What is the recommended treatment for a man with hematuria (blood in urine) and a urinary tract infection (UTI)?

Treatment of Hematuria in a Man with UTI

A man with hematuria and UTI should be treated as a complicated UTI with 7-14 days of antibiotics (14 days preferred when prostatitis cannot be excluded), along with mandatory urine culture and management of any underlying urological abnormality. 1

Classification and Clinical Significance

• UTI in males is automatically classified as complicated UTI (cUTI) regardless of other factors, as male gender itself is a complicating factor. 1
• Acute hematuria is a recognized symptom of complicated UTI, particularly in catheter-associated infections, but can occur in any cUTI presentation. 1
• The presence of hematuria does not change the fundamental treatment approach but reinforces the need for thorough evaluation and appropriate antibiotic duration. 1

Empirical Antibiotic Selection

For Patients with Systemic Symptoms (Fever, Rigors, Flank Pain)

Use combination therapy with strong recommendation: 1

• Amoxicillin plus an aminoglycoside, OR
• Second-generation cephalosporin plus an aminoglycoside, OR
• Intravenous third-generation cephalosporin (e.g., ceftriaxone 1-2g daily)

For Stable Patients Without Systemic Symptoms

Ciprofloxacin may be used ONLY if: 1

• Local resistance rate is <10%, AND
• Patient does not require hospitalization, AND
• Entire treatment can be given orally, AND
• Patient has not used fluoroquinolones in the last 6 months, AND
• Patient is not from a urology department

Do NOT use fluoroquinolones empirically in patients from urology departments or with recent fluoroquinolone exposure due to high resistance rates. 1

Treatment Duration

• Standard duration: 7-14 days 1
• Recommend 14 days for men when prostatitis cannot be excluded (which is most cases in male UTI with hematuria) 1
• Shorter 7-day course may be considered only when patient is hemodynamically stable, afebrile for ≥48 hours, and there are relative contraindications to prolonged antibiotic use 1
• Recent evidence supports 7 days of ciprofloxacin or trimethoprim/sulfamethoxazole as noninferior to 14 days in afebrile men with UTI (93.1% vs 90.2% symptom resolution), though this was in uncomplicated presentations 2

Mandatory Diagnostic Steps

Before or immediately after initiating empirical therapy: 1

• Obtain urine culture and susceptibility testing - this is mandatory for all complicated UTIs
• Tailor antibiotic therapy based on culture results and local resistance patterns
• Assess for urological abnormalities - obstruction, stones, incomplete voiding, or anatomic abnormalities that require intervention

Expected Microbial Spectrum

The microbial spectrum in complicated UTI is broader than uncomplicated UTI: 1

• E. coli (most common)
• Proteus spp.
• Klebsiella spp.
• Pseudomonas spp.
• Serratia spp.
• Enterococcus spp.

Antimicrobial resistance is more likely in complicated UTI compared to uncomplicated cystitis. 1

Critical Management Principle

Management of any underlying urological abnormality or complicating factor is mandatory (strong recommendation). 1 Treatment duration should be closely related to resolution of the underlying abnormality. 1

Common Pitfalls to Avoid

• Do not treat as simple cystitis - male UTI with hematuria requires longer duration and broader coverage 1
• Do not use nitrofurantoin - it does not achieve adequate tissue concentrations for complicated UTI or potential prostatitis 1
• Do not skip urine culture - culture-directed therapy is essential for complicated UTI 1
• Do not ignore persistent hematuria - if hematuria persists after infection treatment, urological evaluation for malignancy or other pathology is warranted, particularly in men over 40 3, 4
• Avoid empirical fluoroquinolones in high-risk settings (urology patients, recent fluoroquinolone use) due to resistance concerns 1

Follow-Up Considerations

• Monitor for clinical improvement within 48-72 hours of appropriate antibiotic therapy 1
• If hematuria persists after infection resolution, consider urological referral to evaluate for underlying malignancy, stones, or structural abnormalities 3, 4
• Risk of malignancy with gross hematuria exceeds 10% in primary care settings, warranting thorough evaluation 3