Aetiology of acute epididymitis

European Association of Urology Guidelines on Urological Infections: Summary of the 2024 Guidelines

BACKGROUND AND OBJECTIVE

Urological infections significantly impact the wellbeing and quality of life of individuals owing to their widespread occurrence and diverse clinical manifestations. The objective of the guidelines panel was to provide evidence-based guidance on the diagnosis, treatment, and prevention of urinary tract infections (UTIs) and male accessory-gland infections, while addressing crucial public health aspects related to infection control and antimicrobial stewardship.

METHODS

For the 2024 guidelines on urological infections, new and relevant evidence was identified, collated, and appraised via a structured assessment of the literature. Databases searched included Medline, EMBASE, and the Cochrane Libraries. Recommendations within the guidelines were developed by the panel to prioritise clinically important care decisions. The strength of each recommendation was determined according to a balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including the certainty of estimates), and the nature and variability of patient values and preferences.

KEY FINDINGS AND LIMITATIONS

Key recommendations emphasise the importance of a thorough medical history and physical examination for patients with urological infections. The guidelines stress the role of antimicrobial stewardship to combat the rising threat of antimicrobial resistance, providing recommendations for antibiotic selection, dosing, and duration on the basis of the latest evidence.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This overview of the 2024 EAU guidelines offers valuable insights into managing urological infections and are designed for effective integration into clinical practice.

PATIENT SUMMARY

The European Association of Urology has issued an updated guideline on urological infections. The guidelines provide recommendations for diagnosis, treatment, and prevention, with a particular focus on minimising antibiotic use because of the increasing global threat of antimicrobial resistance.

Advances in the antibiotic management of epididymitis

INTRODUCTION

Acute epididymitis is commonly encountered and typically presents acutely within a wide clinical spectrum. Most cases of acute epididymitis are caused by bacterial infection, most often by sexually transmitted organisms and urinary pathogens. Current treatment regimens remain empirical, although recent advances using modern diagnostic techniques support a change in the management paradigm.

AREAS COVERED

The choice of the initial antibiotic regimen is empirical and based on the most likely causative pathogen, whether sexually transmitted, enteric or other. Adherence of clinical practice remains short of available guidance, which may be improved by thorough clinical and microbiologic assessment, supported by a knowledge of the commonly associated pathogenic organisms, and the appropriate choice of tests required for their identification. Use of advanced microbiology techniques and studies of current practice provide new insights that have challenged traditional management paradigms. The authors discuss these points in and provide their expert perspectives on its treatment and future developments.

EXPERT OPINION

Relatively sparse direct trial data exists on antimicrobial treatments for acute epididymitis. Much of the presently available guidance is derived from previous guidance recommendations, knowledge of antimicrobial activities of specific agents, and treatment outcomes in uncomplicated infections. Identification of specific pathogens and prescribing accuracy is dependent on the extent to which cases are investigated and is therefore variable.

The role of ultrasound in detecting renal tract abnormalities following a single episode of epididymitis

AIM

The aim of the study was to establish the utility of ultrasound scan in detecting renal tract abnormalities following a single episode of epididymitis.

METHODS

A single-centre retrospective review of all boys diagnosed with epididymitis between October 2012 and 2017 including review of follow up imaging and clinical course was completed. Primary outcome was new diagnosis of renal tract abnormality by ultrasound.

MAIN RESULTS

Eighty-four boys with a first diagnosis of epididymitis were identified. Sixty-four cases (76%) were diagnosed at scrotal exploration, the remaining twenty clinically. Median age was 7.30 years (range 0.08-15.83 years), and five had a positive urine culture at presentation. Forty-eight boys (57%) had a follow-up ultrasound scan (at median 4.57 weeks [range 1-31 weeks]). Only two renal tract abnormalities were identified by ultrasound scan, both in boys aged < 6 months, and neither was clinically relevant. Recurrent epididymitis occurred in 4 cases at median 26 days after initial presentation, of whom 3 had been followed up by ultrasound after initial presentation, all of which were normal. Further investigation revealed posterior urethral valves in 1 boy (age 6.5 months at initial presentation).

CONCLUSION

Following a single episode of epididymitis, ultrasound was not helpful at detecting clinically relevant renal tract abnormalities, and furthermore did not identify the only patient with a clinically relevant abnormality. Based on these data, we propose follow-up imaging only in boys ≤ 6 months of age with a positive urine culture or a recurrent episode with consideration given to micturating cystogram even if ultrasound normal.

LEVEL OF EVIDENCE

IV.

Testicular infarction as a rare complication of pyogenic epididymoorchitis due to Pseudomonas aeruginosa: A case report and systematic literature review

BACKGROUND

Testicular infarction is a known serious complication associated with epididymitis. It is known to be idiopathic in 70% of cases but the frequency, risk factors, and management are yet to be elucidated. This paper aims to report a case of testicular infarction secondary to pyogenic epididymoorchitis caused by Pseudomonas aeruginosa.

