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Three Part Question

Does [a man with a UTI] require [urologic investigation] to [identify possible underlying abnormalities]?

Clinical Scenario

A man presents with dysuria and fever. Urine microscopy and culture confirm the diagnosis of UTI. Are urologic investigations necessary to exclude an underlying abnormality?

Search Strategy

MEDLINE and OLDMEDLINE (1953 - July 2004) using the PUBMED interface.
(cystitis OR "urinary tract infection" OR pyelonephritis) AND (imaging OR investigation* OR radiograph* OR radiology OR ultraso* OR urogra* OR pyelogra* OR cystoscop* OR urodynamic* OR CT OR tomogr*) AND Human[MeSH] AND Male[MeSH] AND English[Lang]

Search Outcome

2405 papers were found of which 5 were relevant. Their bibliographies revealed 2 further relevant papers.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Pead L et al 1981 UK	999 men aged 15-50 whose urine specimens were sent to the laboratory for microscopy and culture. 223 of them had a UTI, of which 71 were referred for investigation with IVU. Results are available for only 54.	Retrospective consecutive case series study.	Abnormal IVU	26%	Many patients were not investigated, or the results of their investigations are not available.
Booth CM et al 1981 UK	50 men aged 18 to 72 (mean 47) referred to a urology department for a first or recurrent UTI without prior urinary symptoms or disorders. All had IVU followed by urodynamic pressure/flow videocystography.	Retrospective consecutive case series study.	Abnormal IVU	22%	Small numbers.
			Abnormal videocystography	80%
Krieger JN et al 1993 USA	38 men with UTI aged 15 to 40 without known genitourinary disorders. They had IVU, uroflow study and ultrasound determination of post-void residual urine. Only 11 men (29%) agreed to recommended investigations.	Prospective consecutive case series study.	Urologic abnormalities	0%	Small numbers. Many patients did not agree to investigations.
Ulleryd P et al 2001 Sweden	85 men aged 18-86 (71% aged 50 or more) were followed for 1 year after and episode of febrile UTI. Each was investigated with several of the following: IVU, CT, ultrasonography, urethrocystoscopy, uroflowmetry, digital rectal examination.	Prospective case series study.	Upper urinary tract abnormalities	19 (22%). One required surgery.	There was no standarized set of investigations. Incomplete data of many patients due to refusal to participate with lower urinary tract investigations (14% missed cystoscopy, 73% missed uroflow measurements). Not explicitly stated if the cases were consecutive.
			Lower urinary tract abnormalities	35 (41%). 19 required surgery.
Andrews SJ et al 2002 UK	114 men aged 18-88 (mean 54) referred to the department of urology for investigation of proven UTI. They had ultrasonography, IVU and assessment of urinary flow rate. After clinical assessment, further investigations were undertaken as required (cystoscopy, urodynamic studies, and transrectal ultrasonography with biopsy).	Prospective consecutive case series.	Urologic abnormalities	53%	Small numbers. Complete data obtained for 100 patients only, so 14 not included. Highly selected group of patients (already referred for investigation).
			Sensitivity of Ultrasonography + X-Ray (compared with IVU)	100%
			Specificity of Ultrasonography + X-Ray (compared with IVU)	93%
Abarbanel J et al 2003 Israel	29 healthy men aged 16 to 45 (mean 30.5) hospitalized for a first UTI. All underwent ultrasonography and IVU. Those with macroscopic haematuria underwent cystoscopy. All had uroflowmetry, and those with maximal flow rate of less than 15ml/s underwent a pressure flow study.	Prospective consecutive case series.	Urologic abnormalities	10% (2 high postvoid volumes and 1 bladder outflow obstruction on urodynamic studies – all the rest of investigations were normal)	Small numbers.
Yuyun MF et al 2004 Cameroon	206 men aged 18-75 (90% aged 50 or more), whose urine samples were sent for microscopy, culture and sensitivity. 179 completed the study. 63 of them were found to have UTI. 116 did not. Both groups had history, examination, abdominal ultrasound, abdominal X-Ray, PSA, urea and creatinine. Some patients also had transrectal ultrasound, urethrocystoscopy and biopsies.	Prospective cohort study.	Urological abnormalities in patients without UTI	11.2%	27 (13%) patients did not complete the study. These results might not apply to a Western population.
			Urological abnormalities in patients with UTI	65.1% (statistically significant diference, P<0.001)

Comment(s)

Two retrospective (Pead, Booth) and three prospective (Krieger, Andrews, Yuyun) studies found a high prevalence (26-80%) of urologic abnormalities of different clinical significance among men with UTI. The most common disorders were benign prostate hypertrophy, renal cortical scarring, urinary tract stones, bladder diverticula, urethral strictures and prostate cancer. Many patients with these pathologies may benefit from surgical intervention, as shown by Ulleryd et al. In their study a total of 20 (24%) patients had disorders that warranted surgery. Only one study (Yuyun et al) compared the prevalence of urological disorders in men with and without UTI. It confirmed that it is significantly higher in men with UTI (65.1% vs 11.2%, P<0.001). The difference is also significant when specific pathologies are taken separately: Benign prostatic enlargement (41.3% vs 7.8%, P<0.001) Urethral stricture (7.9% vs 0.9%, P<0.001) Prostate cancer (6.3% vs 1.7%, P<0.001) Two studies (Krieger, Abarbanel) found that in young (under 40-45) otherwise healthy men, UTIs are rarely associated to any urologic abnormality. Unfortunately both studies had very small patient groups.

Clinical Bottom Line

Healthy young (under 45) men with a first event of UTI who respond to antimicrobial treatment probably do not need investigation - but further studies with larger numbers are required to confirm this. Any other men with UTI are likely to have underlying urologic anomalies, and need urologic investigation.

References

1. Pead L, Maskell R. Urinary tract infection in adult men. J Infect. 1981 Mar;3(1):71-8.
2. Booth CM, Whiteside CG, Milroy EJ, Turner-Warwick RT. Unheralded urinary tract infection in the male. A clinical and urodynamic assessment. Br J Urol. 1981 Jun;53(3):270-3.
3. Krieger JN, Ross SO, Simonsen JM. Urinary tract infections in healthy university men. J Urol. 1993 May;149(5):1046-8.
4. Ulleryd P, Zackrisson B, Aus G, Bergdahl S, Hugosson J, Sandberg T. Selective urological evaluation in men with febrile urinary tract infection. BJU Int. 2001 Jul;88(1):15-20.
5. Andrews SJ, Brooks PT, Hanbury DC, King CM, Prendergast CM, Boustead GB, McNicholas TA. Ultrasonography and abdominal radiography versus intravenous urography in investigation of urinary tract infection in men: prospective incident cohort study. BMJ. 2002 Feb 23;324(7335):454-6.
6. Abarbanel J, Engelstein D, Lask D, Livne PM. Urinary tract infection in men younger than 45 years of age: is there a need for urologic investigation? Urology. 2003 Jul;62(1):27-9.
7. Yuyun MF, Angwafo III FF, Koulla-Shiro S, Zoung-Kanyi J. Urinary tract infections and genitourinary abnormalities in Cameroonian men. Trop Med Int Health. 2004 Apr;9(4):520-5.