Management of UTIs in men

NICE suggest that (1):

• send midstream urine for culture and susceptibility
• immediate antibiotic treatment should be offered
• refer to hospital if a person aged 16 or over has any symptoms or signs suggesting a more serious illness or condition (for example, sepsis)
• if there is a history of fever or back pain, patient should be suspected as having upper UTI and should be managed as possible acute pyelonephritis
  
  
• choice of antibiotic 1,2:
  • first choice3
    • trimethoprim
      • 200 mg twice a day for 7 days
    • OR
      
      
    • nitrofurantoin - if eGFR >=45 ml/minute4, 5
      • 100 mg modified-release twice a day for 7 days
        
        
    • note in previous PHE guidance (2),
      • pivmecillinam 400mg STAT then 200mg TDS for 1 week was an alternative first choice antibiotic
      • however this has not been advised as an alternative first choice antibiotic for a UTI in a man by NICE
        
        
  • second choice (no improvement in UTI symptoms on first choice taken for at least 48 hours or when first choice not suitable)3
    
    
    
    • 1 see BNF for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment.
    • 2 doses given are by mouth using immediate-release medicines, unless otherwise stated.
    • 3 check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly.
    • 4 nitrofurantoin is not recommended for men with suspected prostate involvement because it is unlikely to reach therapeutic levels in the prostate.
    • 5 may be used with caution if eGFR 30-44 ml/minute to treat uncomplicated lower UTI caused by suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk (BNF, August 2018)
      
      
• reassess at any time if symptoms worsen rapidly or significantly or do not improve in 48 hours of taking antibiotics, sending a urine sample for culture and susceptibility if not already done. Take account of:
  • other possible diagnoses
  • any symptoms or signs suggesting a more serious illness or condition
  • previous antibiotic use, which may have led to resistance
    

Antibiotics should be avoided in elderly men with asymptomatic bacteriuria (1).

If male under 65 years old then consider (6):

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Risk factors for increased resistance include (2):

• care home resident,
• recurrent UTI,
• hospitalisation >7d in the last 6 months,
• unresolving urinary symptoms,
• recent travel to a country with increased antimicrobial resistance (outside Northern Europe and Australasia) especially health related,
• previous known UTI resistant to trimethoprim, cephalosporins or quinolones

If increased resistance risk, send culture for susceptibility testing & give safety net advice. If GFR<45 ml/min or elderly consider pivmecillinam or fosfomycin (3g stat plus 2nd 3g dose in men 3 days later)

Further investigation/referral depends on various factors (1,2,3,4)

• referral for assessment is not routinely indicated
  • however, referral for assessment should be considered for men who have:
    • symptoms of upper urinary tract infection (pyelonephritis) (1)
    • failure to respond to appropriate antibiotic therapy (1)
    • frequent episodes of urinary tract infection (UTI) - this is stated as two or more episodes in a 3-month period
    • features of urinary obstruction (e.g. in older men, enlarged prostate)
    • history of pyelonephritis, calculi, or previous genitourinary tract surgery
      
      
  • urgent referral is indicated for men with suspected cancer
    • any age with painless macroscopic haematuria:
      • if haematuria is associated with symptoms of UTI
        • culture the urine before referring
        • if UTI is not confirmed by urine culture, or if haematuria does not resolve with treatment of the UTI
          • refer urgently
    • recurrent or persistent UTI associated with haematuria, in a male aged 40 years or older
    • unexplained microscopic haematuria, in a male aged 50 years or older
    • with an abdominal mass identified clinically or on imaging that is thought to arise from the urinary tract

There has been a flowchart developed for the diagnosis and management of ALL adults over 65 years old (6):

Open Image in Modal

Open Image in Modal

Reference:

• (1) NICE (October 2018). Urinary tract infection (lower): antimicrobial prescribing
• (2) Public Health England (October 2014). Management of infection guidance for primary care for consultation and local adaptation
• (3) Harper M, Fowlis G. Management of urinary tract infections in men. Trends in Urology, Gynaecology & Sexual Health 2007;12(1):30-35
• (4) Health Protection Agency (2009). Management of infection guidance for primary care: for consultation and local adaptation
• (5) CKS (2014). UTI (lower) in men
• (6) Public Health England (August 2019). Diagnosis of urinary tract infections - Quick reference tool for primary care for consultation and local adaptation