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Urinary Tract Infection in Males Differential Diagnoses

  • Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD  more...
 
Updated: Oct 22, 2015
 
 

Diagnostic ConsiderationsPyuriaProstatitisEpididymitisCystitisEmphysematous and xanthogranulomatous pyelonephritisTuberculosis

One of the difficulties in diagnosing urinary tract infections (UTIs) in males lies in the fact that dysuria, with or without discharge, is the typical chief complaint with urethritis, which is a much more common disease. Determining the history of urinary and genital tract symptoms and sexual encounters, combined with laboratory testing of urine and urethral swabs, should allow differentiation of the 2 conditions. Absence of bacteruria despite symptoms of frequency, urgency, or dysuria suggests urethritis. However, bacteruria may be symptomatic or asymptomatic.

In males aged 15-50 years, UTI is more common in males with anatomic abnormalities; in the sexually active male with no urinary tract abnormalities, sexually transmitted disease (STD) – related urethritis predominates, although UTI may occasionally be diagnosed.

In elderly patients, the typical manifestations of UTI may be absent or replaced by vague findings of failure to thrive or worsening mental status. In addition, failure to consider an obstructing urinary calculus in this patient population results in delay of inpatient consultation with a urologist in the septic elderly patient.

Patients with diabetes and those with recent urinary tract instrumentation, recent hospitalization, or taking broad-spectrum antibiotics have an increased incidence of resistant organisms.

The differential diagnoses for infectious causes of sterile pyuria include perinephric abscess, urethral syndrome, chronic prostatitis, renal tuberculosis, and fungal infections of the urinary tract, including C neoformans and Coccidioides immitis.

Noninfectious causes of pyuria include uric acid and hypercalcemic nephropathy, lithium and heavy metal toxicity, sarcoidosis, interstitial cystitis, polycystic kidney disease, genitourinary malignancy, and renal transplant rejection.

Prostatitis can coexist with benign prostatic hyperplasia (BPH) and prostate cancer. The symptom complex of BPH and chronic prostatitis overlap; older men are sometimes misdiagnosed with one or the other. In addition, prostatitis can increase prostate-specific antigen levels, raising the concern for prostate cancer.

Young men have a very low incidence of UTI; if UTI is diagnosed frequently in this population, the physician is probably overlooking the far more likely sexually transmitted disease (STD)–related urethritis/prostatitis.

Among patients with acute scrotum, 90% of cases are caused by epididymitis, torsion of the spermatic cord, and torsion of a testicular appendage. Bacteria and leukocytes observed on a urethral Gram stain support a diagnosis of epididymitis, although some overlap may be observed between epididymitis, torsion of the spermatic cord, and torsion of a testicular appendage.

Consultation with a urologist is mandatory in all but the most clear-cut cases for operative salvage of the torsed testicle. Torsion of the spermatic cord must be assumed until proven otherwise, because unresolved torsion of the cord is likely to result in irreversible necrosis in less than 12 hours.

In men older than 50 years, the presentation of cystitis is difficult to differentiate from that of obstructive prostatism due to prostatic hyperplasia, transitional cell carcinoma of the bladder, or acute or chronic bacterial prostatitis. In young men, urolithiasis, bladder cancer, and strictures are included in the differential diagnoses.

Microscopic hematuria is found in approximately half of cystitis cases; when found without symptoms or pyuria, it should prompt a search for malignancy. Other factors to be considered in the differential diagnoses include calculi, vasculitis, renal tuberculosis, and glomerulonephritis. In a developing country, hematuria is suggestive of schistosomiasis, which can be associated with salmonellosis and squamous cell malignancies of the bladder.

Emphysematous pyelonephritis is an infection caused by gas-forming organisms. It results in a necrotizing infection of the renal and perirenal tissue. This process occurs mostly in patients with diabetes. Glucosuria enhances organism fermentation and carbon dioxide production. Obstruction of the upper urinary tract by calculi or necrotic renal papillae is common in this condition. The mortality rate for this complication is reported to be 43%. E coli is the most common pathogen, followed by Klebsiella and Proteus.

