eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions

Epididymal Tuberculosis

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan

Updated: Nov 21, 2008

Introduction

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. Genitourinary tuberculosis is the most common extrapulmonary site of tuberculosis.¹

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, hematogenous spread is likely more common. Distal spread through the genitourinary tract from a renal source is also possible.

In very rare cases, 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.^2,3,4

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 tuberculosis can be attributed to tuberculosis in men with HIV infection, which apparently predisposes 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.

Clinical

History

• The typical presentation of epididymal tuberculosis is painful enlargement of the scrotum.
• Involvement is usually unilateral.
• Voiding problems are usually absent when only the external genitalia are involved. However, associated renal, vesical, or prostatic tuberculosis may contribute to irritative voiding symptoms.
• Malaise, fevers, and chills are common in individuals with epididymal tuberculosis.
• Epididymal tuberculosis can result in infertility.¹

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 this organ is involved. The vas deferens may be enlarged and beaded. Occasionally, a draining sinus is 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.
• Tuberculous epididymo-orchitis has been reported as a sequela of intravesical BCG treatment for bladder cancer.^2,3,4

Differential Diagnoses

Other Problems to Be Considered

Testicular teratocarcinoma

Workup

Laboratory 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 are also available for more rapid identification of the organisms in urine.
• Blood studies include complete blood cell count, serum electrolytes, and erythrocyte sedimentation rate (ESR). The ESR is commonly elevated in patients with epididymal tuberculosis, and its normalization can be used to follow the course of therapy.

Imaging Studies

• Chest radiography should be obtained to assess for evidence of pulmonary tuberculosis.
• Plain abdominal radiography is useful to search for evidence of renal or ureteral tuberculosis (ie, renal or ureteral calcifications). Renal ultrasonography to evaluate the upper urinary tract for evidence of hydronephrosis is also 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 a neoplasm is suspected.^5,6

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.

Treatment

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 is usually not considered by the treating physician.
• If no improvement occurs after 2-3 weeks of therapy for bacterial epididymo-orchitis, scrotal ultrasonography is useful to assess for complications of inadequately treated bacterial epididymo-orchitis.
• Ultrasonography also assists in the diagnosis of other elements in the differential diagnoses, 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, chest radiography, and abdominal radiography 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 upon 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 goes unsuspected in the management of refractory epididymo-orchitis in developed countries, the ultimate diagnosis of tuberculous epididymitis is usually made when the pathological specimen from epididymo-orchiectomy is examined.
• 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 specialist is recommended for physicians who are not familiar with the treatment of tuberculosis.

Medication

The chemotherapy used to treat tuberculosis has changed over the past few decades. Currently, a 4-month course generally is recommended for genitourinary tuberculosis. 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.

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.

Pyrazinamide

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.

Dosing

Adult

25 mg/kg/d PO; not to exceed 2 g PO qd

Pediatric

Administer as in adults

Interactions

Reported to produce a pink-brown color with some urine test strips

Contraindications

Documented hypersensitivity; severe hepatic damage; acute gout

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

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

Isoniazid (Laniazid, Nydrazid)

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.

Dosing

Adult

5 mg/kg PO/IM up to 300 mg qd or 15 mg/kg up to 900 mg/d 2-3 times/wk

Pediatric

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

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

Contraindications

Documented hypersensitivity; previous isoniazid-associated hepatic injury; severe adverse reactions to isoniazid such as drug fever, chills, or arthritis; acute liver disease

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

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

Rifampin (Rifadin, Rimactane)

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.

Dosing

Adult

10 mg/kg PO/IV qd; not to exceed 600 mg/d

Pediatric

10-20 mg/kg PO/IV; not to exceed 600 mg/d

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

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

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

Streptomycin

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.

Dosing

Adult

15 mg/kg IV qd maximum 1 g

Pediatric

20-40 mg/kg IV qd maximum 1 g

Interactions

Nephrotoxicity may be increased with aminoglycosides, cephalosporins, penicillins, amphotericin B, and loop diuretics

Contraindications

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

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

Follow-up

Further Outpatient Care

• Patients treated for epididymal tuberculosis should be monitored for resolution of symptoms and swelling of induration, which should begin within a few weeks.
• The urine generally clears 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 transmit the disease venereally.

Complications

• Complications of advanced tuberculous epididymitis include epididymal abscess and fistula formation.
• Both complications are usually treated with scrotal surgery. Failure of the antituberculous regimen to achieve satisfactory local response is also 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

• For excellent patient education resources, visit eMedicine's Men's Health Center and Bacterial and Viral Infections Center. Also, see eMedicine's patient education articles Testicle Infection (Epididymitis), Inflammation of the Testicle (Orchitis), and Tuberculosis.

