eMedicine Specialties > Emergency Medicine > Genitourinary

Urinary Tract Infection, Male: Differential Diagnoses & Workup

Author: David S Howes, MD, Residency Program Director, Professor of Medicine, Section of Emergency Medicine, University of Chicago/Pritzker School of Medicine
Coauthor(s): M Tyson Pillow, MD, Emergency Medicine Resident and Flight Physician, University of Chicago Medical Center
Contributor Information and Disclosures

Updated: Apr 27, 2009

Differential Diagnoses

Aneurysm, Abdominal
Inflammatory Bowel Disease
Appendicitis, Acute
Obstruction, Large Bowel
Back Pain, Mechanical
Obstruction, Small Bowel
Chlamydia
Orchitis
Constipation
Prostatitis
Diverticular Disease
Renal Calculi
Epididymitis
Testicular Torsion
Gastritis and Peptic Ulcer Disease
Trauma, Lower Genitourinary
Gastroenteritis
Trauma, Upper Genitourinary
Gonorrhea
Urethritis, Male

Workup

Laboratory Studies

  • Obtain the urine sample first.
    • If the patient is able, a routine midstream voided sample is adequate. The foreskin must be retracted to ensure an acceptable specimen.
    • If the patient is unable to cooperate, a catheterized specimen or suprapubic aspiration is necessary.
  • Positive urinalysis findings include leukocytes and bacteria in an otherwise uncontaminated urine specimen.
    • The threshold for establishing true urinary tract infection (UTI) includes finding greater than or equal to 2-5 WBCs or 15 bacteria per high power field (HPF) in a centrifuged urine sediment.
    • As with females, a positive nitrite test is poorly sensitive but highly specific for UTI and false-positives are uncommon.
    • In younger men, differentiation of UTI from urethritis may necessitate a urethral smear and culture or urinary antigen testing for chlamydia and Neisseria gonorrhoeae.
    • The decision to treat young men who are sexually active for UTI versus STD-related urethritis rests primarily on epidemiologic grounds (eg, recent new sexual partner, multiple sexual partners). 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, STD-related urethritis predominates, although UTI may occasionally be diagnosed.
  • Obtain a urine culture for all males with UTI. This allows adjustment of the treatment plan if antibiotic sensitivity testing demonstrates a resistant organism. The cut-off for defining a urine culture for a male as positive is controversial, but generally positive results are seen if there are >1000 colony-forming units/mL of urine, much lower than the threshold for women.2

Imaging Studies

  • In males younger than 50 years, referral to a urologist or a nephrologist is appropriate.
    • If an anatomic abnormality or complicating obstructing stone is suspected based on history and physical examination findings, imaging of the urinary system to exclude hydronephrosis is appropriate.
    • Modalities for this include ultrasonography, intravenous pyelography (IVP), contrasted computed tomography (CT scan), or helical computed tomography (HelCT scan) of the urinary system. The latter study is now preferred by most experts.
    • In addition, consider imaging in very sick, immunosuppressed patients (eg, those with diabetes or those on chronic immunotherapy) to rule out emphysematous pyelonephritis.

Other Tests

  • For urinary tract infection (UTI), the tests outlined above should be adequate. Other tests will be needed if there is diagnostic uncertainty and the differential needs to be pursued further.
  • Measurement of the post void residual urine volume is very important in the older patient for whom prostatism is suspected.
    • Although traditionally performed via catheterization, some institutions are now using ultrasonography for this measurement.3
    • In follow up, the urologist may perform additional studies (eg, cystoscopy).

More on Urinary Tract Infection, Male

Overview: Urinary Tract Infection, Male
Differential Diagnoses & Workup: Urinary Tract Infection, Male
Treatment & Medication: Urinary Tract Infection, Male
Follow-up: Urinary Tract Infection, Male
References
Further Reading
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References

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

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

  3. 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. Feb 2004;55(1):16-7. [Medline].

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

  5. Anandkumar H, Kapur I, Dayanand A. Increasing prevalence of antibiotic resistance and multi drug resistance among uropathogens. J Commun Dis. Jun 2003;35(2):102-8. [Medline].

  6. Ginde AA, Rhee SH, Katz ED. Predictors of outcome in geriatric patients with urinary tract infections. J Emerg Med. Aug 2004;27(2):101-8. [Medline].

  7. Griebling TL. Urologic diseases in america project: trends in resource use for urinary tract infections in men. J Urol. Apr 2005;173(4):1288-94. [Medline].

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

  9. Hooton TM. The current management strategies for community-acquired urinary tract infection. Infect Dis Clin North Am. Jun 2003;17(2):303-32. [Medline].

  10. Howes DS, Bogner MP. Urinary tract infections. In: Tintinalli JE et al, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill; 2004:606-612.

  11. Hummers-Pradier E, Ohse AM, Koch M, et al. Urinary tract infection in men. Int J Clin Pharmacol Ther. Jul 2004;42(7):360-6. [Medline].

  12. Sanford JP. Guide to Antimicrobial Therapy. Dallas, Tex: Antimicrobial Therapy Inc; 2008.

  13. 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. Nov 1 2008;47(9):1150-8. [Medline].

  14. Thompson PDR. Physicians' Desk Reference. 2008.

  15. Weir M, Brien J. Adolescent urinary tract infections. Adolesc Med. Jun 2000;11(2):293-313. [Medline].

  16. Wells WG, Woods GL, Jiang Q, Gesser RM. Treatment of complicated urinary tract infection in adults: combined analysis of two randomized, double-blind, multicentre trials comparing ertapenem and ceftriaxone followed by appropriate oral therapy. J Antimicrob Chemother. Jun 2004;53 Suppl 2:ii67-74. [Medline].

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Further Reading

Clinical guidelines

 Prevention of catheter-associated urinary tract infections. In: Prevention and control of healthcare-associated infections in Massachusetts. Prevention of catheter-associated urinary tract infections. In: Betsy Lehman Center for Patient Safety and Medical Error Reduction, JSI Research and Training Institute, Inc. Prevention and control of healthcare-associated infections in Massachusetts. Part 1: final recommendations of the Expert Panel. Boston (MA): Massachusetts Department of Public Health; 2008 Jan 31. p. 83-9.

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Keywords

urinary tract infection men, UTI, cystitis, pyelonephritis, Escherichia coli infection, gonococcal urethritis, nongonococcal urethritis, prostatitis, epididymitis, orchitis, dysuria, urgency, frequency, nocturia, hematuria, prostatic enlargement, urinary dribbling, urinary hesitancy, indwelling catheter, Foley catheter, nephrolithiasis, neurogenic bladder, meatal discharge, scrotal hematoma, hydrocele, costovertebral angle tenderness, CVA tenderness, prostatic tenderness, prostatic hypertrophy

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Contributor Information and Disclosures

Author

David S Howes, MD, Residency Program Director, Professor of Medicine, Section of Emergency Medicine, University of Chicago/Pritzker School of Medicine
David S Howes, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

M Tyson Pillow, MD, Emergency Medicine Resident and Flight Physician, University of Chicago Medical Center
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.

Medical Editor

Joseph A Salomone, III, MD, Associate Professor, Department of Emergency Medicine, Truman Medical Center, University of Missouri at Kansas City School of Medicine
Joseph A Salomone, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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