Lower Urinary Tract Infection (UTI) in Males Clinical presentation For patients in care homes see UTI in adults where IV Antibiotics in the community may be appropriate (under development) History and examination Consider background Lower Urinary Tract Symptoms (LUTS) See Lower Urinary Tract Symptoms (LUTS) in Males (under development) RED FLAG! Cancer suspected Refer 2 week wait urology Evidence of pyelonephritis/ bloodstream infection Diagnosis of UTI Consider differential diagnoses Management Considerations for catheterised patients Considerations for the elderly - age 65 years Follow-up For patients in care homes see UTI in adults where IV Antibiotics in the community may be appropriate (under development) RED FLAG! Cancer suspected Consider referral to nephrologist UTI complicated by pyelonephritis/ bloodstream infection Consider referral to a urologist Refer 2 week wait urology Consider background Lower Urinary Tract Symptoms (LUTS) See Lower Urinary Tract Symptoms (LUTS) in Males (under development)
Clinical presentation Symptoms of lower UTI in men: dysuria frequency urgency nocturia suprapubic discomfort pain in the following may be present: flank loin lower back scrotum perineum Signs of UTI (may be absent): suprapubic tenderness cloudy, bloody, or foul-smelling urine - isolated visible haematuria without symptoms is unlikely to be due to lower UTI fever consider the possibility of pyelonephritis in patients presenting with symptoms or signs of UTI who have a history of fever or back pain systemic features are suggestive of pyelonephritis or blood stream infection, e.g.: flank pain and tenderness signs of dehydration systemic features of sepsis, e.g. rigors, sweats, pallor, tachycardia nausea and vomiting high temperature (> 38 C) costovertebral angle tenderness
History and examination Ask about: nature, duration, and severity of symptoms consider underlying LUTS and the possibility of chronic retention of urine and assess for prostatic symptoms consider background LUTS previous UTIs or epididymo-orchitis medical history genito-urinary symptoms suggestive of STD (STD; important differential diagnosis and may co-exist with UTI): penile discharge perineal pain tender scrotal contents (usually epididymis) features that predispose to UTI, e.g.: immunosuppression renal calculi anatomical urinary tract abnormality, especially bladder outlet obstruction recurrent UTI refractory UTI recent hospital stay or catheter diabetes mellitus (DM) Assess for features of pyelonephritis and blood stream infection, e.g.: flank pain and tenderness signs of dehydration systemic features of sepsis, e.g. rigors, sweats, pallor, tachycardia nausea and vomiting high temperature costovertebral angle tenderness Patients with indwelling catheters: look for associated localising or systemic features, e.g.: loin tenderness suprapubic tenderness exclude other sources of infection
RED FLAG! Cancer suspected Refer urgently if: male adult patients of any age present with painless macroscopic haematuria male patients with symptoms suggestive of a UTI also present with macroscopic haematuria: investigations should be undertaken to diagnose and treat the infection before consideration of referral if infection is not confirmed the patient should be referred urgently all adult patients age 40 years present with recurrent or persistent UTI associated with haematuria patients age 50 years who are found to have unexplained microscopic haematuria any patient with an abdominal mass identified clinically or on imaging that is thought to be arising from the urinary tract in patients age < 50 years with microscopic haematuria - the urine should be tested for proteinuria and serum creatinine levels measured: those with proteinuria or raised serum creatinine should be referred to a renal physician if there is no proteinuria and serum creatinine is normal, a non-urgent referral to a urologist should be made Raised PSA
Evidence of pyelonephritis/ bloodstream infection Suspect pyelonephritis if any of the following features supervene: flank pain and tenderness signs of dehydration systemic features of sepsis, e.g. rigors, sweats, pallor, tachycardia nausea and vomiting high temperature (> 38 C) costovertebral angle tenderness
Diagnosis of UTI There is no evidence to suggest the best method of diagnosing bacterial UTI in men. Scottish Intercollegiate Guidelines Network (SIGN) recommends the following approach: urine microscopy should not be undertaken in clinical settings in primary or secondary care in all men with symptoms of UTI a urine sample should be taken for culture in patients with a history of fever or back pain the possibility of upper UTI should be considered Diagnosis of significant bacteriuria: a colony count of greater than or equal to 10 3 cfu/ml may be sufficient to diagnose UTI in a man with signs and symptoms as long as 80% of the growth is of one organism a threshold of greater than or equal to 10 3 cfu/ml for diagnosing UTI is below the threshold of detection for some commonly used laboratory methods, which only detect between 10 4 and 10 5 cfu/ml False-positive culture results: are common are caused by contamination of the urine False-negative culture results can be caused by: antibiotic treatment starting prior to collection of a urine sample boric acid (preservative in the specimen bottle)
Consider differential diagnoses Consider the following: pyelonephritis urethritis bladder pain syndrome drug-induced cystitis epididymitis prostatitis epididymo-orchitis STDs, e.g.: Chlamydia trachomatis (C. trachomatis) Neisseria gonorrhoeae (N. gonorrhoeae) herpes simplex virus urological tumours symptomatic benign prostatic enlargement interstitial cystitis
