EAU GUIDELINES ON

UROLOGICAL INFECTIONS

(Limited text update March 2022)

G. Bonkat (Chair), R. Bartoletti, F. Bruyère, T. Cai, S.E. Geerlings,

B. Köves, S. Schubert, F. Wagenlehner
Guidelines Associates: W. Devlies, J. Horváth, G. Mantica,
T. Mezei, A. Pilatz, B. Pradere, R. Veeratterapillay
Guidelines Office: E.J. Smith

Introduction
The European Association of Urology (EAU) Urological
Infections Guidelines Panel has compiled these clinical
guidelines to provide medical professionals with evidence-
based information and recommendations for the prevention
and treatment of urological tract infections (UTIs). These
guidelines also aim to address the important public health
aspects of infection control and antimicrobial stewardship.

Important notice:
On March 11, 2019 the European Commission implemented
stringent regulatory conditions regarding the use of
fluoroquinolones due to their disabling and potentially long-
lasting side effects. This legally binding decision is applicable
in all EU countries. National authorities have been urged to
enforce this ruling and to take all appropriate measures to
promote the correct use of this class of antibiotics.

Antimicrobial Stewardship
Stewardship programs have two main sets of actions. The
first set mandates use of recommended care at the patient
level conforming to guidelines. The second set describes

Urological Infections 295

 strategies to achieve adherence to the mandated guidance.
These include persuasive actions such as education and
feedback together with restricting availability linked to local
formularies. The important components of antimicrobial
stewardship programs are:
• regular training of staff in best use of antimicrobial agents;
• adherence to local, national or international guidelines;
• regular ward visits and consultation with infectious
diseases physicians and clinical microbiologists;
• audit of adherence and treatment outcomes;
• regular monitoring and feedback to prescribers of their
performance and local pathogen resistance profiles.

Asymptomatic Bacteriuria
Asymptomatic bacteriuria in an individual without urinary
tract symptoms is defined by a mid-stream sample of urine
showing bacterial growth ≥ 105 cfu/mL in two consecutive
samples in women and in one single sample in men.

Recommendations Strength rating

Do not screen or treat asymptomatic Strong
bacteriuria in the following conditions:
• women without risk factors;
• patients with well-regulated diabetes
mellitus;
• post-menopausal women;
• elderly institutionalised patients;
• patients with dysfunctional and/or
reconstructed lower urinary tracts;
• patients with renal transplants;
• patients prior to arthoplasty surgeries;
• patients with recurrent urinary tract
infections.

296 Urological Infections

Screen for and treat asymptomatic Strong
bacteriuria prior to urological procedures
breaching the mucosa.
Screen for and treat asymptomatic Weak
bacteriuria in pregnant women with
standard short course treatment.

Uncomplicated Cystitis
Uncomplicated cystitis is defined as acute, sporadic or
recurrent cystitis limited to non-pregnant women with no
known relevant anatomical and functional abnormalities
within the urinary tract or comorbidities.

Recommendations for the diagnostic Strength rating

evaluation of uncomplicated cystitis
Diagnose uncomplicated cystitis in women Strong
who have no other risk factors for com-
plicated urinary tract infections based on:
• a focused history of lower urinary tract
symptoms (dysuria, frequency and
urgency);
• the absence of vaginal discharge or
irritation.
Use urine dipstick testing for diagnosis of Weak
acute uncomplicated cystitis.
Urine cultures should be done in the Strong
following situations:
• suspected acute pyelonephritis;
• symptoms that do not resolve or recur
within four weeks after the completion
of treatment;
• women who present with atypical
symptoms;
• pregnant women.

Urological Infections 297

 In uncomplicated cystitis a fluoroquinolone should only be
used when it is considered inappropriate to use other
antibacterial agents that are commonly recommended for the
treatment of these infections.

Recommendations for antimicrobial Strength rating

therapy for uncomplicated cystitis
Prescribe fosfomycin trometamol, Strong
pivmecillinam or nitrofurantoin as first-line
treatment for uncomplicated cystitis in
women.
Do not use aminopenicillins or Strong
fluoroquinolones to treat uncomplicated
cystitis.

