[Influence of epididymitis history on the results of vasoepididyostomy in patients with epididymal obstruction].

OBJECTIVE: To evaluate the influence of epididymitis history on the results of microsurgical vasoepididymostomy and spontaneous pregnancy in patients with epididymal obstruction. METHODS: Totally 205 patients with epididymal obstruction underwent microsurgical two-suture longitudinal intussusception vasoepididymostomy from January 2014 to December 2016. After surgery, we evaluated the semen quality of the patients every 3 months till conception and compared the rates of patency and spontaneous pregnancy between the patients with and those without an epididymitis history. RESULTS: The patients ranged in age from 22 to 46 (mean 31) years, 37 (22.2%) with and 126 (77.8%) without an epididymitis history among the 163 patients for whom a 25.4-month follow-up (from 7 to 42 months) was completed. No statistically significant differences were observed postoperatively between the patients with and those without an epididymitis history in the patency rate (73.0% vs 81.7%, P = 0.243), sperm concentration (18 ï¼»1.3－33.6ï¼½ vs 15.2 ï¼»0.8－33.4ï¼½ ×106/ml, P = 0.710), percentage of progressively motile sperm (27.5 ï¼»0－46.1ï¼½% vs 19.3 ï¼»0－41ï¼½% (P = 0.592) or rate of spontaneous pregnancy (24.3% vs 38.9%, P = 0.104). CONCLUSION: Microsurgical vasoepididymostomy is an effective method for the treatment of epididymal obstruction, and epididymitis history does not affect the results of the strategy.

The challenging diagnosis of acute scrotum: remaining difficulties and further insights.

The main target during management of a male pediatric patient with clinical signs of acute scrotum is the timely diagnosis, in order not to jeopardize the viability of the affected testicle. Thorough evaluation of the patient's medical history, symptomatology, clinical and ultrasonographic findings, constitutes the basis of the diagnostic procedure. After comprehensive research of the relevant literature, we highlight the remaining difficulties in the evaluation of the clinical and ultrasonographic findings for the accurate diagnosis of the acute scrotum. In conclusion, it is worth emphasizing on the following: a. the most common diseases that come under the diagnosis of the acute scrotum may present with similar symptoms, b. in neglected cases the diagnostic approach becomes more difficult, constituting the evaluation of the pathognomonic clinical signs challenging, and c. inability to exclude the diagnosis of spermatic cord torsion should be an indication for the surgical exploration of the affected hemiscrotum.

Epidydimo-orchitis and anorectal malformations: when and in whom?

PURPOSE: Epididymo-orchitis (EO) is infrequently reported in anorectal malformation (ARM) cases. Therefore, it is difficult to assess its risk factors. METHODS: A total of 110 male patients who were operated on for ARM at the same Institution over a period of 13 years were contacted. Association was assessed between EO and the following: spinal dysraphism (SD), symptomatic VUR (VUR), and bowel management (BM) requiring enemas. The data were analyzed with the Chi-square test. RESULTS: A total of 89 patients were contacted. Ten cases of EO were found, and all occurred in patients with recto-urethral (RU) fistula after reconstruction. The patients' age at first episode ranged between 4 and 11 years. RU fistula patients experiencing EO (Group A, 10 patients) were compared with those without EO (Group B, 33 patients). VUR occurred in 9/10 cases in Group A and in 13/33 cases in group B (Chi-square 7.8658, p = 0.005038). SD was present in 4/10 cases in group A and in 13/33 cases in Group B (Chi-square 0.0434, p = 0.83491). A total of 8/10 cases in Group A and 12/33 cases in Group B were on BM (Chi-square 5.87, p = 0.0015). CONCLUSIONS: EO occurs in approximately in 20 % of male cases with ARM, and recto-urinary communication and should be considered the primary diagnosis in the presence of testicular pain. This could avoid unnecessary surgical exploration, and the family should be counseled about this subject.

Epididymitis in patients with anorectal malformations: a cause for urologic concern.

INTRODUCTION: Epididymitis in patients with anorectal malformation (ARM) represents a unique problem because unlike the general population, an underlying urinary tract problem is frequently identified. We review our experience with epididymitis in ARM population with an emphasis on examining urologic outcomes. MATERIALS AND METHODS: We performed a retrospective review of male patients with ARM cared for from 1980 to 2010. Clinical and pathologic variables recorded included age at presentation, recurrence, associated urologic anomalies, incidence of ureteral fusion with mesonephric ductal structures, glomerular filtration rate and urodynamic parameters. RESULTS: Twenty-six patients were identified with documented episodes of epididymitis. Renal injury was noted in five patients (19%), all of whom were diagnosed with neurogenic bladder (NGB) several years after anorectoplasty. NGB was found in ten patients (38%) in our series. Ectopic insertion of ureter into a mesonephric ductal structure was discovered in five patients (19%). Twelve patients (46%) had recurrent episodes of epididymitis, with seven of these patients (58%) being diagnosed with NGB. Two patients in the pubertal group presented with a history of epididymitis and complained of ejaculatory pain. CONCLUSION: Epididymitis in a patient with ARM warrants a comprehensive urologic investigation, particularly in recurrent episodes. Attempts at surgical intervention (e.g. vasectomy) should be avoided until functional assessment of the urinary tract has occurred. Failure to recognize this association may lead to potentially avoidable complications and morbidity. Long term urological follow up of these patients is warranted to identify at risk patients and minimize renal deterioration.

Unusual isolated tubercolous epididymitis. Case report.

We present an unusual case of tuberculous epididymitis in a 33-year-old African patient, who was referred to our Department of Urology with a right intrascrotal mass. There was no evidence of fever, hematuria, dysuria or symptoms from the lower urinary tract. The patient did not demonstrate any laboratory signs of inflammation (white blood cells, C reactive protein). Scrotal sonography revealed a solid heterogeneous, hypoecoic lesion between the epididymal head and the upper testis pole, with disruption of the architecture of the testicular parenchyma. Strong ultrasound suspicion of tuberculous etiology was confirmed by epididymectomy and partial orchiectomy. The patient started an antitubercular treatment. Although rare, epididymal TB may be the only clinically evident location of infection. Clinical suspicion and prompt diagnosis are important because earlier treatment can prevent complications and lead to clinical improvement.

Inhibition of adhesion and fibrosis improves the outcome of epididymectomy as a treatment for chronic epididymitis: a multicenter, randomized controlled, single-blind study.

PURPOSE: We measured the effectiveness of inhibition of adhesion and fibrosis on patient outcomes after epididymectomy as a treatment for chronic epididymitis. MATERIALS AND METHODS: An initial cohort of 152 patients was treated conservatively for chronic epididymitis. Of these patients 43 did not respond to conservative treatment and following informed consent they were enrolled in the clinical trial. The patients were randomized into 2 groups so that 22 underwent epididymectomy with concurrent administration of the inhibitors of adhesion and fibrosis hyaluronic acid and carboxymethylcellulose (group 1), and 21 underwent epididymectomy only (group 2). Visual analog pain scores and patient satisfaction scores were obtained at postoperative weeks 4, 12 and 24. RESULTS: There were no postoperative complications such as wound infection or hematoma in either group. One patient was lost to followup from group 1 and 2 were lost from group 2. At postoperative week 24, 12 patients (57.1%) from group 1 and 3 (15.8%) from group 2 were pain-free, 6 (28.6%) from group 1 and 6 (31.6%) from group 2 exhibited limited pain relief, 2 (9.5%) from group 1 and 7 (36.8%) from group 2 exhibited no pain relief, and 1 (4.8%) from group 1 and 3 (15.8%) from group 2 exhibited recurrence of pain after initial resolution at earlier followup intervals (p = 0.028). CONCLUSIONS: Inhibition of adhesion and fibrosis after epididymectomy as a treatment for chronic epididymitis improves pain relief and patient satisfaction.

The acute scrotum in infancy: A retrospective regional study.

INTRODUCTION: Testicular torsion during infancy (<1 year) is known to be a rare event with relatively few studies on the subject in the published scientific literature. We reviewed the experience of infant scrotal exploration within a paediatric surgical network of four centres serving an approximate paediatric population of 1.8 million. AIM: To review current practice of scrotal explorations in infancy and explore areas for improvement. METHOD: Retrospective review of emergency operations for acute scrotum between January 2016 and December 2018. Data are presented as median (range) and compared using non-parametric tests. P < 0.05 was regarded as significant. RESULTS: A total of 560 paediatric scrotal explorations were performed. Of these, 25 (4%) were under one year at the time of surgery, median 4 months (1 day-5 months) (Fig. 1). The most common diagnosis was "epididymitis" (11/25, 44%). Testicular torsion was found in 28% (7/25), increasing to 66% (4/6) in those under one month. Of those with confirmed testicular torsion, three (43%) underwent a primary orchiectomy with contralateral fixation and three (43%) detorsion and bilateral fixation, with all three cases found to have testicular atrophy at follow-up. The final case was of metachronous torsion, with the initial presentation not operated on and the subsequent presentation undergoing detorsion and fixation. This was the only case of testicular salvage in our series. There were no underlying urological issues in any patient and no reported complications or ongoing urological issues post-surgery. The rate of follow-up was 17/25 (68%). CONCLUSION: We present one of the only clinical series to focus on acute scrotum in the under one year old and not just the neonatal period. Testicular torsion remains a rare event in this age group but invariably leads to testicular loss.

[Surgical tactics in acute epididymitis in children].

Differentiated surgical policy was applied in the treatment of 147 children aged under 18 years with acute epididymitis. Basing on laboratory, clinical and ultrasound characteristics, three treatment methods were used: conservative treatment, puncture of the scrotum, revision of the scrotum. Puncture treatment of acute epididymitis appeared effective in accurate diagnosis of indications for this therapy and due performance. Ultrasound potential is shown in differential diagnosis in acute scrotum syndrome.

Chronic epididymitis: is epididymectomy a valid surgical treatment?

Chronic scrotal pain (>or=3 months) is multi-factorial in nature and difficult to treat. Epididymectomy for chronic epididymal pain is rarely performed because of perceived poor outcome. We retrospectively audited our results, when published 'cure' following testicular denervation is 97%. The records of 32 males (35 consecutive epididymectomies) were retrospectively analysed. Thirteen had previous scrotal surgery. Eight (group one) had palpable painful epididymal abnormalities on clinical examination, nine (group two) had ultrasonic abnormalities but no palpable abnormality and 15 (group three) had neither. Pain response was recorded as: cured, improved, recurred or no change/worse. The mean time to operation was 23.83 months (2-121) and follow-up was 15.57 months (1-84). There were no significant aetiological differences between groups. In group one, 87.5% were cured with the remainder improved. Sixty-seven per cent of group two had a satisfactory outcome. Of group three, 20% were cured and a further 33% improved. Prior scrotal surgery, duration of symptoms and age were not predictive of outcome (Kruskal-Wallis) in terms of pain relief. Epididymectomy for structural abnormalities had excellent results. Those with chronic pain, normal examination and ultrasound had at best, a 55% chance of improvement. This group must be counselled about the low risk of success. The identification of the optimal surgical management of this difficult problem requires a multi-national registry study.

Tuberculous epididymitis following intravesical Bacillus Calmette-Guérin immunotherapy.

Intravesical Bacillus Calmette-Guérin (BCG) is widely used as an adjuvant therapy in the treatment of superficial bladder cancer. BCG is administered as a live, attenuated form of Mycobacterium bovis, and acts as an immunomodulary agent to delay tumor progression. BCG is generally well tolerated, though localized and systemic infectious complications may occur. A literature search revealed that tuberculous epididymitis is a rarely reported complication of intravesical BCG therapy. We report the case of an 82-year-old male who developed tuberculous epididymitis while undergoing intravesical BCG treatment for transitional cell carcinoma of the bladder. Right orchiectomy was performed, followed by rifampin and isoniazid therapy once M. bovis was identified as the infectious agent. The patient responded well to these treatments, and made a full recovery. Tuberculous epididymitis is an uncommon complication resulting from intravesical BCG therapy, which is likely explained by retrograde migration from the prostatic urethra in this case.

[A young man with a painful scrotum]. / Een jongeman met een pijnlijk scrotum.

A 16-year-old male patient with no known medical history presented at the Emergency Department (ED) with a 2-day history of pain and swelling in his right hemiscrotum. He was diagnosed with non-bacterial epididymitis and discharged home with medical advice. Six days after being diagnosed, the pain and swelling worsened and he was seen by a general practitioner who concluded that the symptoms were attributable to the previously diagnosed epididymitis. No further investigations were performed. Two days later he again presented at the ED, at which time colour Doppler echography revealed a testicular torsion of probably two days old. As after operative detorsion the testis was found to be non-vital, an orchidectomy was performed. This case illustrates that the diagnosis of epididymitis should always be reviewed in patients in whom the scrotum once again becomes painful. Early recognition and treatment of torsio testis gives a better chance of keeping the testis and therefore fertility.

Xanthogranulomatous epididymitis: clinical report and immunohistochemical analysis.

Xanthogranulomatous epididymitis is an uncommon non-neoplastic process with destruction of tissue and replacement by striking cellular infiltration of foamy macrophages, dense lymphocytes and plasma cells. We report on a 72-year-old man with a clinical history of inadequately treated arterial hypertension, who presented with a right scrotal mass associated with right scrotal pain for 10 days. Physical examination revealed pyogenic discharge from the hyperemic and edematous scrotum, with normal body temperature. Testicular tumor markers were normal. Ultrasonography (US) of the right testis showed edematous scrotal layers and a heterogeneous area of poorly defined margins within the testis and epididymis. There was minimal hydrocele, and the right funiculus was of normal diameter with no edema or pathologic formation. The progression of clinical findings, inflammatory parameters, US and color Doppler US findings with negative testicular tumor markers indicated surgical treatment. After preoperative treatment, right orchiepididymectomy was performed. Histology confirmed the diagnosis of xanthogranulomatous epididymitis.

Posterior urethral valve in a child presenting as recurrent epididymo-orchitis.

Epididymo-orchitis is an uncommon complication of posterior urethral valve. A four-year-old boy was admitted because of right-sided epididymo-orchitis. Scintigraphy of the scrotum showed increased uptake of radiotracer on the right side. The posterior urethral valve was disclosed by voiding cystourethrography. Ablation of the valve and antibiotic therapy made the patient free of symptoms.

[Diagnosis and treatment of acute epididymoorchitis].

From 1963 we treated 330 patients aged from 15 to 85 years admitted to the urological clinic with acute epididymoorchitis of mild (n = 106), moderate (n = 82) and grave severity (n = 152). The diagnosis of purulent forms of epididymitis and epididymoorchitis was made basing on clinical and ultrasonic studies. Aspiration thin-needle puncture of epididymic membrane under ultrasonic control with calculation of leucocyte count was made for detection of purulent-process in 17 patients with epididymitis at the stage of diffuse inflammation. 198 patients with mild and moderate forms of acute epididymoorchitis received complex conservative treatment including laser therapy. 132 patients with severe epididymoorchitis were operated. In epididymoorchitis with total inflammatory-purulent process we made epididymectomy, in local - resection. The testis was removed in total necrosis or purulent lesion of its tissues. For comparison we analysed case histories of 150 patients with epididymoorchitis treated before 1983. Comparison of the treatment results in patients with acute inflammatory diseases of scrotal organs favours early surgical treatment.

Isolated polyarteritis nodosa of the male reproductive system associated with a germ cell tumor of the testis: a case report.

Polyarteritis nodosa (PAN) presents mostly as a systemic disease with poor prognosis, rarely in an isolated form with a usually favorable outcome. Both forms may affect the male reproductive system and both forms have been associated with malignancies. We describe for the first time the occurrence of isolated PAN in the reproductive system combined with a mixed germ cell tumor of the testis in a 21-year-old man presenting with symptoms of chronic epididymitis. Two years after surgery he is without evidence of recurrence of either the tumor or PAN.

A 19-year review of paediatric patients with acute scrotum.

BACKGROUND AND AIMS: The aim of the study was to compare incidence, symptoms and signs of spermatic cord torsion to those of other conditions causing acute scrotum. MATERIAL AND METHODS: Records of 388 consecutive boys under 17 years of age treated for acute scrotum at The Hospital for Children and Adolescents in Helsinki in 1977-1995 were reviewed. During the period studied all patients with acute scrotum underwent urgent surgery to ensure accurate diagnosis and treatment. The duration and characteristics of the symptoms, clinical findings prior to operation and the age of the patients were registered. RESULTS: Scrotal explorations revealed 100 cases (26%) of spermatic cord torsion (SCT), 174 cases (45%) of torsion of the testicular appendage (AT), 38 cases (10%) of epididymitis (ED), 32 cases (8%) of incarcerated inquinal hernias and 44 (11%) other conditions. During the first year of life SCT was the most common cause of acute scrotum, another peak incidence being in adolescence. Almost half of the boys with AT were nine to 12 years of age (median 11). Except for infants, the patients' acute symptoms were pain (SCT 88%, AT 94%, ED 76%). Swelling in the hemiscrotum was found in 44% of SCT, in 39% of AT and in 88% of ED cases. Epididymitis was also accompanied by erythema (37%), but infrequently with fever (in 16%). Erythema was found also in AT (32%), but the "blue dot sign" was found positive in only 17 (10%) of the boys with AT. Three quarters of the boys who were operated on within six hours from onset of symptoms had testicle torsion. All testicles were saved when detorsion was performed within six hours, but salvage was possible in only half of the cases when symptoms had lasted more than six but less than 12 hours. CONCLUSIONS: The high probability of SCT among those admitted to an emergency department within six hours from the onset of the symptoms justifies immediate surgical exploration.

THE ACUTE SCROTUM IN CHILDREN.

The acute scrotum syndrome is a medical-surgical emergency and the recognition of this condition by both healthcare professionals and the general population may result into the patients' coming in earlier for medical examination and into the preservation of the gonad in case of torsion. The purpose of this retrospective analytical research is to point out specific epidemiological aspects in pediatric patients suffering from acute scrotum, and to review the existing diagnosis and treatment options. The study included 208 patients, of whom 16 with vanishing testis and 192 with acute scrotum (torsion of testis 25.5%, torsion of the hydatid of Morgagni 68.2%, epididymoorchitis 5.2%). The torsion of the hydatid of Morgagni occurs in boys with a mean age of 10 years and it involves both testes equally, whereas the torsion of testis usually occurs around the age of 13 and is twice more common in the left gonad. Another significant difference between the two conditions is the inflammatory syndrome, which occurs in 45.4% of the children with torsion of testis versus only 18.2% in the torsion of hydatid. Only one out of six testes torted during the neonatal period could be saved (16.6%); the gonad preservation rate was as high as 68.2% in the group of patients with testis torsion occurring outside the neonatal period. These alarming data are accounted for by the non-recognition of the severity of the condition and by the delayed surgical therapy, which occurs on the average 20 hours after the testis torsion has set in. If the asepsis and antisepsis standards are observed, patients with torsion of the hydatid of Morgagni or torsion of testis require neither fluid sampling from the tunica vaginalis for culture, nor antibiotic therapy.

Emphysematous epididymo-orchitis as a camouflage of prostate invasion secondary to rectum cancer: A case report.

INTRODUCTION: Emphysematous epididymo-orchitis is a rare cause of acute scrotum pain characterized by gas formation within the tissue. Diabetes mellitus and recto-seminal fistula secondary to sigmoid diverticulitis are generally accepted as being responsible for this disease. However, prostate invasion secondary to rectal cancer may be considered to be a newly identified pathogenetic mechanism. Herein, we report this rare case and illustrate the pathogenesis. CASE PRESENTATION: A 69-year-old man arrived at our emergency department presenting with sepsis and acute scrotal pain. Emphysematous epididymo-orchitis was diagnosed by scrotal sonography initially; however, advanced rectal cancer with prostate invasion was diagnosed by CT after a recurrent episode. An exploratory laparotomy with abdominoperineal resection and radical prostectomy were performed after neoadjuvant chemoradiotherapy. Histopathologic analysis confirmed the previous diagnosis. Emphysematous epididymo-orchitis caused by advanced rectal cancer is very rare, and our case is the first to be reported according to a literature search. Neoadjuvant chemoradiotherapy plus extended surgery can achieve a good oncological outcome. CONCLUSION: This case indicated that the very rare presentation as emphysematous epididymo-orchitis caused by locally advanced colorectal cancer.

Müllerian duct remnant involving Wolffian system: a case report and literature review.

A 14-month-old boy with repeated left acute epididymitis was admitted to our department. Ultrasonography detected a midline round cystic mass in a retrovesical region. This was easily opacified by cystourethrography and seen to have a free communication with the posterior urethra. Since urethroscopy revealed a passable orifice in the center of the verumontanum, while a cystic-wall biopsy specimen showed squamous epithelium, we considered this cystic lesion to be an enlarged prostatic utricle. Vasography showed that the bilateral vasa was implanted directly into this cystic lesion, and was the possible cause of his left epididymitis. Ligature of the left vas deferens was performed to prevent left epididymitis. An enlarged prostatic utricle involving the vasa is a rare presentation.