URINARY TRACT INFECTION IN MALES

URINARY TRACT INFECTION IN MALES - Scott A. Fields, MD
BASICS
DESCRIPTION
Cystitis is an infection of the lower urinary tract, usually resulting from a single gram-negative enteric bacteria. (See separate chapters for information on prostatitis, pyelonephritis, and nongonococcal urethritis.)
• System(s) Affected: Renal/Urologic
• Synonym(s): UTI; Cystitis
GENERAL PREVENTION
• Prompt treatment of predisposing factors
• Catheter use only when necessary; if needed, use aseptic technique and closed system, with removal as soon as possible
EPIDEMIOLOGY
• Predominant age: Increases with age. Uncommon in men 50 years old; 8 infections/10,000 men, ages 21-50 years
• Predominant sex: Male only (for this discussion)
Prevalence
Not common
RISK FACTORS
• Benign prostatic hypertrophy
• Cognitive impairment
• Fecal incontinence
• Urinary incontinence
• Anal intercourse
• Recent urologic surgery, catheterization
• Infection of the prostate or kidney
• Urinary tract instrumentation
• Immunocompromised host
• Outlet obstruction
Genetics
No specific genetic pattern
ETIOLOGY
• Escherichia coli (80% of infections)
• Klebsiella
• Enterobacter
• Proteus
• Pseudomonas
• Serratia
• Streptococcus faecalis and Staphylococcus
ASSOCIATED CONDITIONS
• Acute bacterial pyelonephritis
• Chronic bacterial pyelonephritis
• Urethritis
• Prostatitis
• Prostatic hypertrophy
• Prostate cancer
ALERT
Geriatric Considerations
Bacteriuria is common in the elderly, appears related to functional status, and is usually transient. If asymptomatic bacteriuria is noted, no treatment is needed.
Pediatric Considerations
Usually associated with obstruction to normal flow of urine, such as vesicoureteral reflux

DIAGNOSIS
SIGNS AND SYMPTOMS
• Urinary frequency
• Urinary urgency
• Dysuria
• Hesitancy
• Slow urinary stream
• Dribbling of urine
• Nocturia
• Suprapubic discomfort
• Low back pain
• Hematuria
• Systemic symptoms (chills, fever) present with concomitant pyelonephritis or prostatitis
History
Careful history and physical exam
TESTS
Urologic investigations are necessary to rule out other disorders.
Lab
• Pyuria
• Bacteriuria
• Urine dipstick leukocyte esterase (75-90% sensitivity, 95% specificity) and nitrate (35-85% sensitivity, 70% specificity)
• Urine culture: 10 high-power colonies of pathogens (or counts >100,000 bacteria/mL of urine) confirm diagnosis (E. coli, Klebsiella, Pseudomonas, other agents). Lower counts may also be indicative of infection, especially in presence of pyuria.
• Segmented bacteriologic localization cultures
- Variable block 1 (VB1): Collect 5-10 mL of urine from patient's initial voiding.
- VB2: Then a sample of sterile midstream urine is obtained.
- Expressed prostatic secretion (EPS): Prostatic massage is performed and EPS is collected from the meatus.
- VB3: Patient completes voiding, and fourth sample is collected.
- Cultures and sensitivity are collected from each specimen.
• Drugs that may alter lab results: Antibiotics prior to culture
Imaging
• IV pyelography
• Cystoscopy
• Ultrasound
Pathological Findings
Depends on site of infection
DIFFERENTIAL DIAGNOSIS
• Anatomic or functional pathology
• Urethritis
• Infections in other sites of the genitourinary tract (e.g., epididymis)
TREATMENT
STABILIZATION
Outpatient treatment, except for acute illness with toxicity or kidney failure
GENERAL MEASURES
• Hydration; analgesia if required
• Discontinue sexual activity until cured.
• 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
Diet
No special diet
Activity
As tolerated
MEDICATION (DRUGS)
First Line
• Acute infection, 1st infection, no risk factors for treatment: Prescribe 7-10 days of oral antibiotics, either empirically or based on culture and sensitivity results. For empiric therapy, trimethoprim-sulfamethoxazole (SMX-TMP) b.i.d. will usually treat the most likely pathogens. (1-4,6-8)[C]
• Complicated or recurrent infection: Prescribe 14-21 days of antibiotics based on antimicrobial sensitivities with repeat urine check after the treatment. (1-4,6-8)[C]
• For contraindications, precautions, and possible significant interactions, refer to the manufacturer's information.
Second Line
According to culture and sensitivity results and patient's history
FOLLOW-UP
PROGNOSIS
Clearing of infections with appropriate antibiotic treatment
COMPLICATIONS
• Pyelonephritis
• Ascending infection
• Recurrent infection
PATIENT MONITORING
• Close follow-up until clinically well
• Repeat urinalysis after treatment.
REFERENCES
1. Finn SD. Urinary tract infectionsdiagnosis and treatment in women and men. Consultant. 1992;10:43-58.
2. Hooton TM, Stamm WE. Management of acute uncomplicated urinary tract infection in adults. Med Clin North Am. 1991;75:339-357.
3. Harrington RD, Hooton TM. Urinary tract infection risk factors and gender. J Gend Specif Med. 2000;3:27-34.
4. Hatton J, Hughes M, Raymond CH. Management of bacterial urinary tract infections in adults. Ann Pharmacother. 1994;28:1264-1272.
5. Khan AJ, Schaeffer HA, Evans H. Urinary tract infections in adolescent boys. J Natl Med Assoc. 1996;88:25-26.
6. Lipsky BA. Urinary tract infections in men. Epidemiology, pathophysiology, diagnosis, and treatment. Ann Intern Med. 1989;110:138-150.
7. Lipsky BA. Managing urinary tract infections in men. Hosp Pract (Off Ed). 2000;35:53-59, discussion 59-60.
8. Naber KG, et al. Urinary Tract Infection (UTI) Working Group of the Health Care Office (HCO) of the European Association of Urology (EAU). EAU guidelines for the management of urinary and male genital tract infections. Urinary Tract Infection (UTI) Working Group of the Health Care Office (HCO) of the European Association of Urology (EAU). Eur Urol. 2001;40:576-588.
MISCELLANEOUS
See also: Prostatic cancer; Prostatic hyperplasia, benign (BPH); Prostatitis; Pyelonephritis