A large percentage of urologic referrals are to evaluate patients with severe or recurrent urinary tract infections (UTIs) or prostatitis syndrome. Although many of the patients with severe infections have underlying anatomic, metabolic, or functional abnormalities, most of those with recurrent UTIs or prostatitis syndrome do not have such abnormalities. The challenge is to identify those patients most likely to harbor abnormalities, evaluate them with appropriate tests, and then implement appropriate medical or surgical management strategies. The decision to evaluate radiologically, endoscopically, urodynamically, or otherwise must be based on the patient's clinical presentation, history, findings, response to antimicrobial therapy, and/or pattern of recurrent UTIs. A presentation or history of severe UTI warrants evaluation: sepsis, fever, history of UTI more than 7 days, gross hematuria, symptoms or signs of obstruction, or history of stones. Concurrent risk factors also trigger evaluation: pregnancy, diabetes, immunosuppression, or other debilitating disease. Male gender is frequently associated with underlying abnormalities, so most men, particularly those over 60 years old, should be evaluated.

In addition, the response to therapy and pattern of recurrent infection can be used to determine whether or not to initiate evaluation. Stamey<sup>30 Stamey T.A. A clinical classification of urinary tract infections based upon origin [editorial] South Med J 1975 ;  68 : 934  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> separated patients with unresolved infections from those whose infections recurred after successful antimicrobial therapy. Unresolved infection requires microbiologic documentation of an infection while the patient is receiving antimicrobial therapy. Based on sensitivity testing, antimicrobial therapy should be modified or in some instances, an evaluation of the urinary tract should be initiated. If a patient has a history of recurrent infection but no culture documentation, cultures can be obtained in the office to verify the absence of infection and then self-start therapy initiated so the patient can conveniently and inexpensively determine if infection is the cause of the urinary tract symptoms. The patient is given a dip-slide culture and a 3-day supply of antimicrobials with instructions to culture their urine and start antimicrobial therapy with the onset of symptoms. Subsequent cultures are used to characterize the pattern of recurrent infection: document the infection, identify the pathogen, and determine the frequency of infection. If the same pathogen is documented repeatedly and at close intervals, we suspect an underlying abnormality and initiate urologic evaluation. Otherwise, we presume the infections are not associated with functional, metabolic, or anatomic abnormalities of the urinary tract (uncomplicated). For women, medical management, such as low-dose prophylaxis, is used. Reinfections in men are uncommon; therefore, a urologic evaluation is usually indicated.

Men with prostatitis syndromes compose a common and difficult challenge. Most have no history of UTIs; therefore, self-start therapy is initiated. If recurrent UTIs with the same strain are present, the probability of bacterial prostatitis is high, and the patient is evaluated by localization cultures of prostatic fluid, which are, if positive, treated with antimicrobials. If the prostatic fluid cultures are repeatedly negative, then another cause of bacterial persistence should be sought. If the urine cultures are repeatedly negative, then other noninfectious causes for the symptoms should be pursued.