Diagnosis And Therapy Of Acute Prostatitis, Epididymitis, And Orchitis

Main Category: Urology / Nephrology
Article Date: 13 Jun 2008 - 3:00 PDT

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UroToday.com - Acute genitourinary infections, in particular acute prostatitis, acute epididymitis and orchitis, represent an important problem in daily urological practice which warrant evidence-based therapeutic strategies to reduce the risk for chronification and severe sequelae, and to optimise the therapeutic outcome.

Acute bacterial prostatitis (ABP):

Data detailing incidence and prevalence of ABP do not exist. According to the classification proposed by the European Association of Urology (EAU) it is summarised analogously to complicated UTIs. ABP does not seem to represent a major diagnostic and therapeutical problem as long as prostatic abscess formation is absent. Its diagnosis is usually based on typical signs and symptoms; leukocyturia and bacteriuria are mandatory. Fever and chills may be found to a various extent and may even result in urosepsis. Sonographic determination of residual volume should rule out infravesical obstruction. Transrectal ultrasound (TRUS) is recommended to reveal prostatic abscess formation. Elevated levels of prostate-specific antigen (PSA), particularly of bound PSA, have been described in the majority of men with ABP which may persist at least 30 days following adequate antimicrobial therapy. Failure of normalisation of PSA has been associated with prostate cancer in about 20% of cases. In severe cases, parenteral administration of high doses of bactericidal antibiotics, such as a broad-spectrum penicillin, a third-generation cephalosporin or a fluoroquinolone, have been recommended. After defeverescence, oral therapy can be substituted for 2-4 weeks. A suprapubic catheter should be placed in men with increased residual volume. Two different forms of acute prostatitis should be differentiated according to their clinical course. Patients with ABP secondary to manipulation may require modified treatment options. Prostatic abscess formation normally warrants surgical treatment options though conservative treatment in men with small abscesses is worth trying.

Acute epididymitis and epididymo-orchitis:

In acute epididymitis, epidemiological data are scanty. Bacterial infections are the most common aetiology for epididymitis. In men <35 years of age, ascending infection from the urethra by sexually transmittable pathogens, namely Chlamydia trachomatis and Neisseria gonorrhoeae, are aetiologically responsible. In contrast, Enterobacteriaceae, particularly Escherichia coli, represent the dominant pathogens in older men with a history of bladder outlet disturbances. The diagnosis of acute epididymitis is usually based on clinical examination. The microbiological work-up depends on the pathomechanism suspected. Increased residual bladder volume indicates subvesical obstruction and the need for the placement of a suprapubic catheter. Scrotal sonography is useful for the detection of epididymal abscess formation which has been described in about 10 - 20% of patients. Proper use of antimicrobial agents against the underlying pathogens is the key in the management of infectious epididymitis to reduce the risk for complications. The guidelines of the EAU are available online (www.uroweb.org). Increasing resistence of Neisseria gonorrhoeae to quinolones in the USA has made the Centers of Disease Control (CDC) withdraw their recommendation of quinolones as a first line drug in gonococcal disease. Neither prevalence studies nor exact treatment options of chronic epididymitis do exist.. Antibiotics and anti-inflammatories are most commonly used. Epididymectomy has been described as a surgical treatment option, but chronic pain may persist despite surgical removal of the epididymis. Epididymal abscess formation normally requires surgical treatment. The development of epididymo-orchitis is unpredictable despite adequate therapy and is of particular concern to andrologists because of its potential significance for male fertility. Although ejaculate quality normalises after 3 months in most patients, severe oligoasthenoteratozoospermia and azoospermia may persist in 15% and 8% respectively indicating an involvement of the clinically unaffected contralateral testis. Typical morphological sperm alterations following epididymitis may contribute to male subfertility.

Acute orchitis:

Acute primary orchitis is a rare event, mostly occuring as mumps orchitis. Orchitis occurs 3 - 10 days after parotitis. Evidence of IgM antibodies in serum provide the diagnosis. Standardized treatment guidelines are not available. In a case report down-regulation of spermatogenesis with a gonadotrophin-releasing hormone agonist has been described. The use of systemic a-2b interferon to prevent testicular atrophy has been suggested in several studies. On the other hand, testicular biopsy after interferon therapy has revealed testicular atrophy in 38% of men so that interferon does not seem to be completely effective in preventing testicular atrophy.

Written by Martin Ludwig, MD, as part of Beyond the Abstract on UroToday.com

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