The 2016 European guideline on the management of epididymo-orchitis

Acute Epididymo-Orchitis Complicated With Abscesses in Testis and Seminal Vesicles: A Case Report

Epididymo-orchitis is a common intra-scrotal inflammation among males that causes swelling of the epididymis and testis. In the era of modern antibiotics, complications associated with this condition are now rare. Herein, we report a 28-year-old man with acute epididymo-orchitis complicated by the formation of several abscesses involving the left testis and seminal vesicles. The literature review showed this patient as the first case with such extensive complications following epididymo-orchitis. Initial antimicrobial therapy was unable to resolve the condition. The management necessitated surgical intervention, which included MRI-guided aspiration of the seminal vesicle abscesses and testicular sparing drainage of the testicular abscess.

A case report of staged testicular infarction

Segmental testicular infarction is a rare clinical condition most often seen as acute unilateral scrotal pain. Segmental testicular infarction should be suspected in patients with scrotal pain; when an ultrasound shows hypoechoic or mixed echogenic lesions within the testicular parenchyma; contrast-enhanced ultrasound shows a little or no contrast filling, along with negative multiple tumor markers. This report presents a 60-year-old male who presented with sudden onset of left testicular pain with no apparent cause. Emergency Doppler ultrasound, contrast-enhanced ultrasound, and laboratory tests showed findings characteristic of Segmental testicular infarction. The patient the final diagnosis was based on a combination of clinical findings (regression or cessation of symptoms, no tumor marker abnormalities, no palpable testicular mass) and ultrasound evidence of improvement (size reduction or shape change from oval to wedge) during a follow-up period of at least 3 months.

Local adrenomedullin gene delivery inhibits Leydig cell dysfunction by rescuing steroidogenic enzymes in vivo

Adrenomedullin (ADM) has beneficial effects on Leydig cells under pathological conditions, including lipopolysaccharide (LPS)-induced orchitis. Our previous studies demonstrated that ADM exerts a restorative effect on steroidogenesis in LPS-treated primary rat Leydig cells by attenuating oxidative stress, inflammation and apoptosis. In this study, we aim to investigate whether ADM inhibits Leydig cell dysfunction by rescuing steroidogenic enzymes in vivo. Rats were administered with LPS and injected with Ad-ADM, an adeno-associated virus vector that expressed ADM. Then, rat testes were collected for 3β-hydroxysteroid dehydrogenase (3β-HSD) immunofluorescence staining. Steroidogenic enzymes or steroidogenic regulatory factors or protein, including steroidogenic factor-1 (SF-1), liver receptor homologue-1 (LRH1), Nur77, steroidogenic acute regulatory protein (StAR), cytochrome P450 cholesterol side chain cleavage enzyme (P450scc), 3β-HSD, cytochrome P450 17α-hydroxylase/17, 20 lyase (CYP17) and 17β-hydroxysteroid dehydrogenase (17β-HSD), were detected via gene expression profiling and western blot analysis. Plasma testosterone concentrations were measured. Results showed that ADM may inhibit Leydig cell dysfunction by rescuing steroidogenic enzymes and steroidogenic regulatory factors in vivo. The reduction in the number of Leydig cells after LPS exposure was reversed by ADM. ADM rescued the gene or protein levels of SF-1, LRH1, Nur77, StAR, P450scc, 3β-HSD, CYP17 and 17β-HSD and plasma testosterone concentrations. To summarize ADM could rescue some important steroidogenic enzymes, steroidogenic regulatory factors and testosterone production in Leydig cells in vivo.

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.

Acute orchiepididymitis: Epidemiological and clinical aspects: An analysis of 152 cases

Introduction

Orchiepididymitis is an inflammation of the testis and epididymis. Epididymitis, orchitis, and true orchiepididymitis are all examples of orchiepididymites. They are the most frequent cause of adult acute scrotal pain.

Objectives

to investigate the epidemiological, clinical, paraclinical, therapeutic, and evolutionary characteristics of acute orchiepididymitis in the urology department of University Hospital Center.

Materials and methods

This is a three-year retrospective, descriptive study of 152 patients who consulted the urology department at the university hospital center for treatment of orchiepididymitis (2017–2019).

