Complicated UTIs with BPH

Author

Jin Bong Choi (Department of Urology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea)

Seung Ki Min (Goldman Urology Clinic, Seoul, Republic of Korea)

Abstract

The purpose of this chapter is to distinguish surgically correctable cases from those that require medical therapy including antibiotics. Urinary tract infection (UTI) related to benign prostatic hyperplasia (BPH) is characterized by antibiotic-resistant pyuria. There is no clear evidence showing that the occurrence of UTI in the aging male population is associated with either post-void residual volume (PVR) or bladder outlet obstruction (BOO). Therefore, antibiotic prophylaxis is not indicated for such patients as the risk of UTI is low in men with lower urinary tract symptoms (LUTS) caused by BPH. In patients with early recurrent or persistent UTI, imaging and urological investigations are recommended to identify underlying abnormalities that might be surgically correctable. Recurrent or persistent UTI in men with bladder outlet obstruction and BPH is an indication for prostatectomy. The detection of infection in patients with BPH should prompt appropriate evaluation and therapy before treatment for BPH is initiated. Screening for and treatment of asymptomatic bacteriuria before transurethral resection of the prostate (TURP) is recommended. Bacteriuria should be evaluated in order to initiate antimicrobial therapy shortly before the procedure. Antimicrobial therapy should not be continued beyond the procedure, unless an indwelling catheter is in place.

Summary of Recommendations

Epidemiology and pathogenesis

1. There is no clear evidence showing that the occurrence of UTI in the aging male population is associated with either PVR or BOO; therefore, antibiotic prophylaxis is not indicated for such patients (LE: 2, GR: B).

2. In men with LUTS due to benign prostatic hyperplasia (BPH) the risk of UTI is low; therefore antibiotic prophylaxis is not indicated (LE: 1, GR: A).

Diagnosis

1. In patients with early recurrent or persistent UTI, imaging and urological investigations are recommended to identify underlying abnormalities that may be surgically correctable (LE: 1, GR: A).

2. Screening for the presence of bacteriuria is recommended before direct antimicrobial therapy is initiated prior to the procedure (LE: 1, GR: A).

Treatment

1. Medical therapy for BPH, i.e., alpha blockers and/or 5 alpha reductase inhibitors cannot reduce the incidence of UTI (GR: A).

2. Recurrent or persistent UTI in men with BOO and BPH is an indication for prostatectomy (GR: A).

3. The presence of infection in patients with BPH should prompt appropriate evaluation and therapy before prostatectomy (GR: A).

4. Screening for and treatment of asymptomatic bacteriuria before transurethral resection of the prostate is recommended (GR: A).

5. Antimicrobial therapy should be initiated shortly before the procedure (GR: A).

6. Antimicrobial therapy should not be continued beyond the procedure, unless an indwelling catheter remains in place (GR: B).

Introduction

Urinary tract infection (UTI) with urinary tract obstruction is a type of complicated UTI. Structural or functional obstruction and urinary stasis represents an underlying condition that interferes with host-defense mechanisms, which increases the risk of infection or therapy failure. Benign prostatic hyperplasia (BPH) is the most frequent cause of lower urinary tract obstruction. This chapter covers the association between UTIs and BPH.

Methods

The Guidelines were first published in 2016. Updates for the 2019 version are based on recent literature and guidelines. A systematic PubMed search was performed for the last 10 years using the following key words: BPH and urinary tract infections. The studies were rated according to the level of evidence (LE) and the grade of recommendation (GR).

Definition

Complicated urinary tract infection, which may involve either the bladder or kidneys, is a symptomatic urinary infection in individuals with functional or structural abnormalities of the genitourinary tract (1). Asymptomatic bacteriuria or asymptomatic urinary tract infection is diagnosed quantitatively based on the isolation of a specified bacterial count in an appropriately collected urine specimen obtained from a person without symptoms or signs related to urinary tract infection (2).

Epidemiology

BPH is the major risk factor predisposing to UTIs in men (3). The incidence of UTIs in patients with BPH -treated with placebo was 0.1/100 patient years (4). A history of BPH was also associated with urinary bacteremia among hospitalized male patients (5). Urinary tract abnormalities may predispose to infection with organisms other than E. coli, and long-term antibiotic therapy often leads to bacterial resistance or fungal super infection with Candida albicans (6). The reported prevalence rates of bacteria isolated from serious UTI are as follows: E. coli, 21-54%; Enterococci species, 6-23%; miscellaneous Gram-negative bacteria, 4-20%; Pseudomonas aeruginosa, 2-19%; Providencia species, 18%; Klebsiella pneumoniae, 2-17%; Enterobacter species, 2-10%; Proteus mirabilis, 1-10%; Citrobacter species, 5-6%; coagulase-negative Staphylococci, 1-4%; group B Streptococci, 1-4%; and Staphylococcus aureus, 1-2% (7, 8).

