eMedicine Specialties > Infectious Diseases > Genitourinary Tract Infections

Urinary Tract Infection, Males: Follow-up

Author: 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
Contributor Information and Disclosures

Updated: Oct 19, 2009

Follow-up

Further Inpatient Care

  • If a patient fails to respond to antibiotics, an abscess should be considered. Upper- and lower-tract studies (eg, IVP, cystoscopy) are important to consider in older patients at risk for anatomic abnormalities.

Further Outpatient Care

  • Follow-up urine cultures are warranted in males with urinary tract infections (UTIs). Follow-up urethral cultures are not routinely warranted unless the man is symptomatic, in which case the symptoms are likely to be the result of exogenous reinfection.

Deterrence/Prevention

  • Preoperative antibiotics can reduce complications. Procedures of concern include open, transurethral, or laser prostatectomy; transrectal prostate biopsy; or cystoscopy in patients with preoperative bacteruria or a preoperative indwelling catheter. Before antibiotic coverage, the rate of septicemia from a transrectal biopsy was 5-10%; currently, the rate is less than 0.1%. Fluoroquinolones are the prophylactic drugs of choice for urologic procedures.
  • The American Heart Association recommends antimicrobial prophylaxis to prevent bacterial endocarditis in patients with moderate- to high-risk cardiac conditions. High-risk conditions include prosthetic valves, previous bacterial endocarditis, complex cyanotic congenital heart diseases, and surgically constructed systemic pulmonic shunts. Moderate-risk conditions include most other congenital heart diseases, hypertrophic cardiac myopathy, and mitral prolapse with regurgitation. For patients with moderate- or high-risk cardiac conditions, urologic procedures that warrant prophylaxis include prostate surgery, cystoscopy, and urethral dilatation; prophylaxis is not recommended for inserting a Foley catheter in a patient with uninfected urine.
    • Regimens for high-risk patients include ampicillin (or vancomycin) plus gentamicin. Ampicillin is given as 2000 mg IM or IV within 30 minutes of starting the procedure; 6 hours later, 1000 mg of ampicillin (or amoxicillin PO) is given once. Gentamicin is dosed at 1.5 mg/kg IV or IM (not to exceed 120 mg) and is given only once with the first dose of ampicillin. For patients allergic to ampicillin, 1000 mg of vancomycin is given IV over 1-2 hours only once; it should be completed within 30 minutes of starting the procedure.
    • Regimens for moderate-risk patients include amoxicillin or vancomycin. Amoxicillin is given only once as 2000 mg PO 1 hour before the procedure. For patients allergic to amoxicillin, 1000 mg of vancomycin is given IV over 1-2 hours only once; it should be completed within 30 minutes of starting the procedure.
  • Condoms are useful in preventing sexually transmitted diseases such as urethritis; latex condoms help prevent transmission of HIV. Remember that these patients are at risk for more than one infection (gonorrhea, chlamydia, syphilis, hepatitis B, herpes, Trichomonas, HIV). The risk of acquiring HIV from an infected sexual partner is approximately 0.3% on average; the risk is 30-50% for herpes and gonorrhea. If abstaining is not an option, condoms are the best protection.
  • At least 8 steps can be taken to prevent catheter-associated UTIs; these steps can postpone a UTI for weeks but will not be totally successful in patients with long-term catheterization.
    1. Catheterization should be avoided when not required (catheters were found to be unnecessary in 41-58% of patient-days) and should be terminated as soon as possible. 
    2. Suprapubic catheters are associated with a lower risk of UTI. For men who require long-term catheterization, local genitourinary complications (meatal erosion, prostatitis, epididymitis) may be reduced and patients may be more satisfied, but mechanical complications are increased. Contraindications include bleeding disorders, previous lower abdominal surgery or irradiation, and morbid obesity. 
    3. Condom catheters are also associated with a lower risk of bacteriuria than indwelling catheters, as long as the catheter is not manipulated frequently. However, these are difficult to use in uncircumcised men. 
    4. Most patients using intermittent catheterization become bacteriuric within a few weeks. The incidence rate is 1-3% per insertion. 
    5. Aseptic indwelling catheter insertion and a properly maintained closed-drainage system are essential. Catheters with hydrophilic coatings reduce or delay the onset of bacteriuria and are more comfortable for the patient. 
    6. Urinary catheters coated with silver also reduce the risk. Silver alloy seems to be more effective than silver oxide, and using these more expensive catheters in those who are at highest risk is reasonable.5  
    7. Receiving systemic antimicrobial drug therapy has been shown repeatedly to lower the risk for developing a UTI in catheterized patients; the most significant benefit was observed in those catheterized for 3-14 days. Most hospitalized patients are already receiving antibiotics for other reasons; risks include creating resistant organisms. 
    8. Because many of these infections occur in clusters, good handwashing before and after catheter care is essential.
  • The following are of little benefit: (1) instillation of antimicrobial agents into the bladder (unidirectional flow from the bladder to the bag is best), (2) placing antimicrobials in the urine-drainage bag (which breaks the closed-drainage system), (3) methenamine, and (4) rigorous meatal cleansing.
  • Appropriate indications for indwelling urethral catheters include the relief of bladder outlet obstruction, treating urinary incontinence in a patient with an open sacral wound, monitoring urine output, and during prolonged surgical procedures.
  • Antibiotic prophylaxis is valuable in patients undergoing TURP or renal transplantation.
    • Post-TURP bacteriuria rates are approximately 10% in those who receive systemic antibiotics, compared to approximately 35% in those who do not. Single-dose therapy is as effective as longer courses.
    • For kidney transplant recipients, TMP/SMX (1 dose PO qd) beginning 2-4 days after surgery and continuing for 4-8 months reduced the incidence rate of UTIs from 38% to 8% (especially after the catheter was removed), cut febrile hospital days and bacterial infections (during and after hospitalization) in half, and reduced graft rejection.
    • Neither cefuroxime nor ciprofloxacin was shown to reduce the rate of bacteriuria (approximately 20%) after lithotripsy.

