Urinary tract infections (UTIs) are one of the most common bacterial infections globally, affecting millions of people each year. It is estimated that UTIs account for over 150 million cases annually worldwide. UTIs are a frequent cause of GP consultations, particularly among women.
Why specific strategies are needed for UTIs in men
Nearly 50% of women will have at least one UTI in their lifetime. While UTIs are more prevalent in women, they also represent a significant health concern for men, particularly as they age. The incidence of UTIs in men is lower than in women; however, when men do develop UTIs, these infections are often more severe and associated with underlying anatomical abnormalities, such as prostate enlargement, which can complicate treatment and increase the risk of recurrence.
The global and national burden of UTIs has been rising, partly due to the increasing prevalence of antibiotic-resistant pathogens, which complicates treatment and leads to higher healthcare costs. The complexity of managing UTIs in men, coupled with the growing challenge of antibiotic resistance, underscores the need for ongoing research and tailored management strategies. Understanding UTIs in men is
crucial for effective diagnosis, treatment and prevention. That’s why it is important for nurses to be given comprehensive information on the subject, to help improve patient care and encourage critical thinking about the unique challenges and considerations in managing UTIs in men.
Anatomy & Physiology
As a recap, the male urinary system includes the kidneys, ureters, bladder and urethra. Notably, the male urethra, which extends through the penis, is significantly longer than the female urethra. This anatomical difference provides a natural barrier to infection because the greater length of the male urethra makes it more difficult for bacteria to travel from the external environment to the bladder. However, the presence of the prostate gland introduces another layer of complexity in male urinary health. These anatomical features can create barriers to effective urine flow, contributing to a higher likelihood of complications such as prostatitis, urethral strictures and incomplete bladder emptying, all of which can increase the risk of recurrent infections.
Causes & Risk Factors
UTIs in men are commonly caused by bacterial infections, with E. coli being the most frequent pathogen. Other bacteria, such as Proteus, Klebsiella and Enterococcus, can also cause UTIs. The category of adult male UTIs encompasses conditions including urethritis, prostatitis, orchitis, epididymitis, cystitis and infections related to urinary catheters.
Older men are more susceptible to UTIs due to several factors.
Conditions such as neurological conditions, benign prostatic hyperplasia (BPH) and bladder neck muscular obstruction (BNO) can obstruct urine flow, leading to retained urine in the bladder and increasing the risk of infection. An incomplete bladder may lead to the formation of bladder stones, which can act as a reservoir for bacteria, increasing the risk of recurring UTIs and making it difficult to clear the infection. Kidney stones can also sometimes act as a reservoir for bacteria.
Men who use indwelling or selfcatheterisation need to ensure good standards of hygiene, a ‘no touch’ technique and regular reviews to monitor compliance to minimise UTI occurrence. There is evidence to suggest that men often struggle with compliance with intermittent self-catheterisation (ISC), considering it a nuisance and time-consuming, and also struggle with toilet facilities when out and about. This is an important factor to consider when supporting male patients with ISC.
Additionally, a weakened immune system, often due to autoimmune conditions, or cancer, and health issues such as poorly controlled diabetes, can impair immune function and bladder emptying. It’s important to remember that several of these factors can coexist.
Dehydration is another significant risk, particularly in older patients. As we age, the sense of thirst can become blunted, partly due to changes in the regulation of antidiuretic hormone (ADH). This leads to a reduced ability to concentrate urine, which accelerates dehydration. Constipation is also a contributing factor as it can put pressure on the urinary tract, leading to incomplete bladder emptying. Both constipation and diarrhoea can cause bacterial contamination of the perineum increasing the risk of UTI.
Incidence of UTIs in Men
UTIs are a significant health issue, especially over the age of 50 with the incidence increasing with age. Older men experience higher rates of infection due to associated risk factors, such as an enlarged prostate and a weakened immune system. Recurrent UTIs in men are a concern, though specific recurrence rates are hard to capture and can vary based on individual health factors and underlying conditions.
Symptoms & Diagnosis
Men with UTIs may experience frequent urination, an urgent need to urinate and a pain or burning sensation during urination (dysuria). They may also experience lower abdominal, pelvic, and rectal pain, along with cloudy, foul-smelling, or bloody urine. If the infection reaches the upper urinary tract, symptoms may include fever and chills.
