Should male patients with suspected urinary tract infection routinely undergo a prostate exam?

Yes! That’s because any urinary tract infection (UTI) in men has the potential for prostatic involvement1 —-as high as 83% by one report. 2  

To make the matters more confusing, patients with acute bacterial prostatitis (ABP) often present with symptoms just like those of UTI,  such as urinary frequency, dysuria, malaise, fever, and myalgias. 3  In the elderly, atypical presentation is not uncommon (eg, confusion, incontinence, fall). 4  Under these circumstances, bacteriuria and pyuria may also be related to ABP and the prostate exam should be an important part of your evaluation.

Although the sensitivity of prostate tenderness on digital rectal exam varies widely for ABP (9%-100%), a painful exam should raise suspicion for ABP, and by itself may be an independent predictor for clinical and bacteriologic failure of therapy. 1 Along with tenderness, fluctuance of prostate, particularly in the setting of voiding difficulties and longer duration of symptoms, may also suggest the presence of prostatic abscess. 5,6 

But be gentle when performing a prostate exam and don’t massage it because you could potentially cause bacteremia and worsening of sepsis! 1,7

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References

  1. Etienne M, Chavanet P, Sibert L, et al. Acute bacterial prostatitis: heterogeneity in diagnostic criteria and management. Retrospective multicentric analysis of 371 patients diagnosed with acute prostatitis. BMC Infectious Diseases 2008;8:12. https://bmcinfectdis.biomedcentral.com/track/pdf/10.1186/1471-2334-8-12?site=bmcinfectdis.biomedcentral.com
  2. Ulleryd P, Zackrisson B, Aus G, et al. Prostatic involvement in men with febrile urinary tract infection as measured by serum prostate-specific antigen and transrectal ultrasonography. BJU Int 1999;84:470-4. http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410x.1999.00164.x/pdf
  3. Krieger JN, Nyberg L, Nickel JC. NIH consensus definition and classification. JAMA 1999;282:236-37. http://jamanetwork.com/journals/jama/article-abstract/1030245
  4. Harper M, Fowlis. Management of urinary tract infections in men. Trends in Urology Gynaecology & Sexual Health. January/February 2007. http://onlinelibrary.wiley.com/doi/10.1002/tre.8/pdf
  5. Lee DS, Choe HS, Kim HY, et al. Acute bacterial prostatitis and abscess formation. BMC Urology 2016;16:38. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4936164/
  6. Oliveira P, Andrade JA, Porto HC, et al. Diagnosis and treatment of prostatic abscess. International Braz J Urol 2003;29: 30-34. http://www.scielo.br/pdf/ibju/v29n1/v29n1a06.pdf
  7. Lipsky BA, Byren I, Hoey CT. Treatment of bacterial prostatitis. Clin Infect Dis 2010; 50:1641-52. https://academic.oup.com/cid/article/50/12/1641/305217

 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

Should male patients with suspected urinary tract infection routinely undergo a prostate exam?

When should I consider treating my hospitalized patients with asymptomatic bacteruria (ASB)?

The great majority of hospitalized patients with ASB do not need treatment with antibiotics.

In fact, there are only a couple of conditions for which treatment of ASB is indicated:  pregnant women (due to risk of pyelonephritis and low-birth infants/pre-term delivery) and before  GU instrumentation, such as transurethral resection of the prostate or other GU procedures for which mucosal bleeding is anticipated (1).  

So for the great majority of our hospitalized patients, including the elderly, diabetic women, institutionalized residents of long-term facilities, and spinal cord injury patients treatment of ASB is not indicated.  Even in the case of renal transplant patients, supportive evidence for the  use of prophylactic antibiotics in ASB is so far lacking (2).  

The estimated prevalence of ASB varies widely in the population,  with rates of 15-20% among community-dwelling women > 70 yrs of age, and 5-10% for men>65 yrs for community-dwelling men. In long-term care facility residents, 25-50% of women, 15-40% of men, and 100% of those with chronic indwelling catheters have ASB (3).  

So keep these rates in mind before attributing patient’s symptoms to ASB (ie, patient’s presentation may have nothing to do with urine findings).  It’s also worth emphasizing that pyuria accompanying ASB is not an indication for treatment.

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References

1. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643-54.  https://academic.oup.com/cid/article/40/5/643/363229

2. Coussement J, Abramowicz D. Should we treat asymptomatic bacteriuria after renal transplantation? Nephrol Dial Transplant 2013;0:1-3. https://academic.oup.com/ndt/article/29/2/260/1913512

3. Nicolle LE. Asymptomatic bacteriuria in older adults. Geriatrics & Aging 2003;6:24-28. https://www.healthplexus.net/files/content/2003/October/0609bacteriuria.pdf

When should I consider treating my hospitalized patients with asymptomatic bacteruria (ASB)?

My 70 year old male patient with recent hip fracture has developed fevers with sterile pyuria. How do I interpret the sterile pyuria in this patient?

Although historically sterile pyuria (SP) has been associated with genitourinary (GU) tuberculosis, there are many more common causes to consider in the hospitalized patient (1-3).    

Recent antibiotic exposure (within past 2 weeks) in the setting of UTI is one of the most frequent causes.  Prostatitis is also an often overlooked cause.  Sexually transmitted diseases such as gonorrhea and Chlamydia trachomatis should also be considered in at risk patients. Hospitalized patients with systemic infections outside of the GU tract (e.g. pneumonia, appendicitis, diverticulitis) may also have SP (1-3). High prevalence of SP (>70%) has been reported among patients with appendicitis or diverticulitis (2). 

Non-infectious causes include current or recent catheterization of bladder, urinary stones, stents, GU malignancy, papillary necrosis,  Kawasaki’s disease, autoimmune diseases (eg, SLE) and analgesic nephropathy. 

I would start with repeating the u/a as 50% of sterile pyuria may be transient (3). If repeat u/a still shows pyuria, a prostate exam in our elderly male is indicated to exclude prostatitis. 

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References:

  1. Wise GJ, Schlegel PN. Sterile pyuria. N Engl J Med 372;11:1048-54. https://www.nejm.org/doi/pdf/10.1056/NEJMra1410052
  2.  Goonewardene S, Persad R. Sterile pyuria: a forgotten entity. Ther Adv urol 2015; 7:295-298.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4549703/ 
  3. Hooker JB, Mold JW, Kumar S. Sterile pyuria in patients admitted to the hospital with infections outside of the urinary tract. J Am Board Fam Med 2014;2&:97-103. https://www.jabfm.org/content/27/1/97.long#T1 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

My 70 year old male patient with recent hip fracture has developed fevers with sterile pyuria. How do I interpret the sterile pyuria in this patient?