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Literature review current through: Feb 2015. | This topic last updated: May 30, 2014.

INTRODUCTION — Acute cystitis refers to infection of the bladder (lower urinary tract); it can occur alone
or in conjunction with pyelonephritis (infection of the kidney – the upper urinary tract). Acute cystitis,
pyelonephritis, and asymptomatic bacteriuria in men will be reviewed here. Issues related to prostatitis
are discussed separately. (See "Acute bacterial prostatitis" and "Chronic bacterial prostatitis".)

Acute cystitis, pyelonephritis, and asymptomatic bacteriuria in women are discussed separately.
(See "Acute uncomplicated cystitis and pyelonephritis in women" and"Acute complicated cystitis and
pyelonephritis" and "Urinary tract infections and asymptomatic bacteriuria in pregnancy" and "Approach to
the adult with asymptomatic bacteriuria".)

PATHOGENESIS — Asymptomatic bacteriuria and symptomatic urinary tract infection are much less
common in men than in women. This is due to longer urethral length, drier periurethral environment (with
less frequent colonization around the urethra), and antibacterial substances in prostatic fluid.

It has been conventional to consider all UTIs (and presumably asymptomatic bacteriuria) in men as
complicated, since the majority occur in infants or the elderly in association with urologic abnormalities,
such as bladder outlet obstruction (eg, due to prostatic hyperplasia) or instrumentation (table 1). However,
acute uncomplicated UTIs occur in a small number of men between 15 and 50 years of age. Risk factors
associated with these infections include insertive anal intercourse and lack of circumcision [1].

ASYMPTOMATIC BACTERIURIA — Asymptomatic bacteriuria refers to the presence of a positive urine

culture in the absence of symptoms. For men, asymptomatic bacteriuria is defined as a single, clean-
catch voided urine specimen with one bacterial species isolated in counts ≥10 5 CFU/mL in the absence of
symptoms [2]. Asymptomatic bacteriuria in young healthy men is rare [3]. Among the elderly, the
prevalence of asymptomatic bacteriuria is lower in men than in women; in one report, the prevalence was
6 versus 18 percent respectively [4].

In general, men should not be screened for and/or treated for asymptomatic bacteriuria. However, there
are a few circumstances in which screening may be reasonable. Screening for asymptomatic bacteriuria
is warranted prior to transurethral resection of the prostate or other urologic procedures for which mucosal
bleeding is anticipated because of the risk of post-procedure bacteremia and sepsis [2]. (See "Acute
bacterial prostatitis", section on 'Risk factors'.)

There is less apparent benefit to screening for asymptomatic bacteriuria prior to other surgical
procedures. In a retrospective study of 489 men who had urine cultures performed prior to undergoing
orthopedic, cardiothoracic, and vascular procedures, bacteriuria was uncommon (11 percent of patients)
[5]. Preoperative bacteriuria was not associated with an increased risk of surgical site infection.
Furthermore, the incidence of subsequent urinary tract infection was not decreased with antibiotic therapy
for bacteriuria (3 of 43 untreated versus 2 of 11 treated patients). A detailed discussion on the evaluation
for asymptomatic bacteriuria prior to joint arthroplasty, specifically, is found elsewhere. (See "Approach to
the adult with asymptomatic bacteriuria", section on 'Patients undergoing joint arthroplasty'.)

ACUTE CYSTITIS AND PYELONEPHRITIS — Cystitis is an infection of the bladder (lower urinary tract),
which can occur alone or in conjunction with pyelonephritis (infection of the kidney - upper urinary tract) or
prostatitis. The incidence of symptomatic UTI in young healthy adult men is much lower than that in
women; approximately five to eight UTIs occur per year per 10,000 young to middle-aged men [6,7].
Clinical manifestations — Clinical manifestations of cystitis consist of dysuria, frequency, urgency,
suprapubic pain, and/or hematuria. Clinical manifestations of pyelonephritis consist of the above
symptoms (symptoms of cystitis may or may not be present) together with fever (>38ºC), chills, flank pain,
costovertebral angle tenderness, and nausea/vomiting. Rarely, patients with acute pyelonephritis present
with sepsis, multiple organ system dysfunction, shock, and/or acute renal failure.

