eMedicine Specialties > Infectious Diseases > Genitourinary Tract Infections
Urinary Tract Infection, Males: Treatment & Medication
Updated: Oct 19, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Prostatitis
- To eradicate prostatitis, therapeutic drug levels must be achieved within the prostatic acini. Other challenges include prostatic calculi (a nidus for infection), inspissated secretions and microabscesses, and biofilms produced by offending organisms. Bladder outlet obstruction promotes stasis (and thus infection).
- Nitrofurantoin, sulfonamides, vancomycin, penicillins, and cephalosporins do not penetrate well into the prostate, although carbenicillin cures approximately 60% of patients with chronic bacterial prostatitis.
- Antibiotics that penetrate well into the acid milieu of the prostate are nonpolar and lipid-soluble and have a high measure of acid strength, a small molecular radius, and low serum protein binding. Drugs that best fit these criteria are the fluoroquinolones, doxycycline, trimethoprim, rifampin, and erythromycin. Of the group, the fluoroquinolones appear to achieve the best tissue levels.
- Quinolones can be divided into first, second, third, and fourth generations. First-generation drugs (nalidixic acid) are not effective for prostatic infections. Third-generation and fourth-generation fluoroquinolones provide increased streptococcal and anaerobic coverage, which is not needed to treat prostatic infections.
- The second-generation quinolones widely used to treat prostatic infection include ciprofloxacin, ofloxacin, norfloxacin, and levofloxacin. These drugs all are bactericidal against gram-negative bacilli; however, because of increased resistance, they are no longer recommended by the CDC for N gonorrhoeae infections . Levofloxacin is most effective against susceptible strains of Enterococcus faecalis and has the advantage of once-daily dosing. Although all of the second-generation drugs are used to treat prostatitis, only ofloxacin is approved by the US Food and Drug Administration for this indication.
- Doxycycline, trimethoprim-sulfamethoxazole (TMP-SMX), and erythromycin are often used as second-line agents, especially when culture-directed therapy is possible. Of note, only the trimethoprim (and not sulfamethoxazole) readily penetrates the prostate.
- Regarding antibiotic concentrations in the prostate, interpreting the literature is difficult because many different terms are used (eg, "mean concentration in prostatic tissue," "mean concentration in prostatic fluid, prostatic tissue/serum ratio, prostatic fluid/serum ratio," and "stromal/epithelial ratio"); furthermore, these specimens are often obtained in patients with benign prostatic hypertrophy or carcinoma (ie, not prostatitis). One also must note the host being tested; TMP-SMX penetrates the dog prostate far better than the human prostate, probably because of differences in semen pH. Although some antibiotics appear to be more suitable by certain criteria, clinical efficacy is probably the bottom line.
- Acute bacterial prostatitis
- The intensely inflamed prostate allows antimicrobials to easily pass from the plasma.
- Hospitalized patients could receive various antimicrobials; parenteral ampicillin and gentamicin often are used. In most cases, the fever resolves in 2 days.
- Once improved, appropriate oral agents include TMP-SMX or a fluoroquinolone; the latter is generally preferred.
- Therapy should be continued for a minimum of 4 weeks to prevent chronic bacterial prostatitis from developing. Analgesics and stool softeners may be helpful.
- Chronic bacterial prostatitis
- An attempt should be made to cure chronic bacterial prostatitis.
- Long-term results with TMP-SMX (15-60% cure rate) probably reflect the inability of sulfa drugs to penetrate the noninflamed prostate; the usual regimen is one double-strength TMP-SMX dose twice a day for 3 months. The combination of trimethoprim with rifampin may be useful but needs further study.
- Some evidence suggests that 30 days of a fluoroquinolone may be superior to TMP-SMX.
- Coverage for Chlamydia and Ureaplasma should be considered for patients with category IIIA prostatitis (ie, leukocytosis without demonstrable bacteria).
- If therapy fails, appropriate management is to either treat acute exacerbations or try chronic suppressive therapy (using half-normal doses).
- Antimicrobials are not needed for asymptomatic patients who have evidence of inflammation on biopsy specimens or in secretions (category IV prostatitis); antimicrobials should be considered for men who are infertile who have bacteria or inflammation in their semen.
- Nonantimicrobial modalities for prostatitis
- Many nonantimicrobial modalities of therapy are available for prostatitis.
- Narcotics, nonsteroidal anti-inflammatory drugs, and tricyclic antidepressants (eg, amitriptyline) may be needed for pain relief.
- Diazepam and baclofen may decrease sphincter or perineal muscle spasm.
- Alpha-blockers may minimize ductal reflux and dysfunctional voiding.
- Hormonal manipulation with a 5-alpha-reductase inhibitor (finasteride) may decrease glandular inflammation.
- Conflicting evidence suggests that allopurinol may reduce prostatic urate reflux.
