Association between left-sided varicocele and epididymo-orchitis with sonographic findings

OBJECTIVE

The aim of this study was to investigate the relationship between left-sided varicocele and epididymitis or epididymo-orchitis.

MATERIALS AND METHODS

The study included 72 patients with left side epididymitis (EP) or epididymo-orchitis (EPO) (Group 1) and a control group of 72 patients without EP or EPO (Group 2). Those with right EP-EPO were excluded due to possible other underlying retroperitoneal pathologies causing varicocele. Groups were evaluated for presence of left side varicocele, varicocele grade and pampiniform plexus vein diameter.

RESULTS

The average age was 38 ± 8.4 years (range, 18-50 years) in Group 1, and 36 ± 9.1 years (range, 16-47 years) in Group 2. Varicocele was significantly more common in patients with EP or EPO (p < .001). The rate of varicocele was 66.7% (48/72) in Group 1, and 22.3% (16/72) in Group 2. The median grade of varicocele was 2 in Group 1, and 0 in Group 2. Pampiniform plexus vein diameters were found to be significantly larger in patients with EP or EPO compare to patients without EP and EPO. The median vein diameter was 3.3 mm with the 25th and 75th percentiles at 2.7 and 3.8 mm, and was 1.9 mm with the 25th and 75th percentiles at 1.7 and 2.3 mm, respectively (p < .001).

CONCLUSIONS

Left-sided varicocele was significantly more common in patients with EP or EPO and it is an important cause for the development of EP/EPO because of chronic venous stasis.

Epididymitis with Pasteurella multocida isolated from two male Japanese Black beef calves

Two male Japanese Black calves developed an enlarged scrotum and testis. Orchiectomy was performed and pus was collected during surgery. After removal of the testis, bacteriological and histopathological examinations were conducted to investigate the cause and confirm the diagnosis. Based on the results obtained, both cases were diagnosed with epididymitis caused by an infection with Pasteurella multocida. This is the first study to show that P. multocida causes epididymitis in male calves. Further studies are required to clarify the details underlying the infection of calves with P. multocida.

Infective endocarditis due to Citrobacter koseri following testicular trauma: case report and literature review

Infective endocarditis (IE) is a condition with low prevalence but high mortality rates within intensive care units. Microbiologically, most cases are attributed to Gram-positive cocci, while Gram-negative bacilli are less commonly involved. This case report describes a patient with IE caused by Citrobacter koseri (C. koseri) with secondary bacteremia due to blunt testicular trauma and epididymitis. We conducted a review of the literature to assess the clinical and associated risk factors of this underreported condition. Elderly and urinary tract infections could be associated with this entity. Cefazolin was used as the final targeted treatment. The use of precision medicine in IE is required for specific interventions.

Role of High-Resolution Ultrasonography With Colour and Duplex Doppler in the Evaluation of Acute Scrotal Diseases

Introduction The term 'acute scrotum' denotes the sudden initiation of pain in the scrotal region. Acute scrotum is a frequent medical condition in children and adults. Ultrasound facilitates precise diagnosis and differentiation of numerous causes of acute scrotum. The objective of our research was to assess the utility of ultrasonography in the identification and prevalence determination of causes of acute scrotum. Materials and methods Patients with acute scrotal pain referred to the Department of Radiodiagnosis at Great Eastern Medical School & Hospital (GEMS), Srikakulam, India, were added in the research. This is a prospective observational study. High-frequency linear transducer (4-15 MHz) was used for imaging. Grey scale, colour and duplex Doppler were performed routinely. The ultimate diagnosis was established by considering the clinical results, follow-up observations, intraoperative observations and, when accessible, histopathological analysis. For the statistical analysis, IBM SPSS Statistics for Windows, version 22 (released 2013; IBM Corp., Armonk, New York, United States). was used. Descriptive analysis was conducted. The Kendall rank correlation coefficient was used to evaluate the non-parametric association between side and torsion. Results A total of 120 patients were included for statistical analysis. Inflammatory pathology was the most common cause of acute scrotum, followed by testicular torsion and torsion of testicular appendage. Testicular torsion and side of pain did not show a significant association. Conclusion High-resolution ultrasonography with colour and duplex Doppler sonography is an excellent imaging modality exhibiting exceptional sensitivity and specificity for the accurate diagnosis of acute scrotal diseases. Inflammatory pathology was the most common cause of acute scrotum, followed by testicular torsion and torsion of the testicular appendage.

Testicular and scrotal abnormalities in pediatric and adult patients

Testicular and scrotal abnormalities can occur in children, adolescents, and adults. The lesions, often accompanied by pain and swelling/enlargement of the scrotum, can cause anxiety in patients and their parents. Regardless of age, proper diagnosis is based on adequate anamnesis and physical examination. Color Doppler ultrasound is the first-line test in the differential process of testicular and scrotal diseases. Testicular and scrotal lesions require differentiation for benign and malignant processes as well as therapeutic management, including urgent surgical intervention. The aim of this paper is to present the most common causes of testicular and scrotal abnormalities in pediatric and adult patients and to outline the symptoms and diagnostic and therapeutic management.

A rare presentation of Zinner syndrome as recurrent epididymitis: A case report

Zinner syndrome is a rare congenital malformation characterized by ipsilateral renal agenesis, atresia of the ejaculatory duct, and cystic distension of the seminal vesicles. Symptoms typically arise in adolescence or adulthood and may include painful urination, perineal discomfort, and post-ejaculatory pain. Diagnosis, often made between the ages of 20 and 50 years, involves differentiating Zinner syndrome from other cystic disorders using techniques such as cystoscopy, MRI, intravenous urography, and transrectal ultrasound. Treatment varies based on symptom severity, ranging from conservative approaches to invasive surgeries. Regular follow-up is essential to identify complications and preserve fertility. Herein, we present a 27-year-old male with recurrent scrotal swelling and erythema incidentally diagnosed with Zinner syndrome. The patient had a history of recurrent epididymitis and was found to have cystic dilatation of the seminal vesicle, ipsilateral renal agenesis, and obstruction of the left ejaculatory duct on imaging. Given the patient's mild symptoms, he was managed conservatively with antibiotics and pain medication, resulting in significant improvement.

New aspects of activin biology in epididymal function and immunopathology

The activins (A and B) and their binding protein, follistatin, play crucial roles in development, immunoregulation and inflammation throughout the body. In the male reproductive tract of the mouse, activin A and B production is largely confined to the initial segment and proximal caput of the epididymis and the efferent ducts, under normal conditions, with very low expression in the corpus, cauda and vas deferens. However, activin A protein is present throughout the epididymis and vas deferens and is largely associated with the epithelium and interstitial macrophages. Conversely, the activin-binding protein follistatin is produced in the distal epididymis, with very high expression in the vas deferens. Activin activity in the distal tract is inhibited by follistatin, and the activin-follistatin balance is important for regulating coiling of the duct during epididymal development. In further experiments, as described in this report, in situ hybridisation was used to localise activin A mRNA principally to cells in the periductal zone and interstitium in the efferent ducts and proximal caput. Activin B mRNA, on the other hand, was localised to periductal cells in the efferent ducts and proximal epididymis and, most notably, to epithelial cells in the initial segment. Activin A is implicated in the regulation of mononuclear phagocyte function and immune responses in the caput and stimulates the expression of the key immunoregulatory protein, indoleamine 2,3-dioxygenase in this region. Activin A production in the corpus and cauda increases dramatically during bacterial epididymitis in mice, promoting inflammation and fibrosis and causing damage to the epithelium and obstruction of the epididymal duct. Consequently, it appears that the activin-follistatin axis is crucial for maintaining normal epididymal structure and function, but disruption of this balance during inflammation has deleterious effects on male fertility. Follistatin has therapeutic potential in ameliorating the proinflammatory and profibrotic effects of activins.

Antigenic and molecular evidence of Brucella sp.-associated epididymo-orchitis in frugivorous (Artibeus lituratus) and nectarivorous (Glossophaga soricina) bats in Brazil

This study included 47 free-ranging bats from the State of Minas Gerais, Brazil. Six bats (12.8%) had genital inflammatory lesions, and two of them (one Artibeus lituratus and one Glossophaga soricina, a frugivorous and a nectarivorous, respectively) were diagnosed with Brucella sp. infection through PCR, and antigens in intralesional macrophages were detected using immunohistochemistry.

