The new French recommendations on the diagnosis and management of urinary tract infections (UTIs) in men, presented at the French Urology Congress in 2025, signal a major shift in routine clinical practice.

Developed under the auspices of the Société de Pathologie Infectieuse de Langue Française with support from the Association Française d’Urologie, these guidelines are expected to be published in early 2026.

Ahead of publication, Maxime Vallée, MD, PhD, a urologist at the Centre Hospitalier Universitaire de Poitiers in Poitiers, France, and head of the Infectious Diseases Committee of the Comité d’Infectiologie de l’Association Française d’Urologie, outlined the key messages from the forthcoming recommendations.

Key updates include phasing out urine dipstick testing in men; formal recognition of male cystitis treated with fosfomycin trometamol on days 1, 3, and 5; and clearly defined treatment durations of 7, 14, and up to 21 days for pyelonephritis, prostatitis, and undrained prostatic abscesses, respectively.

Diagnosis of Acute UTIs

Urgent bladder drainage is recommended in men presenting with acute urinary retention without clinical signs of UTI or sepsis of unidentified etiology. In this setting, urine culture should not be performed, and any associated urinary colonization should not be treated.

The recommendations also introduced a new diagnostic category: bacteriuria of indeterminate clinical significance. This term applies to individuals with documented bacteriuria accompanied by nonspecific systemic symptoms in the absence of clinical signs of cystitis. This is particularly common in men older than 75 years.

“Uncomplicated acute urinary retention does not justify a urine culture,” said Vallée.

In nonfebrile acute urinary retention, there is no indication to request urine cultures “just in case” fever develops or because of diagnostic uncertainty. In the absence of sepsis, clinical monitoring without antibiotic therapy is recommended.

Urine dipstick testing is no longer recommended as a diagnostic strategy for UTIs in men. Urine cultures should be obtained before initiating antibiotic therapy for any suspected male UTI.

Male cystitis is now formally recognized with symptoms similar to those observed in female cystitis. These include burning during urination, frequency, urgency, dysuria, nocturia, and lower abdominal pain. Macroscopic hematuria may also occur in some patients.

“The distinction from prostatitis relies on the absence of fever,” said Vallée. “This allows a diagnosis of cystitis, provided the urine culture is positive. This concept must now be integrated into practice. Male cystitis is frequently observed in men performing intermittent self-catheterization.”

Resistance Patterns

Epidemiologic data underlying the recommendations show that Escherichia coli remains the predominant pathogen, accounting for approximately 40% of the isolates identified in both community and hospital laboratories in community-acquired male UTIs.

Enterococcus faecalis ranked second, accounting for 13.2%-14.6% of isolates, followed by Klebsiella pneumoniae (6.2%-7.8%), Proteus mirabilis (4.6%-5.8%), and other clinically relevant Enterobacterales (14.7%-16.1%).

Extended-spectrum beta-lactamase-producing strains account for 2%-8.4% of E coli isolates and 11%-22.8% of K pneumoniae isolates. Among men older than 65 years living in nursing homes, resistance to third-generation cephalosporins is estimated to be 15%-18% for E coli and 32%-36% for K pneumoniae. Carbapenemase-producing strains remain rare, at approximately 0.1% for E coli and 0.3% for K pneumoniae.

“In community-acquired male UTIs, E coli shows 15%-20% resistance to fluoroquinolones, which represents a therapeutic challenge,” Vallée noted. “The proportion of extended-spectrum beta-lactamase-producing strains has not changed substantially in France and remains between 6% and 9% in symptomatic UTIs.”

Optimizing Antibiotic Therapy

The group recommends optimizing beta-lactam therapy using higher doses and continuous or prolonged infusion in individuals at a risk for underdose, including those with increased renal clearance, obesity, and sepsis. This approach is also relevant for infections caused by organisms with high minimum inhibitory concentrations, aiming to improve pharmacokinetic and pharmacodynamic target attainment in these patients.

Urologists should consider tissue penetration, dose selection, and route of administration. Beta-lactams, which have long been used to treat prostate infections, remain effective. However, in severe or complex clinical settings, optimization of dosing strategies is recommended, favoring continuous rather than intermittent administration when appropriate.

