https://orcid.org/0000-0002-0529-0954
Abstract
Background
Male urinary tract infections (mUTIs) are rare in primary care. The definition of mUTIs varies across countries. The therapeutic management of mUTIs in France is based on a 14-day course of fluoroquinolones despite a high risk of antimicrobial resistance.
Objectives
The objective of this qualitative study was to explore general practitioners’ (GPs) experiences and behaviours regarding the diagnostic and therapeutic management of mUTIs.
Methods
GPs were recruited by convenience sampling in Haute Normandie (France) and interviewed individually with semi-structured guides. GPs’ experiences and behaviours were recorded and analysed using an interpretive phenomenological approach.
Results
From March 2021 to May 2022, 20 GPs were included in the study. Defining a mUTI was perceived as a diagnostic challenge. A diagnosis based on clinical evidence alone was insufficient and complementary tests were required. For GPs: ‘male cystitis does not exist’. A mUTI was considered an unusual disease that could reveal an underlying condition. GPs considered fluoroquinolones to be ‘potent’ antibiotics and treated all patients with the same 14-day course. GPs implemented improvement strategies for antibiotic stewardship and followed the guidelines using a computerised decision support system.
Conclusions
GPs’ experiences of mUTIs are limited due to low exposure and variable clinical presentations in primary care, representing a diagnostic and therapeutic challenge. In order to modify GPs’ antibiotic prescribing behaviours, a paradigm shift in the guidelines will need to be proposed.
Defining a male urinary tract infection represents a diagnostic challenge for GPs.
A diagnosis based on clinical evidence alone is insufficient and complementary tests are required.
A male urinary tract infection is an unusual disease in primary care and suggests a more serious underlying condition.
KEY MESSAGES
Introduction
The definition of adult male urinary tract infections (mUTIs) varies according to country. Two categories can be distinguished: ‘febrile mUTIs’ (prostatitis, pyelonephritis) and ‘afebrile mUTIs’ (cystitis) [Citation1]. The incidence of mUTIs is low and increases with age from around three episodes per 100 person‐years (100 PY) aged 65 to 74 years old, to 8-11/100 PY aged more than 85 years old [Citation2,Citation3]. The ratio of UTIs (women to men) was 4.6 in general practice [Citation4]. Male UTIs were rare with fewer than two cases per general practitioner (GP) per year [Citation5].
The diagnosis of mUTIs in primary care is complex and challenging. GPs consider mUTIs to be rare with variable clinical presentations, representing a diagnostic and therapeutic challenge. Sexually transmitted infections (STIs) are investigated as a priority in young men when they present with symptoms similar to a mUTI. Frail and demented elderly people present few specific urinary symptoms. Compliance with guidelines varies according to GPs’ interpretation and the severity of symptoms [Citation6,Citation7]. The diagnostic approach to mUTIs according to French guidelines is comparable to other international guidelines [Citation1]. A digital examination of the prostate is not recommended. The use of a urinary dipstick is considered insufficient to establish a diagnosis. Cytobacteriological examination of urine (CBEU) is the gold standard to confirm diagnosis. Urinary tract ultrasound is used to identify local complications and to investigate recurrences [Citation8].
The therapeutic management of mUTIs in primary care lacks international consensus: a 14-day course of fluoroquinolones (FQs) for febrile mUTIs is consensual despite a high risk of antimicrobial resistance (AMR), but FQ-sparing treatment and/or a shorter course of FQ treatment for afebrile mUTIs is not [Citation1]. Guidelines from North European countries (Norway, Sweden, Finland, Denmark, the United Kingdom, and the Netherlands) suggest a 7-day course of FQ-sparing treatment (nitrofurantoin, pivmecillinam, trimethoprim) in afebrile mUTIs [Citation1]. However, FQ-sparing is not recommended in France [Citation8]. The antibiotic stewardship of febrile or afebrile mUTIs is the same (a 14-day course of FQs). French guidelines suggest a watchful-waiting approach, deferring FQ treatment and waiting for confirmation of the infection by CBEU (Box 1).