• Urinalysis – Limitations: While urinalysis can detect signs of infection, such as the presence of white blood cells (leukocytes) and nitrites, it does not directly detect bacteria. The reliability of urinalysis is increasingly coming under scrutiny due to its potential for false positives and negatives, which can lead to either unnecessary treatment or missed infections. False positives can occur due to contamination, while false negatives can occur if the bacteria are not present in sufficient concentrations in the sampled urine.
• Urine Culture and Diagnostic Challenges: Urine cultures, which identify the specific pathogen and determine antibiotic sensitivity, remain the gold standard for diagnosis. However, it’s important to note that some culturing can be problematic if the laboratory’s parameters for bacterial count are set too high. For example, a common threshold for significant bacteriuria is 100,000 colony-forming units (CFU) per millilitre (10^5 CFU/mL). This threshold can sometimes miss infections in symptomatic patients who may have lower bacterial counts, such as 1,000 CFU/ mL (10^3 CFU/mL) or 10,000 CFU/mL (10^4 CFU/mL), which are still clinically significant. Laboratories can lower the threshold based on clinical context and patient symptoms to improve diagnostic accuracy.
• Emerging diagnostic methods: PCR (polymerase chain reaction) testing and advanced microbial analysis, are being explored for their potential to offer more accurate and rapid detection of urinary pathogens. Nurses should stay informed about these developments and their local availability to ensure the most effective diagnostic strategies are employed. Additionally, when interpreting culture results, it’s crucial to consider the patient’s symptoms and clinical history to make informed treatment decisions.
• Physical Examination: Physical examinations, including checking for prostate tenderness or enlargement, are crucial. If indicated, imaging tests like ultrasound or CT scans help detect any obstructions or abnormalities in the urinary tract. Flexible cystoscopy is an essential diagnostic tool that should be routinely considered when evaluating men with suspected urinary tract obstructions or recurrent infections.
Treatment & Management
Treatment typically involves antibiotics such as trimethoprimsulfamethoxazole, ciprofloxacin, levofloxacin, or nitrofurantoin, tailored to the specific bacteria and resistance patterns. Unlike women, men generally require a longer antibiotic course, often 7-14 days, this is because good antibiotic penetration into the prostate tissue is a challenge, and the prostate is a likely reservoir for bacteria in the male urinary tract. A 3-day course of antibiotics in male patients should always be challenged. Pain relief with over-the-counter analgesics like ibuprofen can help alleviate discomfort during urination.
Follow-up care ensures the infection is cleared, often through repeat urine tests. Completing the entire course of antibiotics, even if symptoms improve, is crucial so as to increase the likelihood of successful elimination of the UTI and reduce the risk of recurrence/ resurgence. Patients should be educated on maintaining proper hydration, especially older men who may have a blunted sense of thirst. Encouraging good hygiene and avoiding irritants like caffeine and alcohol are also important.
Prevention Strategies
Preventing UTIs in men involves several strategies, some of which are similar to those recommended for women, but with additional considerations specific to men:
• Hydration and Diet: Staying well-hydrated helps flush bacteria from the urinary tract. Addressing constipation with diet and lifestyle changes is important to prevent additional pressure on the urinary tract. Instructing patients and their carers or family members on the importance of ensuring fluids are made available and encouraging regular intake.
• Hygiene: Good personal hygiene, particularly after bowel movements, is optimal. Uncircumcised men should be vigilant about gently pulling back the foreskin and washing the head of the penis with warm water daily. There is evidence that uncircumcised males have a greater lifetime risk of UTI than men who are circumcised as infants. While the use of non-perfumed soaps and products is often recommended for women to avoid irritation, similar precautions can be beneficial for men, particularly those with sensitive skin or recurring infections.
• Sex: Safe sexual practices are crucial. Couples who have anal sex should use condoms to reduce the risk of introducing bacteria into the urinary tract. Additionally, washing the genital and anal areas thoroughly before and after sex can help minimise the risk of bacterial contamination and infection. Urinating after intercourse can help flush out any bacteria that may have entered the urethra during sexual activity.
