Treatment of Urinary Tract Infections in Men
For men with UTI, obtain a urine culture before starting antibiotics and treat with a 7-day course of ciprofloxacin or trimethoprim-sulfamethoxazole if the patient is afebrile and hemodynamically stable, or extend to 14 days if prostatitis cannot be excluded. 1, 2, 3
Initial Diagnostic Approach
Always obtain urine culture and susceptibility testing before initiating therapy in men, as all male UTIs are classified as complicated UTIs by the European Association of Urology 1, 2
The microbial spectrum is broader than in uncomplicated UTIs, including E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp., with higher rates of antimicrobial resistance 1, 2
Empiric Antibiotic Selection
For oral empiric therapy:
Fluoroquinolones (ciprofloxacin or levofloxacin) are first-line options ONLY if local resistance rates are <10% 1, 2
Do NOT use fluoroquinolones if the patient has used them in the last 6 months 1, 2
Trimethoprim-sulfamethoxazole is an alternative oral option for empiric therapy 4, 3
For patients requiring parenteral therapy (systemic symptoms):
- Amoxicillin plus an aminoglycoside 1, 2
- Second-generation cephalosporin plus an aminoglycoside 1, 2
- Intravenous third-generation cephalosporin 1, 2
Treatment Duration: The Critical Decision Point
This is where the evidence diverges and requires careful clinical judgment:
7-Day Course (Preferred for Uncomplicated Cases)
A 2021 JAMA trial demonstrated that 7 days of ciprofloxacin or trimethoprim-sulfamethoxazole was noninferior to 14 days in afebrile men with 93.1% symptom resolution in the 7-day group versus 90.2% in the 14-day group 3
Use 7 days when the patient is hemodynamically stable and has been afebrile for at least 48 hours 1
This shorter duration reduces antibiotic exposure and adverse events (20.6% vs 24.3% in the 7-day vs 14-day groups) 3
14-Day Course (Required for Specific Situations)
Extend to 14 days when prostatitis cannot be excluded, as this is the European Urology guideline recommendation 1, 2
The American Urological Association cites a 2017 trial showing 7-day ciprofloxacin was inferior to 14-day treatment in men (86% vs 98% cure rate), though this conflicts with the more recent 2021 JAMA trial 2
Given the conflicting evidence, err on the side of 14 days if there is any clinical suspicion of prostatic involvement (perineal pain, obstructive symptoms, tender prostate on exam) 1, 2
Special Situations
Catheter-associated UTIs:
- Remove or change the catheter when possible before or during treatment 1
Recurrent infections:
- Evaluate for structural or functional urinary tract abnormalities with imaging studies 1, 2
- Management of underlying urological abnormalities is mandatory alongside antibiotic therapy 1, 2
Tailoring Therapy Based on Culture Results
Switch from empiric to targeted therapy once culture and susceptibility results are available 1, 2
Consider follow-up urine culture in complicated cases to confirm eradication 2
Critical Pitfalls to Avoid
Failing to obtain urine culture before starting antibiotics - this is the most common error 1
Using fluoroquinolones empirically in areas with resistance rates >10% or in patients recently exposed to them 1, 2
Treating all male UTIs with 14-day courses when 7 days may be appropriate for afebrile, hemodynamically stable patients without prostatic involvement 1, 3
Not evaluating for and addressing underlying anatomical abnormalities that predispose to recurrent infections 1, 2