Urinary Tract Infections in Men: Symptoms and Treatment
Symptoms
Men with UTIs typically present with dysuria, urinary frequency, urgency, and suprapubic discomfort, though the clinical presentation varies significantly based on the site of infection. 1
Key Clinical Presentations by Location:
- Cystitis (bladder infection): Dysuria, frequency, urgency, suprapubic pain, and occasionally hematuria 2
- Prostatitis: Pelvic pain, voiding symptoms, perineal discomfort, and potentially fever (present in only 14% of male UTI consultations) 3, 2
- Epididymitis: Unilateral testicular pain and tenderness, with hydrocele and palpable epididymal swelling commonly present 4
- Pyelonephritis: Fever, flank pain, and systemic symptoms 2
Important Diagnostic Considerations:
- Urethritis often accompanies sexually transmitted epididymitis and is frequently asymptomatic 4
- In primary care settings, male UTI presentations are often undifferentiated (52% of cases), followed by prostatitis (36%), cystitis (8.5%), and pyelonephritis (3.5%) 2
- Fever is documented in only 14% of male UTI consultations, making it an unreliable indicator 2
Diagnostic Approach
Obtain urine culture and susceptibility testing before initiating antimicrobial therapy—men with UTI symptoms should not be treated empirically without culture. 1, 5
Essential Diagnostic Steps:
- Urine culture is mandatory: 40% of symptomatic men have sterile urine, and low-count bacteriuria (23% of cases) or multiple bacterial growth (7%) are common 5
- Dipstick tests are unreliable in men: Leukocyte sensitivity is only 54% with 55% specificity; nitrite sensitivity is 38% with 84% specificity 5
- Evaluate for underlying urological abnormalities: 41% of men with UTI have additional risk factors including anatomical abnormalities, recent instrumentation, or immunocompromising conditions 1, 5
Age-Specific Pathogen Considerations:
- Men <35 years: C. trachomatis or N. gonorrhoeae are most common in sexually active men 4
- Men >35 years: Gram-negative enteric organisms (E. coli, Proteus, Klebsiella, Pseudomonas, Serratia) and Enterococcus predominate, especially with urological abnormalities or recent instrumentation 4, 1
Treatment Recommendations
First-Line Empiric Therapy (While Awaiting Culture):
For uncomplicated UTI when prostatitis cannot be excluded, treat for 14 days with fluoroquinolones as first-line (if local resistance <10%), or use amoxicillin plus aminoglycoside, second-generation cephalosporin plus aminoglycoside, or intravenous third-generation cephalosporin. 1
Specific Antibiotic Regimens:
Fluoroquinolones (preferred when appropriate):
- Ciprofloxacin 500 mg orally twice daily for 14 days 1, 6
- Ofloxacin 300 mg orally twice daily for 10 days (for epididymitis) 4
- Critical restriction: Use only when local resistance <10%, patient has not used fluoroquinolones in last 6 months, and patient is not from a urology department 1
Alternative regimens:
- Trimethoprim-sulfamethoxazole 160/800 mg twice daily 7, 3, 8
- Nitrofurantoin (limited role in male UTI due to poor prostatic penetration) 3, 8
- Beta-lactam combinations (amoxicillin-clavulanate, cephalosporins) 1
Treatment Duration:
The standard duration is 14 days when prostatitis cannot be excluded, based on definitive evidence showing 7-day ciprofloxacin was inferior to 14-day treatment in men (86% vs 98% cure rate). 1
- 7 days may be considered only for hemodynamically stable patients afebrile for ≥48 hours without complicating conditions 1, 9
- Chronic bacterial prostatitis requires 6-12 weeks of fluoroquinolone or trimethoprim-sulfamethoxazole therapy 3
- Acute bacterial prostatitis requires 4 weeks of appropriate antibiotic therapy 3
Age-Specific Treatment for Epididymitis:
Men <35 years (sexually transmitted):
- Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 4
Men >35 years (enteric organisms):
- Ofloxacin 300 mg orally twice daily for 10 days 4
Critical Pitfalls and Cautions
Antibiotic Resistance Concerns:
- Resistance rates in male UTI are substantial: 53% for amoxicillin, 34% for trimethoprim-sulfamethoxazole, 25% for nitrofurantoin, and 22% for ciprofloxacin 5
- Fluoroquinolones should be avoided if patient used them in last 6 months or is from urology department due to high resistance risk 1
- Beta-lactams are not effective as empirical first-line therapy for male UTI 8
Common Diagnostic Errors:
- Do not rely on dipstick testing alone—it has poor predictive value in men (negative predictive values of 44-46%) 5
- Do not assume all symptomatic men have infection—40% have sterile urine despite symptoms 5
- Consider testicular torsion urgently in men with acute testicular pain, especially if onset is sudden, pain is severe, or no evidence of infection/inflammation exists 4
Management of Underlying Conditions:
- Identify and manage urological abnormalities: Structural or functional abnormalities contribute to infection and require specific intervention 1
- Adjunctive measures for epididymitis: Bed rest, scrotal elevation, and analgesics until fever and inflammation subside 4
- Hospitalization indicated for severe pain suggesting complications (torsion, abscess, infarction), fever, or concerns about compliance 4
Follow-Up Requirements:
- Reassess at 3 days: Failure to improve requires reevaluation of diagnosis and therapy 4
- Follow-up urine culture recommended in complicated cases to confirm eradication 1
- Persistent swelling/tenderness after treatment completion warrants comprehensive evaluation for tumor, abscess, infarction, testicular cancer, or tuberculous/fungal epididymitis 4
Special Populations
Sexually Active Men:
- Evaluate and treat sex partners for gonorrhea and chlamydia when epididymitis is sexually transmitted 4
- Test for syphilis and HIV in men with epididymitis 4
- Men who have sex with men: Consider E. coli epididymitis in insertive partners during anal intercourse 4