Diagnosis — The diagnosis of uncomplicated cystitis or pyelonephritis begins with assessment of the

clinical history, guided by the clinical manifestations above. Physical examination should include
assessment for fever, costovertebral angle tenderness, abdominal examination, and possibly a digital
rectal examination.

Laboratory diagnostic tools consist of urinalysis (either by microscopy or by dipstick) and urine culture
with susceptibility data. A urine Gram stain may be helpful in guiding the choice of empiric therapy
pending culture results. A urine culture should be performed in all men with symptoms suggestive of
cystitis.

Urinalysis — Urinalysis for evaluation of pyuria is the most valuable laboratory diagnostic test for UTI.
Pyuria is present in almost all men with acute cystitis or pyelonephritis; its absence strongly suggests an
alternative diagnosis [8,9] or, in a patient with pyelonephritis, the presence of an obstructing lesion [8].

The most accurate method for assessing pyuria is to examine an unspun voided midstream urine
specimen with a hemocytometer; an abnormal result is ≥10leukocytes/microL [8]. White blood cell casts in
the urine are diagnostic of upper tract infection. The presence of hematuria is helpful since it is common
in the setting of UTI but not in urethritis. Hematuria is not a predictor for complicated infection and does
not warrant extended therapy.

Urinalysis is discussed further separately. (See "Acute uncomplicated cystitis and pyelonephritis in

women", section on 'Urinalysis' and "Sampling and evaluation of voided urine in the diagnosis of urinary
tract infection in adults".)

Urine culture — A midstream urine culture is recommended to confirm the diagnosis of urinary tract
infection in men, using colony count criteria of ≥10 4 CFU/mL [10]. However, when coliform bacteria
(eg, Escherichia coli) are isolated, lower colony counts are likely to represent significant bacteriuria, as
has been documented in studies among women [11,12].

The spectrum of isolates causing uncomplicated cystitis in men is similar to that in women and consists
mainly of E. coli (75 to 95 percent), with occasional other species of Enterobacteriaceae, such as Proteus
mirabilis  and Klebsiella pneumoniae [13,14]. Other gram-negative and gram-positive species are rarely
isolated in uncomplicated UTIs.

Additional evaluation — An evaluation for predisposing features or causative factors should be pursued
(table 1). If an underlying risk factor is not obvious, further evaluation should be considered. Men with
recurrent cystitis should undergo evaluation for prostatitis (see "Chronic bacterial prostatitis", section on
'Diagnosis'). Urologic evaluation is probably not necessary in young healthy men with no obvious
complicating factors who have a single episode of cystitis that responds promptly to antimicrobial
treatment [3,15].

Imaging studies are not routinely required for diagnosis of acute uncomplicated pyelonephritis but can be
helpful in certain circumstances. (See "Acute complicated cystitis and pyelonephritis", section on
'Radiographic imaging'.)
Differential diagnosis — Dysuria, urinary frequency and urgency, and pyuria can also be seen with
acute bacterial prostatitis. The presence of fever, chills, malaise, myalgias, pelvic or perineal pain, or
obstructive symptoms such as dribbling and hesitancy (due to acute urinary retention) in a man with
symptoms of cystitis suggests acute bacterial prostatitis. Such signs and symptoms should prompt
performance of gentle digital rectal examination, and the finding of an edematous and tender prostate
helps to confirm this alternate diagnosis. (See "Acute bacterial prostatitis", section on
'Diagnosis' and "Acute bacterial prostatitis", section on 'Differential diagnosis'.)  

Underlying chronic prostatitis should be considered in men with cystitis, particularly in those men who
have recurrent UTIs. (See "Chronic bacterial prostatitis".)