CASE PRESENTATION

A 64-year-old male with a past medical history of benign prostate hypertrophy using intermittent self-catheterization and a recent history of culture-negative pyogenic epididymoorchitis treated with oral cefpodoxime was admitted to our hospital due to a 4-week history of fever, right scrotal pain, and swelling. Scrotal ultrasonography showed a hypoechoic testis without testicular torsion. He was diagnosed with testicular infarction and a scrotal abscess due to Pseudomonas aeruginosa, and was treated with cefepime along with transcutaneous drainage. Despite the antimicrobial treatment, he experienced testicular loss with necrotic tissue. Because little is known about the risk factors, clinical characteristics, management, and prognosis of testicular infarction secondary to epididymitis, we performed a systematic review of the literature.

CONCLUSION

This is a case of testicular necrosis during the treatment of epididymitis with negative urine culture and detection of Pseudomonas aeruginosa in tissue culture. Clinicians should perform frequent blood flow evaluation to the testis for early urologic intervention.

A Descriptive Analysis of Men Diagnosed With Epididymitis, Orchitis, or Both in the Emergency Department

Introduction Epididymitis and orchitis are illnesses characterized by pain and inflammation of the epididymis and testicle. They represent the most common causes of acute scrotal pain in the outpatient setting. Epididymitis and orchitis have both infectious and noninfectious causes, with most cases being secondary to the invasive pathogens chlamydia, gonorrhea, and Escherichia coli (E.coli). The study's objective was to examine the epidemiology and clinical characteristics of men diagnosed with epididymitis or orchitis in a United States emergency department. Methods We examined a dataset of 75,000 emergency department (ED) patient encounters from a single health system in Northeast Ohio who underwent nucleic acid amplification testing (NAAT) for chlamydia, gonorrhea, or trichomonas, or who received a urinalysis and urine culture. All patients were ≥18 years of age, and all encounters took place between April 18, 2014, and March 7, 2017. The analysis only included men receiving an ED diagnosis of epididymitis, orchitis, or both. We evaluated laboratory and demographic data using univariable and multivariable analyses. Results There were 1.3% (256/19,308) of men in the dataset diagnosed with epididymitis, orchitis, or both. Only 50.1% (130/256) of men diagnosed with epididymitis, orchitis, or both were tested for gonorrhea and chlamydia during their clinical encounter, and among those 13.8% (18/130) were positive. Chlamydia (12.3% [16/130]) was more common than both gonorrhea (3.1% [4/129]) and trichomonas (8.8% [3/34]) among men <35 years of age diagnosed with epididymitis, orchitis, or both. Only 62.1% of men diagnosed with epididymitis, orchitis, or both received a urine culture, of which 20.1% grew bacteria at ≥10,000 CFU/ml. E. coli (N= 20) was the most common bacteria growing in urine culture followed by Streptococcus (N= 3), Klebsiella (N= 2), Pseudomonas (N= 2), and Serratia (N= 2). Men diagnosed with epididymitis, orchitis, or both who had a positive urine culture were more likely to be ≥35 years of age, married, had higher urine white blood cells (WBCs), more urine bacteria, higher urine leukocyte esterase, more likely to have urine nitrite, and were less likely to be empirically treated for gonorrhea and chlamydia (P≤.03 for all).  Conclusions In the ED, epididymitis, orchitis, or both are uncommonly diagnosed among patients undergoing genitourinary tract laboratory testing. Sexually transmitted infections (STIs) are common in men <35 years of age diagnosed with epididymitis, orchitis, or both, with chlamydia being most common. E. coli was the most common bacteria growing in urine culture.

United Kingdom British association for sexual health and HIV national guideline for the management of epididymo-orchitis, 2020

The British Association for Sexual Health and HIV (BASHH) UK guideline for the management of epididymo-orchitis has been updated in 2020. It offers advice on diagnostic tests, treatment and health promotion principles in the effective management of epididymo-orchitis. Empirical treatment should be started in patients with objective swelling and tenderness on testicular examination. First-line empirical treatment for sexually acquired epididymo-orchitis has changed to ceftriaxone 1g intramuscularly and doxycycline. Higher dose of ceftriaxone in line with the BASHH 2018 gonorrhoea guideline ensures effective treatment of strains with reduced susceptibility. Ofloxacin or doxycycline is recommended in patients with epididymo-orchitis probably due to non-gonococcal organisms (e.g. negative microscopy for gram-negative intracellular diplococci or no risk factors for gonorrhoea identified). Where Mycoplasma genitalium is tested and identified, treatment should include an appropriate antibiotic (e.g. moxifloxacin). If enteric pathogens are a likely cause (e.g. older patient, not sexually active, recent instrumentation, men who practice insertive anal intercourse, men with known abnormalities of the urinary tract or a positive urine dipstick for leucocytes and nitrites), ofloxacin and levofloxacin are recommended. A clinical care pathway has been produced to simplify the management of epididymo-orchitis. A patient information leaflet has been developed.

The epididymal immune balance: a key to preserving male fertility

Up to 15% of male infertility has an immunological origin, either due to repetitive infections or to autoimmune responses mainly affecting the epididymis, prostate, and testis. Clinical observations and epidemiological data clearly contradict the idea that the testis confers immune protection to the whole male genital tract. As a consequence, the epididymis, in which posttesticular spermatozoa mature and are stored, has raised some interest in recent years when it comes to its immune mechanisms. Indeed, sperm cells are produced at puberty, long after the establishment of self-tolerance, and they possess unique surface proteins that cannot be recognized as self. These are potential targets of the immune system, with the risk of inducing autoantibodies and consequently male infertility. Epididymal immunity is based on a finely tuned equilibrium between efficient immune responses to pathogens and strong tolerance to sperm cells. These processes rely on incompletely described molecules and cell types. This review compiles recent studies focusing on the immune cell types populating the epididymis, and proposes hypothetical models of the organization of epididymal immunity with a special emphasis on the immune response, while also discussing important aspects of the epididymal immune regulation such as tolerance and tumour control.

