Society for the Study of Male Reproduction by Harris Nagler Saturday, May 20, 2006

Dr. Peter Chan, Director of Male Reproductive Medicine, McGill University discussed epididymitis and other inflammatory conditions in the male excurrent ductal system.

The most common pathogens for adult epididymitis are Chlamydia trachomatis and Neisseria gonorrhoeae, and less common causes are Ureaplasma, E. Coli, Enterococus, and Pseudomonas. He added that E. Coli is rare in young, heterosexual men but more common in men engaging in anogenital intercourse and older men. The differing organisms in older men reflect the fact that their infections are due to bladder outlet obstruction causing higher voiding pressure leading to reflux of infected urine through the vas deferens into the epididymis. Alternatively, sterile urine in this setting can cause a chemical epididymitis.

An unusual cause of epididymitis is iatrogenic chemical epididymitis secondary to amiodarone, a class III antiarrythmic agent. This medication can cause a chemical epididymitis as result of the high concentrations which are achieved in the epididymis (> 300x serum concentrations). This chemically induced epididymitis appears to be dose and duration dependent effect and is associated with antibodies against antiamiodarone. This implies that a chemical or autoimmunue phenomenon is involved. Iatrogenic epididymitis can also arise from a variety of urological procedures, including instrumentation of the urinary tract, placement of an indwelling urethral catheter, vasectomy, and prostate surgery.

Dr. Chan then explained the concept of stress-induced epididymitis. This particular theory is controversial. Contemporary series describe up to 70% of men with acute epididymitis reported an immediate/preceding event of heavy lifting. The mechanism is thought to be reflux of sterile urine. They should undergo an initial culture, with antibiotics/anti-inflammatory therapy.

Other unusual but important causes of epididymitis presented were: 1. Tb epididymitis, and 2. fungal or opportunistic infections. in patients with HIV or other immune suppressing states 3. Sarcoidosis, 4. xanthogranulomatous epididymitis, 5.and Behçet syndrome, which is a systemic vasculitis with associated (noninfectious) epididymitis in 5-19% of cases. The diagnosis of these unusual entities may be suggested by the failure to respond to standard treatment options.

Infectious vasitis is a rare clinical entity which may be the result of epididymitis or surgical intervention. It may present as a thick mass/cord in groin or spermatic cord. Iatrogenic vasitis may arise from vasal trauma.

Dr Chan suggested that epididymitis may affect fertility by: 1. altering secretory function of the male accessory glands, 2. decreasing epididymal secretion, 3 the promotion of antisperm antibody formation, 4. direct effect on sperm function of pathogens. Inflammation can also cause fibrosis and obstruction

Editorial Comments:

The epididymis is a complex organ which is poorly understood. The treatment of epididymitis is an important part of the practice of most urologists. Although the etiology may be unclear, most patients will often be treated with antibiotics with or without anti-inflammatory agents. The antibiotics should reflect the risk category of the patient as determined by age and sexual behavior. When a patient does not respond to standard therapy alternative etiologies must be entertained.

Written by Harris M. Nagler, MD, a Contributing Editor with UroToday.

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