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Recurrent lower urinary tract infection in a man — MSRA MCQ

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HardUrinary Tract InfectionsRecurrent lower urinary tract infection in a manMSRA

A 64-year-old man requests prevention of recurrent urinary tract infection (UTI). He has had three culture-confirmed episodes of Escherichia coli lower UTI in the past 7 months, each causing dysuria, frequency and suprapubic discomfort without fever, rigors, loin pain, perineal pain or vomiting. Each episode resolved with culture-directed antibiotics. He is currently asymptomatic. He has no urinary catheter, diabetes, renal stones, visible haematuria, obstructive lower urinary tract symptoms or recent instrumentation. Digital rectal examination is unremarkable and eGFR is 68 mL/minute/1.73 m². Increased fluid intake and avoiding delayed voiding have not prevented further episodes. He wishes to avoid long-term antibiotics and asks to start methenamine hippurate. He intermittently uses over-the-counter potassium citrate sachets for urinary discomfort. What is the most appropriate management now?

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Correct answer: E — Refer or seek specialist advice for investigation and prophylaxis planning before starting preventive treatment

This man meets the definition of recurrent UTI, having had three culture-confirmed episodes within 12 months. The decisive feature is his male genitourinary anatomy: NICE recommends referral or specialist advice for men with recurrent UTI to investigate an underlying cause and guide management. This remains appropriate despite the absence of obstructive symptoms, abnormal examination findings or renal impairment. Methenamine hippurate may be an antibiotic-sparing option, and potassium citrate should not be used with it because urinary alkalinisation reduces its effectiveness. However, NICE specifically advises seeking specialist advice before considering methenamine hippurate in men. Starting it directly is therefore premature. Similarly, daily antibiotic prophylaxis in men should be considered only with specialist advice after any necessary investigations. Single-dose prophylaxis is appropriate where there is a clear, reproducible trigger, which is absent here. A repeat urine culture in an asymptomatic man would not replace referral and should not be used to direct treatment of asymptomatic bacteriuria.

Reference: NICE NG112: Urinary tract infection (recurrent): antimicrobial prescribing — Recommendations (Last updated 12 December 2024) — https://www.nice.org.uk/guidance/ng112/chapter/recommendations NICE NG112: Urinary tract infection (recurrent): antimicrobial prescribing — Methenamine hippurate (Last updated 12 December 2024) — https://www.nice.org.uk/guidance/ng112/chapter/recommendations NICE NG112: Urinary tract infection (recurrent): antimicrobial prescribing — Daily antibiotic prophylaxis (Last updated 12 December 2024) — https://www.nice.org.uk/guidance/ng112/chapter/recommendations