Results

In our study, 152 patients were included. The average age was 49,5 years (17–82 years). The average of consultation delay was 7 days. Prostatic pathology was found to be the main medical antecedent in 18.5% of patients, and transurethral resection of the prostate was found to be the main surgical antecedent in 8.5% of cases. Clinical examination revealed that the predominant clinical symptom was painful inflammatory bursa in 94% of cases, followed by lower urinary tract disorders in 57.5% of cases, and fever in 10% of cases.

A germ was isolated in 26 cases after a systematic cytobacteriological examination of the urine (CBEU) (17%). All patients received medical treatment, and 21% of them were received urgical treatment. In 84.5% of cases, the outcome was favorable.

Conclusion

Acute orchiépididymitis is a common cause for a consultation to the emergency room. Diagnosis is based on clinical examination and ultrasound. Because of the frequency of complications and sequelae that might influence fertility in the long term, it is a diagnostic and therapeutic emergence

Orchiepididymitis is an inflammation of the testis and epididymis, most often of infectious origin.

Acute orchiépididymitis is a frequent reason for consultation in the emergency room.

Diagnosis is based on clinical examination and scrotal ultrasound.

The early and appropriate antibiotic treatment avoided serious complications

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.

Mixed Sexually Transmitted Infections in Infertile Couples: Empirical Treatment and Influence on Semen Quality

BACKGROUND

Trichomonas vaginalis (TV), Mycoplasma genitalium (MG) and Ureaplasma urealyticum (UU) are common sexually transmitted infections (STIs) that are diagnosed in infertile couples (cps). In cases with their simultaneous presence in a patient (mixed STI, MSTIs), treatment is complicated by the different sensitivity of microorganisms to antibacterial drugs. Moreover, in cases of complicated infections, the empirical treatment should be started before obtaining the results of drug susceptibilities.

OBJECTIVE

The objective of the current study is to find the effective and well-tolerated combination of drugs for the empirical antibacterial treatment of mixed STIs presented by TV, MG and UU in infertile couples. We also aimed to establish the influence of mixed STIs on semen quality.

METHODS

Our prospective study included 154 infertile couples (308 patients) with confirmed symptomatic MSTIs in one of the couples caused by the simultaneous presence of TV, MG and UU. All couples were randomized on three groups for empirical treatment: Group 1 (n=49 cps, 98 pts) who were treated by initial prescribing of anti-trichomoniasis drug Secnidazole, 2.0 g po followed by Azythromycin 500 mg on day 1 continuing by 250 mg on days 2-7; Group 2 (n=52 cps, 104 pts: Secnidazole, 2.0 g po followed by Josamycin 1000 mg bid for 12 days); Group 3 (n=53 cps, 106 pts: Secnidazole, 2.0 g po followed by Moxifloxacin 400 mg once daily for 12 days). The endpoints were clinical and microbiological cure rates as well as the frequency of side-effects in analyzed groups. We determined the basic parameters of the spermogram and Deoxyribonucleic acid (DNA) fragmentation levels in 59 patients with MSTIs before and at the 3rd, 6th and 9th month after pathogens eradication comparing them with results in 63 healthy sperm donors.

RESULTS

After the treatment, clinical cure rates in analyzed groups were 82.6% (Group 1) vs. 96.1% (Group 2) vs. 92.3% (Group 3). Microbiological cure rates (UU+MG) were 73.9% vs. 97.1% vs. 84.5% correspondingly (p<0.05). TV microbiological cure rates were 97.8% vs. 98.0% vs. 96.1% (p>0.05). Side-effects were registered in 28.6% vs. 12.5% vs. 18.9% cases correspondingly (p<0.05). In MSTIs patients, we registered the increasing DNA fragmentation rates, leucocytes count and decreasing semen volume, motility, vitality, sperm concentration, total spermatozoa number and number of spermatozoa with normal morphology. At the 6th month after complete pathogens eradication, these parameters approached normal values.

CONCLUSION

At the present time, the combination of Secnidazole+Josamycin can be considered the most effective and well-tolerated for the empirical treatment in patients with MSTIs presented by TV, MG and UU. Complete eradication of these MSTIs in males improves their semen parameters.

