Genitourinary Infections in Men
Cystitis
Cystitis is uncommon in young men and recurrence should prompt evaluation for prostatitis; E. coli is the most frequent pathogen. Risk factors include urologic abnormality, anal intercourse, and lack of circumcision.
Pyuria may also be an indication of sexually transmitted infections. A pretreatment urinalysis and culture should be sent. Other urologic studies are appropriate when treatment fails, in recurrent infections, or when pyelonephritis occurs.Prostatitis
• Acute prostatitis usually presents with fever, chills, dysuria, pelvic pain, obstructive symptoms, and a boggy, tender prostate on examination. It is caused by E. coli and other gram-negative organisms. Diagnosis is made by physical examination, urinalysis, and culture. Prostatic massage is contraindicated as it can lead to bacteremia.
• Chronic prostatitis is defined as the presence of urinary symptoms for >3 months. It is often noninfectious. Chronic bacterial prostatitis is caused by enteric gram-negative organisms. Symptoms include frequency, dysuria, urgency, perineal discomfort, and recurrent UTIs. Urine cultures should be obtained when the patient is symptomatic. Referral to a urologist for quantitative cultures before and after prostatic massage may be necessary. Transrectal ultrasound can be used if prostatic abscess is suspected.
TREATMENT
• Acute bacterial prostatitis should be treated with a 4- to 6-week course of either ciprofloxacin 500 mg PO q12h or TMP-SMX 160 mg/800 mg (double strength) PO q12h.
• Chronic prostatitis is difficult to treat. Culture-positive chronic bacterial prostatitis should receive prolonged therapy (for at least 6 weeks with a fluoroquinolone or TMP-SMX).
Epididymitis
Epididymitis presents as a unilateral scrotal ache with swollen and tender epididymis on examination.
Causative organisms are usually N.
gonorrhoeae or C. trachomatis in sexually active young men and gram-negative enteric organisms in older men. Diagnosis and therapy should be directed according to this epidemiology, with NAAT testing and ceftriaxone and doxycycline in young men, and levofloxacin in older men.32Pyelonephritis
Pyelonephritis is infection of the kidney, usually due to ascending infection from the lower urinary tract. The causative agents are typically Enterobacterales such as E. coli, Klebsiella spp., or Proteus spp. The incidence of MDRO is rising, especially in patients with recent use of broad-spectrum antibiotics, exposure to healthcare facilities, or travel to areas with high rates of MDROs.
DIAGNOSIS
CLINICAL PRESENTATION
Patients present with fever, chills, flank pain, nausea/vomiting, and costovertebral angle tenderness, often along with cystitis symptoms. Patients may present with sepsis or multiorgan dysfunction, especially if they have urinary obstruction and recent instrumentation or are elderly or diabetic.
DIAGNOSTIC TESTING
• Urinalysis reveals significant bacteriuria, pyuria, red blood cells, and occasional leukocyte casts. A urine culture should always be sent. Blood cultures should be obtained in hospitalized patients as bacteremia may be present in 15%-20% of cases, especially in severely ill, elderly, and immunocompromised patients.
• Imaging may be considered if symptoms persist despite 48-72 hours of appropriate antibiotics or for suspected urinary tract obstruction. Ultrasonography or CT scan may demonstrate the presence of obstruction, a renal abscess, or renal calculi, which may require more invasive management.
TREATMENT
• Start empiric antibiotics promptly. See Tables 14-11 and 14-12.
• Patients with severe illness and pregnant patients should be treated initially with IV therapy. Patients with mild to moderate illness who can tolerate oral medications can be managed as outpatients.