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Epididymal Tuberculosis
Article Last Updated: Nov 27, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center
J Stuart Wolf, Jr, is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Editors: Martha K Terris, MD, FACS, Professor, Department of Surgery, Medical College of Georgia; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine; Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio
Author and Editor Disclosure
Synonyms and related keywords:
epididymal tuberculosis, epididymal TB, tuberculous epididymitis, genital tuberculosis, genitourinary tuberculosis, Mycobacterium tuberculosis, MTB, granulomas
Background
Tuberculosis has plagued humankind since before recorded history. The story of humankind's battle against tuberculosis parallels that of the development of the practice of medicine in general. Although largely controlled in developed countries, tuberculosis remains a significant worldwide health problem because of the incidence in developing countries. Genitourinary tuberculosis represents 2-4% of cases of tuberculosis or approximately 15% of nonpulmonary manifestations of tuberculosis.
Pathophysiology
The spread of tuberculosis to the epididymis is thought to occur hematogenously or by retrocanalicular descent of organisms from the hematogenously infected prostate. Because epididymal tuberculosis is more common than prostatic tuberculosis, the former mechanism is likely the more common one. Distal spread through the genitourinary tract from a renal source also may occur.
Tuberculous epididymitis has been reported following intravesical bacille Calmette-Guérin (BCG) therapy for superficial bladder tumors, presumably due to retrocanalicular descent of organisms from the prostatic urethra. This is a very unusual occurrence.
The formation of granulomas in the epididymis is responsible for the clinical manifestations of epididymal tuberculosis, as in other organ systems.
Frequency
United States
Approximately 4000 cases of extrapulmonary tuberculosis are reported annually in the United States. This incidence is stable, despite a decreasing incidence of pulmonary tuberculosis. Much of the increase in the relative incidence of genital tuberculosus can be attributed to disease in men infected with HIV because of an apparent increased susceptibility to tuberculosis.
International
The incidence of tuberculosis in some developing countries is 30 times greater than that in the United States. In developing countries, the percentage of cases of tuberculosis with genitourinary involvement is approximately double that in developed areas.
Race
In developed countries, most cases of tuberculosis are observed in the immigrant population. Only 20% occur in white people.
Age
Epididymal tuberculosis most commonly develops in sexually active young men. Before the age of antituberculous chemotherapy, the typical patient was aged 16-40 years. Now, more than 70% of men with genital tuberculosis are older than 35 years, and 15-20% are older than 65 years.
History
- The typical presentation is painful enlargement of the scrotum.
- Involvement usually is unilateral.
- With involvement of only the external genitalia, problems with voiding usually are absent. Associated renal, vesical, or prostatic tuberculosis may contribute to irritative voiding symptoms.
- Malaise, fevers, and chills are common.
Physical
- In the early phases, tuberculous epididymitis is indistinguishable from bacterial epididymo-orchitis. The scrotal contents are enlarged and tender, with loss of definition between the epididymis and testicle.
- Secondary tuberculous involvement of the testicle can be observed in advanced cases.
- Prostatic examination may reveal induration or bogginess of the prostate if prostatic involvement occurs. The vas deferens may be enlarged and beaded. Occasionally, a draining sinus may be based posteriorly upon the epididymis.
Causes
- Venereal acquisition of male genital tuberculosis is unlikely, although cases of male-to-female transmission of genital tuberculosis have been reported.
- Male genital tuberculosis usually is a manifestation of the usual pulmonary acquisition of tuberculosis.
Epididymitis
Hydrocele
Scrotal Trauma
Spermatocele
Testicular Seminoma
Testicular Torsion
Testicular Trauma
Testicular Tumors: Nonseminomatous
Other Problems to be Considered
Testicular teratocarcinoma
Lab Studies
- Microscopic urinalysis often reveals pyuria or hematuria.
- Obtain urine for culture.