Impacts of Immunometabolism on Male Reproduction

The physiological process of male reproduction relies on the orchestration of neuroendocrine, immune, and energy metabolism. Spermatogenesis is controlled by the hypothalamic-pituitary-testicular (HPT) axis, which modulates the production of gonadal steroid hormones in the testes. The immune cells and cytokines in testes provide a protective microenvironment for the development and maturation of germ cells. The metabolic cellular responses and processes in testes provide energy production and biosynthetic precursors to regulate germ cell development and control testicular immunity and inflammation. The metabolism of immune cells is crucial for both inflammatory and anti-inflammatory responses, which supposes to affect the spermatogenesis in testes. In this review, the role of immunometabolism in male reproduction will be highlighted. Obesity, metabolic dysfunction, such as type 2 diabetes mellitus, are well documented to impact male fertility; thus, their impacts on the immune cells distributed in testes will also be discussed. Finally, the potential significance of the medicine targeting the specific metabolic intermediates or immune metabolism checkpoints to improve male reproduction will also be reassessed.

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.

An Investigation of the Male Genitourinary Abscess Originated from Urinary Tract in a Tertiary Hospital, Shanghai, China, from 2004 to 2019

Background

Male genitourinary abscess is one of the serious complications of urinary tract infections (UTIs). There were few researches on the clinical and pathogenic characteristics of male genitourinary abscess.

Patients and Methods

A retrospective observational study was conducted between January 2004 and April 2019. Male patients with genitourinary abscess originated from urinary tract, including sites of scrotum, testis, epididymis, spermatic cord, and prostate, were enrolled. Clinical and microbial records were collected and analyzed, and antimicrobial susceptibility testings were performed according to CLSI standard. Whole-genome sequencing was applied to detect the β-lactamase genes and virulence genes, as well as to determine the multilocus-sequence typing (MLST) of the collected Klebsiella pneumoniae (K. pneumoniae) isolates.

Results

A total of 22 male patients were included. The main clinical symptoms were fever (86.4%), scrotal swelling (68.2%), local skin warmth (59.1%) and ulceration (45.5%). Urinary irritation was often presented in prostate involved abscess. Ultrasound features had a 94.7% positive rate. Surgical treatment, including abscess drainage, was helpful to the prognosis. No matter where the specimens obtained from, including blood, urine or pus, multidrug-resistant K. pneumoniae was the dominant (11 cases, 50.0%) microorganism in positive cultures. Nine of eleven K. pneumoniae isolates had been preserved and recovered. As for MLST typing, all the nine available isolates of K. pneumoniae belonged to the ST11 type and characterized with bla_KPC-2 carbapenemase gene. Virulence genes rmpA2, ybtS, kfuC, wzi, aerobactin genes (iucABCD and iutA) and type 3 fimbriae genes (mrkAD) were identified in all the K. pneumoniae isolates.

Conclusion

It seemed that more patients under 35 years old were vulnerable to genitourinary abscess. There was an increasing trend that multidrug-resistant K. pneumoniae isolates with multiple virulence genes were involved in male genitourinary abscess. Prompt and proper antibiotic use, combined with adequate drainage of the abscess, was important to prognosis.

Etiology and Clinical Features of Epididymo-orchitis: A Single-center Study in Tehran, Iran

CDATA[Introduction: Epididymo-orchitis is a common urological disease among men. Little is known about the clinical and epidemiological aspects of the disease in Iran. Thus, the present study was aimed at investigating the etiology, clinical sequelae and risk factors of patients with epididymo- orchitis in Tehran, Iran.

METHODS

Patients presenting with epididymo-orchitis were prospectively analyzed in order to study the etiology and pattern of the disease. Bacteriological, molecular and serological tests were undertaken to look for Chlamydia trachomatis, Neisseria gonorrhoeae, Brucella spp., Mycoplasma spp, and other bacteria.

RESULTS

Fifty patients with epididymo-orchitis were evaluated according to their clinical symptoms, duration of symptoms, physical examination, and laboratory studies. The mean age of the patients was 53 years. Fever, dysuria, pain in the flanks, urinary frequency and discharges occurred in 58.0%, 50.0%, 50.0%, 28.0% and 6.0%, respectively. Bacterial pathogen was identified in 26% (13/50) of patients by urine culture. Escherichia coli was the etiological agent in 11/13 patients (84.6%). Two out of 50 patients (4.0%) were also positive for Chlamydia trachomatis. Two samples were serologically positive for Brucella spp. High Mean age, fever, urinary frequency, history of the underlying disease and history of urinary tract infections were found to have a significant association with the positive bacteriologic urine culture (P<0.05).

