History
In men, the most frequent chief complaint related to urinary tract infection (UTI) is dysuria. In fact, complaints of dysuria, urinary frequency, and urgency are approximately 75% predictive for UTI, whereas the acute onset of hesitancy, urinary dribbling, and slow stream are only approximately 33% predictive for it. Other aspects to inquire about include the following:
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Previous UTI(s)
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Nocturia, gross hematuria, any changes in the color and/or consistency of the urine
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Prostatic enlargement
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Urinary tract abnormalities - personally and within their families
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Comorbid conditions - eg, diabetes
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Human immunodeficiency virus (HIV) status
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Immunosuppressive treatments for other conditions - eg, prednisone
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Any previous surgeries or instrumentation involving the urinary tract
In a younger man, the presence of UTI often is associated with anatomic abnormality. In the absence of this history, a detailed sexual history may implicate activities such as sex with a new partner, sex with multiple partners, or other risk-taking behavior associated with sexually transmitted disease (STD)-related urethritis, prostatitis, or epididymitis that may lead to UTI.
Certain patients are at increased risk for urosepsis and complications, such as the very sick and the immunosuppressed, as well as those with a history of genitourinary surgery, a neurogenic bladder, papillary necrosis (sickle cell disease, diabetes, or analgesic abuse), and a history of ureteral stricture or tumor with obstruction.
Physical Examination
Males who present with genitourinary complaints warrant a thorough general physical examination, with particular attention to the vital signs, kidneys, bladder, prostate, and external genitalia.
Auscultation over the upper abdominal quadrants and the costovertebral angles may reveal the bruits of renal artery stenosis, an aneurysm, or an arteriovenous malformation. The costovertebral angles should be percussed for tenderness. Palpation of the suprapubic area should be performed; a bladder that contains 500mL or more of fluid often is palpable as a suprapubic mass.
The external genitalia should be examined carefully. The penis should be examined for the presence of ulcers or lesions, and special attention should be paid to the urethral meatus for the presence of erythema or discharge. The testes and epididymis must be examined and palpated for tenderness and swelling.
A rectal examination with a 360° sweep of the interior of the rectum followed by careful palpation of the prostate can be performed. However, in patients with suspected acute bacterial prostatitis, palpation can be painful and may lead to bacteremia. Some authorities note that it is of little benefit in diagnosing acute prostatitis and state that prostatic massage should not be conducted in the setting of UTI or urethritis.
Physical findings of UTI may include the following:
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Fever
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Tachycardia
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Flank pain/costovertebral angle tenderness
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Abdominal tenderness in the suprapubic area
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Scrotal hematoma, hydrocele, masses, or tenderness
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Meatal discharge
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Prostatic tenderness
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Inguinal adenopathy
Prostatitis Syndromes
These syndromes tend to occur in young and middle-aged men. Symptoms may include pain (in the perineum, lower abdomen, testicles, or penis or with ejaculation), bladder irritation, and, sometimes, blood in the semen.
Acute prostatitis
Acute prostatitis typically presents with spiking fever, chills, malaise, myalgia, dysuria, pelvic or perineal pain, and cloudy urine. Obstructive symptoms can result from swelling of the acutely inflamed prostate, and these range from dribbling and hesitancy to anuria. A less common presentation is with a vague, flulike illness.
Careful examination of the prostate is not contraindicated in acute bacterial prostatitis, but prostatic massage is contraindicated. Upon examination, the prostate is warm, swollen, soft ("boggy"), and extremely tender. The patient may have a fever and appear acutely uncomfortable; hypotension may be noted.
A rectal examination with a 360° sweep of the interior of the rectum followed by careful palpation of the prostate can be performed. However, in patients with suspected acute bacterial prostatitis, palpation can be painful and may lead to bacteremia. Some authorities note that it is of little benefit in diagnosing acute prostatitis and state that prostatic massage should not be conducted in the setting of UTI or urethritis.
Chronic prostatitis
Patients with chronic prostatitis, by definition, have had symptoms for at least 3 months. Although this condition is not life threatening, the patient's quality of life has been compared with someone with unstable angina or active Crohn disease. Interestingly, many with chronic bacterial prostatitis are asymptomatic.
Chronic bacterial prostatitis and nonbacterial prostatitis have similar presentations, including dysuria, frequency, urgency, perineal discomfort, and a low-grade temperature. The only way to differentiate between these 2 entities is through culture of prostatic secretions.