Brucella suis biovar 1 infection in a dog with orchitis in Germany

In 2021, a case of canine brucellosis diagnosed in a dog with orchitis was presented to a veterinary practice in Germany. Serological testing excluded Brucella (B.) canis as a causative agent, but molecular analysis revealed the presence of B. suis biovar 1. Since biovar 1 is not endemic in Europe and the dog had no history of travel to endemic areas, a comprehensive epidemiological investigation was conducted using whole genome sequence data to determine the source of infection. We describe the clinical progress of the animal and the potential infection of a veterinary clinic employee. The findings highlight the importance of considering less common Brucella species as possible causes of canine brucellosis. The data also emphasize that it is quite challenging to identify Brucella species in a routine diagnostic laboratory and to conduct epidemiological investigations to unveil possible transmission routes.

Comprehensive Evaluation of Hematospermia in Patients with Acute Epididymitis Compared to Patients with Isolated Hematospermia

BACKGROUND

Among the most common known causes of hematospermia are infections in the genitourinary tract, but no study exists that has comprehensively investigated hematospermia in patients with acute epididymitis.

OBJECTIVES

To assess the impact of hematospermia in patients with acute epididymitis and its association with clinical, microbiological and semen parameters.

MATERIALS AND METHODS

Since May 2007, a total of 324 sexually active patients with acute epididymitis were recruited in a prospective cohort study. Patients received a comprehensive medical and sexual history, clinical, sonographic, laboratory and microbiological diagnostics. Antibiotic therapy was given according to EAU guidelines. Semen analysis was offered 14 days after first presentation and initiation of therapy. Since 2013, a separate control group of 56 patients presenting with isolated hematospermia ( = no other urogenital symptoms) were prospectively recruited, and differences between the groups were statistically evaluated.

RESULTS

Of 324 patients with acute epididymitis, 50 patients (15%) had self-reported hematospermia. This occurred with a median of 24 hours before the onset of scrotal symptoms and was associated with significantly elevated PSA levels compared to 274 patients without hematospermia (3.1 vs. 1.8 ng/ml, p<0.01). The two most common etiological pathogens were Escherichia coli and Chlamydia trachomatis, and the bacterial spectrum was comparable in both epididymitis subgroups (p = 0.859). Semen analysis at 14 days still showed hematospermia in 24% of patients associated with massive leukocytospermia. Compared to the hematospermia control group, the two epididymitis subgroups showed significantly increased inflammation markers (pH, leukocytes, elastase), reduced sperm concentration, and reduced levels of alpha-glucosidase and zinc (always p<0.01).

DISCUSSION AND CONCLUSION

In sexually active patients who develop acute epididymitis, self-reported hematospermia is evident in 15% of patients as early as one day before the onset of scrotal symptoms. Conversely, none of the 56 patients presenting with isolated hematospermia developed epididymitis within the next four weeks. This article is protected by copyright. All rights reserved.

Acute orchitis deciphered: Coxsackievirus B strains are the main etiology and their presence in semen is associated with acute inflammation and risk of persistent oligozoospermia

Although various viruses are considered to be the clinical cause for acute orchitis, it is completely unclear to what extent and which viruses are etiologically involved in acute orchitis and what the clinic and course of these patients are like. Therefore, a prospective study was set up to decipher acute isolated orchitis. Between July 2007 and February 2023, a total of 26 patients with isolated orchitis were recruited and compared with 530 patients with acute epididymitis. We were able to show for isolated orchitis, that (1) orchitis is usually of viral origin (20/26, 77%) and enteroviruses with coxsackievirus B strains (16/26, 62%) are predominant, (2) virus isolates could be received from semen indicating the presence of replication-competent virus particles, (3) a polymerase chain reaction (PCR) for enteroviruses should be conducted using semen provided at the onset of disease, because the virus is not detectable in serum/urine, (4) there is a circannual occurrence with the maximum in summer, (5) orchitis is associated with a characteristic inflammatory cytokine panel in the semen and systemic inflammation, (6) orchitis is usually rapidly self-limiting, and (7) about 30% of patients (6/20) suffer ongoing oligozoospermia. These seven emerging aspects are likely to fundamentally change thinking and clinical practice regarding acute isolated orchitis.

Chronic epididymitis due to Chlamydia trachomatis LGV-L2 in an HIV-negative heterosexual patient: a case report

Chlamydia trachomatis is an obligate intracellular pathogen and the leading bacterial cause of sexually transmitted infections worldwide. Chlamydia trachomatis genovars L1-L3 are responsible for lymphogranuloma venereum (LGV), an invasive sexually transmitted disease endemic in tropical and subtropical regions of Africa, South America, the Caribbean, India and South East Asia. The typical signs and symptoms of C. trachomatis LGV urogenital infections in men include herpetiform ulcers, inguinal buboes, and/or lymphadenopathies. Since 2003, endemic cases of proctitis and proctocolitis caused by C. trachomatis LGV emerged in Europe, mainly in HIV-positive men who have sex with men (MSM). Scarce data have been reported about unusual clinical presentations of C. trachomatis LGV urogenital infections. Herein, we report a case of a 36-year-old heterosexual, HIV-negative male declaring he did not have sex with men or trans women, who presented to the Urology and Andrology outpatient clinic of a healthcare center from Cordoba, Argentina, with intermittent testicular pain over the preceding 6 months. Doppler ultrasound indicated right epididymitis and funiculitis. Out of 17 sexually transmitted infections (STIs) investigated, a positive result was obtained only for C. trachomatis. Also, semen analysis revealed oligoasthenozoospermia, reduced sperm viability as well as increased sperm DNA fragmentation and necrosis, together with augmented reactive oxygen species (ROS) levels and the presence of anti-sperm IgG autoantibodies. In this context, doxycycline 100 mg/12 h for 45 days was prescribed. A post-treatment control documented microbiological cure along with resolution of clinical signs and symptoms and improved semen quality. Strikingly, sequencing of the ompA gene revealed C. trachomatis LGV L2 as the causative uropathogen. Remarkably, the patient did not present the typical signs and symptoms of LGV. Instead, the infection associated with chronic testicular pain, semen inflammation and markedly reduced sperm quality. To our knowledge, this is the first reported evidence of chronic epididymitis due to C. trachomatis LGV L2 infection in an HIV-negative heterosexual man. These findings constitute important and valuable information for researchers and practitioners and highlight that C. trachomatis LGV-L2 should be considered as putative etiologic agent of chronic epididymitis, even in the absence of the typical LGV signs and symptoms.

Myd88 Signaling Is Involved in the Inflammatory Response in LPS-Induced Mouse Epididymitis and Bone-Marrow-Derived Dendritic Cells

Epididymitis is an epididymal inflammation that may lead to male infertility. Dendritic cells (DCs) and myeloid differentiation primary response gene 88 (Myd88) were associated with epididymitis in rodents. However, the functions of Myd88 on epididymal DCs remain unclear. This study investigated the role of Myd88 in DCs for epididymitis. The Myd88 signaling pathway, phenotypes of DC subsets, and cytokines were investigated in lipopolysaccharide (LPS)-induced epididymitis in mice. CRISPR-Cas9 was used to knockout Myd88 in bone-marrow-derived dendritic cells (BMDCs) and immortalized mouse epididymal (DC2) cell line. In the vivo experiments, levels of the proinflammatory cytokines IL-1α, IL-6, IL-17A, TNF-α, IL-1β, MCP-1, and GM-CSF, mRNA for MyD88 related genes, and the percentages of monocyte-derived DCs (Mo-DCs) were significantly elevated in mice with epididymitis. In the vitro experiments, LPS significantly promoted the apoptosis of BMDCs. In addition, the concentration of inflammatory cytokines in BMDCs and DC2s were increased in the LPS group, while decreasing after the knockout of Myd88. These findings indicate that Myd88 on DCs is involved in the inflammation of epididymitis in mice, which may be a potential target for better strategies regarding the treatment of immunological male infertility.

An Overview of Emphysematous Epididymo-Orchitis: A Systematic Review of Case Reports

Emphysematous epididymo-orchitis (EEO) is a rare but serious condition that involves the presence of gas within the tissues of the testicle and/or the epididymis. It is a medical emergency that can be life-threatening if left untreated. Management of this condition may involve a combination of antibiotics, surgical drainage, and supportive care. In March 2023, A systematic review of case reports was conducted to identify and examine cases of EEO. We used PubMed, ScienceDirect, and Google Scholar for a methodical search. Only seven out of 136 studies met our criteria for this review of case reports. However, this review discusses symptom presentation, imaging findings, complications, and possible management of EEO.

