Urinary Tract Infections in Men

Urinary tract infections (UTI) are a serious health issue that affects millions of men each year. That is why men with a urinary tract infection should understand the causes and treatments for their infection.

Urinary tract infections are the second most common type of infection in males and females. Urinary tract infections account for approximately 8.3 million doctor visits each year*, with approximately 20% of all urinary tract infections occurring in men. The overall lifetime prevalence of urinary tract infections in men between 1988 to 1994, was estimated to be 13,689 cases per 100,000 adult men, based on the National Health and Nutrition Examination Survey.

Rates of urinary tract infections increase with age and are 1.5 times higher in African American men than in other racial/ethnic groups such as Caucasian or Hispanic. Asian men have the lowest rates of inpatient hospitalization for UTI care, followed by Hispanics and Caucasians.

The causes of UTIs in men

Normally urine is sterile and free from bacteria, viruses, and fungi, however, usually contains fluids, salts, and waste products. An infection occurs when tiny organisms, usually bacteria from the digestive tract, adhere to the opening of the urethra and begin to reproduce. The urethra is the tube that carries urine from the bladder to be expelled outside the body. Most infections are caused by Escherichia coli (E. coli) bacteria, which normally live in the colon.

Typically bacteria first travel to the urethra, so when this bacteria multiplies, an infection can occur. An infection confined to the urethra is called urethritis. If the infection moves to the bladder, a bladder infection occurs, called cystitis. If the infection is not treated immediately, bacteria could travel further up the ureters to infect the kidneys, which may result in a kidney infection called pyelonephritis.

Chlamydia and Mycoplasma, both microorganisms, can also cause urinary tract infections in men, but the trend of these types of infections is to remain limited to the urethra and reproductive system. Unlike E. coli, Chlamydia and Mycoplasma can be sexually transmitted and infections require treatment of both male and female partners.

The urinary system is biologically structured to help ward off infection. The ureters and bladder are supposed to prevent urine from backing up toward the kidneys and the flow of urine from the bladder is designed to wash bacteria out of the body. In men, the prostate gland produces secretions that slow bacterial growth and immune defenses also help avoid infection. Despite these physiological safeguards, infections still occur.

Bladder outlet obstruction due to benign prostatic hyperplasia (BPH) may be associated with urinary stasis. Although a causal relationship has been difficult to prove, chronic prostatic obstruction is considered to increase the risk of urinary tract infections in older men with BPH.

Men who are uncircumcised are more at risk to become infected, because the bacteria can build up much more easily in the folds of the extra skin on the penis, as are men who engage in anal intercourse.

The Risk Factor for Men

Some men are more prone to getting a urinary tract infection than others. Any irregularity of the urinary tract that obstructs the flow of urine (i.e., a kidney stone) increases the risk factor for an infection. An enlarged prostate gland can also impede and slow the flow of urine, thus raising the risk of infection. A common source of infection is catheters, or tubes, placed in the urethra and bladder. A man who cannot void or is unconscious or critically ill might use a catheter that stays in place for a prolonged period. Some men, especially the elderly and those with nervous system disorders that cause loss of bladder control, may need a catheter for life.

Men with diabetes have a higher risk of a UTI because of changes in the immune system. Any other disorder that suppresses the immune system raises the risk of a urinary tract infection. Urinary tract infections may occur in infant boys who are born with abnormal urinary tracts, which sometimes need to be corrected with surgery. Urinary tract infections occur less frequently in boys and young men than girls and young women.

Recurrent Infections in Men

In recurrent infections in men, the latest infection stems from a strain or type of bacteria that is different from the previous infection, indicating a separate infection. Even when several urinary tract infections in a row are caused by E. coli, slight differences in the bacteria indicate distinct infections.

Research funded by the National Institutes of Health (NIH) suggests that one factor behind recurrent urinary tract infections may be the ability of bacteria to attach to cells lining the urinary tract. A recent study found that bacteria created a protective film on the inner lining of the bladder in mice. If a similar occurrence can be demonstrated in humans, the discovery may lead to new treatments that will be able to prevent recurrent urinary tract infections.

Urinary tract infections in men are often a result of an obstruction, such as a urinary stone or enlarged prostate-or a medical procedure involving a catheter. The first step is to identify the infecting organism and the drugs to which it is sensitive. Doctors recommend longer therapy in men than in women to prevent the infection from spreading to prostate gland.

Prostate infections (chronic bacterial prostatitis) are harder to cure because antibiotics are unable to treat infected prostate tissue effectively. Men with prostatitis often need long-term treatment with a carefully selected antibiotic. Urinary tract infections in older men are frequently associated with acute bacterial prostatitis, which can have serious consequences if not treated immediately.