Male UTIs are rare in primary care and despite guidelines, their diagnosis and treatment are challenging. The objective of this qualitative study was to explore GPs’ experiences and behaviours regarding the diagnostic and therapeutic management of mUTIs.
Methods
Study design
We conducted a qualitative study with an interpretive phenomenological analysis approach. Before any data collection, the respective postures and points of view of the researchers were discussed, in order to manage the effect of their experiences and behaviours on the data analysis process. The report followed the COREQ 32 guidelines (Supplementary Material).
Population
Sampling
Data were collected from March 2021 to May 2022 in the Haute Normandie region (France). All practicing or locum GPs were eligible and formed a homogeneous population regarding the research objective. Convenience sampling was used to provide a diverse sample with regards to sex, age, practice setting (rural or urban), and involvement in teaching and/or in postgraduate medical education.
Recruitment
The researchers first carried out convenience sampling among their direct contacts. At the end of each interview, the participant was asked to suggest one or two new participants. The recruitment ended after data saturation was reached, that is, when no new information emerged from the last interviews or was needed to fulfil the interpretation.
Data collection
Semi-structured interviews were conducted using an interview guide (Box 2). The initial interview guide was based on the study by Fallon et al. [Citation6] and explored GPs’ experiences, diagnostic approach, and therapeutic management of male UTIs. Two pilot interviews were conducted (BS, AG) to improve the interview guide and management. The remaining interviews were conducted by the second author (AG), face-to-face, or by telephone when face-to-face was not possible. Interviews were transcribed verbatim in Microsoft Word®, anonymised and checked for inconsistencies with the original recording. Remarks on non-verbal communication were added to the transcript. Transcripts were not returned to participants for comments. All interviews were included in the final analysis.
Data analysis
A step-by-step interpretive analysis was conducted seeking patterns across cases and drawing on existing concepts to further explore the data [Citation9]. Each interview was analysed individually and summarised in a conceptual map focussed on GPs’ experiences. Initial coding was carried out independently by two researchers (BS, AG) and discrepancies were resolved by discussion, with the arbitration of a third researcher (MS) if needed. The emergent themes were triangulated with the same process, clustered into superordinate themes and compared between interviews. Any disagreement about interpretation was discussed until an agreement was reached. Analysis was conducted using QSR NVvivo7®. The final coding tree can be found in supplementary material.
Ethics and regulations
Participating GPs provided recorded oral consent to participate in the study at the beginning of the interview. All transcripts and recordings were encrypted and password protected and was only accessible by members of the research team. Transcripts were anonymised, and audio recordings were destroyed after transcription.
This study was approved by the Ethics Committee of Rouen University Hospital (CERDE) n°E2022-44 and registered by Rouen University n°2021.054.
Results
GPs’ characteristics
From March 2021 to May 2022, 20 GPs (9 women and 11 men) were included in the study (). Four GPs were less than 35 years old, four were locum GPs and 13 practiced in urban areas. Only one GP practiced alone or with one other GP, the remaining 19 GPs were in multi-professional practices. Two interviews were conducted by telephone. The median duration of the interviews was 24 min (Interquartile range: 13-46 min).
Table 1. General practitioners’ characteristics.
Diagnostic approach to mUTIs
Male UTIs are rare in primary care
All GPs declared that they had a low exposure to patients with mUTIs and had difficulty recalling the clinical history of these patients at the beginning of the interview.
I do get one once every 3 months or so? Yes, every 3 months I would say. [GP12]
Patients do not identify the disease
Unlike cystitis in women, men often delayed making an appointment with their GP, especially if they had symptoms of incomplete functional urinary syndrome.
It’s mainly urinary burning that people describe to us. Which is really unusual for them. Because women have cystitis quite often, they know. They spot the symptoms quicker, but [men say]: ‘Well that’s weird, it’s been burning for a week and I have a bit of blood’. [GP3]
The definition of mUTI is unclear
The diagnostic hypothesis was simple: pollakiuria and urinary burning were the main symptoms leading to a diagnostic suspicion of a mUTI.
