management of UTIs in men

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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):

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):


Last edited 09/2019 and last reviewed 03/2020