What is the workup for a Urinary Tract Infection (UTI) in a male?

From the Guidelines

The workup for a urinary tract infection (UTI) in males should include a thorough history, physical examination, urinalysis with culture, and consideration of underlying anatomical or functional abnormalities, with empiric antibiotic therapy typically including trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 7-14 days, or fluoroquinolones like ciprofloxacin 500 mg twice daily for 7 days. For complicated UTIs or pyelonephritis, treatment should be extended to 14 days, potentially with initial intravenous antibiotics such as ceftriaxone 1-2 g daily 1. Unlike in women, UTIs in men are often considered complicated due to potential underlying structural or functional abnormalities, so further evaluation with imaging studies like renal ultrasound or CT scan may be warranted, especially for recurrent infections 1. Some key points to consider in the workup and treatment of UTIs in males include:

• Urinalysis with culture to guide antibiotic therapy 1
• Consideration of underlying anatomical or functional abnormalities, such as obstruction at any site in the urinary tract, recent history of instrumentation, or immunosuppression 1
• Empiric antibiotic therapy with TMP-SMX or fluoroquinolones for 7-14 days, with potential extension to 14 days for complicated UTIs or pyelonephritis 1
• Further evaluation with imaging studies for recurrent infections or risk factors like urinary tract obstruction, recent catheterization, or immunosuppression 1
• Post-treatment urinalysis to confirm resolution 1
• Urological evaluation including possible cystoscopy for men with recurrent UTIs, those over 50 years old with first-time UTIs, or those with risk factors like urinary tract obstruction, recent catheterization, or immunosuppression 1

From the Research

UTI in Male Workup

• The diagnosis and management of male urinary tract infections (UTIs) are imprecise, and there is a need for new guidelines 2.
• Male UTIs are rare in general practice, accounting for 0.097% of visits, and have different presentations, including undifferentiated UTIs, prostatitis, cystitis, and pyelonephritis 2.
• The most commonly isolated uropathogens in male UTIs are Escherichia coli, followed by other enterobacteriaceae and enterococci 3.
• The susceptibility rates of uropathogens to antibiotics vary, with low rates for amoxicillin and trimethoprim, and high rates for fluoroquinolones and amoxicillin-clavulanic acid 3.

Antibiotic Treatment

• Fluoroquinolones are the most prescribed antibiotics for male UTIs, followed by beta-lactams, trimethoprim-sulfamethoxazole, and nitrofurantoin 2.
• The resistance rate for trimethoprim/sulfamethoxazole is significant, with 34% of E. coli isolates resistant to this antibiotic 4.
• The resistance rate for fluoroquinolones is also significant, with 16.4% of E. coli isolates resistant to this class of antibiotics 4.
• The choice of empiric antibiotic therapy for male UTIs should be guided by local susceptibility patterns and the patient's medical history 5.

Diagnostic Approach

• Urine dipstick tests and urine culture are not commonly used in the diagnosis of male UTIs, with only 1.8% of consultations including a urine dipstick test and 50.4% of bacteriological tests positive for E. coli 2.
• The definition of male UTIs needs to be specified by prospective studies, and diagnostic evidence of male cystitis may reduce the duration of antibiotic therapy and spare critical antibiotics 2.