It was a simple thing, the patient who came in reported burning quite recently, and quite intensely. He still had discomfort, with urinary frequency and dysuria, and it was the first time it happened to him. [GP8]
However, the diagnosis was challenging in patients with incomplete functional urinary syndrome or isolated fever.
Last time, I was almost fooled, a patient was convinced he had the flu [laughs] but nothing suggested the flu […]. I did a rectal examination and he had painful prostatitis. He was convinced he had the flu: he was shivering, shaking, aching, so it had to be the flu! [GP20].
GPs encountered challenges in categorising and labelling this infection. Various definitions were proposed, often intertwined: generic (mUTI) or organ-specific (prostatitis, pyelonephritis).
A 40-year-old man, who was not febrile but who had dysuria and very clear discomfort. […] I couldn’t tell the difference with a mUTI, as I didn’t have any clear signs of prostatitis, of pyelonephritis. [GP4]
When symptoms occurred in young men (not defined), STIs or testicular disease were considered a differential diagnosis.
When they are young, it is true that I easily ask them anyway, about urinary STIs, a CBEU, and if there is urethral discharge, I do a swab. [GP4]
Confirm the diagnosis
For all GPs, bacteriological confirmation (or refutation) was required when a mUTI was suspected, then antibiotic adjustment.
I always try to do the same thing, get the result of the CBEU… which allows me after 5 days to be able to adjust the antibiotic for 10 or 14 days. [GP17]
The diagnostic value of the digital rectal examination varied according to the characteristics of the GPs. Experienced male GPs performed it to confirm a suspected mUTI.
Touching the prostate when they have prostatitis, just putting your finger in is really painful! […] it is a disease of general medicine which is perfectly accessible because we have the diagnosis at our fingertips. [GP13]
However, younger GPs mostly women, considered it painful and irrelevant in the management strategy.
It’s not a pleasant examination, I think, either for the patient or for you. So, if you bother the patient with a rectal examination and then do not know how to interpret it and then say: ‘Well I don’t know how to conclude’. [GP12]
GPs did not use a urine dipstick because CBEU was prescribed systematically.
When you’re not sure, let’s say that if it [urine dipstick] is positive, that’s it, you know that… In any case, I'll send you for a CBEU, to identify the germ. […] But whether I buy some or not remains to be seen, […] It’s not going to bother me enough to go to the pharmacy and buy some. [GP8]
GPs reported a threefold benefit of ordering a prostate-specific antigen (PSA) test: confirming or refuting the diagnosis, guiding treatment and monitoring kinetics.
PSA? […] Yes, for a differential diagnosis: either it’s a urinary infection, or it’s more dysuria due to the prostate. If the CBEU is negative, I order PSA. [GP8]
So, PSA I really do them, if I suspect prostatitis. Because honestly, I find it’s not the same treatment. [GP9]
PSAs are high when there’s inflammation of the prostate. I check again at one month and two months to see if it’s back to normal or not. [GP1]
Representation of mUTIs
For GPs, male cystitis does not exist
There was a strongly held belief of a risk of complications with a mUTI. Defining ‘male cystitis’ was complicated for GPs. No GP defined an afebrile mUTI as cystitis because for GPs ‘male cystitis does not exist’.
First of all, cystitis doesn’t exist! Cystitis in general is prostatitis, so you shouldn’t give [fosfomycin]! [GP16]
This lack of awareness of ‘male cystitis’ is induced by medical education, which is strongly rooted in the knowledge and beliefs of GPs. All mUTIs were presumed to be prostatitis.
The medical lecturers, in my time, always gave some kind of punch line that left an impression on us: ‘a male urinary infection is never benign, and is always prostatitis, until proven otherwise’. [GP11]
The definition of cystitis was strongly associated with female sex. Male UTIs, even if well tolerated, were not defined as simple or ordinary.
With women, cystitis is a common event. You always have to tell yourself that it’s not something that’s immediately commonplace in a man. You must check that there isn’t a good reason for it. So, you can’t just say: ‘Well, let’s treat it and then move on to something else’. That’s why I find it hard to say ‘cystitis’. [GP20]
An unusual infection
A sense of alarm automatically emerged when a mUTI was suspected. GPs were cautious of the rarity of the disease in men.