Table 1: Suggested regimens for antimicrobial therapy in

uncomplicated cystitis
Antimicrobial Daily dose Duration Comments
of
therapy
First-line women
Fosfomycin 3 g SD 1 day Recommended
trometamol only in women with
Nitrofurantoin 50-100 mg 5 days uncomplicated
macrocrystal four times cystitis
a day
Nitrofurantoin 100 mg b.i.d 5 days
monohydrate/
macrocrystals
Nitrofurantoin 100 mg b.i.d 5 days
macrocrystal
prolonged release
Pivmecillinam 400 mg t.i.d 3-5 days

298 Urological Infections

 Alternatives
Cephalosporins 500 mg b.i.d 3 days Or comparable
(e.g. cefadroxil)
If the local resistance pattern for E. coli is < 20%
Trimethoprim 200 mg b.i.d 5 days Not in the first
trimenon of
pregnancy
Trimethoprim- 160/800 mg 3 days Not in the last
sulphamethoxazole b.i.d trimenon of
pregnancy
Treatment in men
Trimethoprim- 160/800 mg 7 days Restricted to men,
sulphamethoxazole b.i.d fluoroquinolones
can also be
prescribed in
accordance with
local susceptibility
testing.
SD = single dose; b.i.d = twice daily; t.i.d = three times daily.

Recurrent UTIs
Recurrent UTIs are recurrences of uncomplicated and/or
complicated UTIs, with a frequency of at least three UTIs/year
or two UTIs in the last six months.

Recommendations for the diagnostic Strength rating

evaluation and treatment of recurrent UTIs
Diagnose recurrent UTI by urine culture. Strong
Do not perform an extensive routine Weak
workup (e.g cystoscopy, full abdominal
ultrasound) in women younger than 40 years
of age with recurrent UTI and no risk factors.
Advise pre-menopausal women regarding Weak
increased fluid intake as it might reduce
the risk of recurrent UTI.

Urological Infections 299

 Use vaginal oestrogen replacement in post- Strong
menopausal women to prevent recurrent
UTI.
Use immunoactive prophylaxis to reduce Strong
recurrent UTI in all age groups.
Advise patients on the use of local or oral Weak
probiotics containing strains of proven
efficacy for vaginal flora regeneration to
prevent UTIs.
Advise patients on the use of cranberry Weak
products to reduce recurrent UTI episodes;
however, patients should be informed that
the quality of evidence underpinning this is
low with contradictory findings.
Use D-mannose to reduce recurrent UTI Weak
episodes, but patients should be informed
that further studies are needed to confirm
the results of initial trials.
Use endovesical instillations of hyaluronic Weak
acid or a combination of hyaluronic acid
and chondroitin sulphate to prevent
recurrent UTIs in patients where less
invasive preventive approaches have been
unsuccessful. Patients should be informed
that further studies are needed to confirm
the results of initial trials.
Use continuous or post-coital antimicrobial Strong
prophylaxis to prevent recurrent UTI when
non-antimicrobial interventions have failed.
Counsel patients regarding possible side
effects.
For patients with good compliance self- Strong
administered short-term antimicrobial
therapy should be considered.

300 Urological Infections

Uncomplicated Pyelonephritis
Uncomplicated pyelonephritis is defined as pyelonephritis
limited to non-pregnant, pre-menopausal women with no
known relevant urological abnormalities or comorbidities.

Recommendations for the diagnostic Strength rating

evaluation of uncomplicated
pyelonephritis
Perform urinalysis (e.g. using a dipstick Strong
method), including the assessment of
white and red blood cells and nitrite, for
routine diagnosis.
Perform urine culture and antimicrobial Strong
susceptibility testing in patients with
pyelonephritis.
Perform imaging of the urinary tract to Strong
exclude urgent urological disorders.

Recommendations for the treatment of Strength rating

uncomplicated pyelonephritis
Treat patients with uncomplicated Strong
pyelonephritis not requiring hospitalisation
with short course fluoroquinolones as
first-line treatment.
Treat patients with uncomplicated Strong
pyelonephritis requiring hospitalisation
with an intravenous antimicrobial regimen
initially.
Switch patients initially treated with Strong
parenteral therapy, who improve clinically
and can tolerate oral fluids, to oral
antimicrobial therapy.

Urological Infections 301

 Do not use nitrofurantoin, oral fosfomycin, Strong
and pivmecillinam to treat uncomplicated
pyelonephritis.

