Jags 1996;44:1235 (elderly); Ann IM 1989;110:138

Cause: E. coli(25%); other gram negatives (25+%), including proteus and providencia; enterococci and Staph. epidermidis(20%)

Rare unless obstruction by BPH, foreign body like catheter or stone, bladder tumors, or urethral strictures

Increased incidence in elderly, mainly due to BPH, so that by age 65 yr UTI incidence is same as in women

Sx:Urethritis syndrome: dysuria, frequency, and urgency

Obstructive syndrome (with prostatic involvement): hesitancy, nocturia, dribbling, slow stream, and inability to void; as well as terminal dysuria to penile tip

Si:Fever, with prostatitis not cystitis

Rectal shows tender swollen prostate in prostatitis

Pyelonephritis, chronic prostatitis, epididymitis (see Epididymitis), prostatic abscess

r/o gonorrhea, chlamydia, orchitis

Lab:

No workup of occult urinary tract lesions indicated with first UTI in adult men; episode should be worked up in boys and male infants w renal US and VCUG to r/o urethral valves and reflux

Bact:Culture of urine, >10³ col/cc with single or predominant organism (97% sens/specif); >10⁵ col/cc if taken from condom catheter, reliable if clean glans, new catheter, and take urine within 2 h of placing catheter. “4-glass” (mid, terminal void, and postprostatic massage specimens) cultures showing >10× higher colony counts in last 2 compared to first 2 is diagnostic of prostatitis.

Rx:

of asymptomatic bacteriuria, no rx indicated; although it worsens prognosis in elderly, rx doesn’t improve prognosis (Ann IM 1994;120:827)

of cystitis and acute prostatitis: Tm/S 160/800 bid; or if resistance suspected, ciprofloxacillin; all for 7-10 d first time, but for 6-12 wk for recurrence

of chronic prostatitis (Nejm 2006;355:1690): Tm/S, ciprofloxacin esp if Pseudomonas aeruginosa(Nejm 1991;324:392), doxycycline, or aminoglycoside; all × 6-12 wk; still have 30-40% failure rates probably because much chronic prostatitis is abacterial and unresponsive to rx (Ann IM 2004;141:581; 2000;133:367)

of sterile prostatitis/pelvic pain syndromes (Nejm 2006;355:1690): -blockers like doxazosin (Cardura), tamsulosin (Flomax), and terazocin (Hytrin) vs not helpful (Nejm 2008;359:2663)