- Lycopene, prominent in tomato sauces, may also diminish glandular swelling.
- Saw palmetto is a popular herbal remedy for prostate problems, and small studies have suggested benefit; it warrants further study.
- Nonpharmaceutical approaches
- Nonpharmaceutical approaches also may be used.
- An example of "what's old is new" is prostate massage. For decades, prostate massage was the primary therapy for prostatitis, but it was largely abandoned in the antibiotic era. More clinicians now are using repetitive prostate massage; it may improve circulation and antibiotic penetration and may help drain clogged ducts.
- Applications of heat can be beneficial, but some of the techniques (transrectal and transurethral) limit its widespread application; hot sitz baths are simple and help, probably by relaxing muscle spasms.
- Biofeedback, relaxation exercises, acupuncture, massage therapy, and chiropractic manipulation may be beneficial.
- Epididymitis
- For epididymitis, antibiotic treatment for patients younger than 35 years should target Chlamydia and gonococci. Ceftriaxone (250 mg IM) followed by doxycycline (100 mg PO bid for 7-10 d) is usually effective.
- Therapy for older men should address enteric gram-negative rods. TMP-SMX (double-strength, 1 dose PO bid) or a fluoroquinolone can be used; a 30-day course covers concomitant prostatic infection.
- When risk factors for urosepsis are present, such as fever or urinary retention, the patient should be hospitalized and intravenous antibiotics should be started.
- Urethritis
- For urethritis, ceftriaxone (125 mg IM as a single dose) treats penicillinase-producing N gonorrhoeae.
- Treatment for NGU should also be given (doxycycline 100 mg PO bid for 7 d).
- Sexual partners should also be treated, and patient counseling regarding safe sex is paramount; cases need to be reported to public health departments.
- Pyelonephritis
- Most patients with pyelonephritis should undergo imaging studies to rule out other lesions.
- Intravenous antibiotic treatment should be initiated empirically with an aminoglycoside and ampicillin.
- Third-generation and fourth-generation cephalosporins, a carbapenem, or aztreonam also provides broad gram-negative rod coverage.
- Fluid resuscitation is important if the blood pressure is unstable or if the patient is very old.
- Intravenous antibiotics are usually continued until the patient is afebrile for 24 hours, and then oral therapy is prescribed to complete 7-10 days of treatment.
- Urologic consultation should be considered for patients who do not respond rapidly to antibiotics. In one study, fever persisted for 3 days in 13% of hospitalized patients with pyelonephritis, but none had complications; prolonged fever was associated with high baseline creatinine levels, younger age, and a high peripheral WBC count.
- Cystitis
- For the few men with uncomplicated cystitis, TMP-SMX can be used in areas where resistant E coli number less than 20%; alternatively, a fluoroquinolone can be used.
- Length of treatment should be 7-10 days.
Surgical Care
- Acute prostatitis
- If the patient with acute prostatitis has significant urinary obstruction, a Foley catheter can be gently inserted. If this is too uncomfortable, a suprapubic cystotomy may be required.
- The catheter can usually be removed 1-2 days later.
- Chronic bacterial prostatitis
- This condition is very difficult to cure medically, but surgery is indicated only for a few specific conditions.
- Transurethral incision of the bladder neck benefits some patients with bladder neck obstruction; transurethral balloon dilatation of the prostate is not helpful. A partial transurethral prostatectomy (TURP) removes only part of the infected gland and thus, benefits only one third of patients.
- Radical or total prostatectomy is usually not required or beneficial; complications include incontinence and impotence. Patients for whom a radical TURP or total prostatectomy should be considered are those with either prostatic calculi (see Image 1) or those in whom the same bacteria have been consistently isolated from prostatic specimens. A prostate biopsy may confirm that the bacteria are actually originating from the prostate.
Urinary tract infections, males. Prostatic calcifications.
- Prostatic abscesses
- These are rarely cured by antimicrobials alone; drainage is best achieved by an ultrasound-guided needle.
- Other surgical interventions may be needed to remove or address other complications, such as calculi (see Image 2).
Urinary tract infections, males. Bladder calculi.
- Emphysematous pyelonephritis: Patients with diabetes are prone to develop emphysematous pyelonephritis, which is characterized by gas formation in the urinary tract. It often requires immediate nephrectomy for survival.
- Acute scrotum
- Of cases of acute scrotum, 90% are caused by epididymitis, torsion of the spermatic chord, 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 present among these 3 conditions.
- 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).
Consultations
- Consultation with a specialist in pharmacokinetics is suggested when using aminoglycosides.
- Consultation with an infectious diseases specialist is suggested when unusual or resistant microorganisms have been isolated or if the infection is in an unusual host.
- Consultation with the patient's primary care provider is suggested.
