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Urinary tract infection (lower) - men - Management
When should I refer a man with lower urinary tract infection?

  • Admit the man to hospital if symptoms are severe (for example severe nausea and vomiting, confusion, tachypnoea, tachycardia, or hypotension) — intravenous antibiotics may be required.
  • Referral for urological assessment is not routinely required for men who have had a urinary tract infection (UTI).
  • Refer for urological assessment men who:
    • Have failed to respond to appropriate antibiotic treatment.
    • May have an underlying cause for the UTI (such as urinary obstruction, which is more likely in older men, especially if they have hesitancy, straining, or weak urinary stream).
    • Have frequent episodes of UTI (for example two or more episodes in a 3-month period).
    • Have a history of pyelonephritis, calculi, or previous genitourinary tract surgery.
    • Are younger than 50 years of age and have persistent microscopic haematuria with otherwise normal renal function tests (urinary protein and serum creatinine).
  • Refer for renal assessment if the man has persistent microscopic haematuria with proteinuria or raised serum creatinine.
  • Refer urgently if cancer is suspected. Refer the man to a team specializing in the management of urological cancer if:
    • He is of any age, with macroscopic haematuria and urine culture fails to confirm a UTI or the haematuria does not resolve with treatment of the UTI. 
    • He is 40 years of age or older, and presents with recurrent or persistent UTI associated with haematuria.
    • He is 50 years of age or older, and is found to have unexplained microscopic haematuria.
    • An abdominal mass is identified (clinically or on imaging) that is thought to arise from the urinary tract.
Clarification / Additional information
  • Urological assessment aims to identify and manage possible underlying causes, such as:
    • Prostatitis.
    • Prostatic enlargement due to cancer or benign prostatic hypertrophy.
    • Calculi.
    • Bladder cancer.
Basis for recommendation
  • The referral guidelines for suspected cancer are those published by the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Primary Care, 2005].
  • The other recommendations are pragmatic. National and European guidelines agree that the value of urological evaluation in men who have had a single uncomplicated urinary tract infection (UTI) has not been determined sufficiently well to make recommendations on referral [SIGN, 2006; European Association of Urology, 2009].
  • However, the recommendations on referral do take account of weak evidence from a systematic review of urological investigations in men with lower UTI that urological abnormalities are most likely to be found in men who are more than 45 years of age, who do not respond well to antibiotics, or who have recurrent UTIs [Fernandez, 2004].

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