Table 2: Suggested regimens for empirical oral antimicrobial

therapy in uncomplicated pyelonephritis
Antimicrobial Daily dose Duration Comments
of
therapy
Ciprofloxacin 500-750 mg 7 days Fluoroquinolone
b.i.d resistance should
Levofloxacin 750 mg q.d 5 days be less than 10%.
Trimethoprim 160/800 mg 14 days If such agents are
sulphamethoxazol b.i.d used empirically, an
Cefpodoxime 200 mg b.i.d 10 days initial intravenous
dose of a long-
Ceftibuten 400 mg q.d 10 days
acting parenteral
antimicrobial (e.g.
ceftriaxone) should
be administered.
b.i.d = twice daily; q.d = every day.

Table 3: Suggested regimens for empirical parenteral

antimicrobial therapy in uncomplicated pyelonephritis
Antimicrobials Daily dose Comments
First-line treatment
Ciprofloxacin 400 mg b.i.d
Levofloxacin 750 mg q.d
Cefotaxime 2 g t.i.d Not studied as monotherapy
in acute uncomplicated
pyelonephritis.
Ceftriaxone 1-2 g q.d Lower dose studied, but
higher dose recommended.

302 Urological Infections

 Second-line treatment
Cefepime 1-2 g b.i.d Lower dose studied, but
Piperacillin/ 2.5-4.5 g t.i.d higher dose recommended.
tazobactam
Gentamicin 5 mg/kg q.d Not studied as monotherapy
Amikacin 15 mg/kg q.d in acute uncomplicated
pyelonephritis.
Last-line alternatives
Imipenem/ 0.5 g t.i.d Consider only in patients
cilastatin with early culture results
Meropenem 1 g t.i.d indicating the presence of
multidrug-resistant
Ceftolozane/ 1.5 g t.i.d
organisms.
tazobactam
Ceftazidime/ 2.5 g t.i.d
avibactam
Cefiderocol 2 g t.i.d
Meropenem- 2 g t.i.d
vaborbactam
Plazomicin 15 mg/kg o.d
b.i.d = twice daily; t.i.d = three times daily; q.d = every day; o.d = once
daily.

Complicated UTIs
A complicated UTI occurs in an individual in whom
factors related to the host (e.g. underlying diabetes or
immunosuppression) or specific anatomical or functional
abnormalities related to the urinary tract (e.g. obstruction,
incomplete voiding due to detrusor muscle dysfunction) are
believed to result in an infection that will be more difficult to
eradicate than an uncomplicated infection.

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 Recommendations for the treatment of Strength rating
complicated UTIs
Use the combination of: Strong
• amoxicillin plus an aminoglycoside;
• a second generation cephalosporin plus
an aminoglycoside;
• a third generation cephalosporin
intravenously as empirical treatment
of complicated UTI with systemic
symptoms.
Only use ciprofloxacin provided that the Strong
local resistance percentages are < 10%
when:
• the entire treatment is given orally;
• patients do not require hospitalisation;
• patient has an anaphylaxis for
beta-lactam antimicrobials.
Do not use ciprofloxacin and other Strong
fluoroquinolones for the empirical
treatment of complicated UTI in patients
from urology departments or when patients
have used fluoroquinolones in the last six
months.
Manage any urological abnormality and/or Strong
underlying complicating factors.

Catheter-associated UTIs
Catheter-associated UTI (CA-UTI) refers to UTIs occurring in
a person whose urinary tract is currently catheterised or has
been catheterised within the past 48 hours.

304 Urological Infections

Recommendations for diagnostic Strength rating
evaluation of CA-UTI
Do not carry out routine urine culture in Strong
asymptomatic catheterised patients.
Do not use pyuria as sole indicator for Strong
catheter-associated UTI.
Do not use the presence or absence of Strong
odorous or cloudy urine alone to
differentiate catheter-associated
asymptomatic bacteriuria from catheter-
associated UTI.

Recommendations disease management Strength rating

and prevention of CA-UTI
Treat symptomatic catheter-associated- Strong
UTI according to the recommendations for
complicated UTI.
Take a urine culture prior to initiating Strong
antimicrobial therapy in catheterised
patients in whom the catheter has been
removed.
Do not treat catheter-associated Strong
asymptomatic bacteriuria in general.
Treat catheter-associated asymptomatic Strong
bacteriuria prior to traumatic urinary tract
interventions (e.g. transurethral resection
of the prostate).
Replace or remove the indwelling catheter Strong
before starting antimicrobial therapy.
Do not apply topical antiseptics or Strong
antimicrobials to the catheter, urethra or
meatus.