A UTI in a man, to me that’s suspicious. [GP10]
You have to look for them, a urinary infection in a man… that raises a red flag… [GP13]
Staying alert, in men. [GP9]
All mUTIs were associated with prostatitis and its complications (abscess and chronic prostatitis). The failure to diagnose a mUTI could be a mistake.
If he has a urinary infection, there’s something wrong. [GP1]
At the beginning of my career, it was prostate abscess that was feared […] The greatest risk is not diagnosing the infection. [GP11]
Male UTIs were considered a complicated disease as they could reveal an underlying condition (such as cancer, adenoma or lithiasis). Additional tests were prescribed to identify prostatic cancer.
After [the UTI], you shouldn’t hesitate to investigate further because it could also be an adenocarcinoma or benign prostatic hyperplasia. [GP19]
The risk of serious disease was mitigated by the low probability of diagnosing serious conditions in primary care.
Traditionally, we were always told that UTI, well, cystitis in any case, did not really exist, that it was either directly prostatitis and that pyelo was very rare. […] it’s much broader than what we were taught, yes that’s for sure. [laughs] Like a lot of times, it’s not a big deal. [GP3]
‘Cleaning’ the prostate
GPs considered that an infected prostate was difficult to treat. The belief that a mUTI was linked to prostatitis led to an attitude of ‘cleaning’ the prostate. The search for effective ‘cleaning’ justified the choice of FQ and long-term therapy.
I was always told that the prostate was difficult to clean. [GP1]
Prostatitis is like Venice! There is an infection in the Venetian canals, which must be cleaned: ‘Victory is not guaranteed!’ [GP13]
Efficacy and safety of antibiotics
Fluoroquinolones: Potent antibiotics
Fluoroquinolones were considered as an effective treatment for mUTIs and prescribed immediately regardless of the severity of symptoms.
But it’s mainly the urinary symptoms that contribute to my decision. I start an antibiotic, to stop it getting worse or spreading. As soon as I'm almost sure of the diagnosis I don’t hesitate to prescribe antibiotics whether there is fever or not. [GP1]
A minimum 14-day course of FQs was necessary to limit the risk of treatment failure or disease recurrence.
In men always: 1 ‘fairly incisive’ and 2 ‘fairly long’. [GP2]
On the one hand, FQs were considered to be effective and potent antibiotics; on the other, prescribing them carried a considerable cost and risk.
Levofloxacin is pretty potent, isn’t it? It’s a dangerous drug, but it’s effective for what you want. [GP9]
People who have already had a tendinopathy can’t always be given quinolones! And, of course, all allergies. [GP15]
Indeed, antibiotic adjustments were not proposed in the case of low intensity symptoms (a short course of antibiotics or FQ-sparing). Only one GP suggested treating afebrile mUTIs with FQ sparing (pivmecillinam for 5 to 7 days [GP10]).
Exposure to FQs is acceptable
However, AMR did not change GPs’ therapeutic attitudes. The low incidence of mUTIs justified exposure to antibiotics even for long periods. A risk of AMR did not seem to be the responsibility of GPs.
Antimicrobial resistance is not my concern. But, on the other hand, it’s rare to use an antibiotic in a man! […] he will have an antibiotic, let’s say, once or twice in his life if he has a recurrence. So, there is no danger for him. And he doesn’t hang around hospitals… […] No, the worry is that you could miss something. [GP9]
The benefit-risk balance between unnecessary exposure to FQs and the risk of an untreated infection appeared acceptable, knowing that antibiotic treatment could be stopped early according to CBEU results.
We even reassess by telephone, saying ‘OK, I've received the examination, you should stop the treatment’ or ‘you should continue the treatment and I'll extend it’ because I’ll give you a 2-3 day course of treatment while you wait… [GP16]
An alternative to FQs was proposed but only in cases of contraindication to FQs or recent exposure.
If I had a patient who absolutely didn’t want to give up sport, I'd put them on cotrimoxazole. [GP11]
Improved antibiotic stewardship
Adherence to the guidelines
GPs followed the guidelines in case of uncertainty regarding the type and duration of antibiotics. Adherence to the guidelines enabled GPs to prescribe antibiotics in an efficient and reasoned manner.
