> Table of Contents > Urinary Tract Infection (UTI) in Males
Urinary Tract Infection (UTI) in Males
Amy L. Wiser, MD
image BASICS
DESCRIPTION
  • Cystitis is an infection of the lower urinary tract, usually resulting from a single gram-negative enteric bacteria. (See also “Prostatitis,” “Pyelonephritis,” and “Urethritis.”)
  • System(s) affected: renal/urologic
  • Synonym(s): urinary tract infection (UTI); cystitis
  • Conventional consideration of UTI in male newborn, infant, and elderly men is complicated, with associated functional/structural mechanisms.
  • In otherwise healthy males ages 15 to 50 years, UTI is uncommon and considered uncomplicated.
EPIDEMIOLOGY
Incidence
  • Approximately 20% of UTIs occur in men (1).
  • Predominant age: increases with age
  • Uncommon in men <50 years of age
  • 6 to 8 infections/10,000 men aged 21 to 50 years (2)
Prevalence
Lifetime prevalence approximately 14% (1)
ETIOLOGY
  • Escherichia coli (majority of infections)
  • Klebsiella
  • Enterobacter
  • Enterococcus
  • Proteus
  • Serratia
  • Citrobacter
  • Providencia
  • Streptococcus faecalis and Staphylococcus sp.
  • Pseudomonas and Morganella (more common in elderly and catheterized patients)
  • Pathogenesis—bacterial entry into urinary tract via ascension or bladder instrumentation
Genetics
Not applicable
RISK FACTORS
  • Age
  • Obesity (3)
  • History of prior UTI
  • Outlet obstruction
    • Benign prostatic hypertrophy (BPH)—incidence of 33% of men with UTIs (4)
    • Urethral stricture
    • Calculi
  • Cognitive impairment
  • Fecal incontinence
  • Urinary incontinence
  • Anal intercourse
  • Recent urologic surgery
  • Infection of the prostate/kidney
  • Urinary tract instrumentation, catheterization
  • Immunocompromised host
  • Diabetes
  • Bladder diverticula
  • Neurogenic bladder
  • Institutionalization
  • Uncircumcised
  • Engaging in sex with an infected female partner (2)
GENERAL PREVENTION
  • Prompt treatment of predisposing factors
  • Use a catheter only when necessary; if needed, use aseptic technique and closed system and remove as soon as possible.
  • Currently, cranberry products are not recommended for preventing UTIs in men (5).
COMMONLY ASSOCIATED CONDITIONS
  • Acute bacterial pyelonephritis
  • Chronic bacterial pyelonephritis
  • Urethritis
  • Prostatitis
  • Prostatic hypertrophy
  • Prostate cancer
Geriatric Considerations
Bacteriuria is common among the elderly; may be related to functional status and usually is transient. Of men older than 65 years of age, 5-10% have asymptomatic bacteriuria (ASB). If ASB is noted, no treatment is needed (6,7).
Pediatric Considerations
Can be associated with obstruction to normal flow of urine, such as vesicoureteral reflux. Unique diagnostic criteria and evaluation recommendations exist (see below) (8).
image DIAGNOSIS
PHYSICAL EXAM
  • Suprapubic tenderness
  • Costovertebral angle (CVA) tenderness and/or fever may be present with concomitant pyelonephritis/prostatitis/epididymitis.
DIFFERENTIAL DIAGNOSIS
  • Anatomic/functional pathology of the urinary tract
  • Urethritis/STIs
  • Infections in other sites of the genitourinary tract (e.g., epididymis, prostatitis). More than 90% of men with febrile UTI have concomitant prostate infection (9).
DIAGNOSTIC TESTS & INTERPRETATION
  • Urine dipstick/manual microscopy of clean catch midstream void showing the following:
    • Pyuria (>10 WBCs)
    • Bacteriuria
    • Positive leukocyte esterase (in males: sensitivity, 78%; specificity, 59%; positive predictive value [PPV], 71%; negative predictive value [NPV], 67%)
    • Positive nitrite (in males: sensitivity, 47%; specificity, 98%; PPV, 96%; NPV, 59%)
    • In general, leukocyte esterase is more sensitive and nitrite is more specific in detecting UTI (10).
  • Automated microscopy/flow cytometry that measures cell counts and bacterial counts can be used to improve screening characteristics (sensitivity, 92%; specificity, 55%; PPV, 47%; NPV, 97%). The high NPV of these screening tests allows for more judicious use of urine culture (11).
  • Urine culture: > 100,000 colony-forming units (CFU; >105 CFU) of bacteria/mL of urine confirm diagnosis.
  • Lower counts, such as >103 CFU, also may be indicative of infection, especially in the presence of pyuria.
  • Diagnosis in infants and children <24 months made on the basis of both pyuria and 50,000 CFU on culture.
  • Renal and bladder ultrasound recommended in infants and young children after first confirmed UTI.
Follow-Up Tests & Special Considerations
  • Consider assessing for risk factors for STIs, as chlamydial/gonococcal urethritis can mimic a UTI. If risk factors are present, use urine nucleic acid amplification tests to identify gonococcal and Chlamydia infections and treat as necessary.
  • Further urologic evaluation is warranted to rule out other disorders in men with recurrent UTI, febrile UTI, or pyelonephritis. This may include the following:
    • Ultrasound
    • Cystoscopy
    • Urodynamics
    • IV pyelography
  • Value of a urologic evaluation in a single uncomplicated UTI has not been determined (9).
  • Antibiotics prior to culture or phenazopyridine prior to urine dipstick can alter results.
