Is Male Gender Still Considered a Complicating Factor in UTIs?
Yes, male gender continues to be classified as a complicated UTI in current clinical practice, though this classification is evolving and may not apply universally to all male UTI presentations. 1, 2
Current Guideline Classification
The 2024 European Association of Urology guidelines classify UTIs in men as complicated infections due to anatomical and physiological factors, requiring longer treatment duration (14 days) compared to uncomplicated UTIs in women. 1, 2 This classification stems from the broader microbial spectrum and higher likelihood of antimicrobial resistance in male UTIs, with common pathogens including E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 3, 1
The primary reason for this classification is the difficulty in excluding prostatitis at initial presentation, which necessitates the 14-day treatment duration. 3, 1, 2
Evidence Challenging Universal Classification
However, emerging evidence suggests this blanket classification may be overly broad:
A 2019 outpatient database study of 637 male UTI visits found that men without complicating conditions (urologic abnormalities, immunocompromising conditions, prostatitis, pyelonephritis, nephrolithiasis, or benign prostatic hyperplasia) did not benefit from treatment longer than 7 days. 4
A 1993 study of healthy university men showed that 92% of symptomatic UTIs responded to a single course of antimicrobial therapy, with extensive evaluation appearing unnecessary for young men who respond to treatment. 5
Practical Clinical Approach
When to Treat as Complicated (14 days):
- When prostatitis cannot be excluded (most initial presentations) 3, 1, 2
- Presence of urological abnormalities 3
- Immunosuppression 3
- Recent instrumentation 3
- Healthcare-associated infections 3
- ESBL-producing or multidrug-resistant organisms 3, 6
When Shorter Duration May Be Considered (7 days):
- Patient is hemodynamically stable and afebrile for at least 48 hours 3, 2
- Young, healthy men without anatomical abnormalities who respond promptly to therapy 4, 5
- No evidence of prostate involvement 4
Key Management Principles
Obtain urine culture and susceptibility testing before initiating therapy. 1, 2 This is mandatory for guiding appropriate antimicrobial selection given the broader microbial spectrum and higher resistance rates. 3, 1
Evaluate for underlying urological abnormalities or complicating factors that require management. 1, 2 However, extensive evaluation may be unnecessary for young men with first-time infection who respond to treatment. 5
Common Pitfalls
Undertreating when prostatitis cannot be excluded: The 2017 randomized trial showed 7-day ciprofloxacin was inferior to 14-day treatment in men (86% vs 98% cure rate). 1, 2
Overtreating young, healthy men without risk factors: This increases resistance risk, adverse events, and costs without demonstrated benefit. 4
Using fluoroquinolones inappropriately: Avoid if local resistance >10%, patient is from urology department, or fluoroquinolones used in last 6 months. 3, 1, 2
Failing to address underlying structural abnormalities: Management of urological abnormalities is mandatory for successful treatment. 3, 1, 6
The classification of male UTI as "complicated" remains the standard guideline recommendation, but clinical judgment should be applied based on individual patient characteristics, particularly in young, healthy men without risk factors. 1, 2, 4, 5