We must rely on the guidelines, otherwise we don’t know what to do! We keep running around in circles! Following a certain number of guidelines helps us a lot in our daily practice. [GP17]
The French guidelines for mUTIs appeared less clear and less structured compared to those for UTIs in women.
Having said that, it may not be too clear for men in terms of the French National Authority for Health, but it’s clearer for women in fact. [GP18]
An integrated decision support system
A clinical decision support system (CDSS) was used to help GPs improve their decision-making and antibiotic stewardship. The CDSS specified the diagnostic criteria for mUTIs and then recommended antibiotics in order of choice.
Antibioclic® [French CDSS], we log onto the computer, we just have to click, it’s really easy, there are some well-selected criteria. I use it all the time and I find that it prevents me from making mistakes. […] It’s often updated. It’s a reliable site that you can trust. Many GPs use it. [GP12]
A complicated watchful-waiting approach
A watchful-waiting approach was suggested to confirm or refute the suspected diagnosis in the absence of fever or pain.
If there are no major symptoms, you don’t need to treat immediately. But if there is fever, it’s a sign of spread, it’s not worth waiting, I think. [GP11]
French guidelines recommend delaying the prescribing of antibiotics and waiting for the results of the CBEU. This watchful-waiting approach was a cause of concern, between the need for FQ-sparing on the one hand, and the need for treating the patient on the other hand.
You have to wait for the antibiogram to prescribe the right antibiotic straight away, but… [sigh]… but there you go, and it’s also explained that when the signs are very serious, you can also start straight away and then adapt, so I treat straight away. [GP12].
Discussion
Main findings
Male UTIs were perceived as unusual by GPs due to their rarity and variability of clinical presentation in primary care, leading to a diagnostic and therapeutic challenge. According to their initial medical education, many GPs believed that ‘male cystitis does not exist’ and that a more serious underlying disease should be investigated. Fluoroquinolones were considered to be ‘potent’ antibiotics and GPs prescribed the same 14-day course for all mUTIs.
Strengths and limitations
Interpretive phenomenological analysis allowed us to explore GPs’ experiences and behaviours regarding mUTIs. Interpretive phenomenological analysis also relied on the representations and attitudes of GP researchers (hermeneutic cycle) and influenced the research process. This reflexivity strengthened the adequacy and conceptualisation of the results [Citation9]. Our analysis enabled us to explore GPs’ concerns, sometimes arising from beliefs, and to understand the sense of alarm of GPs in managing mUTIs.
The limitations of this study include the sampling technique. The use of purposive sampling would have facilitated demographic diversity and different practices. However, subsequent verification of the characteristics allowed achieving variations in age, sex and practices (location and duration) meeting the criteria for purposive sampling. We had to conduct semi-structured interviews because GP’s experiences were limited and difficult to recall. The interviews were conducted by a novice researcher, which may have limited the collection of in-depth and comprehensive interviews, sometimes by telephone, and the duration of interviews was sometimes short. However, this limitation was reduced by regular supervision and analysis by an experienced researcher and by the large number of GPs interviewed.
Comparison with the literature
Studies about GPs’ experiences and behaviours are rare and few qualitative studies have focused on mUTIs in primary care [Citation6,Citation7]. Similar to our study, authors reported a low exposure of GPs to patients with mUTIs, leading to diagnostic and therapeutic challenges, and despite being aware of a risk of AMR, GPs considered antibiotic prescribing acceptable at an individual level [Citation6,Citation7]. The experiences of patients are unknown: a recent meta-ethnography found only 30 men interviewed out of 1,038 participants across 16 qualitative studies [Citation10].
The nosology of mUTIs has always been unclear: at the end of the 1990s, prostatitis was perceived as an enigmatic syndrome due to a lack of research and studies. A clinically relevant definition and the determination of the etiologic basis were already recognised as challenges [Citation11]. The term ‘prostatitis’ was removed from French guidelines in 2017 to include the terms ‘symptomatic’ mUTI and ‘pauci symptomatic’ mUTI [Citation8]. However, Norway, Sweden, Finland, Denmark, the United Kingdom, and the Netherlands guidelines affirm the nosology of male cystitis [Citation1].