Urological Infections 305

 Do not use prophylactic antimicrobials to Strong
prevent catheter-associated UTIs.
Do not routinely use antibiotic prophylaxis Weak
to prevent clinical UTI after urethral
catheter removal.
The duration of catheterisation should be Strong
minimal.
Use hydrophilic coated catheters to reduce Strong
CA-UTI.
Do not routinely use antibiotic Weak
prophylaxis to prevent clinical UTI after
urethral catheter removal or in patients
performing intermittent self-catheterisation

Urosepsis
Urosepsis is defined as life threatening organ dysfunction
caused by a dysregulated host response to infection
originating from the urinary tract and/or male genital organs.

Recommendations for the diagnosis and Strength rating

treatment of urosepsis
Perform the quickSOFA score to identify Strong
patients with potential sepsis.
Take a urine culture and two sets of blood Strong
cultures before starting antimicrobial
treatment.
Administer parenteral high dose broad Strong
spectrum antimicrobials within the first
hour after clinical assumption of sepsis.
Adapt initial empiric antimicrobial therapy Strong
on the basis of culture results.

306 Urological Infections

 Initiate source control including removal Strong
of foreign bodies, decompression of
obstruction and drainage of abscesses in
the urinary tract.
Provide immediate adequate life-support Strong
measures.

Table 4: Suggested regimens for antimicrobial therapy for

urosepsis
Antimicrobials Daily dose Duration of therapy
Cefotaxime 2 g t.i.d 7-10 days
Ceftazidime 1-2 g t.i.d Longer courses are
appropriate in patients
Ceftriaxone 1-2 g q.d
who have a slow clinical
Cefepime 2 g b.i.d response
Piperacillin/tazobactam 4.5 g t.i.d
Ceftolozane/tazobactam 1.5 g t.i.d
Ceftazidime/avibactam 2.5 g t.i.d
Gentamicin* 5 mg/kg q.d
Amikacin* 15 mg/kg q.d
Ertapenem 1 g q.d
Imipenem/cilastatin 0.5 g t.i.d
Meropenem 1 g t.i.d
* Not studied as monotherapy in urosepsis
b.i.d = twice daily; t.i.d = three times daily; q.d = every day.

Urethritis
Inflammation of the urethra presents usually with lower
urinary tract symptoms and must be distinguished from
other infections of the lower urinary tract. From a therapeutic
and clinical point of view, gonorrhoeal urethritis caused by
Neisseria gonorrhoeae must be differentiated from non-
gonococcal urethritis.

Urological Infections 307

 Recommendations for the diagnostic Strength rating
evaluation and antimicrobial treatment of
urethritis
Perform a Gram stain of urethral discharge Strong
or a urethral smear to preliminarily
diagnose gonococcal urethritis.
Perform a validated nucleic acid Strong
amplification test (NAAT) on a first-void
urine sample or urethral smear prior to
empirical treatment to diagnose chlamydial
and gonococcal infections.
Delay treatment until the results of the Strong
NAATs are available to guide treatment
choice in patients with mild symptoms.
Perform a urethral swab culture, prior to Strong
initiation of treatment, in patients with a
positive NAAT for gonorrhoea to assess the
antimicrobial resistance profile of the
infective strain.
Use a pathogen directed treatment based Strong
on local resistance data.
Sexual partners should be treated Strong
maintaining patient confidentiality.

308 Urological Infections

Table 5: Suggested regimens for antimicrobial therapy for
urethritis
Pathogen Antimicrobial Alternative regimens
Gonococcal Ceftriaxone: • Cefixime 400 mg p.o.,
Infection 1 g i.m. or i.v.*, SD plus Azithromycin
SD 1 g p.o., SD
Azithromycin:
1-1 g p.o., SD In case of cephalosporin
allergy:
• Gentamicin 240 mg i.m
SD plus Azithromycin
2 g p.o., SD
• Gemifloxacin 320 mg
p.o., SD plus Azithromycin
2 g p.o., SD
• Spectinomycin 2 g i.m., SD
• Fosfomycin trometamol
3 g p.o., on days 1, 3 and 5