Complications

  • Complications of acute bacterial prostatitis include bacteremia, septic shock, prostatic abscess, epididymitis, seminal vesiculitis, and pyelonephritis. Suspect a prostate abscess if fever does not resolve within 48 hours; if confirmed, add anaerobic coverage and arrange for drainage.
  • Both NGU and gonococcal urethritis may progress to prostatitis, epididymitis, and orchitis, especially in younger patients. Urethral strictures may form in up to 5% of patients; this must be kept in mind when evaluating patients with residual obstructive symptoms after treatment.

Prognosis

  • Chronic bacterial prostatitis is very difficult to cure because few antibiotics penetrate well into the noninflamed prostate. Several months of therapy may cure only one third of patients. Some patients may also have prostatic calculi (see Image 1) or abscesses, each of which may serve as a nidus of infection. The fact that some patients may have relapses months later is not surprising.
  • Generally, the prognosis for acute bacterial prostatitis, epididymitis, pyelonephritis, cystitis, and urethritis is good.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Of cases of acute scrotum, 90% 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 among epididymitis, torsion of the spermatic cord, and torsion of a testicular appendage.
    • 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.
    • Consultation with a urologist is mandatory in all but the most clear-cut cases for operative salvage of the torsed testicle.
    • The surgical intervention is detorsion and orchidopexy, with orchidopexy of the contralateral side (because this side is predisposed to torsion at a later date).
  • The patient and his family should be advised that sterility develops in up to 10% of cases of mumps orchitis. Because no treatment is available for this entity, it is important that the measles-mumps-rubella vaccine is given in childhood and repeated in late adolescence.
  • Testicular cancer is the most common malignancy in males aged 15-35 years. Although it usually presents as a painless intraparenchymal mass, 10% of cases present after minor trauma. For this reason, any patient felt to have a lesion within the parenchyma of the testicle should be referred for immediate urologic evaluation.
  • Many lawsuits arise from the complications of long-term aminoglycosides, especially irreversible cranial nerve VIII damage (hearing loss and vestibular dysfunction).
    • Risk factors appear to be prolonged use (>2 wk), high serum trough levels (>2), advanced age, baseline renal insufficiency, concomitant conditions (eg, diabetes mellitus), and concomitant nephrotoxic drugs (eg, amphotericin B).
    • Fortunately, most aminoglycoside use in treating serious urinary tract infections (UTIs) is limited to less than 1 week.
    • Unfortunately, monitoring for cranial nerve VIII dysfunction is less than optimal; by the time it is detectable (even subclinically, by weekly audiograms and/or electronystagmograms), the damage has been done and is irreversible. This is because of differences in half-lives between serum and because of the endolymph and perilymph that bathe the inner ear. However, monitoring allows damage to be minimized. Remember that the auditory and vestibular systems function independently; therefore, consideration should be given to monitoring each.
    • Animal models suggest that doses given at night or to a patient who has been fasting or is dehydrated may be more ototoxic.
    • The possibly protective roles of calcium and calcium channel blockers await further study.

Special Concerns

  • 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. Ironically, although patients may present with infertility, tuberculosis may be spread by semen.
  • 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.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthors Cindy L Tamminga, MD, and Bryan P Blair, MD, to the development and writing of this article.



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References
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Further Reading

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Keywords

male urinary tract infection, urinary infection, UTI, prostatitis, epididymitis, orchitis, pyelonephritis, cystitis, indwelling urethral catheters, catheter, gonorrhea, obstruction, prostatic hypertrophy, urinary tract instrumentation, catheterization, urological surgery

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Contributor Information and Disclosures

Author

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, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

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 Society for Artificial Internal Organs, American Thoracic Society, Physicians for Social Responsibility, and Society of Critical Care Medicine
Disclosure: sepracor Ownership interest None

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD, Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Association of Professors of Medicine, Association of Program Directors in Internal Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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