Guidelines on The Management of Urinary and Male Genital Tract Infections K.G. Naber (Chairman), M.C. Bishop, T.E. Bjerklund-Johansen, H. Botto, M. Çek, M. Grabe, B. Lobel, J. Palou, P. Tenke © European Association of Urology 2006 TABLE OF CONTENTS PAGE 1. INTRODUCTION 7 1.1 Pathogenesis of urinary tract infections 7 1.2 Microbiological and other laboratory findings 7 1.3 Classification of urinary and male genital infections 8 1.4 Aim of guidelines 8 1.5 Methods 9 1.6 Level of evidence and grade of guidline recommendation 9 1.7 References 9 2. UNCOMPLICATED URINARY TRACT INFECTIONS IN ADULTS 11 2.1 Summary and Recommendations 11 2.1.1 Definition 11 2.1.2 Aetiological spectrum 11 2.1.3 Acute uncomplicated cystitis in pre-menopausal, non-pregnant women 11 2.1.4 Acute uncomplicated pyelonephritis in pre-menopausal, non-pregnant women 12 2.1.5 Recurrent (uncomplicated) UTIs in women 12 2.1.6 UTIs in pregnancy 12 2.1.7 UTIs in post-menopausal women 12 2.1.8 Acute uncomplicated UTIs in young men 13 2.1.9 Asymptomatic bacteriuria 13 2.2 Background 13 2.3 Definition 13 2.4 Aetiological spectrum 14 2.5 Acute uncomplicated cystitis in pre-menopausal, non-pregnant women 14 2.5.1 Incidence, risk factors, morbidity 14 2.5.2 Diagnosis 14 2.5.3 Treatment 15 2.5.4 Post-treatment follow-up 19 2.6 Acute uncomplicated pyelonephritis in pre-menopausal, non-pregnant women 19 2.6.1 Diagnosis 19 2.6.2 Treatment 20 2.6.3 Post-treatment follow-up 22 2.7 Recurrent (uncomplicated) UTIs in women 22 2.7.1 Background 22 2.7.2 Prophylactic antimicrobial regimens 23 2.7.3 Alternative prophylactic methods 25 2.8 UTIs in pregnancy 26 2.8.1 Epidemiology 26 2.8.2 Asymptomatic bacteriuria 26 2.8.3 Acute cystitis during pregnancy 27 2.8.4 Acute pyelonephritis in pregnancy 27 2.9 UTIs in postmenopausal women 27 2.10 Acute uncomplicated UTIs in young men 28 2.10.1 Pathogenesis and risk factors 28 2.10.2 Diagnosis 28 2.10.3 Treatment 28 2.11 Asymptomatic bacteriuria 29 2.12 References 29 3. URINARY TRACT INFECTIONS IN CHILDREN 40 3.1 Summary and recommendations 40 3.2 Background 40 3.3 Aetiology 41 3.4 Pathogenesis and risk factors 41 3.5 Signs and symptoms 41 3.6 Classification 41 3.6.1 Severe UTI 42 3.6.2 Simple UTI 42 2 MARCH 2006 3.7 Diagnosis 42 3.7.1 Physical examination 42 3.7.2 Laboratory tests 42 3.7.2.1 Collection of urine 42 3.7.2.1.1 Suprapubic bladder aspiration 42 3.7.2.1.2 Bladder catheterization 42 3.7.2.1.3 Plastic bag attached to the genitalia 42 3.7.2.2 Quantification of bacteriuria 42 3.7.2.3 Other biochemical markers 43 3.7.2.3.1 Nitrite 43 3.7.2.3.2 Leucocyte esterase 43 3.7.2.3.3 C-reactive protein 43 3.7.2.3.4 Urinary N-acetyl-ß-glucosaminidase 44 3.7.2.3.5 Interleukin-6 44 3.7.3 Imaging of the urinary tract 44 3.7.3.1 Ultrasonography 44 3.7.3.2 Radionuclide studies 44 3.7.3.3 Cystourethrography 44 3.7.3.3.1 Conventional voiding cystourethrography 44 3.7.3.3.2 Radionuclide cystography (indirect) 44 3.7.3.3.3 