In case of azithromycin
allergy, in combination with
ceftriaxone or cefixime:
• Doxycycline 100 mg b.i.d,
p.o., 7 days
Non- Doxycycline: Azithromycin
Gonococcal 100 mg b.i.d, 500 mg p.o., day 1,
infection p.o., 7 days 250 mg p.o., 4 days
(non-
identified
pathogen)
Chlamydia Azithromycin: • Levofloxacin 500 mg p.o.,
trachomatis 1.0-1.5 g p.o., SD q.d., 7 days
OR • Ofloxacin 200 mg p.o.,
Doxycycline: b.i.d., 7 days
100 mg b.i.d,
p.o., for 7 days
Urological Infections 309
 Mycoplasma Azithromycin: In case of macrolide
genitalium 500 mg p.o., resistance:
day 1, 250 mg • Moxifloxacin 400 mg q.d.,
p.o., 4 days 7-14 days
Ureaplasma Doxycycline: Azithromycin 1.0-1.5 g p.o.,
urealyticum 100 mg b.i.d, SD
p.o., 7 days
Trichomonas Metronidazole: Metronidazole 500 mg p.o.,
vaginalis 2 g p.o., SD b.i.d., 7 days
Tinidazole: 2 g
p.o., SD
Persistent non-gonococcal urethritis
After first- Azithromycin: If macrolide resistant
line 500 mg p.o., M. genitalium is detected
doxycycline day 1, 250 mg moxifloxacin should be
p.o., 4 days substituted for
plus azithromycin
Metronidazole:
400 mg b.i.d.
p.o., 5 days
After first- Moxifloxacin:
line 400 mg p.o.
azithromycin q.d., 7–14 days
plus
Metronidazole:
400 mg b.i.d.
p.o., 5 days
SD = single dose; b.i.d = twice daily; q.d = everyday; p.o. = orally;
i.m. = intramuscular; i.v. = intravenous.
* Despite the lack of RCTs there is increasing evidence that
intravenous treatment with ceftriaxone is safe and effective for the
treatment of gonorrhoeal infections and avoids the discomfort of an
intramuscular injection for patients.

310 Urological Infections

Bacterial Prostatitis
Bacterial prostatitis is a clinical condition caused by bacterial
pathogens. It is recommended that urologists use the
classification suggested by the National Institute of Diabetes,
Digestive and Kidney Diseases of the National Institutes
of Health, in which bacterial prostatitis, with confirmed or
suspected infection, is distinguished from chronic pelvic pain
syndrome.

Recommendations for the diagnosis of Strength rating

bacterial prostatitis
Do not perform prostatic massage in acute Strong
bacterial prostatitis (ABP).
Take a mid-stream urine dipstick to check Weak
nitrite and leukocytes in patients with
clinical suspicion of ABP.
Take a mid-stream urine culture in patients Weak
with ABP symptoms to guide diagnosis and
tailor antibiotic treatment.
Take a blood culture and a total blood Weak
count in patients presenting with ABP.
Perform accurate microbiological Weak
evaluation for atypical pathogens such as
Chlamydia trachomatis or Mycoplasmata
in patients with chronic bacterial prostatitis
(CBP).
Perform the Meares and Stamey 2- or Strong
4-glass test in patients with CBP.
Perform transrectal ultrasound in selected Weak
cases to rule out the presence of prostatic
abscess.
Do not routinely perform microbiological Weak
analysis of the ejaculate alone to diagnose
CBP.

Urological Infections 311

 Recommendations for the disease Strength rating
management of bacterial prostatitis
Acute bacterial prostatitis
Treat acute bacterial prostatitis according Strong
to the recommendations for complicated
UTI.
Chronic bacterial prostatitis (CBP)
Prescribe a fluoroquinolone (e.g. Strong
ciprofloxacin, levofloxacin) as first-line
treatment for CBP.
Prescribe a macrolide (e.g. azithromycin) Strong
or a tetracycline (e.g. doxycycline) if
intracellular bacteria have been identified
as the causative agent of CBP.
Prescribe metronidazole in patients with Strong
Trichomonas vaginalis CBP.

