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Upper genital tract infection in men

Epididymitis

Epidiymitis presents as pain in the affected testicle. Swelling and tenderness begin in the lower pole of the epididymis , but, as the epididymis is lined with a single cell layer of susceptible columnar epithelium, frequently involves the whole of the epididymis and adjacent testicle. Marked swelling may make the two testes difficult to distinguish [epidiymo-orchitis]. When severe, the condition may be accompanied by abdominal pain, malaise and fever  [Oriel & Ridgway, 1983].  Not infrequently chlamydial epididymitis presents as a scrotal mass which may mimic a testicular tumor [Molijn & Bogdanowicz, 1997; Ward et al., 1999].

In men of 50 or more, epidiymitis is usually a complication of urinary tract infection with coliforms arising from prostatic enlargement or urogenital surgery leading to urinary obstruction. Ureaplasma may also play a role in this group [Eickhoff et al., 1999].  In contrast, in younger men epididymitis is caused by the sexually transmitted bacteria C. trachomatis, N. gonorrheae, or Mycoplasma or Ureaplasma species  [Hoosen et al., 1993; Joly-Guillou & Lasry, 1999; Zdrodowska-Stefanow et al., 2000]. In many cases no cause is identified. Rarely, mainly in developing countries, it may be caused by tuberculosis. 

Chlamydial epididymitis cannot be differentiated with certainty from the other causes of epididymitis on clinical grounds alone. Ideally nucleic acid based chlamydial diagnostic methods should be used to determine whether symptomatic or asymptomatic chlamydial urethral infection is present [Ely et al., 1992]. In one series, chlamydial epididymitis was milder but persisted longer than epididymitis of other causes and it was not always preceded by symptoms of urethritis or by a raised semen white blood cell count  [Ostaszewska et al., 2000]. Histologically, C. trachomatis inclusions can be detected in the columnar epithelia of the epididymis being characterized by minimally destructive, periductal, and intraepithelial inflammation with active epithelial proliferation. Squamous metaplasia and formation of lymphoepithelial complexes were occasionally noted.  In contrast, coliform related epididymitis was characterized by highly destructive large abscesses and granulomas. Clinically, the E. coli-positive cases were accompanied by scrotal pain, pyuria, leukocytosis, a raised erythrocyte sedimentation rate and a positive C-reactive protein test [lay reader: signs of severe acute inflammation]. In contrast, C. trachomatis-positive cases were clinically indolent and manifested by an epididymal tumor-like mass [Hori & Tsutsumi, 1995]. 

Epididymitis is important because fertility may be impaired as a result of inflammation and obstruction of the small diameter sperm collecting tubes and vasa, particularly where both testes are affected  [Oriel & Ridgway, 1983]. However, in recent years it has received regrettably little attention compared to its female counterpart of  pelvic inflammatory disease. The strong association of C. trachomatis with cases of acute epididymitis in younger men and its identification in epididymal masses suggests that it probably plays a primary causative role. Direct inoculation of C. muridarum [the former C. trachomatis mouse pneumonitis agent] into the Wistar rat causes epididymitis and accompanying fibrosis similar to that observed in the human, supporting the notion of a direct causal role [Jantos et al., 1992]. Further research is needed into the pathological mechanisms involved chlamydial epididymitis and associated infertility.

Chronic epididymitis is defined as involving symptoms of discomfort or pain of at least 3 months duration in the scrotum, testicle or epididymis localized to one or each epididymis on clinical examination. In a review of  50 consecutive men aged 21 to 83 years old (average age 46) with chronic epididymitis of average duration of 4.9 years (range 0.25 to 29) no significant epidemiological, sexual, medical or associated factors were identified that differentiated these patients from  20 control subjects [Nickel et al., 2002] . Chronic epididymitis was classified as being either inflammatory, obstructive or due to epididymyalgia. Previous therapies included antibiotics (74%), anti-inflammatory agents (36%) and medication for pain (26%). A symptom assessment index based on assessing pain and impact on the quality of life was developed. However, the causes of chronic epididymitis remain enigmatic. 