Cystosonography 45 3.7.3.4 Additional imaging 45 3.7.3.5 Urodynamic evaluation 45 3.8 Schedule of investigation 45 3.9 Treatment 45 3.9.1 Severe UTIs 45 3.9.2 Simple UTIs 46 3.9.3 Prophylaxis 46 3.10 Acknowledgement 47 3.11 References 47 4. UTIs IN RENAL INSUFFICIENCY, TRANSPLANT RECIPIENTS, DIABETES MELLITUS 52 AND IMMUNOSUPRESSION 4.1 Summary 52 4.1.1 Acute effects of UTI on the kidney 52 4.1.2 Chronic renal disease and UTI 52 4.1.2.1 Adult polycystic kidney disease (APCKD) 53 4.1.2.2 Calculi and UTI 53 4.1.2.3 Obstruction and UTI 53 4.1.3 UTI in renal transplantation and immunosuppression 53 4.1.4 Antibiotic treatment for UTI in renal insufficiency and after renal transplantation 53 4.2 Background 53 4.3 Acute effects of a UTI on the kidney 53 4.3.1 Vesicoureteric and intrarenal reflux 53 4.3.2 Obstructive neuropathy 54 4.3.3 Renal effects of severe UTI 54 4.3.4 Acute effects of UTI on the normal kidney 54 4.3.5 Renal scarring 55 4.3.6 Specific conditions in which an acute UTI causes renal damage 55 4.3.6.1 Diabetes mellitus 55 4.3.6.2 Tuberculosis 56 4.4 Chronic renal disease and UTI 56 4.4.1 Adult dominant polycystic kidney disease (ADPK) 56 4.4.2 Renal calculi 56 4.5 UTI in renal transplantation 57 4.5.1 Donor organ infection 57 4.5.2 Graft failure 57 4.5.3 Kidney and whole-organ pancreas transplantation 57 4.6 Antibiotic therapy in renal failure/transplantation 58 4.6.1 Treatment of UTI in renal transplant recipients 58 MARCH 2006 3 4.6.2 Fungal infections 59 4.6.3 Schistosomiasis 59 4.7 Immunosuppression 59 4.7.1 HIV infection 59 4.7.2 Viral and fungal infections 59 4.8 References 59 4.8.1 Further reading 63 5. COMPLICATED UTIs DUE TO UROLOGICAL DISORDERS 64 5.1 Summary and recommendations 64 5.2 Definitions and classification 64 5.2.1 Clinical presentation 65 5.2.2 Urine cultures 65 5.3 Microbiology 65 5.3.1 Spectrum and antibiotic resistance 65 5.3.2 Complicated UTIs associated with urinary stones 65 5.3.3 Complicated UTIs associated with urinary catheters 65 5.4 Treatment 66 5.4.1 General principles 66 5.4.2 Choice of antibiotics 66 5.4.3 Duration of antibiotic therapy 66 5.4.4 Complicated UTIs associated with urinary stones 67 5.4.5 Complicated UTIs associated with indwelling catheters 67 5.4.6 Complicated UTIs in spinal-cord injured patients 67 5.4.7 Follow-up after treatment 67 5.5 Conclusions 67 5.6 References 68 6. CATHETER-ASSOCIATED UTIs 70 6.1 Summary and recommendations 70 6.2 Background 70 6.3 Risk of bacteriuria 70 6.4 Pathogenesis 71 6.4.1 At time of catheter insertion 71 6.4.2 After catheter insertion 71 6.4.3 Biofilm infection 71 6.5 Methods of catheterization and risk of UTI 71 6.5.1 Single catheterization - ‘in-out’ 71 6.5.2 Short-term catheterization 71 6.5.3 Long-term catheterization 72 6.6 Alternative methods of urinary drainage 72 6.6.1 Intermittent catheterization 72 6.6.2 Suprapubic catheterization 73 6.6.3 Condom catheters 73 6.6.4 Urethral stents/prostheses 73 6.6.5 Urinary