- If genitourinary tuberculosis is suspected, 3-5 consecutive early morning urine samples should be cultured for acid-fast bacilli.
- Molecular probes also are available for more rapid identification of the organisms in urine.
- Blood studies include complete blood count, serum electrolytes, and erythrocyte sedimentation rate. Elevation in erythrocyte sedimentation rate is common, and its normalization can be used to follow the course of therapy.
Imaging Studies
- A chest radiograph should be obtained to assess for evidence of pulmonary tuberculosis.
- A plain abdominal radiograph is useful to search for evidence of renal or ureteral tuberculosis (ie, renal or ureteral calcifications). A renal ultrasound to evaluate the upper tracts for evidence of hydronephrosis also is warranted.
- Although scrotal ultrasonography is helpful in assessing for complications of epididymal tuberculosis, such as fistula or abscess formation, the appearance of epididymal tuberculosis on ultrasonography is not distinct from that of bacterial epididymo-orchitis.
Other Tests
- Purified protein derivative of tuberculin
- Intradermal injection of purified protein derivative of tuberculin (PPD) is an important component of the tuberculosis evaluation. An indurated area larger than 10 mm in diameter is considered a positive result, and an area greater than 15 mm in diameter may indicate active disease.
- False-negative test results in the setting of malignancy, immunosuppression, liver disease, and nutritional deficiencies must be considered.
- A positive test result, in and of itself, is not confirmatory of the diagnosis of active tuberculosis.
Procedures
- Fine-needle aspiration of the epididymis may be useful to distinguish epididymal tuberculosis from bacterial epididymo-orchitis, but, because of the risk of tumor spillage, fine-needle aspiration should be avoided if neoplasm is suspected.
Histologic Findings
Histologic findings of tuberculous epididymitis are similar to those of tuberculosis elsewhere in the body (granuloma formation, nonspecific inflammatory infiltrate). Additionally, mycobacteria are present.
Medical Care
- The typical presentation of acute tuberculous epididymitis usually prompts antibiotic therapy for presumed acute bacterial epididymo-orchitis.
- A more insidious onset of symptoms, although not suggestive of acute bacterial epididymo-orchitis, often prompts the same therapy because tuberculosis usually is not considered by the treating physician.
- If no improvement occurs after 2-3 weeks of therapy for bacterial epididymo-orchitis, a scrotal ultrasonogram is useful to assess for complications of inadequately treated bacterial epididymo-orchitis.
- The ultrasonogram also assists in the diagnosis of other elements in the differential diagnosis, including hydrocele, spermatocele, scrotal trauma, testicular malignancy, and neoplasms of the epididymis.
- If no such findings are noted, tuberculous epididymitis or a resistant bacterial infection should be considered. Obtaining the PPD skin test, serial first morning urine cultures for acid-fast bacilli, a chest radiograph, and an abdominal radiograph would be reasonable at this point. Additionally, a higher index of suspicion for epididymal tuberculosis is appropriate in men with HIV infection because of its increased incidence in this setting.
- Chemotherapy may be instituted with strong clinical suspicion of tuberculosis. Alternatively, fine-needle aspiration of the epididymis can be performed to obtain material for smear examination.
Surgical Care
- During the course of treatment, if the lesion loses its tenderness while maintaining nodularity, consider testicular malignancy; operative exploration is indicated.
- Additionally, because tuberculous epididymitis often is not suspected in the management of refractory epididymo-orchitis in developed countries, the ultimate diagnosis of tuberculous epididymitis usually is made when examining the pathological specimen from epididymo-orchiectomy.
- Alternative techniques, such as epididymectomy or fine-needle aspiration of the epididymis, can be offered if tuberculosis is suspected preoperatively.
Consultations
Consultation with an infectious disease service is recommended for physicians who are not familiar with the treatment of tuberculosis.