Infectious, inflammatory and 'autoimmune' male factor infertility: how do rodent models inform clinical practice?

BACKGROUND

Infection and inflammation of the reproductive tract are significant causes of male factor infertility. Ascending infections caused by sexually transmitted bacteria or urinary tract pathogens represent the most frequent aetiology of epididymo-orchitis, but viral, haematogenous dissemination is also a contributory factor. Limitations in adequate diagnosis and therapy reflect an obvious need for further understanding of human epididymal and testicular immunopathologies and their contribution to infertility. A major obstacle for advancing our knowledge is the limited access to suitable tissue samples. Similarly, the key events in the inflammatory or autoimmune pathologies affecting human male fertility are poorly amenable to close examination. Moreover, the disease processes generally have occurred long before the patient attends the clinic for fertility assessment. In this regard, data obtained from experimental animal models and respective comparative analyses have shown promise to overcome these restrictions in humans.

OBJECTIVE AND RATIONALE

This narrative review will focus on male fertility disturbances caused by infection and inflammation, and the usefulness of the most frequently applied animal models to study these conditions.

SEARCH METHODS

An extensive search in Medline database was performed without restrictions until January 2018 using the following search terms: 'infection' and/or 'inflammation' and 'testis' and/or 'epididymis', 'infection' and/or 'inflammation' and 'male genital tract', 'male infertility', 'orchitis', 'epididymitis', 'experimental autoimmune' and 'orchitis' or 'epididymitis' or 'epididymo-orchitis', antisperm antibodies', 'vasectomy'. In addition to that, reference lists of primary and review articles were reviewed for additional publications independently by each author. Selected articles were verified by each two separate authors and discrepancies discussed within the team.

OUTCOMES

There is clear evidence that models mimicking testicular and/or epididymal inflammation and infection have been instructive in a better understanding of the mechanisms of disease initiation and progression. In this regard, rodent models of acute bacterial epididymitis best reflect the clinical situation in terms of mimicking the infection pathway, pathogens selected and the damage, such as fibrotic transformation, observed. Similarly, animal models of acute testicular and epididymal inflammation using lipopolysaccharides show impairment of reproduction, endocrine function and histological tissue architecture, also seen in men. Autoimmune responses can be studied in models of experimental autoimmune orchitis (EAO) and vasectomy. In particular, the early stages of EAO development showing inflammatory responses in the form of peritubular lymphocytic infiltrates, thickening of the lamina propria of affected tubules, production of autoantibodies against testicular antigens or secretion of pro-inflammatory mediators, replicate observations in testicular sperm extraction samples of patients with 'mixed atrophy' of spermatogenesis. Vasectomy, in the form of sperm antibodies and chronic inflammation, can also be studied in animal models, providing valuable insights into the human response.

WIDER IMPLICATIONS

This is the first comprehensive review of rodent models of both infectious and autoimmune disease of testis/epididymis, and their clinical implications, i.e. their importance in understanding male infertility related to infectious and non-infectious/autoimmune disease of the reproductive organs.

Retrospective review of the management of epididymo-orchitis in a London-based level 3 sexual health clinic: an audit of clinical practice

The aetiology of epididymo-orchitis is largely related to a patient's age with sexually transmitted pathogens being the common aetiological agents in those below 35 years of age. In individuals aged over 35, uropathogens represent the commonest cause. National guidelines exist for the appropriate management of this condition and its varying aetiology. We aimed to assess the management of epididymo-orchitis in our clinic with reference to the British Association for Sexual Health and HIV national guidelines. We describe the demographics, investigations, treatment and outcomes of patients presenting with epididymo-orchitis to the John Hunter Clinic for Sexual Health, Chelsea and Westminster Hospital.

Epididymitis: revelations at the convergence of clinical and basic sciences

Acute epididymitis represents a common medical condition in the urological outpatient clinic. Mostly, epididymitis is caused by bacterial ascent through the urogenital tract, with pathogens originating either from sexually transmitted diseases or urinary tract infections. Although conservative antimicrobial therapy is possible in the majority of patients and is usually sufficient to eradicate the pathogen, studies have shown persistent oligozoospermia and azoospermia in up to 40% of these patients. Animal models of epididymitis are created to delineate the underlying reasons for this observation and the additional impairment of sperm function that is often associated with the disease. Accumulated data provide evidence of a differential expression of immune cells, immunoregulatory genes and pathogen-sensing molecules along the length of the epididymal duct. The evidence suggests that a tolerogenic environment exists in the caput epididymidis, but that inflammatory responses are most intense toward the cauda epididymidis. This is consistent with the need to provide protection for the neo-antigens of spermatozoa emerging from the testis, without compromising the ability to respond to ascending infections. However, severe inflammatory responses, particularly in the cauda, may lead to collateral damage to the structure and function of the epididymis. Convergence of the clinical observations with appropriate animal studies should lead to better understanding of the immunological environment throughout the epididymis, the parameters underlying susceptibility to epididymitis, and to therapeutic approaches that can mitigate epididymal damage and subsequent fertility problems.