Urethritis must be considered in sexually active men; examination for penile ulcerations and urethral
discharge, evaluation of a urethral swab specimen Gram stain, and diagnostic tests for Neisseria
gonorrhoeae  and Chlamydia trachomatis are warranted. A urethral Gram stain demonstrating leukocytes
and predominant gram-negative rods suggests E. coli urethritis, which may precede or accompany
urinary tract infection [16]. (See "Urethritis in adult men" and "Clinical manifestations and diagnosis of
Neisseria gonorrhoeae infection in adults and adolescents" and "Clinical manifestations and diagnosis of
Chlamydia trachomatis infections", section on 'Diagnosis of chlamydial infections'.)

Treatment

Cystitis

Antibiotic choice — Appropriate antimicrobials for empiric treatment of acute uncomplicated cystitis in

men include trimethoprim-sulfamethoxazole and fluoroquinolones [1,6]. The choice of agents is
extrapolated from data in studies of women; data on treatment of cystitis in men are limited. Once
susceptibility data are available, subsequent therapy should be tailored as appropriate.

Dosing for TMP-SMX is one double strength tablet [160/800 mg] twice daily. Based on data in studies of
UTI in women, empiric TMP-SMX should be avoided if the prevalence of resistance is known to exceed
20 percent [17,18] or if the patient has taken TMP-SMX in the preceding three months [19,20]. In some
regions, trimethoprim(100 mg twice daily) is preferred over TMP-SMX and is considered equivalent based
on studies in women [21]. (See "Acute uncomplicated cystitis and pyelonephritis in women", section on
'Antimicrobial resistance'.)

Appropriate oral fluoroquinolone choices for empiric therapy of acute uncomplicated cystitis in men
include ciprofloxacin (500 mg orally twice daily or 1000 mg extended release once daily)
or levofloxacin (500 to 750 mg orally once daily). Multiple randomized trials in women have demonstrated
that fluoroquinolones are very effective for treatment of acute cystitis [22-30], although increased
resistance is mitigating the usefulness of the fluoroquinolone class.

Nitrofurantoin and beta-lactams should usually not be used in men with cystitis, since they do not achieve
reliable tissue concentrations and would be less effective for occult prostatitis. Data for fosfomycin in men
are limited. (See "Chronic bacterial prostatitis", section on 'Antimicrobial penetration into prostatic tissue'.)

Duration of therapy — Few studies have evaluated the optimal duration of antibiotic therapy in men,
although treatment has traditionally been given for 7 to 14 days.

In men with uncomplicated cystitis who have no signs or symptoms suggestive of severe pyelonephritis or
prostatitis (eg, fever, flank pain, pelvic pain, prostatic tenderness on digital rectal exam if this part of the
examination is performed), a seven-day course of an antimicrobial to which the infecting strain is
susceptible is likely to be sufficient. In a large retrospective study of 33,336 male veterans who received
antibiotic therapy for a urinary tract infection, as identified through billing codes, there was no difference in
the risk of early (less than 30 days after a prior UTI) or late (30 days or longer after a prior UTI)
recurrence between those who received a short (seven days or less) or long (more than seven days)
course of antibiotics [31]. Moreover, in multivariate analysis, there was a non-significant trend toward an
increased risk in the incidence of Clostridium difficile infection among patients who received a longer
course of therapy. Because of the inherent limitations in interpretation of retrospective studies,
prospective studies are warranted to further elucidate the benefits and harms of shorter versus longer-
duration treatment for UTIs in men.

When fluoroquinolones specifically are used, a course as short as five days is likely effective, as
illustrated by a trial of patients with complicated cystitis or pyelonephritis, in which five days
of levofloxacin was equivalent to ten days of ciprofloxacin [32].

Men with persistent or recurrent symptoms following such a course of antibiotic therapy for cystitis
warrant reevaluation for the possibility of underlying prostatitis. (See"Chronic bacterial prostatitis", section
on 'Diagnosis'.)

