No need for routine imaging
Consider a workup for men who have no response to antibiotic therapy or have persistent hematuria.
There is little evidence to support routine imaging in low-risk men with a first UTI, whether with or without fever:
- A very small prospective study of 29 heterosexual, circumcised men 16 to 45 years old (those who were sexually active had a steady partner) who were hospitalized with a first febrile UTI failed to find any significant structural or functional urinary tract abnormalities.4
- Another small prospective study of 85 men, 18 to 86 years of age, with febrile UTI, concluded that routine imaging of the upper urinary tract was unnecessary, and that, if indicated, further workup should focus on the lower urinary tract.7 Abnormalities in this group were suggested by a history of voiding problems, hematuria, or recurrent infection. One limitation of this study was the incomplete urodynamic and endoscopic evaluation of the lower urinary tract.
- Another study enrolled 114 men, 18 to 85 years of age, with proven UTIs, who underwent ultrasonography and plain radiography, as well as an IVP.8 (Only 100 had complete data at enrollment.) All men had urinary flow rates measured. The combination of a plain abdominal film and ultrasonography detected more abnormalities than an IVP. (The primary role of the plain film was in detecting urinary calculi.)
Final “clinical” diagnoses were reported, but the study did not report a comparison of clinical and radiological findings. Almost half of the abnormalities were lower tract obstructions (bladder outlet obstruction, underactive detrusor, and chronic retention). There was no comment on the importance or treatment of any abnormalities found.
Recommendations from others
PRODIGY (from the British National Health Service) recommends:
- Men under 45 years with a first UTI who respond well to antibiotic treatment are not likely to have a urologic abnormality.9
- Older men who do not respond well to antibiotics or who have recurrent UTIs are likely to have abnormalities and may benefit from further investigation.9
Neither the American Academy of Urology, the US Preventive Services Task Force, nor the Agency for Healthcare Research and Quality has published guidelines for evaluation of adult men with a first UTI.