Test Interpretation
Depends on site of infection
P.1087

image TREATMENT
GENERAL MEASURES
  • Hydration
  • Analgesia, if required
  • Patient with indwelling catheters
    • If asymptomatic bacterial colonization, no need to treat (sterilization of urine is not possible, and resistant organisms may take up residence).
    • If symptomatic of acute infection, institute treatment.
MEDICATION
First Line
  • Acute, uncomplicated cystitis
    • Treat empirically; strongly consider if nitrite positive, using local resistance patterns or based on culture and sensitivity results for 7 days (9)[B]. For empirical therapy, a fluoroquinolone or trimethoprim-sulfamethoxazole DS usually used to treat the most likely pathogens (9).
  • Complicated, febrile, or recurrent infection
    • Prescribe a minimum of 2 weeks antibiotics based on antimicrobial sensitivities with repeat urine check after the treatment. In men with febrile UTI or pyelonephritis, prostatic involvement also has to be considered. Treatment of concomitant prostatitis requires antimicrobials with good prostatic tissue and fluid penetration (fluoroquinolones) (9)[B].
Second Line
According to culture and sensitivity results and patient's history
ISSUES FOR REFERRAL
Further urologic evaluation and referral are warranted to rule out other disorders in men with recurrent UTI, febrile UTI, or pyelonephritis.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • Inability to tolerate oral medications
  • Acute renal failure
  • Suspected sepsis
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Close follow-up until clinically well
DIET
Encourage adequate fluid intake.
PATIENT EDUCATION
For patient education materials about this topic that have been reviewed favorably, contact the National Kidney Foundation, 30 E. 33rd Street, Suite 1100, New York, NY 10016; 212-889-2210.
PROGNOSIS
Clearing of infections with appropriate antibiotic treatment
REFERENCES
1. Griebling TL. Urologic diseases in America project: trends in resource use for urinary tract infections in men. J Urol. 2005;173(4):1288-1294.
2. Wagenlehner FM, Weidner W, Pilatz A, et al. Urinary tract infections and bacterial prostatitis in men. Curr Opin Infect Dis. 2014;27(1):97-101.
3. Semins MJ, Shore AD, Makary MA, et al. The impact of obesity on urinary tract infection risk. Urology. 2012;79(2):266-269.
4. Drekonja DM, Rector TS, Cutting A, et al. Urinary tract infection in male veterans: treatment patterns and outcomes. JAMA Intern Med. 2013;173(1):62-68.
5. Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2012;(10):CD001321.
6. Rowe TA, Juthani-Mehta M. Diagnosis and management of urinary tract infection in older adults. Infect Dis Clin North Am. 2014;28(1):75-89.
7. Matthews SJ, Lancaster JW. Urinary tract infections in the elderly population. Am J Geriatr Pharmacother. 2011;9(5):286-309.
8. Roberts KB, Downs SM, Finnell SM, et al. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595-610.
9. Grabe M, Bishop MC, Bjerklund-Johansen TE, et al. Uncomplicated urinary tract infections in adult. In: Guidelines on Urological Infections. Arnhem, The Netherlands: European Association of Urology; 2013:15-25.
10. Koeijers JJ, Kessels AG, Nys S, et al. Evaluation of the nitrite and leukocyte esterase activity tests for the diagnosis of acute symptomatic urinary tract infection in men. Clin Infec Dis. 2007;45(7):894-896.
11. Evans R, Davidson MM, Sim LR, et al. Testing by Sysmex UF-100 flow cytometer and with bacterial culture in a diagnostic laboratory: a comparison. J Clin Pathol. 2006;59(6):661-662.
Additional Reading
&NA;
  • Coupat C, Pradier C, Degand N, et al. Selective reporting of antibiotic susceptibility data improves the appropriateness of intended antibiotic prescriptions in urinary tract infections: a case-vignette randomised study. Eur J Clin Microbiol Infect Dis. 2013;32(5):627-636.
  • Foxman B. Urinary tract infection syndromes: occurrence, recurrence, bacteriology, risk factors, and disease burden. Infect Dis Clin North Am. 2014;28(1):1-13.
  • Gerber GS, Brendler CB. Evaluation of the urologic patient: history, physical examination, and urinalysis. In: Walsh PC, Retik AB, Vaughn ED Jr, et al, eds. Campbell's Urology. 8th ed. Philadelphia, PA: Saunders; 2002:107.
  • Koeijers JJ, Verbon A, Kessels AG, et al. Urinary tract infection in male general practice patients: uropathogens and antibiotic susceptibility. Urology. 2010;76(2):336-340.
See Also
&NA;
  • Prostate Cancer; Prostatic Hyperplasia, Benign (BPH); Prostatitis; Pyelonephritis; Urethritis
  • Algorithms: Dysuria; Urethral Discharge
Codes
&NA;
ICD10
  • N39.0 Urinary tract infection, site not specified
  • N30.90 Cystitis, unspecified without hematuria
  • N30.91 Cystitis, unspecified with hematuria
Clinical Pearls
&NA;
  • Cystitis is an infection of the lower urinary tract, usually resulting from a single gram-negative enteric bacteria.
  • Risk factors/causes: age, history of UTI, obesity, BPH, cognitive impairment, fecal incontinence, urinary incontinence, anal intercourse, recent urologic surgery, catheterization, infection of the prostate/kidney, urinary tract instrumentation, immunocompromised host, diabetes, neurogenic bladder, outlet obstruction, sex with infected female partner
  • Evaluation: urinalysis, urine culture, STI testing (e.g., gonorrhea, Chlamydia by culture/DNA probe)
  • Treat empirically with fluoroquinolones or trimethoprim-sulfamethoxazole DS for 7 days.