Early predictors of Brucella epididymo-orchitis

Introduction

Epididymo-orchitis (EO) is a common urological condition. In endemic areas, EO may be the presenting picture of brucellosis. Early suspicion and proper diagnosis is necessary for patient recovery.

Objective

The aim of our study is to identify early predictors of Brucella EO.

Patients and Methods

We retrospectively collected the data of all patients who were treated at the Urology Unit, Farwaniya Hospital, with acute EO above the age of 12 years between April 2017 and February 2019. Data from electronic and hardcopy files were gathered and analyzed. The diagnosis of acute EO was based on clinical, laboratory, and radiological findings. A total of 120 patients under the diagnosis of EO, epididymitis, and orchitis were reviewed. Thirty-one patients were tested for Brucella based on the history of animal contact, ingestion of unpasteurized dairy products, or persistent fever for more than 48 h. of those patients, 11 tested positive for Brucella orchitis.

Results

A comparison between Brucella-positive and Brucella-negative patients regarding age, presence of fever, complete blood count (CBC) parameters, pyuria, and abscess formation was made. In the Brucella group, 72% of the patients had a history of animal contact compared to 33% in non-Brucella group (P = 0.006). When comparing CBC parameters in the two groups, Brucella group had statistically significant lower total leukocytic count and neutrophil count (mean ± standard deviation [SD]) 13.07 ± 4.22, 6.4 ± 9.98 versus Brucella negative group 17.35 ± 5.28, 7.8 ± 10.53, and P values were 0.037 and 0.004, respectively. Brucella group showed lymphocytosis (mean ± SD) 25.95 ± 9.78 versus non-Brucella group 13.22 ± 8.05 and P < 0.01.

Conclusion

Brucella orchitis constituted 9% of the orchitis patients treated in our hospital. Patients with a history of animal contact, EO with lymphocytosis, and relative neutropenia should raise the suspicion for Brucella orchitis in endemic areas.

Epididymitis in mice experimentally infected with Trypanosoma equiperdum: a histopathological and immunohistochemical study

Trypanosoma equiperdum is a causative agent of dourine in equids and is transmitted from stallions to mares by coitus. Dourine-affected stallions develop orchitis and epididymitis, and these lesions are considered to be responsible for the sexual transmission of T. equiperdum during coitus. However, the parasitic site of trypanosomes in the reproductive organs and the mechanisms underlying transmission have not yet been elucidated histopathologically. We examined the reproductive organs of male mice infected with T. equiperdum histopathologically and identified severe epididymitis with sperm granulomas. Many trypanosomes were detected in the epididymal interstitium and a few were seen within tubular lumen. Interstitial inflammatory cells mainly consisted of Iba1-, iNOS- and CD204-positive cells with a few CD3-, FOXP3- or PAX5-positive cells. There was diffuse immunolabelling of tumour necrosis factor-α (TNF-α) within these inflammatory foci. While caspase-3-positive epithelial cells in the epididymis were not observed in control mice, they were detected multifocally in infected mice and were frequently associated with loss of immunolabelling of zonula occludens-1 (ZO-1), a major protein that forms tight junctions between epididymal epithelial cells. Anti-laminin immunofluorescence revealed an indistinct basement membrane of the epididymal duct. These results suggest that trypanosomes in the epididymal interstitium induce the infiltration of TNF-α-secreting macrophages. Secreted TNF-α may impair the tight junctions of the epididymal duct by inducing apoptosis and downregulating ZO-1 expression.

The regional distribution of resident immune cells shapes distinct immunological environments along the murine epididymis

The epididymis functions as transition zone for post-testicular sperm maturation and storage and faces contrasting immunological challenges, i.e. tolerance towards spermatozoa vs. reactivity against pathogens. Thus, normal organ function and integrity relies heavily on a tightly controlled immune balance. Previous studies described inflammation-associated tissue damage solely in the distal regions (corpus, cauda), but not in the proximal regions (initial segment, caput). To understand the observed region-specific immunity along the epididymal duct, we have used an acute bacterial epididymitis mouse model and analyzed the disease progression. Whole transcriptome analysis using RNAseq 10 days post infection showed a pro-inflammatory environment within the cauda, while the caput exhibited only minor transcriptional changes. High-dimensional flow cytometry analyses revealed drastic changes in the immune cell composition upon infection with uropathogenic Escherichia coli. A massive influx of neutrophils and monocytes was observed exclusively in distal regions and was associated with bacterial appearance and tissue alterations. In order to clarify the reasons for the region-specific differences in the intensity of immune responses, we investigated the heterogeneity of resident immune cell populations under physiological conditions by scRNASeq analysis of extravascular CD45+ cells. Twelve distinct immune cell subsets were identified, displaying substantial differences in distribution along the epididymis as further assessed by flow cytometry and immunofluorescence staining. Macrophages constituted the majority of resident immune cells and were further separated in distinct subgroups based on their transcriptional profile, tissue location and monocyte-dependence. Crucially, the proximal and distal regions showed striking differences in their immunological landscapes. These findings indicate that resident immune cells are strategically positioned along the epididymal duct, potentially providing different immunological environments required for addressing the contrasting immunological challenges and thus, preserving tissue integrity and organ function.

Host defense functions of the epididymal amyloid matrix

The epididymal lumen is an immunologically distinct environment. It maintains tolerance for the naturally antigenic spermatozoa to allow their maturation into functional cells while simultaneously defending against pathogens that can ascend the male tract and cause infertility. We previously demonstrated that a nonpathological amyloid matrix that includes several cystatin-related epididymal spermatogenic (CRES) subgroup family members is distributed throughout the mouse epididymal lumen but its function was unknown. Here, we reveal a role for the epididymal amyloid matrix in host defense and demonstrate that the CRES amyloids and CD-1 mouse epididymal amyloid matrix exhibit potent antimicrobial activity against bacterial strains that commonly cause epididymal infections in men. We show the CRES and epididymal amyloids use several defense mechanisms including bacterial trapping, disruption of bacterial membranes and promotion of unique bacterial ghost-like structures. Remarkably, these antimicrobial actions varied depending on the bacterial strain indicating CRES amyloids and the epididymal amyloids elicit strain-specific host defense responses. We also demonstrate that the CRES monomer and immature assemblies of the epididymal amyloid transitioned into advanced structures in the presence of bacteria, suggesting their amyloid-forming/shape-shifting properties allows for a rapid reaction to a pathogen and provides an inherent plasticity in their host defense response. Together, our studies reveal new mechanistic insight into how the male reproductive tract defends against pathogens. Future studies using a mouse model for human epididymitis are needed to establish the epididymal amyloid responses to pathogens in vivo. Broadly, our studies provide an example of why nature has maintained the amyloid fold throughout evolution.

Sonographic findings of COVID-19 related acute scrotal infection and associations with clinical-laboratory data

BACKGROUND

During the Coronavirus Disease 2019 (COVID-19) pandemic, patients present to hospitals with a wide range of symptoms. Some of these symptoms include acute orchitis and epididymitis. The goal of this research is to see if COVID-19 infection and scrotal infection are associated.

MATERIALS AND METHODS

Patients with a COVID-19 (+) who agreed to a scrotal ultrasound (US) examination were studied prospectively in a tertiary care center between October 2021 and February 2022. The severity of the disease was used to divide patients into groups. Patients diagnosed with acute scrotal infection based on scrotal ultrasonography findings were compared in these groups, as were their age, comorbidities, and laboratory data.

RESULTS

The median age of the 213 participants was 61.7 ± 8.3. During the ultrasonographic examination of the patients, 15 (7%), 8 (3.7%), 17 (7.9%), and 40 (18.7%) were diagnosed with acute orchitis, acute epididymitis, acute epididymo-orchitis, and scrotal infection, respectively. Acute scrotal infection was far more common in patients with a higher clinical severity of the disease. The patients' comorbidities were also assessed, and it was discovered that they were statistically more common in the same group.

