Urinary tract infections (UTIs) are rare in adult males younger than 50 years but increase in incidence thereafter. Causes of adult male UTIs include prostatitis, epididymitis, orchitis, pyelonephritis, cystitis, urethritis, and urinary catheters. Owing to the normal male urinary tract’s many natural defenses to infection, many experts consider UTIs in males, by definition, to be complicated (ie, more likely to be associated with anatomic abnormalities, requiring surgical intervention to prevent sequelae).

Signs and symptoms

Dysuria is the most frequent chief complaint in men with UTI. The combination of dysuria, urinary frequency, and urinary urgency is about 75% predictive for UTI, whereas the acute onset of hesitancy, urinary dribbling, and slow stream is only about 33% predictive for UTI.

Relevant clinical history includes the following:

• Previous UTI(s)
• Nocturia, gross hematuria, any changes in the color and/or consistency of the urine
• Prostatic enlargement
• Urinary tract abnormalities: Personally and within the family
• Comorbid conditions (eg, diabetes )
• Human immunodeficiency virus (HIV) status
• Immunosuppressive treatments for other conditions (eg, prednisone)
• Any previous surgeries or instrumentation involving the urinary tract

Diagnosis

Perform a thorough physical examination in males presenting with genitourinary complaints. Focus particularly on the patient’s vital signs, kidneys, bladder, prostate, and external genitalia.

Examination findings may include the following:

• Fever
• Tachycardia
• Flank pain/costovertebral angle tenderness
• Abdominal tenderness in the suprapubic area
• Scrotal hematoma, hydrocele, masses, or tenderness
• Penile meatal discharge
• Prostatic tenderness
• Inguinal adenopathy

Laboratory testing

The workup of male UTI is dependent on the suspected diagnosis.

Routine laboratory studies include urine studies, such as urinalysis, Gram staining, and urine culture. The threshold for establishing true UTI includes finding 2-5 or more white blood cells (WBCs) or 15 bacteria per high-power field (HPF) in a centrifuged urine sediment.

Note that a positive nitrite test is poorly sensitive but highly specific for UTI; false-positives are uncommon. Proteinuria is commonly observed in UTIs, but it is usually low grade. More than 2g of protein per 24 hours suggests glomerular disease.

Imaging studies

Consider imaging and urologic intervention in patients with the following:

• History of kidney stones, especially struvite stones: Potential for urosepsis
• Diabetes: Susceptibility to emphysematous pyelonephritis and may require immediate nephrectomy; diabetic patients may also develop obstruction from necrotic renal papillae that are sloughed into the collecting system and obstruct the ureter
• Polycystic kidneys: Prone to abscess formation
• Tuberculosis: Prone to developing ureteral strictures, fungus balls, and stones

• Ultrasonography
• Contrasted computed tomography (CT) scanning or helical CT scanning (currently preferred by most experts)
• Intravenous pyelography (IVP) has been replaced by CT scanning techniques and ultrasonography because of its substantial radiation and the necessity of using radiographic dye

Management

In general, all male UTIs are considered complicated. Consider the potential for renal involvement when planning treatment strategies.

Inpatient management is recommended for patients with the following features:

• Appear toxic
• Have obstructive uropathy or stones
• Unable to tolerate oral hydration
• Have significant comorbid conditions
• Unable to care for self at home

• Intravenous (IV) antimicrobial therapy with a third-generation cephalosporin (eg, ceftriaxone, ceftazidime), a fluoroquinolone (eg, ciprofloxacin, levofloxacin, ofloxacin, norfloxacin), or an aminoglycoside (eg, gentamicin, tobramycin) (beware ototoxicity)
• Antipyretics
• Analgesics
• IV fluid resuscitation: To restore appropriate circulatory volume and promote adequate urinary flow

• Antibiotics such as trimethoprim, trimethoprim-sulfamethoxazole, ampicillin, amoxicillin, ertapenem, erythromycin, vancomycin, doxycycline, aztreonam, nitrofurantoin, rifampin
• Urinary analgesics such as phenazopyridine

Surgery

• Prostatitis involving bladder neck obstruction, prostatic or bladder calculi, or recurrent prostatitis with the same bacteria ^[1]
• Emphysematous pyelonephritis (ie, emergent nephrectomy)
• Epididymitis involving spermatic cord torsion