CONCLUSIONS

The most common clinical manifestations were fever, dysuria, and abdominal pain. E. coli and C. trachomatis were the major causative agents. The use of a set of diagnostic approaches including clinical symptoms, urine culture and more precise techniques such as PCR should be taken into consideration for the definitive diagnosis.

Chronic Scrotal Content Pain: a Review of the Literature and Management Schemes

PURPOSE OF REVIEW

Chronic scrotal content pain (CSCP) is a complex condition with multiple etiologies that requires a thorough understanding of its pathophysiology, workup, and treatment options. We performed a comprehensive and contemporary review to augment our current understanding of CSCP.

RECENT FINDINGS

We discuss new advances in CSCP-specific pain questionnaires, modern studies of microscopic spermatic cord denervation and its variations, and novel techniques including electric nerve stimulation and cryoablation in addition to randomized control trials with significant negative findings. We also present literature focusing on the prevention of CSCP secondary to surgical iatrogenic causes. The constantly evolving literature of CSCP has led to the significant evolution in its diagnosis and treatment, from oral medications to salvage options after microscopic spermatic cord denervation. With each advance, we come closer to developing a more thorough, evidence-based algorithm to guide urologists in treatment of CSCP.

Epididymitis and its aetiologies in a central London sexual health clinic

Epididymitis is a common cause of scrotal pain presentation in sexual health clinics; however, it is unclear what fraction is attributable to transmissible infections. We, therefore, reviewed the aetiologies causing epididymitis. A retrospective data analysis of all cases of epididymitis diagnosed from January 2018 to December 2018 in three sexual health clinics was conducted, collecting demographics, results, management and symptom resolution at two weeks follow up. A total of 127 cases of epididymitis (mean age 32 years, heterosexual 97, MSM 30) were included. Among them 14 cases (11%) were caused by sexual transmitted infections (<35 years n = 9; >35 years n = 5): seven cases of chlamydia, six gonorrhoea, one syphilis and one trichomonas vaginalis. There were three cases of urinary tract infection diagnosed. All cases were treated with antibiotics recommended by the British Association for Sexual Health and HIV (BASHH). At two weeks follow up post-treatment 10 (7%) were symptomatic; 91% did not attend for follow up. Sexually transmitted infections were associated with acute epididymitis in 11% of this study cohort.

A Review of the Management of Chronic Scrotal Pain

Chronic scrotal pain (CSP) is a common and poorly understood medical condition that significantly affects individuals' quality of life. Many patients seek evaluation and management of their symptoms from multiple physicians. Our review aims to address diagnostic modalities, clinical evaluation, and surgical and non-surgical management. We conducted a computerised detailed search of the PubMed, Medline, Embase and Cochrane databases for reports pertaining to CSP using the Medical Subject Headings keywords 'chronic scrotal pain', 'testicular pain' and 'orchialgia', and we included in the review those that fulfilled the inclusion (adult male with CSP presenting with the criteria of CSP ) and exclusion (extra-scrotal pain) criteria. After the direct causes of CSP were identified by reviewing the clinical evaluations (history taking and examination are mandatory) and the diagnostic evaluations (urine analysis is crucial and ultrasound can be helpful), the most-used medical and non-surgical treatments for CSP were tricyclic antidepressants (success rate of up to 66.6%) and spermatic block (success rate of more than 90%), and the most-used surgical procedure was microsurgical denervation of the spermatic cord (success rate of up to 70%). The evidence currently available remains rare and of low quality, making it difficult to strongly recommend individual treatment options. However, multimodal treatment modalities using physical therapy and psychotherapy may help patients and provide useful tools for coping with this condition. There are also useful non-surgical and surgical options for CSP that depend on the patient's state, the severity of the complaint and what options have already been tried.