Prostatodynia, a noninflammatory disorder, also has a symptom complex similar to that of chronic prostatitis, except that the patient does not give a history of recurrent UTIs.
In chronic bacterial prostatitis, the physical findings are variable. A low-grade fever may be present, and the rectal examination may be unremarkable or may reveal severe anal sphincter spasm. The prostate may be mildly or extremely tender.
Examination of urine voided after prostate massage is more helpful diagnostically than quantitating the amount of pain experienced during the digital examination. The Meares-Stamey 4-glass test with prostatic massage is a classic diagnostic test for chronic prostatitis. Prostatic massage should not be conducted in the setting of UTI or urethritis.
Epididymitis and Cystitis
In early epididymitis, the epididymis is tender and indurated, but the testis itself is nontender and soft. In hours to days, inflammation progresses to the adjacent testicle and patients may complain of scrotal pain and swelling, as well as urinary frequency, urgency, or dysuria. Identifying the lateral sulcus between the testicle and epididymis then becomes increasingly difficult, and discerning testis from epididymis may be impossible.
Dysuria, frequency, urgency, and suprapubic pain usually are present in patients with cystitis. Fever and flank pain may be present, but not usually. Note that symptoms cannot reproducibly differentiate cystitis (lower UTI) from pyelonephritis (upper UTI).
Orchitis
The most common presentation of orchitis is in a patient in the later stages of epididymitis. In this situation, inflammation has spread to the adjacent testicle and results in a tender, warm, and swollen hemi-scrotal mass. Patients have the characteristic history and urinary findings of epididymitis.
Of patients with orchitis resulting from tuberculosis, 70% have other genitourinary or pulmonary symptoms of this disease.
Viral orchitis is notable for the other symptoms of the particular virus involved. Orchitis occurs in approximately 18% of postpubertal boys infected with the mumps virus; symptoms usually begin within 1 week of parotitis. Up to 30% of cases are bilateral, and sterility develops in up to 10% of cases.
Pyelonephritis
Patients with pyelonephritis appear ill; have fever, chills, and flank pain; and may have hypotension. Although fever is very suggestive of pyelonephritis, it also has been demonstrated in some males with simple cystitis. Note that 30-50% of pyelonephritis cases may be silent, without clinical symptoms.
In the older male, prostate enlargement along with delayed presentation are the primary causes of pyelonephritis. Other historical risk factors include nephrolithiasis, neurogenic bladder, prostatitis, or symptom duration greater than 5 days.
Classic findings with pyelonephritis include fever, chills, and flank pain/costovertebral angle tenderness that follow the symptoms of UTI; these findings are combined with pyuria and bacteriuria. Occasionally, the urinalysis and urine culture findings are negative, such as when an obstruction of the upper urinary tract is present due to stone disease.
The differential diagnoses include appendicitis, diverticulitis, pancreatitis, and lower-lobe pneumonia.
Urethritis
The incubation period of gonococcal urethritis is 2-6 days. Occasionally, 2 weeks may elapse before symptoms such as dysuria; thick, milky discharge; and pruritus occur.
The incubation period of nongonococcal urethritis (NGU) is 2-6 weeks. The symptoms are less severe, and the discharge may be clearer than with gonococcal urethritis. Patients are likely to have a higher level of education (ie, 90% of urethritis cases in college health services is NGU) and fewer sexual contacts.
Because patients with urethritis have a thick, milky discharge, the underpants may be impressively stained. Typically, patients with gonorrhea have a thicker, more copious discharge, but significant overlap with chlamydial urethritis is not uncommon.
Gram stain is the key to an immediate diagnosis, although patients frequently have co-infections.
Catheterized and Hospitalized Patients
Clinical and microbiologic criteria for the diagnosis of UTI are not well established in catheterized hospitalized patients. Symptoms in these individuals may be atypical or may be attributed to other disease processes, and no reliable colony count cutoff defines significant bacteriuria.
Low-level (100-1000 colony-forming units [CFU] per mL) colonization can progress to high-level (>100,000 CFU/mL) bacteriuria within 3 days in 96% of catheterized patients who are cultured on subsequent days (and not treated with antimicrobials). Thus, most experts agree that growth of more than 100 CFU/mL of a predominant pathogen represents catheter-associated UTI (CAUTI).
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Prostatic calcifications in a male with a urinary tract infection.
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Bladder calculi in a male with a urinary tract infection.
