As with females, the usual route of inoculation in males is with gram-negative aerobic bacilli from the gut, with Escherichia coli being the most common offending organism. Recent hospitalization, urinary catheter, and fluoroquinolone use in the past 6 months are independent risk factors for fluoroquinolone resistance in community-onset febrile E coli UTI. Fluoroquinolone resistance may be a marker of broader resistance, including extended-spectrum beta-lactamase (ESBL) positivity. 
In the normal host, UTI may occur due to infection of other portions of the genitourinary tract, typically the prostate. Older males with prostatic hypertrophy have incomplete bladder emptying, predisposing them to UTI on the basis of urinary stasis. However, in males aged 3 months to 50 years, the incidence of UTI is low; therefore, the possibility of an anatomic abnormality must be entertained in this age group.
Entry of microorganisms into the prostate gland almost always occurs via the urethra; with intraprostatic reflux of urine, bacteria migrate from the urethra or bladder through the prostatic ducts. Other possibilities include entry via the hematogenous route, via the lymphatics from the rectum, and during prostate surgery. However, many patients have no known precipitating event.
Prostatic fluid contains various antibacterial substances, including zinc and antibodies, which are lacking in some patients with chronic bacterial prostatitis. Interestingly, acute prostatitis usually does not result in chronic prostatitis, and chronic bacterial prostatitis is usually not antedated by acute prostatitis. Of men referred for prostatitis, less than 10% have either acute or chronic bacterial prostatitis.
Acute and chronic prostatitis
In the 1800s, prostatitis was thought to be secondary to excessive alcohol consumption or physical or sexual activity. It was often associated with gonorrhea and could be fatal or lead to abscess formation. By the 1920s, most cases were attributed to microorganisms, and antibiotics combined with prostate massage were standard therapy after World War II. Although the role of bacteria was questioned in the 1950s, it was reemphasized in 1968 when Meares and Stamey described their "4-glass test." 
Acute prostatitis is caused by an acute infection of the entire prostate gland, resulting in fever and localized pain. Microscopically, neutrophilic infiltrates, diffuse edema, and microabscesses may be seen, which may coalesce into larger collections.
Chronic prostatitis may be caused by inflammatory or noninflammatory diseases. This condition may arise via dysfunctional voiding, intraprostatic reflux, chronic exposure to microorganisms, autoimmune mechanisms, irritative urinary metabolites, and as a variant of neuropathic pain. Chronic bacterial prostatitis often produces few or no symptoms related to the prostate, but it is probably the most common cause of relapsing UTI in men.
Chronic prostatitis has been subdivided by the National Institutes of Health (NIH) into the following categories:
Category II: Chronic bacterial prostatitis
Category III: Chronic abacterial prostatitis. Category IIIA is chronic, inflammatory abacterial prostatitis, and category IIIB is chronic, noninflammatory abacterial prostatitis, also known as chronic pelvic pain or prostatodynia.
Category IV: Asymptomatic, inflammatory prostatitis
Chronic bacterial prostatitis is the most common cause of relapsing UTI in men, with E coli as the main causative organism (80%), but other gram-negative bacteria and enterococci may also be observed. Rare cases may be caused by yeasts (eg, Candida, Blastomyces, Histoplasma, Cryptococcus) and mycobacteria. Whether Staphylococcus epidermidis, S aureus, and diphtheroids are pathogenically significant is doubtful, and the evidence supporting a causative role for Chlamydia and Ureaplasma is not convincing. 
Epididymitis is a clinical syndrome caused by infection or inflammation of the epididymis. This condition is the most common cause of acute scrotum in adult male populations. Long-term complications include abscesses, infarction, recurrence, chronic pain, and infertility
The pathophysiology of epididymitis is divided; Chlamydia trachomatis and Neisseria gonorrhoeae are the most common pathogens in patients younger than 35 years, whereas Enterobacteriaceae and gram-positive cocci are frequent pathogens in older patients. In either case, infection results from retrograde ascent of infected urine from the prostatic urethra into the vas deferens and, finally, into the epididymis.
Because of the widespread use of mumps vaccination, orchitis is no longer a common infection in the United States. Orchitis is one of the few genitourinary infections to result from a viral pathogen.
Mumps orchitis occurs in 18% of postpubertal boys infected with the mumps virus. Other viruses that can cause the disease include coxsackie B, mononucleosis, and varicella. Unlike the majority of genitourinary infections, viral particles are spread to the testicle by the hematogenous route. Granulomatous orchitis is rare and results from hematogenous dissemination of tuberculosis, fungi, and actinomycosis.
Pyelonephritis is an infection of the renal parenchyma. Infection usually occurs in a retrograde, ascending fashion from the bladder, but it may occur hematogenously. The ureteral orifice becomes edematous and loses its one-way valve function during infection. Retrograde flow of bacteria into the upper urinary tracts and into the renal parenchyma results in clinical symptoms.
Bacteremia, particularly with virulent organisms such as S aureus, can result in pyelonephritis with focal renal abscesses. Bacterial adherence allows for mucosal colonization and subsequent infection by an ascending route. Whereas type 1 pili are produced by most uropathogenic strains of E coli, P-pili, which bind to the uroepithelial glycosaminoglycan layer, are found in most strains of E coli that cause pyelonephritis. Genotypic factors may affect uroepithelial susceptibility to these adherence molecules. Endotoxin from gram-negative organisms can retard ureteral peristalsis.
E coli is responsible for approximately 25% of cases in males, with Proteus and Providencia causing many remaining infections; Klebsiella, Pseudomonas, Serratia, and enterococci are less frequent.
Bacterial cystitis without concomitant infection in other portions of the genitourinary tract is believed to be a rare event in males. The abrupt onset of irritative voiding symptoms (eg, frequency, urgency, nocturia, dysuria) and suprapubic pain are clinically diagnostic.
Most cases of bacterial cystitis occur by an ascending mechanism. Bacterial cystitis in the male is uncommon in the absence of anatomic abnormality, defect in bladder emptying mechanism, or urethral catheterization (eg, poor bladder emptying from prostatic obstruction or dysfunctional voiding). Elevated postvoid residuals allow bacteria to multiply to critical levels. High voiding pressures and poor bladder compliance diminish the natural uroepithelial resistance to infection.
Urethritis has been described for thousands of years. The term gonorrhea (gonus meaning seed, rhoia meaning flow) was coined by Galen. The urethral nonsquamous epithelium can be penetrated by N gonorrhoeae, resulting in periurethral microabscesses. Necrotic debris is sloughed into the urethra lumen, producing a milky penile discharge.
Gonococcal urethritis remains the most commonly reported communicable bacterial disease in the United States.
Urinary catheter–associated UTIs
Up to 25% of hospitalized patients have urinary catheters inserted; of these individuals, 10-27% develop UTIs. In fact, UTI accounts for approximately 40% of all nosocomial infections; 15% of these infections occur in clusters and often involve highly resistant organisms.
The single most important risk factor for nosocomial bacteriuria and UTI is the presence of an indwelling urethral catheter; 80% of nosocomial UTIs are associated with the use of urethral catheters. Once the urethral catheter is in place, the daily incidence of bacteriuria is 3-10%. Because most patients who become bacteriuric do so by 30 days, that is a convenient dividing line between short- and long-term catheterization.
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