Acute epididymitis revisited: impact of molecular diagnostics on etiology and contemporary guideline recommendations

BACKGROUND

Acute epididymitis is a common infectious disease of unknown etiology in about 30% of cases with guidelines based on studies published >15 yr ago.

OBJECTIVE

To investigate the etiology of acute epididymitis using state-of-the-art methods and to provide rational data for antimicrobial therapy and clinical management.

DESIGN, SETTING, AND PARTICIPANTS

Between 2007 and 2013, 237 patients (150 antimicrobially naive and 87 antibiotically pretreated) with acute epididymitis underwent comprehensive investigation comprising microbiologic cultures, polymerase chain reaction (PCR) for sexually transmitted infections (STIs), 16S ribosomal DNA (rDNA) analysis, and PCR detection of 23 viruses. Clinical management followed international guidelines.

OUTCOME MEASURES AND STATISTICAL ANALYSIS

Etiology, clinical management, and outcome after 3 mo were assessed.

RESULTS AND LIMITATIONS

A causative pathogen, predominantly Escherichia coli (56%), was identified in 132 antibiotic-naive patients (88%) and 44 pretreated patients (51%); 16S rDNA analysis increased the detection rate by 10%. STIs were present in 34 cases (14%) (25 patients with Chlamydia trachomatis) and were not restricted to a specific age group. Enteroviruses were found in only two patients (1%). In naive patients, cultured bacteria were susceptible to fluoroquinolones and group 3 cephalosporins in >85% of cases (preateted patients: 42% and 67%, respectively). Primary empirical therapy was continued in 88% of naive patients for 11 d and in 77% of pretreated patients for 13 d with indwelling urinary catheters, rendering patients as high risk for switching. Only six patients (2.5%) underwent semicastration. Prostate-specific antigen levels halved within 3 mo, except in patients who were antibiotic naive and without detected pathogens. Study limitations included a lack of susceptibility testing in cases of STIs.

CONCLUSIONS

Even in antimicrobially pretreated patients, acute epididymitis is mainly of bacterial origin. STIs are not limited to patients aged <35 yr. Viral epididymitis seems a rare condition. Current guideline recommendations on empirical antimicrobial therapy are adequate.

PATIENT SUMMARY

Patients with acute epididymitis should receive appropriate diagnostics and antimicrobial therapy for safe conservative management.

The aetiology and current management of prepubertal epididymitis

INTRODUCTION

The aim of this study was to review the published evidence on the pathogenesis and management of acute epididymitis (AE) in prepubertal boys after the authors encountered an unexpectedly large number of such cases in their institution.

METHODS

Using MEDLINE(®), a literature search was performed for articles in English with the words "pre-pubertal" OR "boys" OR "p(a)ediatric" OR "children" AND "epididymitis" OR "epididymo-orchitis".

RESULTS

The literature suggests that it is rare to find a bacterial infection or anatomical anomaly as a cause for AE in this population. A postviral infectious phenomenon is the most likely explanation. The management should be supportive and antibiotics reserved for those with pyuria or positive cultures. Urodynamic studies and renal tract ultrasonography have been advocated for those with recurrent epididymitis.

CONCLUSIONS

AE in prepubertal boys is more common than believed previously. A careful history for recent viral illnesses should be included. Antibiotics, urinary tract imaging and functional studies should be used in selected cases.

All-trans-retinoic acid ameliorates the inflammation by inducing transforming growth factor beta 1 and interleukin 10 in mouse epididymitis

PROBLEM

Epididymitis, one of the most common urological diseases, can lead to the destruction of the epididymal duct and cause transient or permanent sterility. The aim of this study was to investigate the functions and related mechanisms of all trans retinoic acid (atRA) in alleviating the acute inflammation of epididymitis.

METHOD OF STUDY

The mouse model of the epididymitis was induced by injecting Escherichia coli into the cauda epididymis. atRA was administrated for five consecutive days through intraperitoneal injection. The expression levels of inflammatory cytokines were measured by real-time PCR and Western blot. In addition, cultured primary mouse epididymal epithelial cells were treated with different concentrations of atRA and RAR antagonists to identify whether the effect of atRA was mediated through RAR.

RESULTS

Our results demonstrate that atRA ameliorates the inflammation in mouse epididymitis by decreasing the expression of the pro-inflammatory cytokines and increasing the expression of anti-inflammatory factors including TGF-β1 and IL-10. Our results show that the upregulating effect of atRA on TGF-β1 was mediated by RARα, and the enhancing effect of atRA on IL-10 expression was mediated via RARβ.

CONCLUSION

These new results suggest that atRA is involved in regulating the inflammatory response of epididymis.

BASHH UK guideline for the management of epididymo-orchitis, 2010

The BASHH UK guideline for the management of epididymo-orchitis has been updated in 2010. Consideration should be made of the changing potential aetiologies of epididymo-orchitis - mumps in non-immune individuals and tuberculosis in the immunocompromised and men from countries of high prevalence. The treatment of sexually acquired epididymo-orchitis has changed given the high levels of quinolone-resistant gonorrhoea such that ceftriaxone and doxycycline are recommended in those at high risk of gonorrhoea and doxycycline or ofloxacin in those patients where gonorrhoea is considered unlikely (negative microscopy for Gram-negative intracellular diplococci and no risk factors for gonorrhoea identified). A clinical care pathway has also been produced to simplify the management of epididymo-orchitis.