Treatment: For epididymitis most likely related to either chlamydial or gonococcal infection, the CDC 2002 guidelines recommend Ceftriaxone 250 mg intramuscular in a single dose plus doxycycline 100 mg orally twice a day for 10 days.

For epididymitis most likely caused by enteric organisms, for patients allergic to cephalosporins and or tetracyclines or for epididymitis in patients aged more than 35 years old the guidelines recommend Ofloxacin 300 mg orally twice a day for 10 days or Levofloxacin 500 mg orally once daily for 10 days. 

The CDC 2002 guidelines suggest that failure to improve clinically within 3 days of the initiation of treatment is an indication for re-evaluation of both the diagnosis and the therapy. Swelling and tenderness that persist after completion of anti-microbial therapy should be evaluated comprehensively. The possible differential diagnosis includes tumours, abscess, testicular cancer, tuberculosis and fungal epididymitis.

[MEW] November 2002

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References

CDC STI Treatment guidelines, May 2002 CDC Atlanta [For clinicians] 

Eickhoff, J. H., Frimodt-Moller, N., Walter, S. & Frimodt-Moller, C. (1999). A double-blind, randomized, controlled multicentre study to compare the efficacy of ciprofloxacin with pivampicillin as oral therapy for epididymitis in men over 40 years of age. British Journal of Urology Int. 84, 827 - 834.

Eley, A., Oxley, K. M., Spencer, R. C., Kinghorn, G. R., Ben-Ahmeida, E. T. & Potter, C. W. (1992). Detection of Chlamydia trachomatis by the polymerase chain reaction in young patients with acute epididymitis. European Journal of Clinical Microbiology and Infectious Diseases 11, 620 - 623.

Hoosen, A. A., O'Farrell, N.  van den Ende, J (1993). Microbiology of acute epididymitis in a developing community. Genitourinary Medicine 69, 361 - 363.

Hori, S. & Tsutsumi, Y. (1995).  Histological differentiation between chlamydial and bacterial epididymitis: nondestructive and proliferative versus destructive and abscess forming - immunohistochemical and clinicopathological findings. Human Pathology 26, 402 - 407.

Jantos, C., Baumgartner, W., Durchfeld, B. & Schiefer, H. G. (1992). Experimental epididymitis due to Chlamydia trachomatis in rats. Infection and Immunity 60, 2324 - 2328.

Joly-Guillou, M. L. & Lasry S. (1999). Practical recommendations for the drug treatment of bacterial infections of the male genital tract including urethritis, epididymitis and prostatitis. Drugs 57, 743 - 750.

Molijn, G. J. & Bogdanowicz, J. F. (1997). Chlamydial epididymitis presenting as a solid asymptomatic scrotal mass. British Journal of Urology 80, 354.

Nickel, J. C., Siemens, D. R., Nickel, K. R. & Downey, J. (2002). The patient with chronic epididymitis: characterization of an enigmatic syndrome. Journal of Urology 167, 1701 - 1704.

Oriel, J. D. & Ridgway, G. L. (1983). Genital infection in men. British Medical Bulletin 39, 133 - 137.

Ostaszewska I, Zdrodowska-Stefanow B, Darewicz B, Darewicz J, Badyda J, Pucilo K, Bulhak V, Szczurzewski M. (2000). Role of Chlamydia trachomatis in epididymitis. Part II: Clinical diagnosis. Medical Science Monitor 6, 1119 - 1121.

Ward, A. M., Rogers, J. H. & Estcourt, C. S. (1999). Chlamydia trachomatis infection mimicking testicular malignancy in a young man. Sexually Transmitted Infections 75, 270.

Zdrodowska-Stefanow, B., Ostaszewska, I., Darewicz, B., Darewicz, J., Badyda, J., Pucilo, K., Bulhak, V. & Szczurzewski, M. (2000). Role of Chlamydia trachomatis in epididymitis. Part I: Direct and serologic diagnosis. Medical Science Monitor 6, 1113 - 1118.

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