Treatment Strategy for Lower UTIs

Recommended empirical treatment options include fosfomycin trometamol, nitrofurantoin, and pivmecillinam. In individuals with mild, well-tolerated symptoms or when the diagnosis is uncertain, empiric antibiotic therapy may be deferred until urine culture results are available.

Once the infection is microbiologically confirmed, targeted treatment options include amoxicillin, fosfomycin trometamol, nitrofurantoin, pivmecillinam, and trimethoprim, which are listed alphabetically. The standard treatment duration is 7 days, except for fosfomycin trometamol, which is administered as three single doses on days 1, 3, and 5.

“Cystitis in men is generally managed in a manner similar to cystitis in women, with one key distinction related to tissue penetration,” said Vallée. “Therefore, the panel recommended three doses of fosfomycin trometamol on days 1, 3, and 5. This strategy is based on pharmacological rationale rather than clinical trial evidence.”

The available literature suggests that cystitis in men can be effectively treated within 7 days; however, fosfomycin trometamol has not been formally evaluated in randomized clinical trials for this indication.

Upper UTIs and Severe Infection

A new clinical risk score has been defined for men older than 65 years. The variables included body temperature > 38 °C, systolic arterial pressure < 110 mm Hg, heart rate > 100 beats/min, peripheral oxygen saturation < 95%, and recent impairment of higher cognitive functions. A score ≥ 3 indicates an increased risk for progression to sepsis and supports management in an intermediate care unit or ICU.

“This new six-variable clinical score does not replace qSOFA but allows better identification of individuals at risk for sepsis in elderly patients,” the panel noted. “A score ≥ 3 justifies management in an ICU.”

In the absence of disease severity, empirical antibiotic treatment depends on the treatment setting. Cefotaxime or ceftriaxone is recommended for hospitalized patients. In outpatient settings, ceftriaxone, ciprofloxacin, or levofloxacin may be used if fluoroquinolones have not been taken within the previous 6 months and oral absorption is not compromised by nausea, vomiting, malabsorption, or uncertain compliance.

Analysis: “There is no change in acute pyelonephritis; empirical treatment remains based on third-generation cephalosporins. Fluoroquinolones can be used on an outpatient basis only if the patient is not present with severe symptoms. In men, pyelonephritis is relatively rare and is often associated with abnormalities of the upper urinary tract. Outpatient management is probably not the right approach in this population.”

The antibiotic treatment for sepsis combines cefotaxime or ceftriaxone with a single dose of amikacin. In septic shock, if no risk factor for third-generation cephalosporin-resistant Enterobacterales is present, the same combination is used; otherwise, imipenem or meropenem is preferred, again with a single dose of amikacin.

When an oral switch is not feasible because the uropathogen is resistant or oral treatment is contraindicated, acute pyelonephritis and prostatitis should be managed according to susceptibility to third-generation cephalosporins. If Enterobacterales are susceptible, cefotaxime or ceftriaxone is recommended. When resistance occurs, treatment should be guided by underlying mechanisms. Cefepime and temocillin are appropriate for cases of cephalosporinase overproduction. In the presence of extended-spectrum beta-lactamase production, the preferred sequence is temocillin, cefoxitin (only for E coli or Proteus), piperacillin-tazobactam, followed by imipenem, meropenem, or ertapenem.

In acute pyelonephritis or acute prostatitis caused by E faecalis, treatment is based on amoxicillin. Specialist advice is required if resistance or contraindications are present. As the panel noted, “a new concept compared to previous recommendations concerns pyelonephritis and prostatitis secondary to Enterococcus faecalis infection. In this case, treatment with amoxicillin is possible and recommended and can be adapted to prostatic diffusion. The pharmacokinetic novelty probably lies in increasing the doses, for example, in patients with obesity.”

