What should be done for a known adult male patient with a urinary tract infection (UTI) on the 5th day of cefixime (cephalosporin antibiotic) 400mg, who has experienced a decrease in dysuria with good hydration, but had a recurrence of dysuria after masturbation?

Reassure and Continue Current Therapy

The recurrence of dysuria after masturbation is most likely mechanical irritation rather than treatment failure, and you should reassure the patient to continue the current cefixime regimen through completion of a 7-14 day course. 1

Understanding the Clinical Context

UTI in Males is Complicated by Definition

• All UTIs in males are classified as complicated UTIs according to the European Association of Urology, which fundamentally changes the treatment approach 1
• Male UTI requires 7-14 days of antibiotic therapy (14 days when prostatitis cannot be excluded), not the shorter courses used for uncomplicated cystitis in women 1
• The patient is only on day 5, which is insufficient duration for a male UTI regardless of symptom improvement 1

Mechanical Irritation vs. Treatment Failure

• Dysuria recurring immediately after masturbation strongly suggests mechanical urethral irritation rather than antibiotic failure, especially given:
  • Prior symptom improvement with hydration 1
  • Only 5 days into appropriate therapy 1
  • Temporal relationship to physical manipulation 1

Recommended Management Algorithm

Continue Current Antibiotic Course

• Complete a full 7-14 day course of cefixime 400mg daily (lean toward 14 days if prostatitis cannot be excluded) 1
• Cefixime is an appropriate oral cephalosporin for complicated UTI, though not first-line 1, 2
• The 2024 EAU guidelines support oral cephalosporins like cefpodoxime and ceftibuten for complicated UTI; cefixime has similar spectrum 1

Supportive Measures

• Maintain aggressive hydration as this has already demonstrated benefit 1
• Advise temporary sexual abstinence until symptoms fully resolve and treatment is complete 1
• Avoid urethral irritation during the treatment period 1

Red Flags Requiring Reassessment

Monitor for signs that would indicate true treatment failure rather than mechanical irritation:

• Fever, chills, or systemic symptoms suggesting pyelonephritis or prostatitis 1
• Persistent dysuria beyond 24-48 hours after the mechanical event 1
• Worsening symptoms despite continued therapy 1
• New symptoms such as perineal pain, obstructive voiding, or hematuria 1

When to Consider Treatment Modification

Indications for Culture and Sensitivity

• If symptoms persist or worsen after 7 days of therapy, obtain urine culture and tailor antibiotics to susceptibility results 1
• Culture should have been obtained before starting antibiotics ideally, but can still guide therapy if treatment fails 1

Alternative Antibiotic Options if Needed

If true treatment failure occurs (not the current scenario):

• Fluoroquinolones (ciprofloxacin 500-750mg BID or levofloxacin 750mg daily) are preferred for complicated UTI in males when resistance patterns allow 1
• Trimethoprim-sulfamethoxazole 160/800mg BID for 14 days is an alternative 1
• Consider parenteral therapy if patient becomes systemically ill 1

Critical Pitfalls to Avoid

Do Not Stop Antibiotics Prematurely

• Stopping at day 5-7 based on symptom improvement risks treatment failure and recurrence in male UTI 1
• Male anatomy and potential prostatic involvement require longer courses than female uncomplicated cystitis 1

Do Not Misinterpret Mechanical Irritation as Resistance

• Transient symptom recurrence after urethral manipulation is expected and does not indicate antibiotic failure 1
• True treatment failure manifests as persistent or progressive symptoms, not isolated post-coital/post-masturbation discomfort 1

Consider Underlying Urological Abnormalities

• If symptoms recur after completing full therapy, evaluate for anatomical abnormalities, obstruction, or chronic prostatitis 1
• Recurrent male UTI warrants urological investigation 1