INTRODUCTION	Section 2 of 10
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Background: The consideration of male urinary tract infection (UTI) is complicated by the overlap with what might be termed reproductive tract infections. For the purposes of this article, the male UTI includes infections that arise from bacterial colonization of the urinary tract proper (ie, kidney, ureter, bladder). Infections of contiguous structures, for example, urethritis, epididymitis, prostatitis, or orchitis, are covered in other articles.

Pathophysiology: As with females, the usual route of inoculation in males is with gram-negative aerobic bacilli from the gut, with Escherichia coli being the most common offending organism. In males aged 3 months to 50 years, incidence of UTI is low; therefore, the possibility of anatomical abnormalities must be entertained in this age group.

Frequency:

• In the US: The frequency of male UTI is related to age.

• Internationally: In developed countries, the incidence of UTI in males is similar to that in the United States. However, in developing countries where men have shorter life spans, the incidence of UTI due to prostatic hypertrophy is lower.

Mortality/Morbidity: Otherwise healthy males without anatomical abnormalities who promptly seek treatment experience little morbidity besides the discomfort of an infection.

• In more complicated cases (eg, prolonged infection, anatomical variations), the sequelae of infection can be more significant. Complications include strictures secondary to inflammation within the urinary tract, abscess and fistula formation, bacteremia, and a deleterious effect on kidney function.

• In elderly patients, UTI is a significant cause of morbidity and death, with the expected death rate as high as 3% in those who develop pyelonephritis. The high mortality rate is largely due to delayed presentation and the development of bacteremia/sepsis.

Sex: Although this article exclusively addresses UTI in males, the clinician should appreciate that the incidence of UTI is much higher in females during adolescence and childbearing years. The incidence of UTI in men approaches that of women only in men older than 60 years.

Age: The incidence of UTI has an early peak during the first 3 months of life. In neonates, a UTI occurs more frequently in boys than in girls (with a male-to-female ratio of 1.5:1), and it is often part of the syndrome of gram-negative sepsis.

• The cumulative incidence of symptomatic UTI (including pyelonephritis) in boys during the first 10 years of life has been reported at 1.1-1.6%.

• The incidence of true UTI in adult males younger than age 50 years is low (approximately 5-8 per year per 10,000). In this population, the symptoms of dysuria or urinary frequency are usually due to sexually transmitted disease (STD)–related infections of the urethra (eg, gonococcal and nongonococcal urethritis) and prostate.

• In men older than 50 years, the incidence of UTI rises dramatically because of enlargement of the prostate, prostatism, and subsequent instrumentation of the urinary tract.

	CLINICAL	Section 3 of 10
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History:

• The most frequent chief complaint with UTI is dysuria.

• Other aspects to inquire about include urgency, frequency, nocturia, gross hematuria, and any changes in the color and/or consistency of the urine.

• Associated signs and symptoms include fever, chills, back/flank pain, suprapubic pain, and nausea and vomiting.

• Ask elderly men about a history of prior UTI, prostatic enlargement, urinary dribbling or hesitancy, or difficulty initiating the urinary stream.

• Ask all men about known urinary tract abnormalities, personally and within their families, as well as any history of prior UTI.

• Particularly in elderly patients, inquire about prior urinary tract manipulation, history of indwelling catheters, or other chronic urinary tract problems; these patients are at much higher risk of UTI.

• Other relevant items in the history include comorbid conditions (eg, diabetes), HIV status, immunosuppressive treatments for other conditions (eg, prednisone), and any prior surgeries or instrumentation involving the urinary tract.

• One of the difficulties in diagnosing UTI in males lies in the fact that dysuria, with or without discharge, is the typical chief complaint with urethritis, which is a much more common disease. Determining the history of urinary and genital tract symptoms and sexual encounters, combined with laboratory testing of urine and urethral swabs, should allow differentiation of the two.

• Classic findings with pyelonephritis include fever, chills, and costovertebral angle (CVA) tenderness that follow the symptoms of UTI. Note that 30-50% of pyelonephritis cases may be silent, without clinical symptoms.

• In the elderly man, 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.

• In the younger man, anatomical abnormalities and a complete sexual history are the most useful historical details.

Physical:

• Fever

• Tachycardia

• CVA tenderness (bruits)

• Abdominal tenderness in the suprapubic area and guarding (pulsatile masses in elderly patients)

• Scrotal hematoma, hydrocele, masses, or tenderness

• Meatal discharge

• Rectal lesions or abscesses

• Prostatic tenderness or hypertrophy

• Inguinal adenopathy

Causes:

• UTI in males typically is caused by bacterial colonization of the urinary tract, though fungal or other types of infection are possible.

• The sources of these bacteria or other agents can vary. Routes of infection include the following:

• Direct ascension up the urinary tract via the urethra

• Hematogenous spread, as with bacteremia

• Spreading from contiguous structures, such as the prostate

• Iatrogenic instrumentation