated to evaluate bladder function. Treatment depends on the underlying cause but often includes a prolonged course of antibiotics based on culture sensitivity. Addressing anatomical abnormalities may require surgical intervention.
Key considerations in the diagnostic workup include:
- Detailed history and physical examination
- Laboratory testing, including urinalysis and urine culture with sensitivity testing
- Imaging studies, starting with renal ultrasound
- Possible voiding cystourethrogram (VCUG) or DMSA renal scan
- Cystoscopy or urodynamic studies as needed
- Treatment based on underlying cause, including antibiotics and possible surgical intervention.
From the Research
Diagnostic Workup for Recurrent UTIs in Young Males
The diagnostic workup for recurrent Urinary Tract Infections (UTIs) in young males involves several steps, including:
- Urine culture: This is the gold standard for detecting UTIs and identifying the causative bacteria 2
- Dipstick urinalysis: This test can detect the presence of nitrites, leukocyte esterase, and blood in the urine, which can indicate a UTI 2
- Microscopic urinalysis: This test can detect the presence of bacteria, white blood cells, and red blood cells in the urine 2
- Symptom assessment: A healthcare provider will assess the patient's symptoms, such as dysuria, frequency, and urgency, to determine the likelihood of a UTI 2
Risk Factors for Resistance
Several risk factors can increase the likelihood of resistance to antibiotics, including:
- Prior UTI caused by a resistant organism 3
- Prior use of fluoroquinolones 3
- Complicated UTI 3
- Being born outside the US 3
Treatment Options
Treatment options for recurrent UTIs in young males include:
- Nitrofurantoin: This antibiotic is effective against most uropathogens and has minimal collateral damage 4, 2
- Fosfomycin: This antibiotic is effective against most uropathogens and has minimal collateral damage 4, 2
- Trimethoprim-sulfamethoxazole: This antibiotic is effective against most uropathogens, but resistance rates are increasing 4, 2
- Trimethoprim/sulfamethoxazole (TRS) can be a cost-effective long-term solution for patients with multidrug-resistant K. pneumoniae UTIs 5
Antibiotic Susceptibility Patterns
Antibiotic susceptibility patterns vary depending on the causative bacteria and the geographic location. In general, Escherichia coli is the most common causative pathogen, followed by Klebsiella pneumoniae 6. High rates of resistance to fluoroquinolones and beta-lactams have been detected, highlighting the need for careful selection of antibiotics and monitoring of resistance patterns 3, 6