CONCLUSIONS

Even if there are no clinical symptoms, ultrasonography can help detect acute scrotal infection in COVID-19 patients. Furthermore, in groups with higher clinical severity, this association is more likely to be seen. It is critical to understand this in order to avoid complications.

Possible case of polyarteritis nodosa with epididymitis following COVID-19 vaccination: A case report and review of the literature

The global outbreak of coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus type 2 has prompted the rapid spread and development of vaccines to prevent the spread of the disease. COVID-19 vaccine has demonstrated excellent efficacy in reducing morbidity and severity of the disease, and most adverse reactions are very minor. However, some patients have been reported to develop autoimmune diseases, such as rheumatoid arthritis, myocarditis, Guillain-Barre syndrome, and vasculitis, following COVID-19 vaccination. Herein, we present a case of polyarteritis nodosa with epididymitis, following COVID-19 mRNA vaccination. The patient's initial symptoms were fever and testicular pain, and magnetic resonance imaging showed epididymitis. He was diagnosed as having polyarteritis nodosa with epididymitis and was treated with high-dose prednisolone, with a good clinical outcome.

A Fatal Case of Penile Calciphylaxis

Calciphylaxis is a rare and serious complication of chronic renal failure characterized by vascular calcium overload. It has a high mortality rate. Penile calciphylaxis is an extremely rare condition of penile necrosis due to calciphylaxis of the penile arterioles. Presented here is a severe case of systemic calciphylaxis initially presented as penile necrosis treated with sodium thiosulfate and amputation.

[CLINICAL AND IMAGING FINDINGS OF ACUTE EPIDIDYMITIS IN CHILDREN]

(Objective) The etiology of acute epididymitis in children remains poorly understood. Several studies have demonstrated that urine tests are negative in the majority of children with acute epididymitis, and the condition is self-limiting. The need for radiological evaluation of the urinary tract in children with acute epididymitis is still debatable. The aim of this study was to describe clinical and imaging findings in children with acute epididymitis. (Methods) We identified 47 children with acute epididymitis at our institute between 2017 and 2021.We retrospectively reviewed their clinical features and radiological and laboratory data. All children underwent ultrasonography of the kidney and urinary tract. (Results) Median patient age was 9 years (range, 6 months-16 years) and 60% of the cases occurred between the ages of 7 and 12 years. Thirteen children (28%) had a past history of genitourinary malformations. The common malformations were hypospadias in eight children and bladder dysfunction in three. Ultrasound revealed no new urinary tract abnormalities in the remaining 34 children. Urinalysis were performed in 27 children, nine of whom (33%) had pyuria. Urine culture was positive in two children. Of the nine children with genitourinary malformations, eight had pyuria. All 18 children without genitourinary malformations had a negative urinalysis except for one patient (p< 0.0001). (Conclusions) Acute epididymitis is a common cause of acute scrotum in pediatric patients. In this study, one-third of acute epididymitis cases presented pyuria, and about 30% had a past history of genitourinary malformations. The presence of pyuria was associated with a past history of genitourinary malformations. For children with no previous genitourinary malformations, routine use of ultrasound for the detection of urinary tract abnormalities is questionable due to the low yield.

Zinner Syndrome-A Rare Cause of Recurrent Epididymitis and Infertility

Zinner syndrome (ZS) is a rare disorder that affects only men. It is characterized by a triad of abnormalities, including unilateral renal agenesis, ipsilateral seminal vesicle cysts, and atresia of the ejaculatory tract. Unfortunately, there is no consensus on the best treatment modality. We describe a case of a young male patient with recurrent epididymitis, dysuria, and frequent urination. In the diagnostic evaluation, we found an extended right seminal vesicle in the ultrasound with hyperechoic fluid inside and an absence of the right kidney. We performed magnetic resonance imaging, computed tomography, and semen analysis confirming Zinner syndrome and deteriorated semen parameters. Urethroscopic evaluation and ultrasound-guided puncture of the seminal vesicle were performed. An abscess was excluded. The cytologic evaluation showed hemosiderophages. Tamsulosin was introduced. We found no signs of relapse in a six-month observation, and the patient had no further symptoms. Therefore, minimally invasive treatment is a feasible option in young patients found with early-stage Zinner syndrome.

Fournier's gangrene mimicking an acute epididymitis

Fournier's gangrene is a urologic emergency secondary to a necrotizing soft tissue infection. Fournier's gangrene is characterized by severe pain and features of Fournier's gangrene may include edema, blisters and bullae, crepitus, subcutaneous gas, and systemic symptoms. Risk factors include male gender, alcohol abuse, immunocompromised state, uncontrolled diabetes mellitus, obesity, and malignancy. The diagnosis is made clinically but is often supported by radiography, ultrasound, computed tomography, and magnetic resonance imaging. Treatment consists of emergent hospitalization and surgery to debride the necrotic tissues. Morbidity and mortality for Fournier's gangrene are very high if left untreated. Early surgical intervention is key to the successful treatment of Fournier's gangrene. This case report presents a case of Fournier's gangrene mimicking acute epididymitis and highlights the importance of a thorough physical examination with high clinical suspicion for Fournier's gangrene.

Activation of PTH1R alleviates epididymitis and orchitis through Gq and β-arrestin-1 pathways

Inflammation in the epididymis and testis contributes significantly to male infertility. Alternative therapeutic avenues treating epididymitis and orchitis are expected since current therapies using antibiotics have limitations associated to side effects and are commonly ineffective for inflammation due to nonbacterial causes. Here, we demonstrated that type 1 parathyroid hormone receptor (PTH1R) and its endogenous agonists, parathyroid hormone (PTH) and PTH-related protein (PTHrP), were mainly expressed in the Leydig cells of testis as well as epididymal epithelial cells. Screening the secretin family G protein-coupled receptor identified that PTH1R in the epididymis and testis was down-regulated in mumps virus (MuV)- or lipopolysaccharide (LPS)-induced inflammation. Remarkably, activation of PTH1R by abaloparatide (ABL), a Food and Drug Administration-approved treatment for postmenopausal osteoporosis, alleviated MuV- or LPS-induced inflammatory responses in both testis and epididymis and significantly improved sperm functions in both mouse model and human samples. The anti-inflammatory effects of ABL were shown to be regulated mainly through the Gq and β-arrestin-1 pathway downstream of PTH1R as supported by the application of ABL in Gnaq± and Arrb1-/- mouse models. Taken together, our results identified an important immunoregulatory role for PTH1R signaling in the epididymis and testis. Targeting to PTH1R might have a therapeutic effect for the treatment of epididymitis and orchitis or other inflammatory disease in the male reproductive system.

COVID-19 vaccination is associated with a decreased risk of orchitis and/or epididymitis in men

Vaccine hesitancy is a major public health obstacle to fighting the ongoing COVID‐19 epidemic. Due to studies that show COVID‐19 infection can affect sperm parameters and lead to orchitis, the public are concerned about the effect of the COVID vaccines on male reproduction. In this study, we investigated the association between COVID‐19 vaccination and risk of developing orchitis and/or epididymitis outcomes in a cohort of men using a large, US‐based, electronic health record database. After balancing for confounding variables, we found that receiving at least 1 COVID‐19 vaccine is associated with a decreased risk of developing orchitis and/or epididymitis.

Evaluating Acute Testicular Pain Using Point-of-Care Hand-Held Doppler in the Emergency Department: A Prospective Pilot Study

Introduction Testicular pain is one of the common conditions in patients visiting the emergency department. The causes of acute testicular pain vary from non-urgent inflammatory conditions like epididymo-orchitis to testicular torsion which is a surgical emergency. Early diagnosis of testicular torsion with early initiation of appropriate surgical intervention helps in salvaging the testes. There is a need for a simple, rapid bedside diagnostic tool for the evaluation and triaging of subjects with acute testicular pain in the emergency department. The aim of this study is to determine whether hand-held Doppler (HHD) examination by the emergency department (ED) physician can safely rule out testicular torsion in a case of acute testicular pain. Materials and Methods A prospective pilot study was conducted in the emergency department of Alkhor Hospital, Hamad Medical Corporation, Qatar. The subjects between 18 to 50 years of age who presented to the ED with testicular pain were included. Subjects with recent trauma to the scrotum, or recent genitourinary surgery and those who had pain for more than 48 hours were excluded. Point-of-care HHD was done by a single ED physician who was blinded for the Doppler study results done by the radiologist. The results of the HHD performed by the ED physician and Doppler study performed by the radiologist were compared and analyzed. Results  Forty-five patients were included in the study. The mean age was 28 years and the mean duration of pain was 20 hours. HHD ruled out testicular torsion in 44 subjects with a specificity of 97.8%. In one subject, HHD was reported as torsion testis which was ruled out by the radiologist. The radiologist Doppler ruled out torsion in all 45 subjects. Conclusion The diagnostic performance of HHD by the ED physicians was almost equal to that of radiologists in ruling out testicular torsion. HHD can be used as a first-line triaging tool by the ED physician to rule out torsion of testis in patients presenting with acute testicular pain. We conclude that patients with testicular pain with a negative HHD for torsion testis can be safely discharged from the emergency department.

