Urinary Tract Infection

Urinary tract infections are relatively rare in male patients, but they do represent a proportion of men attending with AUR. Many of these patients will have a degree of BOO and/or LUTS, and some will be known to have incomplete bladder emptying. They are also commonly seen in BOO caused by stricture disease. The patient will typically give a history of LUTS, but associated with a short-term history of dysuria, offensive-smelling or dark/cloudy urine, and suprapubic pain. Some patients may describe passing debris and others may have frank hematuria. They may have perineal pain if the prostate is infected, with associated pain on defecation. In some cases, one or both epididy-mides and testes may be affected also. The patient will usually volunteer this information, although it tends to be obvious on examination. On examination, the patient will typically complain of suprapubic discomfort on palpation, and in cases with prostatic involvement, the prostate will be exquisitely tender on DRE. It may also be grossly abnormal to palpation, and if so it is important that the patient be re-examined once the infective episode has resolved, typically at 6 - 8 weeks.

The history of the episode of AUR is similar to patients with uncomplicated AUR, but in some cases the patient will have been passing small volumes of urine intermittently. In view of this, it is always worth assess ing the residual urine volume using an ultrasound bladder scanner prior to catheterization. Often the patient will have a very small residual volume and the risks of systemic sepsis associated with catheterizing him can therefore be avoided. In these cases, treatment with systemic antibiotics and -antagonist is often sufficient to overcome the obstructed voiding. However, patients will also often have a full bladder, in which case the AUR should be managed as normal, with broad-spectrum antibiotic cover with systemic antibiotics or quinolones for at least 24 h prior to TWOC. As any episode of UTI causing AUR is by definition a complicated UTI; it should be treated with at least 7 days of antibiotics, and if prostate involvement or epididy-moorchitis is suspected, then this course should be extended to 2 - 3 full weeks.

If acute prostatitis is thought to be the sole cause of the episode of AUR, or there is a prostatic abscess palpable on DRE, then urinary tract instrumentation is contraindicated due to the risk of spreading the infection to the soft tissues (possibly culminating in necrotizing fasciitis or Fournier's gangrene). In these cases, it is best to drain the bladder by suprapubic catheteriza-tion. The choice of antibiotic is important, as some have better prostatic penetration than others. Currently, quinolones offer the best penetration into the tissues and should be used as first-line treatment, although if the patient is showing signs of systemic infection, then broad spectrum intravenous antibiotics such as ampi-cillin, gentamicin, and metronidazole in combination should be used until the patient is consistently apyrexi-al and cultures return to normal. If abscess or evidence to suggest spreading soft tissue infection is present, then surgical debridement is the first-line treatment as well as the above management (Weiss et al. 2001).

Any patient with prostatitis and/or epididymoorchi-tis should be evaluated with a full sexual health history to rule out gonococcal and chlamydial urinary tract infections, as these may require slightly different treatment as well as formal contact tracing to limit the community impact of these potentially sexually transmitted infections.

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