Table 6: Suggested regimens for antimicrobial therapy for chronic

bacterial prostatitis
Antimicrobial Daily dose Duration Comments
of
therapy
Floroquinolone Optimal 4-6
oral daily weeks
dose
Doxycycline 100 mg b.i.d 10 days Only for
C. trachomatis or
mycoplasma
infections
Azithromycin 500 mg 3 weeks Only for
once daily C. trachomatis
infections
Metronidazole 500 mg t.i.d. 14 days Only for T. vaginalis
infections
b.i.d = twice daily; t.i.d = three times daily.

312 Urological Infections

Acute Infective Epididymitis
Acute epididymitis is clinically characterised by pain,
swelling and increased temperature of the epididymis, which
may involve the testis and scrotal skin. It is generally caused
by migration of pathogens from the urethra or bladder.
Torsion of the spermatic cord (testicular torsion) is the most
important differential diagnosis in boys and young men.

Recommendations for the diagnosis and Strength rating

treatment of acute infective epididymitis
Obtain a mid-stream urine and a first-voided Strong
urine sample for pathogen identification by
culture and nucleic acid amplification test.
Initially prescribe a single antibiotic or Strong
a combination of two antibiotics active
against Chlamydia trachomatis and
Enterobacterales in young sexually active
men; in older men without sexual risk
factors only Enterobacterales have to be
considered.
If gonorrhoeal infection is likely give single Strong
dose ceftriaxone 500 mg intramuscularly
or intravenously* in addition to a course
of an antibiotic active against Chlamydia
trachomatis.
Adjust antibiotic agent when pathogen has Weak
been identified and adjust duration
according to clinical response.
Follow national policies on reporting and Strong
tracing/treatment of contacts for sexually
transmitted infections.
* Despite the lack of RCTs there is increasing evidence that
intravenous treatment with ceftriaxone is safe and effective for the
treatment of gonorrhoeal infections and avoids the discomfort of an
intramuscular injection for patients.

Urological Infections 313

 Fournier’s Gangrene
Fournier’s gangrene is an aggressive and frequently fatal
polymicrobial soft tissue infection of the perineum, peri-anal
region, and external genitalia. It is an anatomical sub-category
of necrotising fasciitis with which it shares a common
aetiology and management pathway.

Recommendations for the disease Strength rating

management of Fournier’s Gangrene
Start treatment for Fournier’s gangrene Strong
with broad-spectrum antibiotics on
presentation, with subsequent refinement
according to culture and clinical response.
Commence repeated surgical debridement Strong
for Fournier’s gangrene within 24 hours of
presentation.
Do not use adjunctive treatments for Weak
Fournier’s gangrene except in the context
of clinical trials.

Table 7: Suggested regimens for antimicrobial therapy for

Fournier’s Gangrene of mixed microbiological aetiology
Antimicrobial Dosage
Piperacillin-tazobactam plus 4.5 g every 6-8 h IV
Vancomycin 15 mg/kg every 12 h
Imipenem-cilastatin 1 g every 6-8 h IV
Meropenem 1 g every 8 h IV
Ertapenem 1 g once daily
Gentamicin 5 mg/kg daily
Cefotaxime plus 2 g every 6 h IV
metronidazole or 500 mg every 6 h IV
clindamycin 600-900 mg every 8 h IV

314 Urological Infections

 Cefotaxime plus 2 g every 6 h IV
fosfomycine plus 5 g every 8 h IV
metronidazole 500 mg every 6 h IV
IV = intravenous.

Management of Human papilloma virus in men

Human papilloma virus (HPV) is one of the most frequently
sexually transmitted viruses encompassing both oncogenic
(low- and high-risk variants) and non-oncogenic viruses.

Recommendations for the treatment of Strength rating

anogenital warts
Use self-administered imiquimd 5% cream Strong
applied to all external warts overnight three
times each week for sixteen weeks for the
treatment of anogenital warts.
Use self-administered sinecatechins 15% or 10% Strong
applied to all external warts three times daily
until complete clearance, or for up to sixteen
weeks for the treatment of anogenital warts.
Use self-administered podophyllotoxin 0.5% Strong
self-applied to lesions twice daily for three days,
followed by four rest days, for up to four or five
weeks for the treatment of anogenital warts.
Use cryotherapy or surgical treatment Strong
(excision, electrosurgery, electrocautery and
laser therapy) to treat anogenital warts based
on an informed discussion with the patient.
Recommendation male circumcision
Discuss male circumcision with patients as an Strong
additional one-time preventative intervention
for HPV-related diseases.
Recommendation therapeutic HPV vaccination
Offer HPV vaccine to males after surgical removal Weak
of high-grade anal intraepithelial neoplasia.

