Cystitis and Upper Urinary Tract Infections (UTI) in Men

Background

• Most urinary tract infections in men are a subset of complicated urinary tract infections.
• Most arise in the setting of abnormal urinary tracts, instrumentation, or obstruction such as with benign prostatic hypertrophy.
• Symptoms of cystitis are similar to those in women and include dysuria, frequency, and urgency.
• Fever and flank pain should raise suspicion for pyelonephritis.

Evaluation

• Diagnosis is based on:
  • signs and symptoms of UTI
    • dysuria, frequency, urgency, and suprapubic pain with cystitis.
    • fever, chills, flank pain, nausea and vomiting may also be present with pyelonephritis.
    • fever and chills without flank pain may represent systemic infection or other complication.
  • presence of bacteriuria
    • bacterial count ≥ 10 ⁵ CFU/mL in single midvoid urine sample for men.
    • bacterial count ≥ 10 ²CFU/mL in single urine sample from patient with catheter.
    • lower bacterial counts may indicate infection in proper clinical context.
• Imaging may be considered for:
  • evaluation of urologic abnormalities, but may not be useful in men < 45 years or older men without symptoms of voiding difficulties or hematuria.
  • patients with sepsis or delayed response to antimicrobial treatment.
• A digital rectal examination should be performed to assess for prostatitis.

Management

• Initial empiric therapy should be based on local antibiotic resistance patterns and the individual patient's history.
• Common options for empiric therapy include:
  • trimethoprim-sulfamethoxazole (cotrimoxazole) 160/800 mg orally twice daily
  • ciprofloxacin 500 mg orally twice daily
  • levofloxacin 500 mg orally once daily
• Definitive therapy should be based on culture and antibiotic susceptibility testing results due to the wide variety of potential causative organisms.
• Consider need for source control, such as immediate relief of outlet obstruction such as that due to an enlarged prostate or kidney stone.
• No definitive data is available to recommend the optimal duration of therapy but common clinical practice is to treat 7 days for acute cystitis and 10-14 days for pyelonephritis.
• Evaluate men with persistent fever or delayed response for complications, such as prostatitis or renal abscess.