The chemotherapy of tuberculosis has changed over the past few decades. Currently, for genitourinary tuberculosis, a 4-month course generally is recommended. Two alternative regimens are provided, as follows:
- Two months of pyrazinamide (25 mg/kg/d, maximum dose 2 g/d), isoniazid (300 mg/d), and rifampin (450 mg/d): This is followed by isoniazid (600 mg 3 times/wk) and rifampin (900 mg 3 times/wk) for an additional 2 months.
- Two months of streptomycin (1 g/d), isoniazid (300 mg/d), rifampin (450 mg/d), and pyrazinamide (25 mg/kg/d, maximum dose 2 g/d for 2 mo): This is followed by isoniazid (600 mg 3 times/wk) and rifampin (900 mg 3 times/wk) for an additional 2 months.
Drug Category: Antituberculous drugs
Any regimen must contain multiple drugs to which the Mycobacterium tuberculosis (MTB) is susceptible. In addition, the therapy must be taken regularly and continued for a sufficient period.
| Drug Name | Pyrazinamide |
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| Description | This pyrazine analogue of nicotinamide is absorbed well from the GI tract. Its half-life is 9-10 h with normal renal and hepatic function. May be bacteriostatic or bactericidal against MTB, depending on the concentration of drug attained at site of infection. |
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| Adult Dose | 25 mg/kg/d PO; not to exceed 2 g PO qd |
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| Pediatric Dose | Administer as in adults |
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| Contraindications | Documented hypersensitivity; severe hepatic damage; acute gout |
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| Interactions | Reported to produce a pink-brown color with some urine test strips |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Use only in combination with other effective antituberculous agents; inhibits renal excretion of urates; may result in hyperuricemia (usually asymptomatic); perform baseline serum uric acid determinations; discontinue drug if signs of hyperuricemia with acute gouty arthritis occur; perform baseline LFTs (closely monitor in liver disease); discontinue pyrazinamide if signs of hepatocellular damage appear; caution in history of diabetes mellitus |
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| Drug Name | Isoniazid (Laniazid, Nydrazid) |
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| Description | The hydrazide of isonicotinic acid. Within 1-2 h of oral administration, produces peak blood levels, which decline to 50% or less within 6 h. Isoniazid acts against actively growing tubercle bacilli. Isoniazid-resistant MTB bacilli develop rapidly when isoniazid monotherapy is administered. |
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| Adult Dose | 5 mg/kg PO/IM up to 300 mg qd or 15 mg/kg up to 900 mg/d 2-3 times/wk |
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| Pediatric Dose | 10-15 mg/kg PO/IM up to 300 mg qd or 20-40 mg/kg up to 900 mg/d 2-3 times/wk |
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| Contraindications | Documented hypersensitivity; previous isoniazid-associated hepatic injury; severe adverse reactions to isoniazid such as drug fever, chills, or arthritis; acute liver disease |
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| Interactions | Higher incidence of isoniazid-related hepatitis can occur with alcohol ingestion on daily basis; aluminum salts may decrease isoniazid serum levels (administer 1-2 h before taking aluminum salts); may increase anticoagulant effects with coadministration; may inhibit metabolic clearance of benzodiazepines; carbamazepine toxicity or isoniazid hepatotoxicity may result from concurrent use (monitor carbamazepine concentrations and liver function); coadministration with cycloserine may increase CNS adverse effects (eg, dizziness); acute behavioral and coordination changes may occur with coadministration of disulfiram; coadministration with rifampin after halothane anesthesia may result in hepatotoxicity and hepatic encephalopathy; may inhibit hepatic microsomal enzymes and increase toxicity of hydantoin |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Monitor patients with active chronic liver disease or severe renal dysfunction; periodic ophthalmologic examinations during isoniazid therapy are recommended even when visual symptoms do not occur |
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| Drug Name | Rifampin (Rifadin, Rimactane) |
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| Description | Semisynthetic antibiotic derivative of rifamycin SV. Readily absorbed from gastrointestinal tract. In healthy adults, half-life of rifampin in serum averages 3-4 h after a 600-mg oral dose, with increases up to 4-6 h reported after a 900-mg dose. With repeated administration, the half-life decreases and reaches average values of approximately 2-3 h. Has bactericidal activity against both intracellular and extracellular MTB organisms. |