Differential tissue-specific damage caused by bacterial epididymo-orchitis in the mouse

Ascending bacterial urinary tract infections can cause epididymo-orchitis. In the cauda epididymidis, this frequently leads to persistent tissue damage. Less coherent data is available concerning the functional consequences of epididymo-orchitis on testis and caput epididymidis. This in vivo study addresses the functional and spatial differences in responsiveness of murine epididymis and testis to infection with uropathogenic Escherichia coli (UPEC). Whole transcriptome analysis (WTA) was performed on testis, caput, corpus and cauda epididymidis of adult C57BL/6 J wildtype mice. Following UPEC-induced epididymo-orchitis in these mice, epididymal and testicular tissue damage was evaluated histologically and semi-quantitatively at 10 days and 31 days post-inoculation. Expression of inflammatory markers and candidate antimicrobial genes were analysed by RT-qPCR. WTA revealed distinct differences in gene signatures between caput and cauda epididymidis, particularly amonst immunity-related genes. Cellular and molecular signs of testicular inflammation and disruption of spermatogenesis were noticed at day 10, but recovery was observed by day 31. In contrast to the cauda, the caput epididymidis did not reveal any signs of gross morphological damage or presence of pro-inflammatory processes despite confirmed infection. In contrast to beta-defensins, known UPEC-associated antimicrobial peptides (AMP), like Lcn2, Camp and Lypd8, were inherently highly expressed or upregulated in the caput following infection, potentially allowing an early luminal protection from UPEC. At the time points investigated, the caput epididymidis was protected from any obvious infection/inflammation-derived tissue damage. Studies addressing earlier time-points will conclude whether in the caput epididymidis a pro-inflammatory response is indeed not essential for effective protection from UPEC.

Acute epididymo-orchitis: relevance of local classification and partner's follow-up

Introduction

Acute epididymo-orchitis (AEO) is a male urological emergency without an approved clinical classification. We aimed to determine the clinical value of proposed in 2012 local AEO classification system and summarize results of partner's follow-up.

Material and methods

A total of 293 patients with AEO were enrolled into our study. Based on the investigated AEO classification, they were divided into four groups: 118 patients (40.3%) with Stage I AEO; 97 patients (33.1%) with Stage II AEO; 42 patients (14.3%) with Stage IIIA AEO; 36 patients (12.3%) with Stage IIIB AEO.

If after 72 hours of conservative treatment there was no clinical improvement, AEO patients underwent surgery. We analyzed the clinical value of the investigated classification system and results of partner's follow-up.

Results

Only 3 (2.5%) patients with Stage I AEO required surgery. In patients with Stage II AEO, conservative treatment was effective in 79 (81.4%) cases. A total of 27 (64.3%) patients with Stage IIIA and 36 (100%) patients with stage IIIB AEO underwent surgery. Sexually transmitted infections (STIs) were detected in 176 (60.1%) cases among 293 patients with AEO and bacterial infection in 117 (39.9%) cases. We registered a statistically lower incidence rate of trichomoniasis in AEO patients compared to their sole female partners (13.8% vs. 23.3%, p <0.05). Distribution of other STIs in AEO patients and their sole partners was similar.

Conclusions

The investigated classification system enables the determination of a treatment strategy in patients with AEO. Partner's follow-up allows for the clarification of the etiology of disease, complete evaluation of STIs and prevents reinfection in couples.

The applied value of medical history, physical examination, colour-Doppler ultrasonography and testis scintigraphy in the differential diagnosis of acute scrotum

Acute scrotum, especially testicular torsion, is a common surgical emergency. A delay in diagnosis or management may lead to permanent testicular ischaemic damage. Thus, it is particularly important to differentiate testicular torsion from other acute scrotum conditions as soon as possible. Our study has retrospectively investigated 358 patients with acute scrotum admitted to our hospital from the year 2007 to 2016. We have collected a thorough history and clinical data and drew the conclusion by comparing clinical features of different acute scrotum cases, medical history, imaging and surgical findings. Therefore, we propose an innovative "Testicular Torsion (TT) Green Channel" concept. Through the combination of a comprehensive medical history, physical examination and auxiliary colour-Doppler ultrasonography, the diagnosis of testicular torsion is definite in most circumstances. Testis scintigraphy is a novel and complementary diagnostic modality that can reduce the negative exploration rate in ambiguous and certain cases. The TT Green Channel is a new concept in the management of testicular torsion.