Management Scottish Intercollegiate Guidelines Network (SIGN) states that there is no high quality evidence for the treatment of bacterial UTI in men. Antibiotic treatment: treat men of any age with symptoms or signs of acute lower UTI with a 7-day course of trimethoprim or nitrofurantoin: trimethoprim 200mg twice daily for 7 days nitrofurantoin 100mg m/r twice daily for 7 days: if considering prescribing nitrofurantoin: take care when prescribing to elderly patients, who may be at increased risk of toxicity do not use in patients with egfr less than 45mL/min/1.73m 2 : however, a short course 3 to 7 days may be used with caution in patients with an egfr of 30 to 44mL/min/1.73m 2 to treat lower UTIs with multidrug resistant pathogens when the benefits outweigh the risks of side effects advise the patient not to take alkalinising agents, such as potassium citrate second line treatment: take a urine sample for culture to guide change of antibiotic for patients who do not respond to trimethoprim or nitrofurantoin resistance to amoxicillin is common, only use if susceptible community multi-resistant extended-spectrum Beta-lactamase E.coli are increasing consider nitrofurantoin, or fosfomycin 3g stat plus a second 3g dose 3 days later, after seeking guidance from a microbiologist the European Association of Urology (EAU) guidelines also suggest the following treatment regimen as a second line agent: pivmecillinam 400 mg stat followed by 200mg twice daily for 7 days NB: fosfomycin should only be administered after seeking advice from a microbiologist treat bacterial UTI empirically with a quinolone in men with symptoms suggestive of prostatitis
Considerations for catheterised patients Do not routinely prescribe antibiotic prophylaxis to prevent symptomatic UTI in patients with catheters. Do not treat asymptomatic bacteriuria in those with indwelling catheters, as bacteriuria is very common and antibiotics increase side effects and antibiotic resistance. Do not rely on classical clinical symptoms or signs for predicting the likelihood of symptomatic UTI in catheterised patients. Do not use dipstick testing to diagnose UTI in patients with catheters. Do not use laboratory microscopy to diagnose UTI in patients with catheters. Only send urine for culture in catheterised patients if there are features of systemic infection to determine the infecting organism and susceptibility to antibiotics, not because the appearance or smell of the urine suggests that bacteriuria is present: always exclude other sources of infection Symptoms that may suggest UTI in catheterised patients include: new costovertebral tenderness rigors new onset delirium fever > 37.9 C or 1.5 C above baseline on two occasions during 12 hours Look for associated localising (loin or supra-pubic tenderness) or systemic features: check that the catheter drains correctly and is not blocked consider need for continued catheterisation if the catheter has been in place for than 7 days, consider changing it before/when starting antibiotic treatment when changing catheters, antibiotic prophylaxis should only be used for people with a history of catheter-associated UTI following catheter change Consider antibiotic therapy taking into account the severity of the presentation and any comorbid factors. Patients with indwelling catheters should be admitted to hospital if they present with systemic symptoms, such as the following: fever rigors chill vomiting confusion
Considerations for the elderly - age 65 years The presence of bacteriuria does not always indicate disease. Asymptomatic bacteriuria is very common in the elderly and should not be treated with antibiotics. Do not send asymptomatic dipsticks for further testing. Urine microscopy and culture should be considered in the following cases but should not be done routinely: in elderly patients with two or signs of infection, especially dysuria, fever > 38 C or new incontinence Common side effects of nitrofurantoin include: nausea vomiting diarrhoea acute and chronic pulmonary reactions NB: Particular care should be taken when prescribing nitrofurantoin to elderly patients, who may be at increased risk of toxicity: consider checking renal function when choosing to treat with nitrofurantoin do not use nitrofurantoin in patients with estimated glomerular filtration rate (egfr) < 45mL/min/1.73m 2 : a short course 3-7 days may be used with caution in certain patients with an egfr of 30 to 44mL/min/1.73m 2 to treat UTIs with multidrug resistant pathogens when the benefits outweigh the risks of side effects
Follow-up Review after 48 hours (or as clinically appropriate) to assess: response to treatment culture results - if urine culture is resistant to current antibiotic: and symptoms have not resolved, change to another antibiotic that the organism is sensitive to and symptoms have resolved, consider continuing the current antibiotic Consider if there are any risk factors that need to be excluded/managed, e.g.: abnormalities of the urinary tract or structure incomplete bladder emptying previous urinary tract surgery immunocompromised state Consider referral for specialist assessment when the man has recovered. Refer men for urological assessment if they: have symptoms of upper UTI fail to respond to appropriate antibiotics have recurrent UTI may have an underlying cause for the UTI are age < 50 years with persistent microscopic haematuria with otherwise normal renal function tests
Consider referral to nephrologist If patient does not meet the criteria for urological referral or if they have had a urological cause of haematuria excluded, consider referral to a nephrologist if the following present with haematuria: evidence of declining GFR as measured by estimated GFR (egfr) stage 4 or 5 CKD significant proteinuria isolated haematuria with hypertension in patients < 40 years visible haematuria coinciding with intercurrent infection
UTI complicated by pyelonephritis/ bloodstream infection Suspect pyelonephritis if any of the following features supervene: flank pain and tenderness signs of dehydration systemic features of sepsis, e.g. rigors, sweats, pallor, tachycardia nausea and vomiting high temperature (> 38 C) costovertebral angle tenderness
Consider referral to a urologist have symptoms of upper UTI fail to respond to appropriate antibiotics have recurrent UTI may have an underlying cause for the UTI are age < 50 years with persistent microscopic haematuria with otherwise normal renal function tests
'Cystitis' (URL) from Bupa: http://www.bupa.co.uk/health-rmation/directory/c/cystitis 'Urine infection in men' leaflet from Patient Info: http://patient./health/urine-infection-in-men Urinary tract infection in adults from NHS Choices: http://www.nhs.uk/conditions/urinary-tract-infection-adults/pages/introduction.aspx