UTIs and Older Men: 3 Questions You Were Afraid to Ask
A new review on the topic in the NEJM covers everything you need to know. We preview with a short Q&A for primary care.
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Why are older men vulnerable to UTIs?
Older men have a number of risk factors that are absent when they are younger. Prostatic hyperplasia impairs normal voiding and may cause obstruction and turbulent urinary flow.1 The older demographic also is likely to have comorbid conditions-such as diabetes-that increase the risk of infections. Elderly men with functional disability, incontinence, immobility, and dementia have urine more frequently colonized by bacteria.1 Some studies have found that men are more likely than women to have urinary pathogens that are extended beta-lactamase producers.2 Bottom line, note the NEJM authors, is that the “majority of older men with urinary tract infection have underlying urologic abnormalities.”1
Why are men from Mars, women from Venus when it comes to UTIs?
Treatment for cystitis in women is usually empiric without culture. But in men, a urine culture is critical. The rule in men is that, “specimens should always be obtained before the initiation of antibiotic therapy.”1 A bacterial count of at least 105 colony-forming units of a single organism is diagnostic. The Mars/Venus analogy also applies to work-up (see previous question, underlying urologic abnormalities). For men with a first UTI, evaluation of both the upper and lower urinary tract is recommended. Ultrasound should assess residual urine volume. Patients with fever should undergo CT imaging. Further urologic study may become necessary (eg, if an obstruction is discovered).
What are some special circumstances in the context of male UTIs?
The authors of the NEJM review observe, “Effective treatment of infection requires determining whether the site of infection is the kidney, bladder, or prostate.”Why is this so important? If the diagnosis is chronic bacterial prostatitis, treatment is continued for 30 days (fluoroquinolone or trimethoprim-sulfamethoxazole).Repeated identification of the same strain of bacteria suggests bacterial persistence in the urinary tract. Persistence should make you consider a bladder stone or a prostatic infection.
There are many more pearls to be found in the journal article – all of interest to the primary care practitioner.
References
1. Schaeffer AJ, Nicolle LE. Urinary tract infections in older men. N Engl J mMed. 2016; 374:562-571.
2. Briongos-Figuero LS, Gomez-Traveso T, Bachhiller-Luque P, et al. Epidemiology, risk factors, and comorbidity for urinary tract infections caused by extended-spectrum beta-lactamase (ESBL)-producing enterobacteria. Int. J. Clin. Pract. 2012; 66:891-898.
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