Are antibiotics necessary for pediatric epididymitis?

OBJECTIVES

To determine the percentage of cases of epididymitis in pediatric patients that is of bacterial cause and to identify factors that predict a positive urine culture.

METHODS

We conducted a retrospective chart review of patients diagnosed with acute epididymitis or epididymo-orchitis in 1 pediatric emergency department for 11 years. Charts were reviewed for historical, physical, laboratory, and radiologic data. A positive urine culture was used to identify patients with a bacterial cause of epididymitis.

RESULTS

A total of 160 patient records were initially identified as having a diagnosis of epididymitis; of these, 20 met exclusion criteria or did not have records available for review and 140 cases of epididymitis were reviewed. Patients' age ranged from 2 months to 17 years, with a median age of 11 years. Of these patients, 91% received empiric antibiotic therapy. Also, of these patients, 97 (69%) had a urine culture sent, of whom 4 (4.1%; 95% confidence interval, 1.1%-10.2%) were positive. Of the 4 positive urine cultures, 3 had organisms not sensitive to usual empiric therapy for urinary tract infections. The boys with positive urine cultures were not significantly different from the other patients in age, maximum temperature, or number of white blood cells on urinalysis.

CONCLUSIONS

Given the low incidence of urinary tract infections in boys with epididymitis, in prepubertal patients, antibiotic therapy can be reserved for young infants and those with pyuria or positive urine cultures. Because it is difficult to predict which patients will have a positive urine culture, urine cultures should be sent on all pediatric patients with epididymitis.

Male infertility and genital chlamydial infection: victim or perpetrator?

The role of Chlamydia trachomatis in the cause of male infertility is under discussion. This paper attempts to summarize data from the literature, which support the role of C. trachomatis in male infertility or oppose this suggestion. The following observations are based on a survey of the literature: 1) Chlamydia trachomatis is a frequent pathogen in male genital inflammation, the micro-organisms are rarely present in healthy men. 2) Without doubt, C. trachomatis causes inflammations of the male urethra and the epididymis. Prostatitis and glandulitis vesicalis are discussed controversially. 3) Chlamydia trachomatis antigen or DNA is not demonstrable in secretions of the male accessory glands including the semen with sufficient reproducibility. However, it is easily demonstrable in urethral swabs and the urine. 4) Determination of chlamydial antibodies in serum or semen does not conclusively indicate a current infection with C. trachomatis. 5) There are no conclusive studies showing that men infected with C. trachomatis are less fertile than uninfected men. 6) The male genital chlamydial infection is a threat to the female genital organs, because C. trachomatis infection of the female genital organs may be deleterious to female fertility.

Infection and pyospermia in male infertility

Infections of the male genitourinary tract may contribute to infertility by adversely affecting sperm function, causing anatomical obstruction or initiating a leukocyte response. The majority of infertile males are asymptomatic, and the significance and the criteria for the diagnosis of a genital tract infection are controversial. The evaluation for a genital tract infection focuses on urine and semen cultures as well as on the accurate quantitation of seminal leukocytes. An elevated seminal leukocyte count, pyospermia, can be associated with male infertility and may reflect an infectious or inflammatory disorder. In addition, the role of specific genital tract infections such as chlamydiosis, gonorrhea, ureaplasma and trichomoniasis and their possible association with male infertility is addressed.

Seroepidemiological and socioeconomic studies of genital chlamydial infection in Ethiopian women

OBJECTIVE

To measure the prevalence of chlamydial genital infection in Ethiopian women attending gynaecological, obstetric and family planning clinics; to identify the epidemiological, social and economic factors affecting the prevalence of infection in a country where routine laboratory culture and serological tests for chlamydial species are unavailable; to determine the risk factors for genital chlamydial infection in those with serological evidence of other sexually transmitted diseases.

SUBJECTS

1846 Ethiopian women, outpatient attenders at two teaching hospitals and a mother and child health centre in Addis Ababa, Ethiopia.

SETTING

Gynaecological outpatient department, antenatal, postnatal and family planning clinics.

METHODS

Sera were tested for type-specific anti-chlamydial antibodies using purified chlamydial antigens (C. trachomatis A-C (CTA-C), C. trachomatis D-K (CTD-K), Lymphogranuloma venereum (LGV1-3), and C. pneumoniae (CPn)), in a micro-immunofluorescence test. The genital chlamydia seropositivity was analysed against patient's age, clinic attended, ethnic group, religion, origin of residence, age at first marriage and first coitus, income, number of sexual partners, duration of sexual activity, marital status/profession, obstetric and contraceptive history, and seropositivity for other sexually transmitted diseases.

