Материал: Oxford American Handbook of Urology ( PDFDrive )

162 CHAPTER 5 Infections and inflammatory conditions

Epididymitis and orchitis

This is an inflammatory condition of the epididymis, often involving the testis, and caused usually caused by bacterial infection. It has an acute onset and a clinical course lasting <6 weeks. It presents with pain, swelling, and tenderness of the epididymis.

It should be distinguished from chronic epididymitis, where there is longstanding pain in the epididymis but usually no swelling. Untreated, bacterial epididymitis can extend to the testicle, resulting in epididmo-orchitis.

Infection ascends from the urethra or bladder. In men aged <35 years, the infective organism is usually N. gonorrhoeae, C. trachomatis, or coliform bacteria (causing a urethritis that then ascends to infect the epididymis).

In children and older men, the infective organisms are usually coliforms (such as E coli, Pseudomonas, Proteus, and Klebsiella species). Occasionally, Ureaplasma urealyticum, Corynebacterium, or Mycoplasma is the cause.

Mycobacterium tuberculosis (TB) is a rarer cause—the epididymis feels like a beaded cord.

A rare, noninfective cause of epididymitis is the antiarrhythmic drug amiodarone, which causes inflammation and resolves on discontinuation of the drug. Vasculitis, sarcoidosis, and more rare infections (coccidioidomycosis, blastomycosis) can be seen in immunocompromised men.

Differential diagnosis

Torsion of the testicle is the leading differential diagnosis. A preceding history of symptoms suggestive of urethritis, STD or urinary infection (dysuria, frequency, urgency, and suprapubic pain) suggest that epididymitis is the cause of the scrotal pain, but these symptoms may not always be present in epididymitis.

In epididymitis pain, tenderness and swelling may be confined to the epididymis, whereas in torsion, the pain and swelling are localized to the testis. However, there may be overlap in these physical signs.

Where the diagnosis is not clear between torsion or epididymitis, exploration is the safest option. Though radionuclide scanning can differentiate between a torsion and epididymitis, this is not available in many hospitals.

Color Doppler ultrasonography, which provides a visual image of blood flow, can differentiate between a torsion and epididymitis, but its sensitivity for diagnosing torsion is only 80% (i.e., it ‘misses’ the diagnosis in as many as 20% of cases—these 20% have torsion but normal findings on Doppler ultrasonography of the testis). Its sensitivity for diagnosing epididymitis is about 70%.

Again, if in doubt, explore. Complications of acute epididymitis abscess formation, infarction of the testis, chronic pain, and infertility.

Treatment of epididymitis

Culture urine, any urethral discharge, and blood (if the patient appears systemically ill). Urine cultures are often sterile. Management consists of bed rest, analgesia, anti-inflammatories, ice packs and antibiotics. Any form of urethral instrumentation should be avoided.

EPIDIDYMITIS AND ORCHITIS 163

•With suspected gonorrhea infection: Ceftriaxone 125 mg IM in a single dose or Cefixime 400 mg orally in a single dose or 400 mg by suspension (200 mg/5 mL) with treatment for chlamydia if chlamydial infection is not ruled out.

•Where C. trachomatis is a possible infecting organism, prescribe a 10–14 day course of tetracycline 500 mg 4 times a day or doxycycline 100mg twice daily.

•For non-STD related epididymitis, prescribe antibiotics empirically (until culture results are available). Typically levofloxin or ofloxacin x 14 days.

•When the patient is systemically ill, IV gentamicin and ampicillin are often used. When afebrile complete a 14 day total antibiotic course based on sensitivities.

Chronic epididymitis

Chronic epididymitis is diagnosed in patients with long-term pain in the epididymis and testicle. It can result from recurrent episodes of acute epididymitis. Clinically, the epididymis is thickened and may be tender. Treatment is with the appropriate antibiotics (guided by cultures), or epididymectomy in severe cases.

Supportive therapy with gabapentin and tricyclic antidepressants has shown to sometimes control symptoms.

Orchitis

Orchitis is inflammation of the testis, although it often occurs with epididymitis (epididymo-orchitis). Causes include mumps; M. tuberculosis; syphilis; autoimmune processes (granulomatous orchitis). The testis is swollen and tense, with edema of connective tissues and inflammatory cell infiltration. Treat the underlying cause.

Mumps orchitis occurs in 30% of infected post-pubertal males. It manifests 3–4 days after the onset of parotitis, and can result in tubular atrophy. 10–30% of cases are bilateral and are associated with infertility.

164 CHAPTER 5 Infections and inflammatory conditions

Periurethral abscess

This can occur in patients with urethral stricture disease, in association with gonococcal urethritis and following urethral catheterization. These conditions predispose to bacteria (gram-negative rods, enterococci, anaerobes, gonococcus) gaining access through Buck fascia to the periurethral tissues. If not rapidly diagnosed and treated, infection can spread to the perineum, buttocks, and abdominal wall.

The majority (90%) of patients present with scrotal swelling and a fever. Up to 20% will have presented with urinary retention, 10% with a urethral discharge, and 10% having spontaneously discharged the abscess through the urethra.

The abscess should be incised and drained, a suprapubic catheter placed to divert the urine away from the urethra, and broad-spectrum antibiotics commenced (gentamicin and cefuroxime) until antibiotic sensitivities are known.

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166 CHAPTER 5 Infections and inflammatory conditions

Prostatitis: epidemiology and classification

Prostatitis is infection and/or inflammation of the prostate.

Classification of prostatitis

Given the variation in the descriptions of prostatitis clinically, in 1999 the National Institutes of Health (NIH) developed a classification system for prostatitis:1

IAcute bacterial prostatitis (ABP)

Acute and chronic bacterial (NIH I and II) forms of prostatitis are defined by documented bacterial infections of the prostate.

Chronic pelvic pain syndrome (NIH III) is characterized primarily by urological pain complaints in the absence of urinary tract infection.

Asymptomatic inflammatory prostatitis (NIH IV) is the incidental finding of prostatic inflammation on a biopsy specimen without any specific symptoms.

Epidemiology

The most common type of prostatitis is NIH III chronic pelvic pain syndrome, accounting for 90–95% of cases of prostatitis. Acute and chronic bacterial prostatitis (NIH I and II) each makes up another 2–5% of cases.

Pathogenesis

The tissues surrounding the prostatic acini become infiltrated with inflammatory cells (lymphocytes). The most common infective agents are gramnegative Enterobacteriaceae (Escherichia coli, Pseudomonas aeruginosa, Klebsiella, Serratia, Enterobacter aerogenes). From 5% to 10% of infections are caused by gram-positive bacteria (Staphylococcus aureus and saprophyticus, Streptococcus faecalis).

The etiology of inflammatory and noninflammatory forms of prostatitis is not well understood. Theories include the presence of functional or structural bladder pathology failure of the external sphincter to relax during voiding or some form of primary bladder neck obstruction.

Appropriate prostatic antimicrobial choice is critical because the prostate has an epithelial lining and a pH gradient that inhibits antimicrobials from entering the acini. The best agents have a high dissociation constant that allows diffusion of their unionized components into the prostate. If the antibiotic is basic, it can concentrate much higher in prostatic fluid because of the pH gradient.