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Recurrent lower urinary tract infection in a man with lower urinary tract symptoms — MSRA MCQ

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HardUrologyRecurrent lower urinary tract infection in a man with lower urinary tract symptomsMSRA

A 71-year-old man attends for review after his second culture-confirmed lower UTI in 4 months. Both episodes caused dysuria, frequency and suprapubic discomfort, resolved with culture-directed antibiotics, and grew different coliform organisms. He is currently asymptomatic. He has had 2 years of hesitancy, weak stream and nocturia despite fluid advice and tamsulosin. Digital rectal examination shows a smooth enlarged prostate. He has no visible haematuria, fever, loin pain, palpable bladder, neurological symptoms or weight loss. Creatinine is unchanged from baseline. What is the most appropriate next management plan?

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Correct answer: C — Arrange routine urology referral for investigation and management, continuing tamsulosin

Explanation lettering: D = shown as A · A = shown as C · E = shown as D · C = shown as E

This man has recurrent UTI, defined as at least 2 UTIs in 6 months, and is currently well following treatment of his second microbiologically confirmed lower UTI. NICE recommends referral or specialist advice for further investigation and management for men aged 16 years and over with recurrent UTI. His concurrent voiding LUTS raise the possibility of bladder outlet obstruction or incomplete emptying as a contributory factor; recurrent infection also makes his LUTS complicated, supporting specialist assessment. B is initially attractive because antibiotic prophylaxis can reduce recurrences in selected patients, but recurrent UTI in a man warrants specialist assessment rather than empirical primary-care prophylaxis. C could be appropriate for persistent predominant storage symptoms after appropriate assessment, but adding an antimuscarinic does not address the present indication for investigation of recurrent infection and possible obstruction. D is inappropriate because he has neither acute retention nor evidence of renal impairment or upper-tract obstruction requiring catheterisation. E misses both the recurrent-UTI threshold and the higher-risk context of recurrent infection in a man.

Reference: NICE NG112: Urinary tract infection (recurrent): antimicrobial prescribing — Recommendations (2018; amended 2024) — https://www.nice.org.uk/guidance/ng112/chapter/recommendations NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (2010) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations