Presented within this summary review will be information regarding several inflammatory conditions of the male genitalia. The areas of discussion are prostatitis, epididymitis and testicular torsion, and Fournier's gangrene.
Prostatitis is probably the most common inflammatory process of male genitalia and denotes an exceedingly large number of etiologic factors leading to prostatic inflammation. This brief review will focus on the diagnosis and treatment of acute and chronic bacterial prostatitis. Other areas of "prostatitis" refer to non-bacterial prostatic inflammation and to "prostatodynia". These are not well understood but fortunately do not lead to truly serious morbidity.
Acute bacterial prostatitis is characterized by fever, chills, myalgias, low back and perineal pain, and voiding symptoms such as dysuria, frequency, and nocturia. Aerobic gram-negative enteric bacteria are the most common infecting agents (the most common is E. Coli).; however, enterococcus, pseudomonas, staphylococcus, streptococcus, Chlamydia trachomatis, and Ureaplasma urealyticum are also known to cause prostatic inflammatory processes.1 Physical findings of acute prostatitis include elevated temperature, lower abdominal-suprapubic tenderness, prostatic enlargement with tenderness, and possibly induration. Concomitant prostatic massage should be avoided to decrease patient discomfort and the possibility of causing bacteremia. Prostatic specific antigen (PSA) determination should be delayed until the acute process has been treated and has resolved.2
Marked inflammatory changes in the prostate gland with sheets of polymorphonuclear leukocytes in and around acini and ducts are characteristic of acute bacterial prostatitis. Macrophages, lymphocytes, plasma cells, diffuse stromal edema, and hyperemia along with microabscesses may be seen.3 Urine analysis usually shows pyuria and bacteriuria. The pathogen is identified by voided urine culture and sensitivity.
Therapy for acute bacterial prostatitis is usually successful. Preferred treatment is bacteriocidal agents as the newer fluoroquinolone agents. Other useful antibiotics include trimethoprim- sulfamethoxazole and cephalosporins. Antibiotic therapy should be continued for four to six weeks to maximize prevention of chronic bacterial prostatitis. General measures such as adequate hydration, antipyretics, analgesics, bed rest and stool softeners are also used as needed. Urethral instrumentation should be avoided if possible.4 Prostatitis imaging is not recommended in evaluation of acute or chronic prostatitis due to nonspecificity of either computed tomography or ultrasonography.5
Symptoms of chronic bacterial prostatitis are quite variable but are typically irritative voiding complaints and perineal-suprapubic and low backache or pain. Dysuria, urgency, frequency, nocturia, post-ejaculatory pain, and hematospermia are often noted. Fever, chills, and general systemic symptoms are not common. The hallmark of chronic bacterial prostatitis is recurrent infections caused by the same pathogen.6 Medical therapy generally controls symptoms and sterilizes the urine. Unfortunately, symptoms often recur and urine reinfection reappears after antibiotic therapy is stopped. The offending pathogen persists in prostatic fluid and is very difficult to eradicate due to poor perfusion of antimicrobial agents into prostatic secretions. Expressed prostatic secretions commonly show large numbers of leukocytes and macrophages containing fat. The diagnosis is best determined by culture techniques that localize the pathogen to prostatic secretions. Selection of antibacterial agents should be based on culture and sensitivity testing. Often suppressive long-term therapy is utilized. Commonly prescribed agents include trimethoprim, nitrofurantion, trimethoprim-sulfamethoxazole, carbenicillin, doxycycline, and quinolones such as ciprofloxacin, ofloxacin, or norfloxacin. Surgical therapy is rarely indicated, but transurethral resection in patients harboring infected prostatic calculi may be tried if antibiotic therapy fails.
Non-bacterial prostatitis is an inflammatory process of unknown etiology. Symptoms are the same as chronic bacterial prostatitis; however, cultures are negative. Expressed prostatic secretions reveal increased numbers of leukocytes and macrophages. The treatment regimen is designed to control symptoms. If a bacterial etiology (including Chlamydia) is suspected, a short-term course of antibacterials is often prescribed. More important in treatment is patient reassurance, warm sitz baths, and non-steroidal anti-inflammatory drugs; anticholinergics are usually effective for irritative voiding symptoms.
Prostatodynia denotes prostatitis symptoms without objective evidence of prostatic inflammation. Perineal-pelvic floor muscle spasms and subsequent myalgia is the likely cause. Treatment includes alpha-adrenergic blockers, tranquilizers, and anti-inflammatory drugs.
Other types of prostatitis include gonococcal, tuberculous, mycotic, and non-specific granulomatous causes.
Acute epididymitis is an inflammatory process generally caused by either sexually transmitted organisms or gram-negative bacteria. Typical symptoms include swelling, pain, fever, and scrotal hyperemia. At times, these occur concomitantly with acute cystitis, acute urethritis, or acute prostatitis episodes. Complications from epididymitis include chronic pain, infertility, epididymo-orchitis, abscess formation, and rarely, testicular infarction. The etiology of acute epididymitis is often a sexually transmitted pathogen in sexually active males due to gonorrhea or chlamydia and other organisms that cause urethritis or cystitis. Epididymal inflammation results from retrograde passage of the pathogens through the vas deferens. In men over thirty-five the incidence of sexually transmitted epididymitis is less common. Bacteriuria secondary to acquired obstructive urinary disease is common, and the most common cause of epididymitis in older men is coliform organisms that cause the bacteriuria.7 Postoperative epididymitis (TURP) occurs less commonly today than in the past.8
Physical findings noted in acute epididymitis reveal tenderness and induration of the epididymis _ usually beginning in the tail prior to involving the entire epididymis. The spermatic cord is typically tender. Also fever, urethral discharge, and pyuria often accompany acute epididymitis. In severe epididymitis, the testicular tissues are infected with resulting epididymo-orchitis. This presents as a confluent tender mass with an associated inflammatory hydrocele.
The differential diagnosis from testicular torsion is clearly of utmost importance, as torsion constitutes a surgical emergency. Torsion is most common during adolescence (ages twelve to eighteen) and is very uncommon or rare in men older than twenty-five years. Physical examination will quite often lead to the appropriate diagnosis. However, radionuclide scanning of the scrotum is probably the most accurate way to confirm the diagnosis. Doppler ultrasound of the spermatic cord and testis may be useful if the operator is skilled and experienced. When the diagnosis is still not fairly clear, scrotal exploration should be done promptly.
Treatment of acute epididymitis is dependent on the specific pathogen involved. General guidelines for sexually transmitted cases are followed and call for gram stain of urethral smear and culture. Antibiotics commonly used include ceftriaxone, tetracycline, doxycycline, and quinolones. General supportive measures include bed rest, ice pack, pain control, and scrotal elevation.
Fournier's Gangrene is a very uncommon (fortunately)
inflammatory process of the male genitalia. This process refers
to a very aggressive fulminating cellulitis and necrotizing
fasciitis usually due to mixed infections including staph, strep,
gram-negative and anaerobic organisms. Prompt diag
nosis and management are required to prevent debilitating
prolonged morbidity and/or death from this gangrenous process.
Invasive infections of the lower genitourinary tract, colon,
rectum, or genital skin are the most common prodromes. Most
patients are adults. Alcoholism, diabetes mellitus, and
immuno-suppression are the most likely underlying risk factor.
Necrotizing fasciitis of the male genitalia involves Colles' fascia, dartos fascia, and the adjacent subcutaneous fat and spreads along superficial fascial planes. Symptoms consist of the acute onset of painful swelling of the penis or scrotum, fever, chills, and malaise. Painful induration, swelling, edema, blistering, and desquamation are noted. Palpable crepitus is usually very notable.
Management is operative with immediate and repetitive surgical debridements as needed. Fluid resuscitation and multi-drug antibacterial therapy with activity against bacteria is begun after blood and urine specimens are obtained for culture.9 Post-operative intensive wound care with follow-up debridements is required. Hyperbaric oxygen therapy may be beneficial. Replacement of debrided skin with a variety of reconstructive plastic procedures must be accomplished as necessary. Plastic surgery consultation and management is recommended for most of these patients.
References
1. Fowler, Jr., JE. Prostatitis. In Gillenwater JY, Grayhack JT, Howards SS, et al. (Eds.): Adult and Pediatric Urology. St. Louis, Mosby Year Book. 1991; 1395.
2. Dalton DL. Elevated serum prostate-specific antigen due to acute bacterial prostatis. Urology. 1989; 33:465.
3. Meares Jr. EM. Prostatitis and related disorders. In Walsh PC, Retik AB, Stamey TA, and Vaughan, Jr. (ED (Eds.): Campbell's Urology. Philadelphia, W.B. Saunders Co., 1992; 814.
4. Meares Jr., EM. Prostatitis and related disorders. In Walsh PC, Retik AB, Stamey TA, and Vaughan, Jr. ED (Eds.): Campbell's Urology. Philadelphia, W.B. Saunders Co., 1992; 815.
5. Fowler, Jr. JE. Prostatitis. In Gillenwater JY, Grayhack JT, Howards SS, et al. (Eds.): Adult and Pediatric Urology. St. Louis, Mosby Year Book, 1991; 1405.
6. Meares, Jr. EM. Prostatitis and related disorders. In Walsh PC, Retik AB, Stamey TA, and Vaughan, Jr. ED (Eds.): Campbell's Urology. Philadelphia, W.B. Saunders Co., 1992; 815.
7. Berger RE, Alexander ER, Harnish JP, et al. Etiology, manifestations, and therapy of acute epididymytis: prospective study of 50 cases. J Urol. 1979; 121:750-754.
8. Drach GE. Diagnosis and management of infectious complications of urologic surgery. In Smith RB and Skinner DG (Eds.): Complications of urologic surgery prevention and management. Philadelphia, W.B. Saunders Co., 1976; 29.
9. Fowler, Jr., JE. Necrotizing fasciitis of the male genitalia. In Stamey TA (Ed.): 1996 Monographs in urology. Montverde, FL., Medical Directions Publishing C., 1996; 3-12.
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