Treatment duration varies according to the type of infection and antibiotic used. Acute pyelonephritis requires 7 days of treatment when managed with parenteral beta-lactams, fluoroquinolones, or trimethoprim-sulfamethoxazole; 10 days when the oral regimen uses an agent other than fluoroquinolone or TMP-SMX; and 5 days when amikacin alone is administered. Acute prostatitis required 14 days of antibiotic treatment. In cases of prostatic abscesses, treatment lasts 14 days from the time of drainage when performed, recommended for abscesses ≥ 3 cm, and 21 days when drainage is not performed.

The panel noted that “publications show that treatment for pyelonephritis in women can be limited to 5 days of fluoroquinolone, with no less efficacy compared with 7 or 10 days. Data on men and other molecules are limited. This is probably why the group recommends a treatment of 7-10 days, depending on the molecules used. If fluoroquinolones or TMP-SMX are prescribed, a total treatment duration of 7 days is recommended. In acute prostatitis, the standard antibiotic treatment remains at 14 days.”

For epididymitis or orchitis, empirical antibiotic treatment depends on the history of resistance. In the absence of a history of infection or colonization with third-generation cephalosporin-resistant Enterobacterales within the previous 3 months, treatment consists of cefotaxime or ceftriaxone when initiated in a hospital setting and ceftriaxone, ciprofloxacin, or levofloxacin when initiated in an outpatient setting.

If there is a history of infection or colonization with third-generation cephalosporin-resistant Enterobacterales within the previous 3 months and susceptibility data are available, outpatient treatment may be administered with a fluoroquinolone, such as ciprofloxacin, levofloxacin, or ofloxacin, according to susceptibility. In hospital settings or in cases of fluoroquinolone resistance, treatment depends on the mechanism of resistance. Cefepime or temocillin is used in cases of cephalosporinase overproduction, whereas temocillin, piperacillin-tazobactam, cefoxitin (only for E coli or Proteus), or carbapenems — including imipenem, meropenem, or ertapenem — are used in cases of extended-spectrum beta-lactamase production.

Follow-up treatment guided by susceptibility testing favors oral TMP-SMX or fluoroquinolone. If these agents are contraindicated or ineffective, beta-lactams may be used in the following order: amoxicillin, amoxicillin-clavulanic acid, and cefixime. As the panel noted, “there is no major change compared to previous practices, but a precise duration of 10 days of antibiotic treatment has been defined, whereas it was not clearly indicated before.”

If the symptoms of acute prostatitis are resolved slowly or persist, evaluation for prostatic abscesses is recommended. Digital rectal examinations may identify abscesses in approximately one third of the cases. Prostate MRI is preferred, followed by contrast-enhanced CT or transrectal ultrasound, if MRI is not available. If prostatic abscess is confirmed, urine and blood cultures should be obtained.

In cases of large prostatic abscesses (> 2-3 cm), drainage or flattening, preferably using minimally invasive approaches, should be discussed to facilitate microbiological diagnosis and clinical resolution. As the panel discussed, “a diameter of 2-3 cm should prompt consideration of drainage regardless of the type chosen. However, the literature does not offer a clear cutoff. Generally, drainage should be considered for abscesses > 3 cm. No approach to abscess aspiration has been shown to be superior.

Options include transperineal, transrectal, or endoscopic approaches, as well as conventional resection, the latter of which carries a higher risk for postoperative sepsis exacerbation. The transurethral surgical approach remains a viable alternative, particularly in patients with multiple abscesses. In cases of Staphylococcus aureus prostatic abscess, it is recommended to investigate for an infectious focus other than the urinary tract, including endocarditis or spondylodiscitis.”

Referral to a urologist is recommended if red flags are identified by general practitioners or infectious disease specialists. These include the detection of a treatable underlying cause, such as early-stage benign prostatic hyperplasia managed with alpha-blockers, in which case follow-up may remain in primary care for several years, or the presence of aggravating factors.

These include acute pyelonephritis, macroscopic hematuria, International Prostate Symptom Score > 7, postvoid residual volume > 100 mL, initial acute urinary retention, induration on digital rectal examination, and urologic abnormalities on imaging. These situations warrant urologic consultation. In the absence of red flags, the occurrence of a second infectious episode is an indication for referral to a urologist.

The authors declared having no conflicts of interest.

This story was translated from Medscape’s French edition.