S100A4 promotes the progression of lipopolysaccharide-induced acute epididymitis in mice†

S100A4 has been suggested to be a critical regulator of tumor metastasis and is implicated in the progression of inflammation. The aim of this study is to investigate the expression and possible role of S100A4 in epididymitis. Using a mouse model of epididymitis induced by the injection of lipopolysaccharide (LPS) in the deferent duct, we found that LPS administration induced an upregulation of S100a4 transcription (P < 0.05) and a recruitment of S100A4 positive cells in the epididymal interstitium of wild type (WT) mice. Co-immunofluorescence showed that S100A4 was mainly expressed by granulocytes, CD4 lymphocytes, and macrophages. Deficiency of S100A4 reduced epididymal pathological reaction and the mRNA levels of the pro-inflammatory cytokines IL-1β and TNF-α (P < 0.01), suggesting that S100A4 promotes the progression of epididymitis. Furthermore, S100A4 deficiency alleviated the decline of sperm motility and rectified the abnormal expression of sperm membrane protein AMAD3, which suggested that in the progression of epididymitis, S100A4 aggravates the damage to sperm vitality. In addition, both Ki-67 marked cell proliferation and transferase-mediated dUTP-biotin nick end labeling detected cell apoptosis were reduced in S100a4-/- mice compared with WT mice after LPS treatment, indicating that S100A4 promotes both cell proliferation and cell apoptosis in epididymitis. Overall, these results demonstrate that S100A4 promotes the progression of LPS-induced epididymitis and facilitates a decline in sperm vitality, and its function may be related to the process of cell proliferation and apoptosis during inflammation.

C-Type Natriuretic Peptide Plays an Anti-Inflammatory Role in Rat Epididymitis Induced by UPEC

Human epididymitis is mainly caused by retrograde urinary tract infection with uropathogenic Escherichia coli (UPEC). This disease is an important factor (accounting for 20-30%) causing male infertility. C-type natriuretic peptide (CNP), a protein composed of 22 amino acids, is proved to play an immunoregulatory role in respiratory and cardiovascular systems. CNP is expressed extremely high in the epididymis, but whether CNP plays the same role in acute epididymitis is unclear. At first, we established an acute caput epididymitis model in rats with UPEC and treated them with CNP to measure inflammatory damage. Then RNA-seq transcriptome technology was used to reveal potential signal pathways. Secondly, the turbidity and activity of UPEC were assessed using a microplate reader and the amount of UPEC by agar plates after incubation with CNP. Thirdly, macrophages in caput epididymis were tested by immunohistochemistry (IHC). Meanwhile, lipopolysaccharide (LPS) with or without CNP was used to stimulate the macrophage (RAW264.7) in vitro and to detect the expression level of pro-inflammatory factors. Finally, the macrophage (RAW264.7) was treated with CNP, 8-Br-cGMP [cyclic guanosinc monophosphate (cGMP) analog] and KT5823 [protein kinase G (PKG) inhibitor], and the expression level of nuclear factor-k-gene binding (NF-kB) signal pathway was examined. The results showed that the damage of epididymis induced by UPEC as well as the pro-inflammatory factors could be alleviated significantly with CNP treatment. CNP could inhibit the activity and numbers of bacteria in both in vivo and in vitro experiments. Moreover, CNP repressed the invasion, and the expression of pro-inflammatory factors (such as NF-kB, IL-1β, IL-6, TNF-α) in macrophages and its effect could be inhibited by KT5823. Therefore, we drew a conclusion from the above experiments that CNP alleviates the acute epididymitis injury induced by UPEC. On one hand, CNP could inhibit the growth of UPEC. On the other hand, CNP could decrease invasion and inflammatory reaction of macrophages; the mechanism was involved in inhibiting NF-kB signal pathway through the cGMP/PKG in macrophages. This research would open up the possibility of using CNP as a potential treatment for epididymitis.

Damaged male germ cells induce epididymitis in mice

Epididymitis can be caused by infectious and noninfectious etiological factors. While microbial infections are responsible for infectious epididymitis, the etiological factors contributing to noninfectious epididymitis remain to be defined. The present study demonstrated that damaged male germ cells (DMGCs) induce epididymitis in mice. Intraperitoneal injection of the alkylating agent busulfan damaged murine male germ cells. Epididymitis was observed in mice 4 weeks after the injection of busulfan and was characterized by massive macrophage infiltration. Epididymitis was coincident with an accumulation of DMGCs in the epididymis. In contrast, busulfan injection into mice lacking male germ cells did not induce epididymitis. DMGCs induced innate immune responses in epididymal epithelial cells (EECs), thereby upregulating the pro-inflammatory cytokines such as tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and interleukin-1β (IL-1β), as well as the chemokines such as monocyte chemotactic protein-1 (MCP-1), monocyte chemotactic protein-5 (MCP-5), and chemokine ligand-10 (CXCL10). These results suggest that male germ cell damage may induce noninfectious epididymitis through the induction of innate immune responses in EECs. These findings provide novel insights into the mechanisms underlying noninfectious epididymitis, which might aid in the diagnosis and treatment of the disease.

Henoch-Schönlein Purpura With Scrotal Involvement: A Case Report and Literature Review

Henoch-Schönlein purpura (HSP) is the most common vasculitis of childhood and affects the small blood vessels, leading to arthritis, abdominal pain, and renal involvement. However, scrotal involvement is a rare complication of HSP and scrotal pain. Swelling is the most frequent clinical presentation and can be easily confused with testicular torsion. If not treated in time, the scrotal inflammation will result in irreversible testicular necrosis. We report a 6-year-old male with HSP and scrotal involvement, characterized by swelling and pain on the left side of the scrotum, rashes on both lower extremities, and epididymitis. He was treated with conservative care, corticosteroids, and antibiotic therapy. We were able to avoid surgical intervention. On the 10 days of treatment, he recovered sufficiently well and was discharged. We have reviewed the literature related to HSP with scrotal involvement, identified 21 cases, and revealed that steroid therapy and/or antibiotics are the first-line of therapy in children with scrotal involvement. Vasculitis in the scrotum may predispose to testicular torsion, which is a complication that should not be overlooked. Clinicians should be aware of the atypical types of HSP. Timely diagnosis and appropriate treatment are essential for achieving the best results.

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.

Tuberculosis Relapse in the Epididymis After the Completion of Nine Months of Anti-Tuberculosis Chemotherapy in a Patient with Poorly Controlled Diabetes Mellitus

The standard six-month tuberculosis (TB) treatment comprises an intensive phase lasting two months, followed by a continuation phase lasting four months. Meanwhile, the nine-month regimen, which has a prolonged continuation phase, is indicated for patients with complicated diabetes mellitus (DM) because of their poor response to treatment. A 61-year-old Japanese man with poorly controlled DM for five years presented with bilateral scrotal swelling noticed two weeks ago. He had a history of pleuritis, pericarditis, and peritonitis two years ago. These symptoms led to the diagnosis of culture-negative extrapulmonary TB. He received the nine-month chemotherapy regimen (isoniazid, rifampin, pyrazinamide, and ethambutol for two months, followed by isoniazid and rifampin for seven months), and his symptoms significantly improved. The swollen scrotum was accompanied by mild tenderness and pus discharge from a fistula. Imaging study revealed bilaterally diffusely enlarged epididymis. However, the acid-fast bacilli smear and culture and polymerase chain reaction using urine and pus discharge tested negative. Bilateral epididymectomy was performed. Although the acid-fast bacilli smear was negative, the pathology demonstrated granuloma formation and acid-fast bacilli tissue culture confirmed multi-drug resistant Mycobacterium tuberculosis. The optimal treatment regimen and duration for extrapulmonary TB with unknown drug susceptibility are debatable. The nine-month regimen can be insufficient in some cases. Thus, detailed follow-up is essential, and TB relapse should be thoroughly monitored.