Clinical features

Unlike other manifestations of BPH, UTI is not a disease or gender-specific condition. Caution is essential before assuming a causal relationship with BPH. The presence of a large post-void residual volume (PVR) allows more time for bacterial adherence and multiplication, which may lead to severe UTI that is difficult to eradicate. However, there is little evidence showing that the occurrence of UTI in the aging male population is associated with either PVR or bladder outflow obstruction (BOO) (9).

Diagnosis

Physical examination of the external genitalia is indicated to exclude meatal stenosis or a palpable urethral mass. An abdominal examination is also necessary to exclude urinary retention. Assessment of pain associated with costovertebral angle (CVA) and digital rectal examination (DRE) should be performed to rule out acute pyelonephritis and acute bacterial prostatitis. Urinalysis is recommended for patients with BPH to ensure that the symptoms are not related to infection. Urinalysis is performed to rule out urinary tract infection, and in case of a suspected infection, a urine specimen should be sent for culture and sensitivity testing. Urine culture is recommended for patients with BPH and UTI symptoms, and significant bacteriuria is defined by counts >10⁴ cfu/mL in the midstream urine or straight catheter urine sample (2). The diagnosis of asymptomatic bacteriuria in patients with BPH but without UTI symptoms should be based on culture results of a urine specimen collected with minimal contamination. Diagnostic criteria are listed in Table 1. Upper tract imaging is indicated for patients with BPH and a history of urinary infection. Ultrasound with abdominal radiography is equivalent to intravenous urography to screen patients with complicated UTIs. It is the imaging study of choice, while computerized tomography is indicated if more detailed information is required.

Table 1. Diagnostic criteria for asymptomatic bacteriuria in patients with BPH

Treatment

The treatment of UTI in the presence of urinary tract obstruction requires effective antibiotic therapy as well as appropriate urological intervention to eliminate predisposing factors and to restore the normal anatomy and function of the urinary tract as far as possible in order to prevent septicemia and recurrent UTI.

BPH treatment

Because the incidence of UTI is relatively uncommon and represents non–disease specific events in the aging male population, it is extremely difficult to design a prospective study to determine whether any BPH treatment prevents this event in an unselected cohort of men. There is no evidence to show that doxazosin, finasteride or a combination therapy reduces the incidence of UTI in patients with BPH (LE: 1) (4), and not even phytotherapy is effective in such cases (LE: 3)(10). Recurrent UTI caused by BOO is one of the indications for transurethral resection of prostate (TURP) (LE: 1) (11). In older surgical series involving approximately 12% of men with BPH, UTI was the indication for surgical intervention (LE: 3) (12-15). In a study of men with BPH treated at hospitals in Japan, UTI was the causative factor in 4% (LE: 3) (16).

Treatment of symptomatic UTI

The presence of infection in patients with BPH should prompt appropriate evaluation and therapy before initiating treatment for BPH. In patients with mild-to-moderate UTI, empirical oral antibiotic treatment is recommended on an outpatient basis.

Severely ill patients with possible sepsis require hospitalization. Empirical therapy should usually include an intravenous anti-pseudomonal agent. Targeted therapy should be initiated once susceptibility data are known. Agents generally prescribed include fluoroquinolone, β-lactam/β-lactamase inhibitor, broad-spectrum cephalosporin, aminoglycoside, and carbapenem (17). Treatment for 10 to 14 days is recommended for patients with fever or more severe systemic infections. Urine cultures should be performed during antibiotic treatment and 7 to 14 days after cessation of therapy to determine the effectiveness of treatment (LE: 3) (18, 19).

Screening and treatment of asymptomatic bacteriuria

Bacteremia occurs in up to 60% of bacteriuric patients who undergo TURP (20), and there is clinical evidence of sepsis in 6% to 10% of these cases (LE: 3) (21). The effectiveness of antimicrobial treatment to prevent these complications in bacteriuric men undergoing TURP is supported by evidence (LE: 1) (22-26). The appropriate timing for initiation of antimicrobial therapy is not well defined. Initiation of therapy at night before or immediately before the procedure is effective (LE: 1) (22, 26). In the absence of an indwelling catheter, antimicrobial therapy can likely be discontinued immediately after the procedure (LE: 1) (22, 23, 26). Continuation of antimicrobial therapy is recommended when an indwelling catheter remains in place after TURP, until the catheter is removed (LE: 1) (25, 26).

Further Research

Further prospective studies are needed to refine the treatment process in patients diagnosed with BPH along with UTI.

Conflict of Interest of each author

The authors declare that they have no competing interests.

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