Intraparenchymal gas can be seen on imaging studies. This is distinctly different from gas occurring in the collecting system per se, which is not infrequent in pyelonephritis and is associated with a much better prognosis. Of emphysematous pyelonephritis cases, 10% are bilateral. Prompt treatment with antibiotics and nephrectomy or surgical drainage is required.

Xanthogranulomatous pyelonephritis is a rare, but severe, renal infection that is clinically difficult to differentiate from renal tumors. It can progress to nonfunction and swelling of the involved kidney, and it is often associated with obstructing calculi. Proteus is the most common pathogen, followed by E coli. A granulomatous reaction with suppuration results in destruction and swelling of the renal parenchyma.

Although no distinguishing characteristics can be observed upon imaging, the diagnosis can be made by examining cytologic specimens; the lipid material collects in macrophages (xanthoma cells). Pus and debris may fill the collecting system, creating the condition known as pyonephrosis.

Tuberculosis may involve the prostate, but epididymitis is the most common presentation of male genital tuberculosis. The testis and seminal vesicles may also be involved. A palpable mass is present in most cases. Ironically, although patients may present with infertility, tuberculosis may be spread by semen.

Differential Diagnoses

 
 
Contributor Information and Disclosures
Author

John L Brusch, MD, FACP Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgements

Bryan P Blair, MD Staff Physician, Department of Urology, Naval Medical Center at Portsmouth

Disclosure: Nothing to disclose.

David S Howes, MD Professor of Medicine and Pediatrics, Section Chief and Emergency Medicine Residency Program Director, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Klaus-Dieter Lessnau, MD, FCCP Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital

Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Sepracor None None

Mark Jeffrey Noble, MD Consulting Staff, Urologic Institute, Cleveland Clinic Foundation

Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwest Oncology Group

Disclosure: Nothing to disclose.

M Tyson Pillow, MD Assistant Director of Medical Education, Ben Taub General Hospital Emergency Center; Assistant Professor, Baylor College of Medicine

M Tyson Pillow, MD is a member of the following medical societies: Air Medical Physician Association, American College of Emergency Physicians, American Medical Association, American Medical Student Association/Foundation, Emergency Medicine Residents Association, Society for Academic Emergency Medicine, and Student National Medical Association

Disclosure: Nothing to disclose.

Joseph A Salomone III, MD Associate Professor and Attending Staff, Truman Medical Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas City, Missouri

Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Richard H Sinert, DO Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Cindy L Tamminga, MD Consulting Staff, Division of Infectious Diseases, Naval Medical Center at Portsmouth

Disclosure: Nothing to disclose.

References
  1. Doluoglu OG, Gokkaya CS, Aktas BK, et al. Impact of asymptomatic prostatitis on re-operations due to urethral stricture or bladder neck contracture developed after TUR-P. Int Urol Nephrol. 2012 Jan 18. [Medline].

  2. van der Starre WE, van Nieuwkoop C, Paltansing S, et al. Risk factors for fluoroquinolone-resistant Escherichia coli in adults with community-onset febrile urinary tract infection. J Antimicrob Chemother. 2011 Mar. 66(3):650-6. [Medline].

  3. Meares EM, Stamey TA. Bacteriologic localization patterns in bacterial prostatitis and urethritis. Invest Urol. 1968 Mar. 5(5):492-518. [Medline].

  4. Chung SD, Keller JJ, Lin HC. A case-control study of chronic prostatitis/chronic pelvic pain syndrome and colorectal cancer. BJU Int. 2012 Feb 7. [Medline].

  5. Foxman B. Epidemiology of urinary tract infections: incidence, morbidity, and economic costs. Am J Med. 2002 Jul 8. 113 Suppl 1A:5S-13S. [Medline].

  6. Johnson JR. Laboratory diagnosis of urinary tract infections in adult patients. Clin Infect Dis. 2004 Sep 15. 39(6):873; author reply 873-4. [Medline].

  7. Chiang IN, Chang SJ, Pu YS, Huang KH, Yu HJ, Huang CY. Major complications and associated risk factors of transrectal ultrasound guided prostate needle biopsy: a retrospective study of 1875 cases in Taiwan. J Formos Med Assoc. 2007 Nov. 106(11):929-34. [Medline].

  8. Nickel JC. The Pre and Post Massage Test (PPMT): a simple screen for prostatitis. Tech Urol. 1997 Spring. 3(1):38-43. [Medline].