• Catheter Care: Men who use indwelling or self-catheterisation should practise good standards of hygiene, using a ‘no touch’ technique and not breaking the connections between drainage systems unnecessarily. It’s important to be aware of the signs of UTI and not necessarily go from the colour of the urine. Asymptomatic bacteriuria that is routinely picked up should not be treated with antibiotics.
• Flow Issues/Prostate Health: Men should be encouraged to check in with their GP if they experience urinary flow issues or discomfort, as these symptoms may indicate problems such as benign prostatic hyperplasia (BPH), prostatitis, or urethral stricture. Addressing these symptoms can help identify and manage conditions that contribute to incomplete bladder emptying and increase the risk of UTIs. Encouraging the use of the double void technique can be beneficial to men as well as women, to help with bladder emptying and thus helping to prevent UTIs.
• General Health: Managing underlying conditions such as diabetes and maintaining a healthy immune system and gut health, through a balanced diet and regular exercise, can help reduce the risk of UTIs.
Criteria for Complex UTIs in Men
Recurrent Infections: Frequent UTIs suggest underlying structural or functional abnormalities that require thorough investigation, including cystoscopy, imaging, flow studies and often long-term management strategies, which may include surgical intervention/correction.
Antibiotic-Resistant Pathogens: UTIs caused by multidrug-resistant organisms are more challenging to treat, necessitating alternative antibiotic regimens and sometimes longer durations of therapy.
Structural Abnormalities: The presence of anatomical issues such as strictures, stones or congenital abnormalities often requires surgical intervention or specialised treatments.
Immunocompromised Status: Conditions like diabetes, HIV the use of immunosuppressive medications for chronic conditions such as rheumatoid arthritis or chemotherapy significantly increase the risk of complications and treatment failures.
Complicated Clinical Presentation: Symptoms extending beyond the lower urinary tract, such as fever, chills, flank pain and systemic symptoms, indicate a more severe infection that requires immediate and comprehensive treatment. Importantly, while women generally experience more cases of complicated and upper-tract UTIs (such as pyelonephritis), men can face a higher risk of mortality from these infections. Aside from men being less likely to seek medical intervention when ill, it is postulated that the increased risk may be influenced by sex hormones, with testosterone potentially dampening immune responses, while oestrogen in women may offer some protective effects. Additionally, millions of men suffer from acute and chronic bacterial prostatitis, further contributing to the overall burden of UTIs in male populations.
Why UTIs in Men are Considered Complex
The complexity of UTIs in men stems from anatomical, physiological, and clinical factors. The longer urethra and the presence of the prostate gland, which can become inflamed or enlarged, often complicate infections. Conditions like BPH, prostatitis, urethral strictures, kidney stones and bladder stones obstruct urine flow and increase infection risk. Bladder dysfunction, including neurogenic bladder dysfunction, also contributes to incomplete emptying and bacterial growth. Diagnosing UTIs in men often requires differentiating them from sexually transmitted infections, which have different treatment protocols.
Clinical Presentation and Diagnostic Challenges in Men
Men treated for UTIs and recurrent UTIs in primary care settings may have underlying conditions such as bladder cancer that can be missed without prompt referral and investigation. While the greater risk appears to be older women in a missed diagnosis scenario, men are also at risk of delayed referral. These patients need to be referred more quickly for cystoscopy to ensure accurate diagnosis and appropriate management. Additionally, bladder pain in men can often overlap with symptoms of chronic prostatitis, making differential diagnosis challenging. Infection may also be present in these cases, further complicating the clinical picture. Men often sit on symptoms for longer or may not be aware that their urinary symptoms are significant. This delay in seeking treatment can lead to complications.
Alternatives to Antibiotics for recurrent/chronic UTIs
Managing recurrent or chronic UTIs in men often requires exploring alternatives to traditional antibiotic therapies. Several non-antibiotic treatments and future prospects are being studied, although many have not been extensively researched in men:
Vitamin C: Vitamin C is believed to acidify the urine and create an inhospitable environment for bacteria. However, clinical evidence supporting its efficacy in preventing UTIs is limited, and again not specifically studied in men.
D-Mannose: D-mannose, a type of sugar, has been suggested to prevent bacteria from sticking to the walls of the urinary tract. Recent research indicates that D-mannose may not be effective in preventing recurrent UTIs in women in a primary care setting. The study findings cannot be applied to more complex cases highlighting the need for further investigation.