RESULTS

Overall exposure to chlamydia species was found in 84%, genital chlamydial infection in 62%, and titres suggestive of recent or present genital infection in 42% of those studied. Genital chlamydial infection was highest (64%) in family planning and lowest (54%) in antenatal clinic attenders. Exposure to genital chlamydia species was influenced by ethnic group and religion. Those married and sexually active under 13 years of age had greater exposure (69%) to genital chlamydial infection than those first sexually active aged over 18 (46%). Prevalence of infection was highest in those with more than five sexual partners (78%) and in bargirls (84%). The lowest income groups had a higher prevalence (65%) of genital chlamydial infection than the wealthiest (48%). Multivariate analysis showed the most important factors to be age at first coitus, religion, prostitution and present age of the woman in that order. Risk for genital chlamydial infection was increased in those with seropositivity for syphilis, gonorrhoea, HSV-2 but not HBV infection. CONCLUSION/APPLICATION: Chlamydial genital infections are highly prevalent in both symptomatic and asymptomatic Ethiopian women. The high prevalence of infection reported reflects a complexity of socioeconomic factors: very early age at first marriage and first coitus, instability of first marriage, subsequent divorce and remarriage or drift into prostitution, all of which are influenced by ethnic group, religion and poverty--together with transmission from an infected group of prostitutes by promiscuous males to their wives, lack of diagnostic facilities and inadequate treatment of both symptomatic and asymptomatic men and women. The problem of chlamydial disease in Ethiopia needs to be addressed urgently in the context of control of STD.

Acute epididymitis: why patient and consort must be investigated

In this prospective study of 49 patients under 35 years of age with clinically diagnosed epididymitis, detailed microbiological investigation identified an infective cause in 67%. Chlamydia trachomatis was the commonest agent, present in 25 patients, but in 12 of these detection was based solely on raised antibody titres; 20 of the 28 female consorts screened were partners of men with chlamydial epididymitis and 80% of them were also positive for this infection. Isolating the micro-organism from 14 of 16 consorts indicated active infection despite the negative swabs from the men. If this important infection is to be adequately treated we recommend that all patients in this age group with epididymitis and their partners should be referred to a specialist unit with access to full chlamydia laboratory facilities.

Per-nasal swabbing as an aid to the diagnosis of chlamydial and adenovirus conjunctivitis

Two hundred and thirty four patients (adults and babies) with conjunctivitis were investigated by taking eye swabs and in addition by taking per-nasal swabs. Chlamydia trachomatis was isolated from 20 patients and adenovirus from 14 patients. Per-nasal swabbing led to a 53% increase in chlamydia diagnosis and a 27% increase in the diagnosis of adenovirus infection. It is suggested that per-nasal swabbing has an important role to play in detecting chlamydial conjunctivitis which itself may be an indicator for high morbidity in patients and their contacts.

Acute epididymitis: a microbiological and ultrasonographic study

In a prospective study of 24 men (mean age 28.3 years) with acute epididymitis who underwent epididymal aspiration, micro-organisms were detected in 15 (62.5%). Chlamydia trachomatis accounted for 10 (42%) of the cases, being located in both the urethra and epididymis in 5 individuals. Chlamydial serology supported the diagnosis of chlamydial infection, there being a strong correlation between the detection of C. trachomatis and elevated titres of both chlamydial IgG and IgM antibodies. In 4 patients (mean age 55.5 years), Escherichia coli was cultured from both mid-stream urine and epididymal aspirate. Transrectal ultrasound revealed abnormal prostatic scans in 19 patients (79%). These data confirm the aetiological role of C. trachomatis, support the notion that micro-organisms spread intra-canalicularly and suggest that the prostate is also involved in the inflammatory process in acute epididymitis.

Infection of the epididymis by Ureaplasma urealyticum

Ureaplasma urealyticum organisms (ureaplasmas) were isolated from the urethra and epididymal aspirate of a man aged 24 who had acute right sided epididymitis. No other microorganisms were detected, and he had no chlamydial antibody response. A fourfold antibody response to the epididymal ureaplasma isolate was detected by two methods, however, and the patient responded clinically to doxycycline, to which the ureaplasmal isolates were susceptible in vitro. These findings suggest that U urealyticum had a causative role.

Local antibody in semen for rapid diagnosis of Chlamydia trachomatis epididymitis

Etiologic studies including micro-immunofluorescence serology for Chlamydia trachomatis were done on 45 consecutive men with acute epididymitis. Of the men 21, all less than 35 years old, had type specific Chlamydia trachomatis antibody in the semen. All patients with semen antibody also had Chlamydia trachomatis antibody in the serum, while only a few of the patients without semen antibody had serum antibody. Chlamydia antibody titers in the semen specimens were higher than those in the sera and they persisted longer. In only 1 patient with semen antibody was another potential etiological agent for epididymitis demonstrated, while most of the patients without semen antibody had bacterial causes for the epididymitis. It was concluded that measurement of Chlamydia trachomatis antibody in semen offered a noninvasive, sensitive and specific method, useful despite prior antibiotic therapy, for diagnosis of the etiology of epididymitis in young men.

The frequency of Chlamydia trachomatis in acute epididymitis

Twenty-five patients with bacteriologically proven epididymitis were studied between 1984 and 1986. Thirteen were less than 35 years old and in 11 of them Chlamydia trachomatis was isolated; of the 2 remaining patients Escherichia coli was found in 1 and Neisseria gonorrhoeae in the other. In patients more than 35 years old, gram negative bacteria were the cause of infection in 10 and only 1 case was attributable to Chlamydia trachomatis. These results suggest that Chlamydia trachomatis is much more frequent in men under the age of 35 and the difference is statistically significant.