Radiological patterns of incidental epididymitis in mild-to-moderate COVID-19 patients revealed by colour Doppler ultrasound

The testis is a potential target organ for SARS-CoV-2 infection. Our study intended to investigate any testicular involvement in mild-to-moderate COVID-19 men. We conduct a cross-sectional study in 18 to 55-year-old men hospitalised for confirmed COVID-19. A senior radiologist executed the ultrasound with multi-frequency linear probe in all participants, regardless of any scrotal complaints. Exclusion criteria involved any situation that could impair testicular function. Statistical analysis compared independent groups, classified by any pathological change. Categorical and numerical outcome hypotheses were tested by Fisher's Exact and Mann-Whitney tests, using the Excel for Mac, version 16.29 (p < .05). The sample size was 26 men (mean 33.7 ± 6.2 years; range: 21-42 years), all without scrotal complaints. No orchitis was seen. Eleven men (32.6 ± 5.8 years) had epididymitis (42.3%), bilateral in 19.2%. More than half of men with epididymitis displayed epididymal head augmentation > 1.2 cm (p = .002). Two distinct epididymitis' patterns were reported: (a) disseminated micro-abscesses (n = 6) and (b) inhomogeneous echogenicity with reactional hydrocele (n = 5). Both patterns revealed increased epididymal head, augmented Doppler flow and scrotal skin thickening. The use of colour Doppler ultrasound in mild-to-moderate COVID-19 men, even in the absence of testicular complaints, might be useful to diagnose epididymitis that could elicit fertility complications.

Catheter Management and Risk Stratification of Patients With in Inpatient Treatment Due to Acute Epididymitis

Objective: This study aims to evaluate catheter management in acute epididymitis (AE) patients requiring inpatient treatment and risk factors predicting severity of disease.

Material and Methods: Patients with diagnosed AE and inpatient treatment between 2004 and 2019 at the University Hospital Frankfurt were analyzed. A risk score, rating severity of AE, including residual urine > 100 ml, fever > 38.0°C, C-reactive protein (CRP) > 5 mg/dl, and white blood count (WBC) > 10/nl was introduced.

Results: Of 334 patients, 107 (32%) received a catheter (transurethral (TC): n = 53, 16%, suprapubic (SPC): n = 54, 16%). Catheter patients were older, exhibited more comorbidities, and had higher CRP and WBC compared with the non-catheter group (NC). Median length of stay (LOS) was longer in the catheter group (7 vs. 6 days, p < 0.001), whereas necessity of abscess surgery and recurrent epididymitis did not differ. No differences in those parameters were recorded between TC and SPC. According to our established risk score, 147 (44%) patients exhibited 0–1 (low-risk) and 187 (56%) 2–4 risk factors (high-risk). In the high-risk group, patients received a catheter significantly more often than with low-risk (TC: 22 vs. 9%; SPC: 19 vs. 12%, both p ≤ 0.01). Catheter or high-risk patients exhibited positive urine cultures more frequently than NC or low-risk patients. LOS was comparable between high-risk patients with catheter and low-risk NC patients.

Conclusion: Patients with AE who received a catheter at admission were older, multimorbid, and exhibited more severe symptoms of disease compared with the NC patients. A protective effect of catheters might be attributable to patients with adverse risk constellations or high burden of comorbidities. The introduced risk score indicates a possibility for risk stratification.

Differential Immune Response to Infection and Acute Inflammation Along the Epididymis

The epididymis is a tubular structure connecting the vas deferens to the testis. This organ consists of three main regions—caput, corpus, and cauda—that face opposing immunological tasks. A means of combating invading pathogens is required in the distally located cauda, where there is a risk of ascending bacterial infections originating from the urethra. Meanwhile, immune tolerance is necessary at the caput, where spermatozoa with immunogenic neo-antigens originate from the testis. Consistently, when challenged with live bacteria or inflammatory stimuli, the cauda elicits a much stronger immune response and inflammatory-inflicted damage than the caput. At the cellular level, a role for diverse and strategically positioned mononuclear phagocytes is emerging. At the mechanistic level, differential expression of immunoprotective and immunomodulatory mediators has been detected between the three main regions of the epididymis. In this review, we summarize the current state of knowledge about region-specific immunological characteristics and unveil possible underlying mechanisms on cellular and molecular levels. Improved understanding of the different immunological microenvironments is the basis for an improved therapy and counseling of patients with epididymal infections.

Lipopolysaccharide-induced epididymitis modifies the transcriptional profile of Wfdc genes in mice†

Whey-acidic protein four-disulfide core domain (WFDC) genes display putative roles in innate immunity and fertility. In mice, a locus on chromosome 2 contains 5 and 11 Wfdc genes in its centromeric and telomeric subloci, respectively. Although Wfdc genes are highly expressed in the epididymis, their contributions to epididymal function remain elusive. Here, we investigated whether Wfdc genes are regulated in response to lipopolysaccharide (LPS)-induced epididymitis, an inflammatory condition that impairs male fertility. We induced epididymitis in mice via (i) interstitial LPS injection into epididymal initial segment and (ii) intravasal LPS injection into the vas deferens towards cauda epididymis. Interstitial and intravasal LPS induced a differential upregulation of inflammatory mediators (interleukin 1 beta, interleukin 6, tumor necrosis factor, interferon gamma, and interleukin 10) in the initial segment and cauda epididymis within 72 h post-treatment. These changes were accompanied by a time-dependent endotoxin clearance from the epididymis. In the initial segment, interstitial LPS upregulated all centromeric (Slpi, Wfdc5, Wfdc12, Wfdc15a, and Wfdc15b) and five telomeric (Wfdc2, Wfdc3, Wfdc6b, Wfdc10, and Wfdc13) Wfdc transcripts at 24 and 72 h. In the cauda epididymis, intravasal LPS upregulated Wfdc5 and Wfdc2 transcripts at 24 h, followed by a downregulation of Wfdc15b and three telomeric (Wfdc6a, Wfdc11, and Wfdc16) gene transcripts at 72 h. Pharmacological inhibition of nuclear factor kappa B activation prevented LPS-induced upregulation of centromeric and telomeric Wfdc genes depending on the epididymal region. We show that LPS-induced inflammation differentially regulated the Wfdc locus in the proximal and distal epididymis, indicating region-specific roles for the Wfdc family in innate immune responses during epididymitis.

The Immune Characteristics of the Epididymis and the Immune Pathway of the Epididymitis Caused by Different Pathogens

The epididymis is an important male accessory sex organ where sperm motility and fertilization ability develop. When spermatozoa carrying foreign antigens enter the epididymis, the epididymis shows "immune privilege" to tolerate them. It is well-known that a tolerogenic environment exists in the caput epididymis, while pro-inflammatory circumstances prefer the cauda epididymis. This meticulously regulated immune environment not only protects spermatozoa from autoimmunity but also defends spermatozoa against pathogenic damage. Epididymitis is one of the common causes of male infertility. Up to 40% of patients suffer from permanent oligospermia or azoospermia. This is related to the immune characteristics of the epididymis itself. Moreover, epididymitis induced by different pathogenic microbial infections has different characteristics. This article elaborates on the distribution and immune response characteristics of epididymis immune cells, the role of epididymis epithelial cells (EECs), and the epididymis defense against different pathogenic infections (such as uropathogenic Escherichia coli, Chlamydia trachomatis, and viruses to provide therapeutic approaches for epididymitis and its subsequent fertility problems.