The Symptoms of UTI

Not all men with a UTI have symptoms, but most men display at least a couple of symptoms. Symptoms may include a frequent urge to urinate and a painful, burning feeling in the vicinity of the bladder or urethra during urination. It is not unusual to generally feel tired, shaky, washed out and to feel pain even when not urinating. It has been documented that some men have experienced the feeling of fullness in the rectum. It is common for a man with a urinary infection to, despite the urge to urinate, pass only a small amount of urine. The urine itself may look cloudy or milky or even reddish if blood is present. Normally, a UTI does not cause fever if it is in the urethra or bladder. A fever may indicate that the infection has spread to the kidneys. Symptoms of a kidney infection include pain in the back or side below the ribs, nausea or vomiting.

UTI Diagnosis

To find out whether your urinary tract has been infected, your doctor will test a sample of your urine for bacteria and pus. The general practice is to ask for a "clean catch" urine sample by washing the genital area and collecting a "midstream" sample in a sterile container. This method of collecting urine prevents bacteria around the genital area from getting into the sample which may complicate the test results. The sample is then sent to a laboratory, if the doctor’s office is not equipped to perform the testing.

In the urinalysis test, the urine is tested for red and white blood cells and bacteria. If found, the bacteria is then grown in a culture and tested against different antibiotics to see which drug is most effective against it.

Some microbes, like Mycoplasma and Chlamydia, can be detected only with specific bacterial cultures. A doctor suspects a microbial infection when a man displays symptoms of a UTI, but a standard culture doesn’t display any bacterial growth.

When treatment does not clear up infection and is traced to the same strain of bacteria, the doctor may order more tests to help determine if your system is normal. One of such tests is an intravenous pyelogram, which allows for x-ray images of the kidneys, bladder and ureters. An opaque dye visible on x-ray film is injected into a vein and a series of x-rays are taken. The film maps the urinary tract, revealing even the minutest changes in the structure of the tract.

If infections continue to recur, your doctor also may recommend an ultrasound exam, which produces pictures from the echo patterns of sound waves bouncing off internal organs. Another useful test is a cystoscopy. A cystoscope is an instrument made of a hollow tube with several lenses and a light source, which allows the doctor to see the inside of the bladder via the urethra.

UTI Treatment

The general treatment of urinary tract infections is the use of antibacterial drugs. The length of treatment and choice of drug depend on the patient's medical history and the “mid-stream” urine tests that help identify the offending bacteria. The drugs most often used to treat routine, uncomplicated UTIs are trimethoprim/sulfamethoxazole (Bactrim, Septra, Cotrim), trimethoprim (Trimpex), nitrofurantoin (Macrodantin, Furadantin), ampicillin (Omnipen, Polycillin, Principen, Totacillin) and amoxicillin (Amoxil, Trimox, Wymox). A class of drugs called quinolones includes four drugs approved in recent years for treating a UTI. These drugs include ciprofloxacin (Cipro), ofloxacin (Floxin), norfloxacin (Noroxin) and trovafloxin (Trovan).

A UTI can be cured within 1 or 2 days of treatment if the infection is not complicated by an obstruction or other disorder. As a precaution, many doctors ask their patients to continue antibiotics for a week or more to make sure that the infection has been cured. Single-dose treatment is not recommended for some patients, for example, those who neglected immediate treatment or display signs of kidney infection, diabetic patients, patients with structural abnormalities, or men with prostate infections. Longer treatment is also needed for men with infections caused by Chlamydia or Mycoplasma, which are generally treated with tetracycline, trimethoprim/sulfamethoxazole (TMP/SMZ), or doxycycline. A follow-up urinalysis test confirms that the urinary tract is free of infection. Symptoms may disappear before the infection is fully cleared so it is important to take the full course of treatment.

Severely ill men with kidney infections may be hospitalized until they can take fluids and necessary drugs on their own. Kidney infections typically require several weeks of antibiotic treatment. Researchers at the University of Washington found that 2-week therapy with TMP/SMZ was as effective as 6 weeks of treatment with the same drug in women with kidney infections that did not involve an obstruction or nervous system disorder. In such cases, kidney infections rarely lead to kidney damage or kidney failure unless untreated.

Several drugs are available to help relieve the pain of a UTI. A heating pad may help and most doctors recommend drinking more water because it helps purify the urinary tract of bacteria. While undergoing treatment, it helps to avoid alcohol, coffee, and spicy foods. One of the most beneficial things a smoker can do for his bladder is to quit smoking. Smoking is one of the major causes of bladder cancer.

Curing infections caused by a urinary obstruction or other systemic disorder depends on diagnosing and fixing the underlying problem, sometimes even surgically. If the root cause is untreated, there is an increased risk of kidney damage. Such infections tend to stem from a wider range of bacteria, and sometimes infections can occur from more than one type of bacteria at a time.

Sources

The National Institute of Health

(Book)-Urinary Tract Infection in Men

Tomas L. Griebling, MD

Associate Professor & Vice Chair of Urology

University of Kansas

Kansas City, Kansas

*Ambulatory Care Visits to Physician Offices, Hospital Outpatient Departments, and Emergency Departments: United States, 1999-2000. Vital and Health Statistics. Series 13, No. 157. Hyattsville, MD: National Center for Health Statistics, Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; September 2004.