What is the appropriate management for a male patient with leukocyturia (white blood cells in the urine)?

Management of Leukocyturia in Adult Males

In adult males with white blood cells in the urine (leukocyturia), the primary diagnostic imperative is to obtain a urine culture to distinguish between infectious and non-infectious causes, as leukocyturia alone is neither sensitive nor specific for urinary tract infection and requires clinical correlation with symptoms and culture results. 1, 2

Initial Diagnostic Approach

The evaluation must begin with specific assessment of:

• Presence or absence of dysuria, frequency, urgency, or suprapubic pain - these symptoms combined with leukocyturia suggest infectious etiology requiring culture 3, 1
• Sexual history and risk factors - in sexually active men under 35, urethritis from Chlamydia trachomatis or Neisseria gonorrhoeae is more common than cystitis 3, 1
• Age and prostate symptoms - in older men, leukocyturia may reflect benign prostatic hyperplasia with urinary stasis rather than infection 3, 1
• Recent instrumentation or catheterization - increases risk of infection and complicates interpretation 4

Critical Diagnostic Testing

Urinalysis findings must be interpreted cautiously, as leukocyturia has poor predictive value for infection in males with chronic lower urinary tract symptoms:

• Leukocyte esterase has only 56-59% sensitivity and 66-84% specificity for UTI in men with lower urinary tract symptoms 5
• Nitrite testing is even less reliable with only 10-20% sensitivity, though 97-99% specificity 5
• Microscopic pyuria (≥10 WBC/hpf) has 56-66% sensitivity and 72-73% specificity 5
• The absence of pyuria effectively excludes bacteriuria (negative predictive value approaches 100%), but presence of pyuria does not confirm infection 3

Therefore, urine culture is mandatory - dipstick and microscopy alone cannot diagnose or exclude UTI in symptomatic males and should be abandoned as sole diagnostic tools in this context 5

Differential Diagnosis Based on Clinical Context

Symptomatic Young Men (<35 years, sexually active)

If urethral discharge or dysuria is present:

• Gram stain of urethral secretions showing ≥5 WBC per oil immersion field confirms urethritis 3
• Test specifically for N. gonorrhoeae and C. trachomatis using nucleic acid amplification on first-void urine 3, 1
• In asymptomatic men whose partners have chlamydia, a urinary WBC count >12.5 WBC/μL has 86.9% sensitivity and 88.6% specificity for predicting chlamydial infection 6
• Treat empirically for both gonorrhea and chlamydia if testing unavailable 3

Older Men with Lower Urinary Tract Symptoms

Leukocyturia in this population is frequently non-infectious:

• In men with chronic prostatitis/chronic pelvic pain syndrome, 50% have ≥5 WBC/hpf in expressed prostatic secretions, but only 8% have localized bacterial cultures - identical to the 8.3% rate in asymptomatic controls 7
• Asymptomatic men commonly have leukocyturia: 40% have ≥5 WBC/hpf and 20% have ≥10 WBC/hpf in expressed prostatic secretions 7
• The high prevalence of WBCs in asymptomatic men raises serious questions about using leukocyte counts as diagnostic criteria 7

Therefore, in older men with leukocyturia but no acute dysuria/frequency:

• Obtain urine culture before treating - do not assume infection based on WBCs alone 1, 5
• Assess for BPH using digital rectal exam, International Prostate Symptom Score (IPSS), and consider PSA if life expectancy >10 years 3, 1
• Measure post-void residual to detect urinary retention (>100-200 mL is significant) 1, 8
• Consider 3-day frequency-volume chart if nocturia is prominent to distinguish nocturnal polyuria from reduced bladder capacity 1, 8

Management Algorithm

If Culture is Positive (≥10⁵ CFU/mL)

• All UTIs in men are considered complicated and require 7-14 days of antibiotic therapy based on culture sensitivities 1
• Initiate empiric therapy based on local resistance patterns while awaiting culture results 1
• Investigate for underlying structural abnormalities, stones, or obstruction 1

If Culture is Negative Despite Leukocyturia

This scenario is common and requires systematic evaluation:

• Rule out sexually transmitted infections if sexually active, even without urethral discharge 3, 6
• Assess for BPH - offer alpha-blocker trial (e.g., tamsulosin) if obstructive symptoms present, with reassessment at 2-4 weeks 1, 8
• Consider non-infectious causes: interstitial cystitis, urolithiasis, bladder cancer (especially with smoking history), or contamination 3, 2
• Optional: urine cytology if irritative symptoms predominate with smoking history to evaluate for bladder carcinoma in situ 3

Mandatory Specialist Referral

Refer to urology before initiating treatment if any of the following are present:

• Hematuria (gross or microscopic) - requires complete urologic evaluation 3, 1
• Abnormal PSA or digital rectal exam suspicious for prostate cancer 3, 1
• Neurological disease affecting bladder function 1, 4
• Severe obstruction (Qmax <10 mL/second on uroflowmetry) 1, 8
• Recurrent infections or treatment failure 1, 8
• Elevated post-void residual suggesting urethral stricture or bladder neck contracture 4

Common Pitfalls to Avoid

• Do not treat leukocyturia as UTI without culture confirmation - this leads to unnecessary antibiotic use and missed diagnoses 5
• Do not rely on dipstick alone - it has inadequate sensitivity and specificity in males with chronic symptoms 5
• Do not dismiss leukocyturia in asymptomatic men as always benign - it may indicate early chlamydial infection in high-risk populations 6
• Do not assume chronic prostatitis based on leukocyturia alone - asymptomatic men have similar WBC counts 7
• Do not start anticholinergics for irritative symptoms without first measuring post-void residual - risk of precipitating acute retention 8, 4