Comprehensive transcriptome analysis based on RNA sequencing identifies critical genes for lipopolysaccharide-induced epididymitis in a rat model

Epididymitis is a commonly diagnosed disease associated with male infertility. However, little is known about the molecules that are involved in its development. This study was to identify critical genes associated with lipopolysaccharide-induced epididymitis and analyze the molecular mechanism of epididymitis through RNA sequencing. Experimental epididymitis models were generated by administering male Sprague–Dawley rats' lipopolysaccharide. A total of 1378 differentially expressed genes, including 531 upregulated and 847 downregulated genes, were identified in the epididymitis model rats compared with those in sham-operated rats by RNA sequencing. Functional enrichment analyses suggested that the upregulated genes were markedly enriched in inflammation-related biological processes, as well as in the tumor necrosis factor (TNF) signaling pathway, cytokine–cytokine receptor interactions, complement and coagulation cascades, and in the chemokine signaling pathway. Four downregulated genes (collagen type XXVIII alpha 1 chain [Col28α1], cyclin-dependent kinase-like 1 [Cdkl1], phosphoserine phosphatase [Psph], and fatty acid desaturase 2 [Fads2]) and ten upregulated genes (CCAAT/enhancer-binding protein beta [Cebpβ], C-X-C motif chemokine receptor 2 [Cxcr2], interleukin 11 [Il11], C-C motif chemokine ligand 20 [Ccl20], nuclear factor-kappa-B inhibitor alpha [Nfkbiα], claudin 4 [Cldn4], matrix metallopeptidase 9 [Mmp9], heat shock 70 kDa protein 8 [Hspa8], intercellular cell adhesion molecule-1 [Icam1], and Jun) were successfully confirmed by real-time polymerase chain reaction. Western blot demonstrated that CDKL1 was decreased, while MMP9 and NFKBIA were increased in the experimental model group compared with those in the sham-operated group. Our study sheds new light on the understanding of the early response of the epididymis during bacterial epididymitis.

Epididymitis rates in Australian hospitals 2009-2018: ecological analysis

OBJECTIVES

To investigate rates of acute epididymitis diagnosed in Australian hospital settings.

METHODS

Yearly hospital admission and emergency department (ED) rates of epididymitis as primary diagnoses were calculated for 15-44-year-old men for three states (Victoria, New South Wales, Queensland) from 2009 to 2014 using population denominators. Zero inflated Poisson regression models were used to analyse variation in rates by year, age, and residential area. Additionally, we investigated national epididymitis admission trends from 2009 to 2018 using generalised linear models.

RESULTS

Between 2009 and 2014, there was a total of 7375 admissions and 17 281 ED presentations for which epididymitis was the main reason for care. Most epididymitis diagnoses (94.0% in admissions, 99.7% in EDs) were without abscess, and 2.5% of admissions were for chlamydial epididymitis. Almost a quarter (23.3%) of epididymitis diagnosed in EDs resulted in hospital admission. In 2014, the epididymitis rate per 100 000 men was 38.7 in admissions and 91.9 in EDs. Comparing 2014 with 2009, the overall epididymitis diagnosis rate increased in admissions by 32% (adjusted incident rate ratio (aIRR) 1.32, 95% CI 1.20 to 1.44) and in ED attendances by 40% (aIRR 1.40, 95% CI 1.31 to 1.49). By age, the highest rates were among men 35-44 years in admissions and men 15-24 years in EDs. National admission rates of epididymitis during 2009-2018 showed a similar pattern.

CONCLUSION

Rates of epididymitis diagnosis in hospital admission and ED presentations increased. Different age-related rates in these settings suggest a different aetiology or differential severity by age group.

Dexamethasone improves therapeutic outcomes in a preclinical bacterial epididymitis mouse model

STUDY QUESTION

Can dexamethasone improve infertility-related cauda epididymidal tissue damage caused by bacterial epididymitis?

SUMMARY ANSWER

Dexamethasone in addition to anti-microbial treatment effectively reduces long-term deleterious epididymal tissue damage by dampening the host's adaptive immune response.

WHAT IS KNOWN ALREADY

Despite effective anti-microbial treatment, ~40% of patients with epididymitis experience subsequent sub- or infertility. An epididymitis mouse model has shown that the host immune response is mainly responsible for the magnitude of epididymal tissue damage that is fundamentally causative of the subsequent fertility issues.

STUDY DESIGN, SIZE, DURATION

Bacterial epididymitis was induced in male mice by using uropathogenic Escherichia coli (UPEC). From Day 3 after infection onwards, mice were treated with daily doses of levofloxacin (20 mg/kg, total n = 12 mice), dexamethasone (0.5 mg/kg, total n = 9) or both in combination (total n = 11) for seven consecutive days. Control animals were left untreated, i.e. given no interventional treatment following UPEC infection (total n = 11). Half of the animals from each group were killed either at 10 or 31 days post-infection.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A mouse model of induced bacterial epididymitis was applied to adult male C57BL/6J mice. At the respective endpoints (10 or 31 days post-infection), epididymides were collected. Effectiveness of antibiotic treatment was assessed by plating of epididymal homogenates onto lysogeny broth agar plates. Overall tissue morphology and the degree and nature of tissue damage were assessed histologically. Quantitative RT-PCR was used to assess local cytokine transcript levels. Blood was drawn and serum analysed for systemic IgG and IgM levels by ELISA. In addition, correlation analyses of clinical data and serum-analyses of IgG and IgM levels in patients with epididymitis were performed.

MAIN RESULTS AND THE ROLE OF CHANCE

The addition of dexamethasone to the standard anti-microbial treatment did not further worsen epididymal tissue integrity. In fact, an obviously dampened immune response and reduced tissue reaction/damage was observed at both 10 and 31 days post-infection following combined treatment. More specifically, epididymal duct continuity was preserved, enabling sperm transit. In contrast, in untreated or antibiotic-treated animals, damage of the epididymal duct and duct constrictions were observed, associated with a lack of cauda spermatozoa. In line with the bacteriostatic/bactericidal effect of levofloxacin (alone as well as in combination), local cytokine transcript levels were significantly and similarly reduced in animals treated with levofloxacin alone (P < 0.01) or in combination with dexamethasone (P < 0.05) compared to UPEC-infected untreated animals. Interestingly, the addition of dexamethasone to the anti-microbial treatment induced a unique dampening effect on adaptive immunity, since systemic IgG and IgM levels as well as the pan-T cell marker CD3 were reduced at both 10 and 31 days post-infection.

LIMITATIONS, REASONS FOR CAUTION

Breeding studies to address the fertility-protecting effect of the combined treatment were not possible in the experimental animals because the vas deferens was ligated (model specific).

WIDER IMPLICATIONS OF THE FINDINGS

Whereas innate immunity is necessary and involved in acute bacterial clearance, adaptive immunity seems to be responsible for long-term, subclinical immunological activities that may negatively affect the pathogenesis of bacterial epididymitis even after effective bacterial eradication. These effects can be reduced in mice by the additional treatment with dexamethasone. This immunological characteristic of bacterial epididymitis shows similarities to the Jarisch-Herxheimer reaction known from other types of bacterial infection.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by grants from the Deutsche Forschungsgemeinschaft, Monash University and the Medical Faculty of Justus-Liebig University to the International Research Training Group on 'Molecular pathogenesis of male reproductive disorders' (GRK 1871). R.W., K.L.L. and M.P.H. were supported by grants from the National Health and Medical Research Council of Australia (ID1079646, ID1081987, ID1020269 and ID1063843) and by the Victorian Government's Operational Infrastructure Support Program. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

No clinical trial involved.

Overview of ultrasound applications for assessing scrotal disorders

The scrotum may be affected by a plethora of different disorders such as infections, vasculopathies, trauma, and manifestations of primary and secondary malignant masses. In addition to the patient's medical history and clinical examination, ultrasound represents the imaging modality of choice to assess scrotal disorders. Time-consuming contrast-enhanced ultrasound and elastography can provide further information to distinguish between benign and malignant testicular mass lesions. The following invited Special Communication gives a comprehensive overview of differential diagnoses of the scrotum and their corresponding sonomorphologic correlates based on representative cases of the Interdisciplinary Ultrasound Center of the University Hospital Munich.

Assessing the Utility of Ultrasound and Urinalysis for Patients with Possible Epididymo-Orchitis - A Retrospective Study

Purpose

Many experts recommend ordering an ultrasound and a urinalysis on all patients with scrotal pain. While the ultrasound may help diagnose a number of potential causes of scrotal pain, the urinalysis primarily has value in assessing for epididymo-orchitis. This study sought to evaluate the utility of these diagnostic tests for patients who presented to the emergency department (ED) with acute scrotal pain and possible epididymo-orchitis.