Pyelonephritis — Treatment of pyelonephritis in men is as outlined for women separately. (See "Acute

uncomplicated cystitis and pyelonephritis in women", section on 'Pyelonephritis'.)

Follow up — Patients with acute cystitis or pyelonephritis who have persistent symptoms after 48 to 72
hours of appropriate antimicrobial therapy or recurrent symptoms within a few weeks of treatment should
have evaluation for complicated infection as discussed separately. Urine culture should be repeated and
empiric treatment should be initiated with another antimicrobial agent. (See "Acute complicated cystitis
and pyelonephritis".)

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patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on "patient info" and the keyword(s) of interest.)

●Beyond the Basics topics (see "Patient information: Urinary tract infections in adolescents and
adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Asymptomatic bacteriuria and symptomatic urinary tract infection are much less common in men
than in women. This is due to longer urethral length, drier periurethral environment (with less
frequent colonization around the urethra), and antibacterial substances in prostatic fluid.
(See 'Pathogenesis' above.)
●For men, asymptomatic bacteriuria is defined as a single, clean-catch voided urine specimen with
one bacterial species isolated in counts ≥105 CFU/mL in the absence of symptoms. Screening for
asymptomatic bacteriuria is warranted prior to transurethral resection of the prostate or other
urologic procedures for which mucosal bleeding is anticipated. (See 'Asymptomatic
bacteriuria' above.)
●Clinical manifestations of cystitis consist of dysuria, frequency, urgency, suprapubic
pain, and/or hematuria. Clinical manifestations of pyelonephritis consist of the above symptoms
(symptoms of cystitis may or may not be present) together with fever (>38ºC), chills, flank pain,
costovertebral angle tenderness, andnausea/vomiting. (See 'Clinical manifestations' above.)
●Laboratory diagnostic tools for cystitis and pyelonephritis consist of urinalysis (either by microscopy
or by dipstick) and urine culture with susceptibility data. A urine culture should be performed in all
men with symptoms suggestive of cystitis. A diagnostic urine culture in men has colony count
≥104 CFU/mL, although lower counts of coliform bacteria (eg, Escherichia coli, the most commonly
isolated pathogen) are likely to represent significant bacteriuria. (See 'Diagnosis' above
and"Sampling and evaluation of voided urine in the diagnosis of urinary tract infection in adults".)
●An evaluation for predisposing features or causative factors should be pursued (table 1). Men with
recurrent cystitis should undergo evaluation for prostatitis. Urologic evaluation is probably not
necessary in young healthy men with no obvious complicating factors who have a single episode of
cystitis that responds promptly to antimicrobial treatment. (See 'Diagnosis' above.)
●The presence of fever, chills, malaise, myalgias, pelvic or perineal pain, or obstructive symptoms
such as dribbling and hesitancy (due to acute urinary retention) in a man with symptoms of cystitis
suggests acute bacterial prostatitis and should prompt performance of a digital rectal exam. Chronic
prostatitis should be considered in men with cystitis, particularly in those men who have recurrent
UTIs. Urethritis must be considered in sexually active men, and diagnostic tests for Neisseria
gonorrhoeae and Chlamydia trachomatis are warranted. (See 'Differential diagnosis' above
and "Acute bacterial prostatitis" and "Chronic bacterial prostatitis" and"Urethritis in adult men".)
●We suggest trimethoprim-sulfamethoxazole or fluoroquinolones for treatment of acute
uncomplicated cystitis in men (Grade 2B). Nitrofurantoin and beta-lactams should usually not be
used in men with cystitis, since they do not achieve reliable tissue concentrations and would be less
effective for occult prostatitis. In men with uncomplicated cystitis who have no signs or symptoms
suggestive of severe pyelonephritis or prostatitis, a five-day course of a fluoroquinolone or a seven-
day course of trimethoprim-sulfamethoxazole is likely to be sufficient. (See 'Cystitis' above.)
●Treatment of pyelonephritis in men is as outlined for women separately. (See "Acute
uncomplicated cystitis and pyelonephritis in women".)
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