- Consultation with a urologist is essential in all forms of prostatitis; in acute bacterial prostatitis, suprapubic drainage may be required if acute urinary retention occurs.
- Consultation with a urologist is essential in all but the most clear-cut cases of acute scrotum.
- For patients with nonbacterial prostatitis, controlling discomfort may require input from pain specialists. Chronic abacterial prostatitis shares the following with other chronic pain syndromes: (1) pain as a primary complaint; (2) discord between symptoms and findings; and (3) history of multiple, unsuccessful treatments. Providers of alternative healing (eg, hypnotherapists) and a psychiatrist or psychologist also may be needed.
Diet
- Keeping well hydrated is important, especially if an obstruction was recently relieved.
- Drinking cranberry juice (10 oz/d) may offer some benefit and does not appear to be harmful. It appears to inhibit E coli from adhering to human uroepithelium; the amounts of bacteriostatic hippuric acid that are present are unlikely to be clinically effective.
- For complicated urinary tract infections (UTIs) associated with struvite calculi, foods and vitamin supplements rich in phosphorus and magnesium are advised. Remember that divalent cations (eg, magnesium) can chelate oral fluoroquinolones, preventing their absorption from the gut.
Activity
- Bedrest and avoiding certain activities (eg, bike riding) may be beneficial in prostatitis. For patients with category IIIB (chronic, noninflammatory, abacterial) prostatitis, bedrest for 2 weeks has been advocated. Sitting on ring cushions can be a simple way to minimize symptoms.
- For viral orchitis, supportive therapy with scrotal support, cold compresses, and bedrest is all that is needed. The use of estrogens, gammaglobulin, and steroids has been advocated by some, but these have not been shown to decrease the risk of sterility or shorten the duration of symptoms. Symptoms usually resolve spontaneously in 7-10 days.
- In urethritis, sexual activity may be resumed when both partners have completed treatment; barrier methods are encouraged. No one knows for sure when sexual activity may be resumed for the other topics discussed in this article.
Medication
The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to prevent complications.
In April 2007, the Centers for Disease Control and Prevention (CDC) updated treatment guidelines for gonococcal infection and associated conditions.4 Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States. The recommendation was based on analysis of new data from the CDC's Gonococcal Isolate Surveillance Project (GISP). The data from GISP showed the proportion of gonorrhea cases in heterosexual men that were fluoroquinolone-resistant (QRNG) reached 6.7%, an 11-fold increase from 0.6% in 2001. The data were published in the April 13, 2007, issue of the Morbidity and Mortality Weekly Report. This limits treatment of gonorrhea to drugs in the cephalosporin class (eg, ceftriaxone 125 mg IM once as a single dose).
Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented. If acute prostatitis or epididymitis is not likely to be caused by gonorrhea, fluoroquinolones may be considered an option. For more information, see the CDC's Antibiotic-Resistant Gonorrhea Web site; CDC Updated Gonococcal treatment recommendations (April 2007); or Medscape Medical News on CDC Issues - New Treatment Recommendations for Gonorrhea.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of this clinical setting.
Ciprofloxacin (Cipro)
Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, S epidermidis, and most gram-negative organisms but no activity against anaerobes. Inhibits bacterial DNA synthesis and growth.
Adult
500-750 mg PO bid
Alternatively, 200-400 mg IV q12h
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Quinolones increase risk of pseudomembranous colitis caused by Clostridium difficile; may cause severe photosensitivity reactions in patients exposed to sunlight or UV light; have been associated with a variety of CNS manifestations such as hallucinations and seizures; factors that increase risk of adverse effects should be noted when considering use of any quinolone; IV solutions should be given by slow infusion over 60 min to reduce risk of phlebitis and hypotension
Levofloxacin (Levaquin)
A fluoroquinolone with better gram-positive activity but less activity against Pseudomonas aeruginosa. Active L-isomer of ofloxacin.
Adult
250-500 mg PO/IV qd
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Quinolones increase risk of pseudomembranous colitis caused by C difficile; may cause severe photosensitivity reactions in patients exposed to sunlight or UV light; have been associated with a variety of CNS manifestations such as hallucinations and seizures; factors that increase risk of adverse effects should be noted when considering use of any quinolone; IV solutions should be given by slow infusion over 60 min to reduce risk of phlebitis and hypotension
Ofloxacin (Floxin)
Pyridine carboxylic acid derivative with broad-spectrum bactericidal effect.
Adult
200-400 mg PO/IV bid
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Quinolones increase risk of pseudomembranous colitis caused by C difficile; may cause severe photosensitivity reactions in patients exposed to sunlight or UV light; have been associated with a variety of CNS manifestations such as hallucinations and seizures; factors that increase risk of adverse effects should be noted when considering use of any quinolone; IV solutions should be given by slow infusion over 60 min to reduce risk of phlebitis and hypotension
Trimethoprim (Proloprim, Trimpex)
Dihydrofolate reductase inhibitor that prevents tetrahydrofolic acid production in bacteria. Active in vitro against a broad range of gram-positive and gram-negative bacteria, including uropathogens such as Enterobacteriaceae and Staphylococcus saprophyticus. Resistance usually is mediated by decreased cell permeability or alterations in amount or structure of dihydrofolate reductase.