The role of Chlamydia trachomatis in epididymitis

Microbiological studies have identified an infective micro-organism in 28 of 54 patients (52%) with epididymitis. Chlamydia trachomatis was the commonest infection isolated, occurring in 15 patients. An additional 17 patients (31%) who were culture negative had serological evidence which suggested recent chlamydial infection. Most patients with chlamydia were under 26 years of age, in contrast to patients over 35 years, in whom coliform infections predominated. Of the 12 consorts of patients with chlamydial epididymitis who were screened, nine were also positive for this micro-organism. These findings have important implications in the management of epididymitis, especially in young men.

Inhibition of Chlamydia trachomatis growth in McCoy, HeLa, and human prostate cells by zinc

Zinc salts (10(-4) and 10(-5) M) inhibited the number of Chlamydia trachomatis inclusions in McCoy, HeLa, and primary human prostate epithelial cell cultures. Addition of zinc salts 1 h before or 24 h after inoculation with C. trachomatis was found to inhibit growth. Both C. trachomatis serotype D and a lymphogranuloma venereum strain were inhibited by the zinc salts. Although the mechanism of inhibition is not known, the continued presence of the zinc appeared necessary for maximal effect. At the concentrations tested, zinc was not directly toxic to the McCoy cells. These results suggest that the levels of zinc in prostatic secretions may be sufficient to preclude the recovery of chlamydia in the diagnostic laboratory or to inhibit chlamydia from infecting the prostate in vivo.

In vitro activity of the spermicide nonoxynol-9 against Chlamydia trachomatis

The in vitro activity of nonoxynol-9 against four serotypes (C, D, H, and K) of Chlamydia trachomatis was investigated. A constant inoculum of each serotype was exposed to serial twofold dilutions (1:100 to 1:800) of Koromex, Conceptrol, or reference preparations (not containing nonoxynol-9) for 4 and 24 h at 37 degrees C. The mixtures of nonoxynal-9 or nonnonoxynol preparations and control inocula were dispensed into triplicate wells containing McCoy cell monolayers. After incubation at 37 degrees C, the monolayers were fixed and stained with iodine and examined for evidence of infection with C. trachomatis. All nonoxynol-9-containing preparations showed marked antichlamydial activity as judged by percent reduction of glycogen-containing intracytoplasmic inclusions. The reference preparations, which did not contain nonoxynol-9, were markedly less active when tested in this in vitro system.

The clinical presentation of Chlamydia trachomatis in a urological practice

Fifty-nine men with Chlamydia trachomatis (CT) infection have been studied. Epididymitis was the most common presentation (26) compared with urethritis (8) and prostatitis (9). Only 13 patients gave a history of a urethral discharge. Fifteen of 21 female consorts screened were CT positive and 13 of these were asymptomatic. This demonstrates the major aetiological role of CT in lower genitourinary infection and indicates the importance of screening and treating consorts.

Cystitis with ureteral reflux caused by ureaplasma urealyticum

The authors present a case of a fifteen-year-old boy with urgency, suprapubic pain, hematuria, and pyuria with negative routine urine cultures. Cystoscopy revealed gross cystitis, and VCUG showed bilateral reflux and ureteral dilatation. Renal arteriograms, percutaneous renal biopsy, and bladder biopsy also were performed. After finding a positive culture for Ureaplasma, therapy with doxycycline rendered the patient asymptomatic and reflux improved on follow-up VCUG. Ureaplasma urealyticum should be considered in patients with symptomatic pyuria and negative routine cultures. Ureteral reflux, reversible with appropriate therapy, may be part of the infectious process.

The aetiology and management of acute epididymitis

The aetiology of acute epididymitis presenting to a surgical unit in a District General Hospital is presented. Patients over 45 years old frequently have a coliform urinary tract infection which may be associated with bladder neck obstruction. These patients require treatment with a suitable antibiotic (Co-trimoxazole) and further investigation. This condition occurs more commonly in patients under 45 years old in whom it is not associated with urinary tract infection. We have not demonstrated significant chlamydial infection and in a double blind study the antibiotic Co-trimoxazole did not hasten recovery. In this group the aetiology remains obscure.

Chlamydial infections

Infections due to Chlamydia are exceedingly important and common in emergency medicine, perhaps more so than any other single infectious agent. Recent studies have documented Chlamydia as a major cause of such commonly seen entities as urethritis, epididymitis, cervicitis, conjunctivitis, and neonatal pneumonia. Because clinical diagnosis and treatment is usually straightforward, and the already tremendous incidence of these "outpatient" infections is certain to increase, emergency physicians must become familiar with their diagnosis and management.

Chlamydial genital infection in Ibadan, Nigeria. A seroepidemiological survey

Sera from patients attending a sexually transmitted diseases (STD) clinic, a family planning clinic, and an antenatal clinic in Ibadan, Nigeria, as well as from male blood donors from the same area were tested for the presence of type specific antichlamydial antibodies using a modified micro-immunofluorescence test. Among men and women attending the STD clinic the exposure rates to Chlamydia trachomatis serotypes D to K (genital pathogens) were 18.7% and 26.7% respectively. Antibody titres suggesting active disease in these men and women were found in 11.8% and 22.7% respectively. The highest rate of exposure (35%) was among women attending the family planning clinic; of these women 25% had antibody suggesting active disease. Titres of IgG antibody in this study were similar to those found among men and women with chlamydial genital infections in the United Kingdom. Antibodies to serotypes D to K were also detected in 10.3% of women attending an antenatal clinic and in 9.9% of male blood donors. The prevalence of antibodies to C trachomatis serotypes A to C and lymphogranuloma venereum serotypes was low. These results suggest that the prevalence of chlamydial genital infections in Ibadan, both among STD patients and especially among those individuals not seeking treatment (family planning and antenatal clinic patients), is high. Since serious sequelae can follow chlamydial genital infections it is imperative to carry out further investigations in this area.