Urological Infections 315

 Recommendations prophylactic HPV vaccination
Offer early HPV vaccination to boys with the Strong
goal of establishing optimal vaccine-induced
protection before the onset of sexual activity.
Apply diverse communication strategies in Strong
order to improve HPV vaccination knowledge in
young adult males.

Figure 1: Diagnostic and treatment algorithm for the

management of HPV in men

Diagnosis Treatment of HPV lesion

Physical examination to • Patient-applied treatments - imiquimod 5%;
identify HPV lesion: sinecatechins 15% and 10%; and
• use a good light source podophyllotoxin 0.5%
Positive
• magnification with a lens • Physician-administered treatment -
may be useful cryotherapy and surgical treatment including
• inspect the urethral excision, electrosurgery, electrocautery and
meatus laser therapy

Physical diagnosis
uncertain
Switch • Follow-up visit
treatment when
• Acetic acid test to treatment
diagnose sub-clinical complete;
HPV lesions • and again at
• Biopsy if there is 6 months.
diagnostic Persistent/
Recurrence
uncertainty or Relapse
suspicion of pre-
cancer or cancer Persistent
• Consider a infection,
dermatological relapse or
consultation Yes recurrence

Negative No

Discuss:
• HPV natural history, onward transmission and the partial protection of condoms against HPV
• Self-surveillance for new lesions
• The role of HPV vaccine in motivated patients

316 Urological Infections

Peri-Procedural Antibiotic Prophylaxis
The available evidence enabled the panel to make
recommendations concerning urodynamics, cystoscopy,
stone procedures (extracorporeal shockwave lithotripsy,
ureteroscopy and per-cutaneous neprolithotomy),
transurethral resection of the prostate, transurethral resection
of the bladder and prostate biopsy. For nephrectomy and
prostatectomy the scientific evidence was too weak to allow
the panel to make recommendations either for or against
antibiotic prophylaxis.

Recommendations for peri-procedural Strength rating

antibiotic prophylaxis
Do not use antibiotic prophylaxis to reduce the Strong
rate of symptomatic urinary infection following:
• urodynamics;
• cystoscopy;
• extracorporeal shockwave lithotripsy.
Use antibiotic prophylaxis to reduce the rate Weak
of symptomatic urinary infection following
ureteroscopy.
Use single dose antibiotic prophylaxis to reduce Strong
the rate of clinical urinary infection following
percutaneous nephrolithotomy.
Use antibiotic prophylaxis to reduce infectious Strong
complications in men undergoing transurethral
resection of the prostate.
Use antibiotic prophylaxis to reduce infectious Weak
complications in high-risk patients undergoing
transurethral resection of the bladder.
Perform prostate biopsy using the transperineal Strong
approach due to the lower risk of infectious
complications.
Use routine surgical disinfection of the perineal Strong
skin for transperineal biopsy.
Use rectal cleansing with povidone-iodine in Strong
men prior to transrectal prostate biopsy.

Urological Infections 317

 Do not use fluoroquinolones for prostate biopsy Strong
in line with the European Commission final
decision on EMEA/H/A-31/1452.
Use either target prophylaxis based on rectal Weak
swab or stool culture; augmented prophylaxis
(two or more different classes of antibiotics);
or alternative antibiotics (e.g. fosfomycin
trometamol, cephalosporin, aminoglycoside) for
antibiotic prophylaxis for transrectal biopsy.

Note: As stated in section 3.15.1.4 of the full text guideline the

panel have decided not to make recommendations for specific
agents for particular procedures, those listed below represent
possible choices only. Urologists should choose a specific
antimicrobial based on their knowledge of local pathogen
prevalence for each type of procedure, their antibiotic
susceptibility profiles and virulence.

