Lower UTI in adult males without pyrexia

N.B. Do not treat asymptomatic bacteriuria or “positive” urine dipsticks in the absence of urinary symptoms.

First line (first UTI or no antimicrobials in last 6 months):

Trimethoprim oral 200mg 12 hourly

Second line:

Nitrofurantoin modified-release (M/R) oral 100mg 12 hourly

or

Nitrofurantoin oral 50-100mg 6 hourly

N.B. Avoid nitrofurantoin if eGFR <45ml/min. Nitrofurantoin does not achieve therapeutic serum or tissue levels and is only used for the treatment of uncomplicated lower UTI. It is not an appropriate agent for upper or bacteraemic UTI. Do not use as IV-to-oral switch in urosepsis.

• Lower UTI in men can present with any of the following symptoms: frequency, urgency, dysuria, nocturia or suprapubic tenderness.
• Dipstick testing is not recommended to confirm a diagnosis of UTI in males. Ensure a urine culture is sent to microbiology and adjust treatment accordingly.
• Cloudy, dark, or smelly urine is not a sign of UTI. 
• Consider pyelonephritis in patients with fever, rigors, or flank pain / tenderness.
• Consider prostatitis in the differential diagnosis of men with acute dysuria or frequency, and in men with recurrent or febrile UTI. 
• Consider epididymitis and sexually transmitted infections, such as chlamydia and gonorrhoea, in the differential diagnosis of men with acute dysuria or frequency.

Most UTIs in men result from anatomic or functional abnormalities or from instrumentation of the genitourinary tract. Refer men to urology if they have had symptoms of upper UTI / pyelonephritis, fail to respond to appropriate antibiotics or have recurrent UTI. Referral to urology is not routinely required for men who have had one episode of lower UTI.