Several studies reported a ‘sense of alarm’ of GPs due to a low exposure to patients with mUTIs and subsequent diagnostic uncertainty [Citation12,Citation13]. Various beliefs increase the sense of alarm of GPs, reinforcing the idea that male UTIs are always a serious disease and require to investigate causes such as prostate cancer. However, no association was found in the literature between mUTIs and prostate cancer [Citation14].
For GPs, the type and duration of antibiotic therapy must be adequate to limit complications or recurrences. In a recent randomised clinical trial, FQs had a strong symbolic value, contributing to the belief of their ‘cleansing’ properties [Citation15]. In two interventional studies, authors suggested that afebrile mUTIs could be treated with a 7-day course of FQs and febrile mUTIs with a 14-day course of FQs [Citation16,Citation17]. Short treatments of 7 days were not associated with higher failure or recurrence rates [Citation18,Citation19]. Fluoroquinolone-sparing treatments (pivmecillinam, nitrofurantoin and trimethoprim) were not associated with a higher risk of complications or recurrences [Citation20,Citation21].
Guidelines are important resources to improve antibiotic stewardship. However, prescribing guidelines alone are insufficient to improve antibiotic stewardship [Citation22–25]. Other valuable tools are CDSS, in particular, Antibioclic®, which relies on a Task-Network Model to translate national clinical practice guidelines into an easy-to-use system. Nearly 50,000 GPs were registered, representing more than half of the French GP population [Citation26]. Male UTIs accounted for 5% of CDSS queries [Citation27]. The integration of a CDSS in the decision-making process of GPs is necessary as well as changes in antibiotic stewardship [Citation26].
Perspectives
Further studies on diagnostic tests (urinary dipstick, PSA, imaging) will be necessary to determine precisely whether or not the prostate is involved in mUTIs. Behavioural modelling like the theory of planned behaviour could be used to understand and predict GPs’ intentions to prescribe antibiotics [Citation28]. Finally, interventional research on FQ sparing in primary care is essential to standardise guidelines.
Conclusion
GPs’ experiences of mUTIs are limited due to low exposure and variable clinical presentations of mUTIs in primary care, representing a diagnostic and therapeutic challenge. French GPs treat mUTIs indifferently with the same 14-day course of FQs for all mUTIs. In order to modify GPs’ antibiotic prescribing behaviours, a paradigm shift in the guidelines will need to be proposed.
Ethics
This study was approved by the Ethics Committee of CHU Rouen (CERDE) n°E2022-44. Participants provided oral consent at the beginning of the interview.
Box 1. French guidelines of empiric antibiotics for male urinary tract infections (mUTIs) in primary care [Citation10].
Box 2. GP interview guide
Section 1: General Practitioners’ experience and behaviour
To begin with, could you tell us about a patient with a male UTI?
Can you describe a ‘typical’ patient with a male UTI?
Section 2: Clinical reasoning and decision making
How did you diagnose the male UTI? What definition did you use?
What did you prescribe? What advice did you give?
And after your diagnosis? How and why did you manage the patient’s follow-up?
Section 3: Learning process and continuing education
Why did you decide on this therapeutic management?
What sources did you use to make your decision?
Supplemental Material
Download MS Word (19.9 KB)Supplemental Material
Download PDF (511.8 KB)Acknowledgements
The authors are grateful to Prof. Manuel Etienne for his expertise and insights on male urinary tract infections, to Prof. Jean-Pierre Lebeau for his expertise on qualitative research and proofreading, and to Nikki Sabourin-Gibbs, CHU Rouen, for her help in editing the manuscript.
Disclosure statement
The authors report no conflict of interest. Authors’ declaration of interest is publicly available on www.transparence.sante.gouv.fr and www.archimede.fr.
Data availability statement
This study was approved by the protection register (National Commission for Informatics and Liberties) of Rouen University n°2021.054. The data presented in this study are available upon request from the corresponding author.
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