diversion 73 6.7 Prevention of catheter-associated bacteriuria 73 6.7.1 Catheter care 73 6.7.2 Additional methods of prevention 73 6.8 Treatment 74 6.8.1 Treatment of asymptomatic bacteriuria 74 6.8.2 Treatment of symptomatic UTI 74 6.9 Prevention of cross-infection 74 6.10 References 75 7. SEPSIS IN UROLOGY (UROSEPSIS) 82 7.1 Summary and recommendations 82 7.2 Background 83 7.3 Definition and clinical manifestation of sepsis in urology 83 7.4 Physiology and biochemical markers 84 4 MARCH 2006 7.4.1 Cytokines as markers of the septic response 84 7.4.2 Procalcitonin is a potential marker of sepsis 84 7.5 Prevention 84 7.5.1 Preventive measures of proven or probable efficacy 84 7.5.2 Appropriate peri-operative antimicrobial prophylaxis 85 7.5.3 Preventive measures of debatable efficacy 85 7.5.4 Ineffective or counterproductive measures 85 7.6 Treatment 85 7.6.1 Relief of obstruction 85 7.6.2 Antimicrobial therapy 85 7.6.3 Adjunctive measures 85 7.7 Conclusion 85 7.8 Acknowledgement 86 7.9 References 86 8. URETHRITIS 87 8.1 Definition 87 8.2 Epidemiology 87 8.3 Pathogens 87 8.4 Route of infection and pathogenesis 87 8.5 Clinical course 88 8.6 Diagnosis 88 8.7 Therapy 88 8.8 Prevention 88 8.9 References 88 9. PROSTATITIS AND CHRONIC PELVIC PAIN SYNDROME 89 9.1 Summary and recommendations 89 9.2 Introduction and definition 90 9.3 Diagnosis 90 9.3.1 History and symptoms 90 9.3.1.1 Symptom questionnaires 90 9.3.2 Clinical findings 90 9.3.3 Urine cultures and expressed prostatic secretion 91 9.3.4 Perineal biopsy 91 9.3.5 Other tests 91 9.3.6 Classification systems 92 9.3.7 Diagnostic evaluation 92 9.3.8 Additional investigations 92 9.4 Treatment 93 9.4.1 Antibiotics 93 9.4.2 Antibiotics and α-blockers in combination therapy 93 9.4.3 Other oral medication 94 9.4.4 Intraprostatic injection of antibiotics 94 9.4.5 Surgery 94 9.4.6 Other treatment forms 95 9.5 References 95 10. EPIDIDYMITIS AND ORCHITIS 98 10.1 Definition and classification 98 10.2 Incidence and prevalence 99 10.3 Morbidity 99 10.4 Pathogenesis and pathology 99 10.5 Diagnosis 99 10.5.1 Differential diagnosis 99 10.6 Treatment 99 10.7 References 100 11. PERI-OPERATIVE ANTIBACTERIAL PROPHYLAXIS IN UROLOGY 100 11.1 Summary 100 MARCH 2006 5 11.2 Introduction 101 11.3 Goals of peri-operative antibacterial prophylaxis 101 11.4 Risk factors 102 11.5 Principles of antibiotic prophylaxis 103 11.5.1 Timing 103 11.5.2 Route of administration 103 11.5.3 Duration of the regimen 103 11.5.4 Choice of antibiotics 103 11.6 Prophylactic regimens in defined procedures 103 11.6.1 Diagnostic procedures 105 11.6.2 Endo-urological treatment procedures 105 11.6.3 Laparoscopic surgery 105 11.6.4 Open urological operations without bowel segment with or without 105 opening of the urinary tract 11.6.5 Open urological operations with bowel segment 105 11.6.6 Post-operative drainage of the urinary tract 105 11.6.7 Implant of prosthetic devices 105 11.7 References 107 12.