Demonstrates synergy with sulfonamides, potentiating inhibition of bacterial tetrahydrofolate production.
Adult
100-200 mg PO bid
Pediatric
Not established
May increase toxicity of phenytoin
Documented hypersensitivity, megaloblastic anemia due to folate deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of skin rash or sign of adverse reaction; monitor CBCs (discontinue therapy if significant hematologic changes occur); prolonged high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholism, elderly patients, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in G-6-PD–deficient individuals; patients with AIDS may not tolerate or respond to TMP-SMX; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation; may cause nausea, vomiting, and hypersensitivity reactions
Trimethoprim-sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)
Combination antimicrobial designed to take advantage of synergy between TMP and sulfonamides as described above. SMX inhibits dihydropteroate synthetase, preventing incorporation of paraaminobenzoic acid (PABA) into dihydrofolate and subsequent synthesis of tetrahydrofolate. SMX has broad bacteriostatic activity against both aerobic gram-positive and gram-negative organisms, with little activity against anaerobes. Unfortunately, SMX does not penetrate well into the kidney.
Adult
160 mg TMP plus 800 mg SMX PO bid; alternatively, 4-5 mg/kg TMP plus 20-25 mg/kg SMX IV q12h
Pediatric
<2 months: Do not administer
>2 months: Not established
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; coadministration with methenamine may lead to increased risk of crystalluria
Documented hypersensitivity; megaloblastic anemia due to folate deficiency; risk/benefit assessment should be considered in patients with G-6-PD deficiency, blood dyscrasias, folate deficiency, porphyria, or hepatic or renal impairment
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of skin rash or sign of adverse reaction; follow CBCs; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholism, elderly patients, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in G-6-PD–deficient individuals; patients with AIDS may not tolerate or respond to TMP-SMX; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); adjust dose if CrCl is <30 mL/min; give fluids to prevent crystalluria and stone formation
Ampicillin (Omnipen, Polycillin, Principen)
Aminopenicillin beta-lactam that impairs cell-wall synthesis in actively dividing bacteria by binding to and inhibiting penicillin-binding proteins in the cell wall. Enhanced activity against anaerobes and gram-negative aerobes. Generally used in combination with an aminoglycoside for empiric or directed activity against E faecalis urinary tract infections (UTIs).
Adult
500 mg PO q6h; 150-200 mg/kg IV divided q4-6h (1 g q6h)
Pediatric
Not established
Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives; decreased bioavailability of atenolol; altered response to coumarin derivatives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure (CrCl <10-30 mL/min); evaluate rash and differentiate from hypersensitivity reaction; do not use alone for treatment of UTIs due to increased resistance to beta-lactams present among uropathogens (30-50%)
Gentamicin (Garamycin, Gentacidin)
Bactericidal aminoglycoside antibiotic that inhibits bacterial protein synthesis by binding to the ribosome. Activity against a variety of aerobic gram-negative bacteria and E faecalis and staphylococcal species. Used with or without ampicillin to treat acute prostatitis in the hospitalized patient when Enterococcus is a concern. Only aminoglycoside with appreciable activity against gram-positive organisms.
Dosing regimens are numerous. Adjust dose based on CrCl and changes in volume of distribution. Ideal body weight (IBW) should be used for calculations (the drug is not fat soluble). Trough serum levels should be monitored to ensure adequate clearance and reduce toxicity (<2 mcg/mL). Peak levels also should be monitored after 4-5 half-lives when dosed more often than qd.
Qd dosing should only be used when treating gram-negative infections; takes advantage of its concentration-dependent killing and its postantibiotic effect. Exhibits neither of these properties against gram-positive infections (for synergy against gram-positive organisms, use 1 mg/kg q8h).
Adult
3-5 mg/kg IV qd; alternatively, 1 mg/kg IV q8h
Pediatric
Not established
Coadministration with other aminoglycosides, cephalosporins, penicillins, vancomycin, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides (possible irreversible cranial nerve VIII dysfunction, ie, hearing, vestibular function, may occur)
Documented hypersensitivity, non–dialysis-dependent renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment; can be nephrotoxic and ototoxic
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| Differential Diagnoses & Workup: Urinary Tract Infection, Males |
 Treatment & Medication: Urinary Tract Infection, Males |
| Follow-up: Urinary Tract Infection, Males |
| Multimedia: Urinary Tract Infection, Males |
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Further Reading
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
