What is the recommended prophylaxis for a male patient with recurrent Urinary Tract Infections (UTIs)?

Prophylaxis for Men with Recurrent UTI

For men with recurrent UTIs, first address any underlying urological abnormalities (especially benign prostatic hyperplasia causing obstruction), and only after non-antimicrobial interventions have failed should you consider continuous antimicrobial prophylaxis with trimethoprim-sulfamethoxazole 40/200 mg or trimethoprim 100 mg daily. 1

Critical First Step: Recognize UTIs in Men Are Always Complicated

• All UTIs in men are classified as complicated UTIs and require more extensive evaluation than in women 2, 1
• Recurrent UTI is defined as ≥3 UTIs per year or ≥2 UTIs in the last 6 months 1
• Confirm each symptomatic episode with urine culture before initiating treatment 1
• Treatment duration for acute episodes should be 7-14 days (14 days when prostatitis cannot be excluded) 2

Mandatory Diagnostic Workup Before Prophylaxis

You must evaluate for correctable anatomical/functional abnormalities that are driving the recurrent infections:

• Urinary tract obstruction at any site (most commonly benign prostatic hyperplasia) 2, 1
• Post-void residual urine measurement to assess for incomplete bladder emptying 1
• Presence of foreign bodies (catheters, stents) 2, 1
• Vesicoureteral reflux 1
• Recent history of urinary tract instrumentation 1
• Screen for diabetes mellitus and immunosuppression 1
• Digital rectal examination to evaluate for prostate disease 2

Common pitfall: Patients with bacterial cystitis recurring rapidly (within 2 weeks of initial treatment) should be reclassified as having bacterial persistence and require imaging to detect treatable structural conditions 3

Treatment Hierarchy: Address the Cause First

1. Correct Underlying Urological Abnormalities (Primary Strategy)

• Surgical management of benign prostatic hyperplasia is recommended for men with recurrent UTIs due to BPH when refractory to other therapies 1, 4
• Appropriate management of the urological abnormality is mandatory before considering prophylaxis 2
• Consider referral to urology if BPH is causing recurrent UTIs 1

2. Acute Episode Treatment (Culture-Directed)

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days is first-line for men 1
• Alternative: Ciprofloxacin 500-750 mg twice daily for 7 days (if fluoroquinolone resistance <10%) 2
• Tailor treatment to the shortest effective duration based on culture results 1
• Adhere to antimicrobial stewardship principles and local antibiogram patterns 1

3. Antimicrobial Prophylaxis (Last Resort)

Only consider prophylaxis when:

• Non-antimicrobial interventions have failed 1
• Underlying anatomical abnormalities have been addressed or cannot be corrected 2

Prophylactic regimens:

• Trimethoprim-sulfamethoxazole 40/200 mg daily (half of a single-strength tablet) 5, 6, 7
• Trimethoprim 100 mg daily 5
• Nitrofurantoin 50 mg daily (alternative option) 5
• Duration typically 6-12 months 5

Non-Antimicrobial Interventions to Try First

• Increase fluid intake and avoid prolonged holding of urine 5
• Maintain adequate hydration 5
• Consider methenamine hippurate as a non-antibiotic alternative 5

Key Differences from Women

Unlike postmenopausal women where vaginal estrogen and probiotics are first-line prevention strategies 5, men require:

• More aggressive evaluation for structural abnormalities 2, 1
• Longer treatment duration for acute episodes (7-14 days vs 3-5 days) 2, 1
• Surgical correction of BPH as primary prevention when present 1, 4

Microbiology Considerations

• E. coli remains most common (75% of cases) 3
• However, men have broader microbial spectrum including Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 2, 3
• Antimicrobial resistance is more likely in men than in women with uncomplicated UTIs 2
• Always obtain culture and susceptibility testing before initiating prophylaxis 1