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| Adult Dose | 10 mg/kg PO/IV qd; not to exceed 600 mg/d |
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| Pediatric Dose | 10-20 mg/kg PO/IV; not to exceed 600 mg/d |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Rifampin is known to induce certain cytochrome P-450 enzymes, adjusting the dosages of the following drugs may be necessary: anticonvulsants, antiarrhythmics, oral anticoagulants, antifungals, barbiturates, beta-blockers, calcium channel blockers, chloramphenicol, clarithromycin, corticosteroids, cyclosporine, cardiac glycoside preparations, clofibrate, oral or other systemic hormone contraceptives, dapsone, diazepam, doxycycline, fluoroquinolones, haloperidol, oral sulfonylureas, levothyroxine, methadone, narcotic analgesics, nortriptyline, progestins, quinine, tacrolimus, theophylline, tricyclic antidepressants, and zidovudine |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Obtain CBCs and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur |
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| Drug Name | Streptomycin |
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| Description | A water-soluble aminoglycoside derived from Streptomyces griseus. Following intramuscular injection of 1 g of streptomycin as sulfate, a peak serum level of 25-50 mcg/mL is reached within 1 h, diminishing slowly to about 50% after 5-6 hours. Excreted by glomerular filtration. Streptomycin sulfate is a bactericidal antibiotic active against many organisms, including MTB. |
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| Adult Dose | 15 mg/kg IV qd maximum 1 g |
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| Pediatric Dose | 20-40 mg/kg IV qd maximum 1 g |
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| Contraindications | Documented hypersensitivity; non–dialysis-dependent renal insufficiency |
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| Interactions | Nephrotoxicity may be increased with aminoglycosides, cephalosporins, penicillins, amphotericin B, and loop diuretics |
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| Pregnancy | D - Unsafe in pregnancy
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| Precautions | Narrow therapeutic index; not intended for long-term therapy; caution in renal failure not on dialysis; caution with myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission |
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Further Outpatient Care
- Patients' cases should be followed for resolution of symptoms and swelling of induration, which should start to occur within a few weeks.
- The urine generally will clear of infectious organisms within 2 weeks.
- Patients should engage in sexual activity only when protected by a condom because semen can be infected with mycobacterium and may provide venereal transmission of the disease.
Complications
- Complications of advanced tuberculous epididymitis include epididymal abscess and fistula formation.
- Both complications usually are treated by scrotal surgery. Failure of the antituberculous regimen to achieve satisfactory local response also is treated surgically.
- Patients may become infertile, either because of extensive duct destruction or because of obstruction of the vas deferens.
Prognosis
- Scrotal surgery may be required, which could include removal of the epididymis and testicle.
- The ultimate prognosis is determined by the degree of systemic illness.
Patient Education
Medical/Legal Pitfalls
- Fine-needle aspiration of the epididymis may be useful to distinguish epididymal tuberculosis from bacterial epididymo-orchitis, but, because of the risk of tumor spillage, fine-needle aspiration should be avoided if neoplasm is suspected.
- The typical presentation of acute tuberculous epididymitis usually prompts antibiotic therapy for presumed acute bacterial epididymo-orchitis. A more insidious onset of symptoms, although not suggestive of acute bacterial epididymo-orchitis, often will prompt the same therapy because tuberculosis usually is not considered by the treating physician.
- Because tuberculous epididymitis often is not suspected in the management of refractory epididymo-orchitis in developed countries, the ultimate diagnosis of tuberculous epididymitis usually is made when examining the pathological specimen from epididymo-orchiectomy.
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Epididymal Tuberculosis excerpt Article Last Updated: Nov 27, 2006
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