  9. Daunt SW. Accuracy of ultrasonography and plain-film abdominal radiography in the diagnosis of urologic abnormalities in men with urinary tract infection: critically appraised topic. Can Assoc Radiol J. 2004 Feb. 55(1):16-7. [Medline].

  10. Guay DR. Contemporary management of uncomplicated urinary tract infections. Drugs. 2008. 68(9):1169-205. [Medline].

  11. Howes DS, Bogner MP. Urinary tract infections. Tintinalli JE, Kelen GD, Stapczyski JS, eds. Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill; 2008.

  12. Talan DA, Krishnadasan A, Abrahamian FM, Stamm WE, Moran GJ. Prevalence and risk factor analysis of trimethoprim-sulfamethoxazole- and fluoroquinolone-resistant Escherichia coli infection among emergency department patients with pyelonephritis. Clin Infect Dis. 2008 Nov 1. 47(9):1150-8. [Medline].

  13. Cunha BA. Antibiotic Essentials. 7th ed. Royal Oak, Mich: Physicians Press.; 2008.

  14. Killgore KM, March KL, Guglielmo BJ. Risk factors for community-acquired ciprofloxacin-resistant Escherichia coli urinary tract infection. Ann Pharmacother. 2004 Jul-Aug. 38(7-8):1148-52. [Medline].

  15. [Guideline] Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006 Aug 4. 55:1-94. [Medline]. [Full Text].

  16. Douglas D. Tadalafil confirmed as helpful in LUTS/BPH. Reuters Health Information. August 20, 2013. Available at http://www.medscape.com/viewarticle/809664. Accessed: August 29, 2013.

  17. Wagenlehner FM, Naber KG. Fluoroquinolone Antimicrobial Agents in the Treatment of Prostatitis and Recurrent Urinary Tract Infections in Men. Curr Infect Dis Rep. 2005 Jan. 7(1):9-16. [Medline].

  18. Wagenlehner FM, Naber KG. Current challenges in the treatment of complicated urinary tract infections and prostatitis. Clin Microbiol Infect. 2006 May. 12 Suppl 3:67-80. [Medline].

  19. Luzzi G. Chronic prostatitis. N Engl J Med. 2007 Jan 25. 356(4):423-4; author reply 424. [Medline].

  20. Wagenlehner FM, Weidner W, Naber KG. Therapy for prostatitis, with emphasis on bacterial prostatitis. Expert Opin Pharmacother. 2007 Aug. 8(11):1667-74. [Medline].

  21. Yoon BI, Kim S, Han DS, et al. Acute bacterial prostatitis: how to prevent and manage chronic infection?. J Infect Chemother. 2012 Jan 5. [Medline].

  22. [Guideline] Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010 Mar 1. 50(5):625-63. [Medline]. [Full Text].

  23. [Guideline] Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010 Apr. 31(4):319-26. [Medline]. [Full Text].

  24. Saint S, Elmore JG, Sullivan SD, Emerson SS, Koepsell TD. The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: a meta-analysis. Am J Med. 1998 Sep. 105(3):236-41. [Medline].

  25. [Guideline] CDC. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. 2007 Apr 13. 56(14):332-6. [Medline]. [Full Text].

  26. McNaughton Collins M, Fowler FJ Jr, Elliott DB, Albertsen PC, Barry MJ. Diagnosing and treating chronic prostatitis: do urologists use the four-glass test?. Urology. 2000 Mar. 55(3):403-7. [Medline].

  27. Porst H, Oelke M, Goldfischer ER, Cox D, Watts S, Dey D, et al. Efficacy and Safety of Tadalafil 5 mg Once Daily for Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia: Subgroup Analyses of Pooled Data From 4 Multinational, Randomized, Placebo-controlled Clinical Studies. Urology. 2013 Jul 19. [Medline].

  28. Olson PD, Hruska KA, Hunstad DA. Androgens Enhance Male Urinary Tract Infection Severity in a New Model. J Am Soc Nephrol. 2015 Oct 8. [Medline].

 
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Prostatic calcifications in a male with a urinary tract infection.
Bladder calculi in a male with a urinary tract infection.
 
 
 
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