Table 8: Suggested regimens for antimicrobial prophylaxis prior to

urological procedures
Procedure Prophylaxis Antimicrobial
recommended
Urodynamics No N/A
Cystoscopy No
Extracorporeal No
shockwave
lithotripsy
Ureteroscopy Yes Trimethoprim
Percutaneous Yes (single dose) Trimethoprim-
nephrolithotomy sulphamethoxazole
Cephalosporin group
Transurethral Yes
2 or 3
resection of the
Aminopenicillin plus
prostate
a beta-lactamase
Transurethral Yes in patients who inhibitor
resection of the have a high risk
bladder of suffering post-
operative sepsis.
318 Urological Infections
 Transrectal prostate Yes 1. Targeted
biopsy prophylaxis - based
on rectal swab or
stool culture.
2. Augmented
prophylaxis - two or
more different
classes of
antibiotics*.
3. Alternative
antibiotics
• fosfomycin
trometamol
(e.g. 3 g before and
3 g 24-48 hrs after
biopsy)
• cephalosporin (e.g.
ceftriaxone 1 g i.m.;
cefixime 400 mg
p.o. for 3 days
starting 24 hrs
before biopsy)
• aminoglycoside
(e.g. gentamicin
3mg/kg i.v.;
amikacin
15mg/kg i.m.)
* Note option 2 is against antibiotic stewardship programmes.
i.m. = intramuscular; i.v. intravenously; p.o. = orally.

Urological Infections 319

 Figure 2: Prostate biopsy workflow to reduce infectious
complications

Indicaon for prostate biopsy?

Transperineal biopsy feasible?

Yes No

Transperineal biopsy - 1st choice ( ) Transrectal biopsy – 2nd choice ( )

with: with:
• perineal cleansing1 • povidone-iodine rectal preparaon
• anbioc prophylaxis1 • anbioc prophylaxis2

Fluoroquinolones licensed?3

No Yes

1. Targeted prophylaxis1,7: based on rectal Duraon of anbioc prophylaxis ≥24 hrs

swab or stool cultures ( )

2. Augmented prophylaxis1,2,4: two

or 1. Targeted prophylaxis6,7 ( ):
more different classes of anbiocs based on rectal swab or stool cultures
3. Alternave anbiocs5 ( ): 2. Augmented prophylaxis 2,4,6,8 ( ):
• fosfomycin trometamol (e.g. 3 g before • Fluoroquinolone plus aminoglycoside
and 3 g 24-48 hrs aŒer biopsy) • Fluoroquinolone plus cephalosporin
• cephalosporin (e.g. ceŒriaxone 1 g i.m.;
cefixime 400 mg p.o. for 3 days starng 3. Fluoroquinolone prophylaxis 5
24 hrs before biopsy) ( ; )
• aminoglycoside (e.g. gentamicin 3mg/kg
i.v.; amikacin 15mg/kg i.m.)

1. No RCTs available, but reasonable intervention.

2. Be informed about local antimicrobial resistance.
3. Banned by European Commission due to side effects.
4. Contradicts principles of Antimicrobial Stewardship.
5. Fosfomycin trometamol (3 RCTs), cephalosporins (2 RCTs),
aminoglycosides (2 RCTs).
6. Only one RCT comparing targeted and augmented prophylaxis.
7. Originally introduced to use alternative antibiotics in case of
fluoroquinolone resistance.
8. Various schemes: fluoroquinolone plus aminoglycoside (3 RCTs);
and fluoroquinolone plus cephalosporin (1 RCT).
9. Significantly inferior to targeted and augmented prophylaxis.

320 Urological Infections

Suggested workflow on how to reduce post biopsy infections. GRADE
Working Group grades of evidence. High certainty: (⊕⊕⊕⊕) very
confident that the true effect lies close to that of the estimate of
the effect. Moderate certainty: (⊕⊕⊕) moderately confident in the
effect estimate: the true effect is likely to be close to the estimate of
the effect, but there is a possibility that it is substantially different.
Low certainty: (⊕⊕) confidence in the effect estimate is limited:
the true effect may be substantially different from the estimate of
the effect. Very low certainty: (⊕) very little confidence in the
effect estimate: the true effect is likely to be substantially different
from the estimate of effect. Figure reproduced from Pilatz et al., with
permission from Elsevier.
i.m. = intramuscular; i.v. intravenously; p.o. = orally.

This short booklet text is based on the more comprehensive

EAU Guidelines (ISBN 978-94-92671-16-5) available to all members
of the European Association of Urology at their website,
http://www.uroweb.org/guidelines.

Urological Infections 321