Methenamine Hippurate: Methenamine acts as a urinary antiseptic by releasing formaldehyde in acidic urine. While it is used to prevent recurrent UTIs, its efficacy in men specifically has not been well-studied and requires further research.
Bladder Instillations: Intravesical treatments, where medications are directly instilled into the bladder, can include agents containing sodium hyaluronate and/or chondroitin sulphate. These treatments aim to reduce bacterial adherence and inflammation, although more research is needed to confirm their effectiveness. In complex cases intravesical administration of Gentamicin may also be used. Direct instillation into the bladder has the benefit of limited systemic absorption/ side-effects and does not come with the additional concern of antibiotic resistance. Further studies are ongoing.
Uromune Vaccine: This vaccine is aimed at preventing recurrent UTIs by stimulating the immune system. It is composed of a combination of inactivated whole bacteria commonly associated with UTIs – Escherichia coli, Klebsiella pneumoniae, Enterococcus faecalis and Proteus vulgaris. It is taken daily as a sublingual spray for 3 months. Currently, in the UK, it is only available via specialist NHS recurrent UTI clinics or on private prescription. More research is required to determine its longterm efficacy.
Phage Therapy: This treatment utilises bacteriophages, viruses that infect and kill bacteria, as a potential treatment for antibiotic resistant infections. This innovative approach shows promise but needs extensive clinical trials.
Other Vaccines: Research into new vaccines targeting UTIcausing pathogens is ongoing, with the hope of providing longterm prevention.
Interdisciplinary Collaboration is Key
Managing UTIs in men often requires collaboration across various urological subspecialties and primary care. Nurses should get to know their fellow specialists and work closely with them to enhance patient outcomes. Collaboration with urologists, nephrologists, infectious disease specialists, endocrinologists, radiologists, microbiologists, community-based nurses and GPs is essential. Regular interdisciplinary meetings and open communication channels are ideal for successful management, along with improved collaboration with GPs and Primary Care.
Conclusions
Understanding UTIs in men is essential for providing effective nursing care, as these infections are often more complex and require a highly individualised approach. Nurses play a crucial role in educating patients, delivering targeted treatments and implementing both prevention strategies and prompt interventions tailored to each patient’s unique circumstances. Continuous education and heightened awareness of the complexities associated with UTIs in men can significantly improve patient outcomes and reduce the incidence of these infections.
This includes how men engage with health services and their reluctance to seek help promptly. The complexities discussed in this article underscore the need for ongoing research and a more nuanced understanding of UTI manifestations in men.
It is hoped that this article has stimulated further thought and discussion in this critical area of urology, encouraging nurses to consider the specific needs of male patients when addressing UTIs.
The Urology Foundation’s UTI Information Service is here to help
The Urology Foundation appreciates the challenges associated with UTIs and is dedicated to providing resources and guidance needed. That’s why we launched a dedicated nurseled UTI Information Service to support and guide both patients and healthcare professionals. It offers valuable resources for healthcare professionals seeking advice and information as well as a telephone helpline.
Do you have ideas for research on UTIs?
The Urology Foundation is committed to driving change in the field of UTIs and to improving the lives of and outlook for patients and their families. UTIs have been identified as one of the research priorities in our Research Strategy 2024 – 2028. Thanks to the generosity of a donor, The Urology Foundation has a fund of £250,000 to support research into UTIs. Expressions of interest are due on 15th November 2024 and we would be delighted to hear from those with ideas.
About The Urology Foundation
The Urology Foundation is the UK’s only charity representing all urological diseases including prostate, bladder, kidney and male reproductive cancers and non-malignant conditions including incontinence, urinary tract infections, erectile dysfunction and kidney stones. We are committed to improving outcomes, quality of life and saving lives through investing in cutting edge urology research; providing and supporting education and training programmes for the medical and scientific urology community; and achieving impact through awareness raising, improving understanding and driving change through policy and campaigns. Working with researchers, urologists, nurses and allied healthcare professionals, influencers and decision makers, patients and their families and those with an interest in urological diseases, we are leading the fight against urology disease.
Written by Helen Lake RN, UTI Information Nurse, The Urology Foundation
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