Chlamydial genital infection in Addis Ababa, Ethiopia. A seroepidemiological survey

A seroepidemiological survey was undertaken in Addis Ababa to assess the prevalence of chlamydial genital infections among patients attending a sexually transmitted diseases (STD) clinic and patients with no overt genital symptoms. In the STD clinic patients antibodies to Chlamydia trachomatis serotypes D to K (genital types) were detected in 68 of 210 (32.4%) men and in 72 of 159 (45.3%) women, a rate of exposure as high or higher than that found in Europe. Serological evidence of active chlamydial infection was present in 26.7% of men and 28.9% of women. Women were at risk of contracting STD, including chlamydial infections, at the age of 14 years or earlier. The titres of antichlamydial IgG were extremely high in some patients attending the STD clinic, with titres of between 1/512 and 1/8192 in 9.5% of men and 13.2% of women. This suggests that some patients had severe or disseminated chlamydial disease. The prevalence of exposure to chlamydial genital infections among 148 patients with no overt genital disease was 14.2%, which is significantly higher than that found in the United Kingdom. Among the total of 517 patients tested the prevalence of exposure to trachoma, lymphogranuloma venereum, and Chlamydia psittaci agents was very low.

Current status of radionuclide scrotal imaging

Scrotal imaging with technetium-99m sodium pertechnetate consists of a radionuclide angiogram and static scrotal scans. Utilization of this study in patients presenting with an acute scrotum can dramatically reduce the number of surgical explorations for acute epididymitis. It can also aid in other aspects of differential diagnosis in patients presenting with either an acutely enlarged and/or painful scrotum or a scrotal mass. Ambiguities in previous descriptions of perfusion through the spermatic and extraspermatic cord vessels are described and distinguished from scrotal perfusion. The clinical and scintigraphic spectrum of testicular torsion, including spontaneous detorsion, early acute testicular torsion, midphase testicular torsion, and late phase or "missed testicular torsion," is discussed and illustrated. The variety of patterns seen in acute epididymitis, including lateral and medial epididymal location, and focal epididymitis are described, as is the appearance of hydrocele as both a primary and secondary entity. The relationship of scrotal imaging to the overall clinical presentation and evaluation of these patients is emphasized in testicular torsion, torsion of the testicular appendages, epididymitis, abscess, trauma, tumor, spermatocele, and varicocele. The techniques, clinical utility, and relationship to radionuclide imaging of Doppler ultrasound and gray scale ultrasound scanning are reviewed. Doppler ultrasound results in many false negative studies in testicular torsion. Gray scale ultrasound is useful in clarifying the nature of scrotal masses.

The intravenous urogram in acute epididymo-orchitis

In a series of patients presenting with acute epididymo-orchitis, the abnormalities detected on intravenous urography were analysed. Urography is recommended in patients aged over 50 and in pre-pubertal boys, but it did not prove useful in adult patients under 50 years of age without other symptoms.

Unconventional bacteria in urinary tract disease: Ureaplasma urealyticum

Bladder-aspirate urine samples (N = 428) were cultured for the presence of fastidious microorganisms. These samples were obtained from 190 patients with urinary tract disease or symptoms suggesting infection of the urinary tract in whom standard bacteriologic investigation had failed to indicate bacterial infection. Ureaplasma urealyticum was recovered alone or in association with other microorganisms from the bladder urine of 75% of patients with reflux scarring and abnormal renal function. Ureaplasma organisms were localized to the upper urinary tract in 80% of patients with bladder counts greater than 10(3) colony-forming units per ml. The results indicate that microorganisms not conventionally associated with urinary tract infection are recoverable from the bladder urine of a high percentage of patients with so-called "sterile pyelonephritis," in which group of patients these microorganisms may contribute to progressive renal disease.

Value and feasibility of screening women attending STD clinics for cervical chlamydial infections

A chlamydial screening service was provided in Bristol over a three-month period for women attending the sexually transmitted disease (STD) clinic either for the first time or with a new complaint. Isolation of Chlamydia trachomatis was attempted in cytochalasin-treated McCoy cells. Of 919 specimens, valid results were obtained in 796. Chlamydial infections were identified and treated in 154 (19%) of these 796 women. Chlamydia were isolated from 52 (37%) of 152 female partners of men with nongonococcal urethritis (NGU); these patients already routinely receive treatment with tetracylcines in this clinic. The remaining 102 infections (34 (48%) of 71 women with gonorrhoea and 68 (12%) of the other 573 women) would have been unrecognised and usually untreated without chlamydial isolation studies. These figures confirm the need to provide chlamydial diagnostic services for selected STD clinic attenders.

The rôle of Chlamydia trachomatis in genital-tract and associated diseases

Images