INFECTION AND ABSCESS OF TESTIS
AND EPIDIDYMIS
Acute testicular infections are rare. More commonly, orchitis develops secondary to suppurative epididymitis and is termed epididymo-orchitis. Orchitis occurs through three possible routes: via lymphatics, via the blood-stream, and ascending through the vas deferens. The most common setting for bacterial orchitis in men older than 35 years is age-related prostatism or urethral strictures resulting in urinary tract obstruction and gram-negative urinary tract infections. In men younger than 35 years, sexually transmitted diseases such as chlamydia and nongonorrheal urethritis (NGU) are the most common culprits. Inflammatory orchitis may occur in response to bacterial toxins, autoimmune responses, trauma, torsion, chemicals such as iodine, thallium, lead and alcohol, and medications (amiodarone). In such cases, pathogenic organisms may not be cultured from the urine or from inflamed or necrotic tissue.
Acute bacterial orchitis is
usually accompanied by
high fevers and sudden
scrotal pain and swelling. The onset is so acute that it may be confused with
testicular torsion, except that the latter has no associated fever or
bacteriuria. A reactive hydrocele is common, and the overlying scrotal skin
shows redness and edema. These associated features often make it clinically
difficult to distinguish among isolated orchitis, epididymitis, or
epididymo-orchitis. The inflamed testicle is tense and bluish in appearance,
with many punctate hemorrhages on the surface. There may be considerable edema
of the testis within the fixed, noncompliant tunica albuginea, which can result
in ischemia and seminiferous tubule loss and atrophy. The process may progress
to suppuration, abscess formation, and in rare cases, testicular
autoamputation.
Mumps orchitis complicates
approximately 20% of mumps cases and rarely occurs before puberty. As a viral
glandular infection, mumps can affect the parotid glands, the pancreas, and the
testis. Epididymis involvement in this process is rare. Orchitis usually
develops 4 to 6 days after parotitis and generally subsides in 7 to 14 days.
The signs and symptoms of this virus infection are similar to those of other
interstitial orchitides. Scrotal pain and testicular swelling are the prominent
features. Early testicular histologic findings include transitory edema that
quickly progresses to marked interstitial inflammation. Seminiferous tubule
sclerosis, gross testicular atrophy, and infertility are serious sequelae.
About 70% of mumps orchitis cases are unilateral, and in 50% demonstrable
testicular atrophy occurs. Treatments have included wide incision of the testis
tunical albuginea and systematic corticosteroids or interferons to reduce the
effects of inflammation and edema.
Epididymitis is by far the
most common type of intrascrotal infection or inflammation. It may be classified
as sexually transmitted (i.e., gonorrheal, chlamydial, NGU), bacterial
(gram-negative, tuberculous), inflammatory, posttraumatic, and idiopathic.
Infecting organisms reach the epididymis through the vas deferens from infected
urine, prostate, or seminal vesicles. Infection may also spread retrograde
through lymphatics and, rarely, through hematogenous routes.
Gonorrheal epididymitis, now
rare, was historically a common complication of gonorrheal urethritis (see
Plate 2-21). It rarely involves the testicle, appearing first in the globus minor or cauda epididymis, which becomes swollen, tense,
and tender. Although small abscesses may develop, suppuration is rare, and
resolution is common, accompanied by sterility due to excurrent ductal
obstruction from scar tissue if bilateral.
Posttraumatic epididymitis
due to urethral catheterization, cystoscopy, and other surgical procedures is
also relatively uncommon with widespread antibiotic use. Epididymitis may
become chronic and be a source of recurrent pain and swelling due to
ejaculatory duct reflux of urine through the vas deferens with
strenuous physical activity or after organ congestion due to vasectomy. If
epididymitis does not respond to rest, scrotal elevation, and antibiotics, antiinflammatories
may be added. Antibiotic-refractory epididymitis should raise clinical
suspicion for tuberculous epididymitis (see Plate 3-23) and warrants
examination of first morning urine or tissue for acid-fast bacillus.
Epididymectomy is a rarely utilize treatment option but can be effective after vasectomy.