Patients and Methods

This was a single-center chart review of patients presenting to the ED with scrotal pain. Trained research assistants reviewed charts to obtain urinalysis and ultrasound results as well as diagnoses and treatments provided. Using the final diagnosis as a gold standard, the sensitivity and specificity of ultrasound and urinalysis were calculated for the diagnosis of epididymo-orchitis. Also, through a prespecified definition of “changed management,” we estimated the percentage of cases in which a urinalysis changed management of patients with acute scrotal pain.

Results

We identified 663 adult and pediatric patients who presented with scrotal pain during 2016. All patients had an ultrasound performed, and 458 (69.1%) had a urinalysis done. The sensitivity of urinalysis for epididymo-orchitis was 58.2% (95% CI 48.9% to 67.1%), and the specificity was 85.1% (95% CI 80.8% to 88.7%). For ultrasound, the sensitivity was 78.8% (95% CI 71.4% to 85.0%) and the specificity was 98.1% (95% CI 96.4% to 99.1%). In 24 of 458 cases (5.2% [95% CI 3.4% to 7.7%]) where a urinalysis was obtained, its results may have changed management of the patient.

Conclusion

The diagnosis of patients who present to the ED with scrotal pain is primarily driven by the ultrasound results. While the urinalysis may occasionally provide some benefit in the evaluation of patients with suspected epididymo-orchitis, the reflexive ordering of a urinalysis in patients with scrotal pain may be unnecessary.

BCCN84.3

Members of the genus Brucella cluster in two phylogenetic groups: classical and non-classical species. The former group is composed of Brucella species that cause disease in mammals, including humans. A Brucella species, labeled as Brucella sp. BCCN84.3, was isolated from the testes of a Saint Bernard dog suffering orchiepididymitis, in Costa Rica. Following standard microbiological methods, the bacterium was first defined as “Brucella melitensis biovar 2.” Further molecular typing, identified the strain as an atypical “Brucella suis.” Distinctive Brucella sp. BCCN84.3 markers, absent in other Brucella species and strains, were revealed by fatty acid methyl ester analysis, high resolution melting PCR and omp25 and omp2a/omp2b gene diversity. Analysis of multiple loci variable number of tandem repeats and whole genome sequencing demonstrated that this isolate was different from the currently described Brucella species. The smooth Brucella sp. BCCN84.3 clusters together with the classical Brucella clade and displays all the genes required for virulence. Brucella sp. BCCN84.3 is a species nova taxonomical entity displaying pathogenicity; therefore, relevant for differential diagnoses in the context of brucellosis. Considering the debate on the Brucella species concept, there is a need to describe the extant taxonomical entities of these pathogens in order to understand the dispersion and evolution.

Traditional Chinese medicine on treating epididymitis: A systematic review and meta-analysis protocol

BACKGROUND

Epididymitis is a common disease in nonspecific infections of the male reproductive system according to the clinical incidence of acute epididymitis and chronic epididymitis. Many clinical trials have proven that Chinese medicine has a significant effect in the treatment of epididymitis. In this systematic review, we aim to evaluate the effectiveness and safety of traditional Chinese medicine (TCM) for epididymitis.

METHODS

We will search for PubMed, Cochrane Library, AMED, Embase, WorldSciNet, Nature, Science online, China Journal Full-text Database (CNKI), China Biomedical Literature CD-ROM Database (CBM), and related randomized controlled trials included in the China Resources Database. The time is limited from the construction of the library to November 2018. We will use the criteria provided by Cochrane 5.1.0 for quality assessment and risk assessment of the included studies, and use the Revman 5.3 and Stata13.0 software for meta-analysis of the effectiveness, recurrence rate, and symptom scores of epididymitis.

ETHICS AND DISSEMINATION

This systematic review will evaluate the efficacy and safety of TCM for treating epididymitis. Because all of the data used in this systematic review and meta-analysis has been published, this review does not require ethical approval. Furthermore, all data will be analyzed anonymously during the review process.Registration number: PROSPERO CRD42019130569.

The safety and efficacy of acupuncture for epididymitis protocol for a systematic review

BACKGROUND

Epididymitis is a common disease in non-specific infections of the male reproductive system. According to the clinical incidence of acute epididymitis and chronic epididymitis, which is more common in chronic epididymitis. There are many clinical trials confirmed that acupuncture treatment can relieve pain and improve symptoms of epididymitis to some extent. In this systematic review, we aim to evaluate the effectiveness and safety of acupuncture for epididymitis.

METHODS AND ANALYSIS

We will search for PubMed, Cochrane Library, AMED, EMbase, WorldSciNet; Nature, Science online and China Journal Full-text Database (CNKI), China Biomedical Literature CD-ROM Database (CBM), and related randomized controlled trials included in the China Resources Database. The time is limited from the construction of the library to November 2018. We will use the criteria provided by Cochrane 5.1.0 for quality assessment and risk assessment of the included studies, and use the Revman 5.3 and Stata13.0 software for meta-analysis of the effectiveness, recurrence rate, and symptom scores of epididymitis.

ETHICS AND DISSEMINATION

This systematic review will evaluate the efficacy and safety of acupuncture for epididymitis. Because all of the data used in this systematic review and meta-analysis has been published, this review does not require ethical approval. Furthermore, all data will be analyzed anonymously during the review process trial.

REGISTRATION NUMBER

PROSPERO CRD42018111348.

Staphylococcus haemolyticus epididymo-orchitis and bacteraemia: a case report

Introduction

Although more often recognized as a culprit in female urinary tract infection, coagulase-negative staphylococci (CoNS) can cause severe genitourinary infections in men. While positive blood cultures with CoNS are usually thought to be contaminants, in the setting of a severe genito-urinary infection they can represent true infection.

Case presentation

We present the case of a 70-year-old male without a central venous catheter or urinary catheter who developed Staphylococcus haemolyticus bloodstream infection secondary to epididymo-orchitis.

Conclusion

This case highlights the importance of prompt recognition of serious CoNS infections, including bacteraemia, in the setting of CoNS genitourinary tract infections.

Chronic epididymitis and Grade III varicocele and their associations with semen characteristics in men consulting for couple infertility

Chronic epididymitis and varicocele are frequently observed genital disorders in men consulting for couple infertility, but their impact on semen characteristics at the time of infertility consultation is still a matter of debate. We investigated 652 male partners of couples who had their first infertility consultation between 1999 and 2015 in Argentina. Men with chronic epididymitis (n = 253), Grade III varicocele (n = 106), and both conditions (n = 125) were compared with a control group (n = 168) composed of men without these disorders or any other recognized causes of male infertility. We showed that men who presented isolated chronic epididymitis were more likely to have high percentages of low sperm motility and abnormal sperm morphology as well as a high number of white blood cells. Men with isolated Grade III varicocele had low sperm production and motility and an increased percentage of abnormal sperm morphology. Finally, men who simultaneously presented chronic epididymitis with Grade III varicocele had a low sperm motility and increased percentage of abnormal sperm morphology as well as a high number of white blood cells. Physical examination of the genital organs may identify common disorders, potentially involved as causal factors of patient's infertility. These disorders are associated with specific seminal profiles that should help in identifying the best treatment from the available therapeutic options, effectiveness, safety, and allowing as much as possible natural conception.

Alveolar paratesticular rhabdomyosarcoma mimicing epididymitis: Case report and literature review

RATIONALE

Most patients with paratesticular rhabdomyosarcoma may typically present as a unilateral, painless palpable scrotum mass. However, only a few cases of RMS presenting as painful edema of the scrotum mimicing epididymitis. We herein report an unusual case of alveolar paratesticular rhabdomyosarcoma misdiagnosed as epididymitis.

PATIENT CONCERNS

A 19-year-old adolescent, presented to urologist with painful swelling of the scrotum on the left side over the preceding several days. Antibiotics were administered by physician for two months and the pain improved, but the swelling did not fade.

DIAGNOSES

Alveolar praratesticular rhabdomyosarcoma.

INTERVENTIONS

A left, soft tissue mass in the scrotum without definite metastasis or lymphadenopathy was confirmed by computed tomography (CT) and magnetic resonance imaging. A radical left orchiectomy via the inguinal approach was performed successfully.

OUTCOME

The patient received 8 cycles of adjuvant chemotherapy, the patient remains recurrence- and metastasis-free at 13 months after surgery.

LESSONS

When paratesticular RMS is presenting with symptoms of epididymitis, this malignant tumor is usually overlooked. When patients complain of painful scrotal swelling, RMS arise from paratesticular tissue should be considered.