Miscellaneous

Medicolegal 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 a 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 prompts the same therapy because tuberculosis is usually not considered by the treating physician.
• Because tuberculous epididymitis often goes unsuspected during management of refractory epididymo-orchitis in developed countries, the ultimate diagnosis of tuberculous epididymitis usually is made when the pathological specimen from epididymo-orchiectomy is examined.

References

1. Madeb R, Marshall J, Nativ O, Erturk E. Epididymal tuberculosis: case report and review of the literature. Urology. Apr 2005;65(4):798. [Medline].

2. Briceño-García EM, Gómez-Pardal A, Alvarez-Bustos G, Artero-Muñoz I, Molinero MM, Seara-Valero R, et al. Tuberculous orchiepididymitis after BCG therapy for bladder cancer. J Ultrasound Med. Jul 2007;26(7):977-9. [Medline].

3. Salvador R, Vilana R, Bargalló X, Araque X, Nicolau C. Tuberculous epididymo-orchitis after intravesical BCG therapy for superficial bladder carcinoma: sonographic findings. J Ultrasound Med. May 2007;26(5):671-4. [Medline].

4. Falkensammer C, Gozzi C, Hager M, Maier H, Bartsch G, Höltl L, et al. Late occurrence of bilateral tuberculous-like epididymo-orchitis after intravesical bacille Calmette-Guérin therapy for superficial bladder carcinoma. Urology. Jan 2005;65(1):175. [Medline].

5. Garbyal RS, Gupta P, Kumar S. Diagnosis of isolated tuberculous orchitis by fine-needle aspiration cytology. Diagn Cytopathol. Oct 2006;34(10):698-700. [Medline].

6. Sah SP, Bhadani PP, Regmi R, Tewari A, Raj GA. Fine needle aspiration cytology of tubercular epididymitis and epididymo-orchitis. Acta Cytol. May-Jun 2006;50(3):243-9. [Medline].

7. Allen FJ, de Kock ML. Genito-urinary tuberculosis--experience with 52 urology inpatients. S Afr Med J. Dec 1993;83(12):903-7. [Medline].

8. Angulo JC, Ramirez JC, Esteban M, Sanchez-Chapado M. Perineal fistulization of genital tuberculosis. J Urol. May 1999;161(5):1576-7. [Medline].

9. Barisic Z, Vrsalovic-Carevic N, Milostic K, et al. Tuberculous orchiepididymitis diagnosed by nucleic acid amplification test: a case report. Int Urol Nephrol. 2003;35(2):203-5. [Medline].

10. Chen F, Brook G, Williams G, Murphy S. Tuberculous epididymo-orchitis presenting within the setting of a sexually transmitted disease clinic. Sex Transm Dis. Mar 2004;31(3):163-5. [Medline].

11. De Backer AI, Mortelé KJ, De Roeck J, et al. Tuberculous epididymitis associated with abdominal lymphadenopathy (2004:1b). Eur Radiol. Apr 2004;14(4):748-51. [Medline].

12. Desmond N, Lynch M, Murphy D, Mulcahy F. Tuberculous epididymitis: a case report in an HIV seropositive male. Int J STD AIDS. May-Jun 1993;4(3):178-9. [Medline].

13. Farer LS, Lowell AM, Meador MP. Extrapulmonary tuberculosis in the United States. Am J Epidemiol. Feb 1979;109(2):205-17. [Medline].

14. Goodman P, Maklad NF, Verani RR, Gottlieb HE. Tuberculous abscess of the testicle in AIDS: sonographic demonstration. Urol Radiol. 1990;12(1):53-5. [Medline].

15. Graham NM, Chaisson RE. Tuberculosis and HIV infection: epidemiology, pathogenesis, and clinical aspects. Ann Allergy. Nov 1993;71(5):421-8; quiz 428-33. [Medline].

16. Heaton ND, Hogan B, Michell M, et al. Tuberculous epididymo-orchitis: clinical and ultrasound observations. Br J Urol. Sep 1989;64(3):305-9. [Medline].

17. Kim SH, Pollack HM, Cho KS, et al. Tuberculous epididymitis and epididymo-orchitis: sonographic findings. J Urol. Jul 1993;150(1):81-4. [Medline].

18. Kumar PV, Owji SM, Khezri AA. Tuberculous orchitis diagnosed by fine needle aspiration cytology. Acta Cytol. Nov-Dec 1996;40(6):1253-6. [Medline].

19. Muttarak M, Lojanapiwat B, Chaiwun B, Wudhikarn S. Preoperative diagnosis of bilateral tuberculous epididymo-orchitis following intravesical Bacillus Calmette-Guerin therapy for superficial bladder carcinoma. Australas Radiol. Jun 2002;46(2):183-5. [Medline].

20. Muttarak M, Peh WC, Lojanapiwat B, Chaiwun B. Tuberculous epididymitis and epididymo-orchitis: sonographic appearances. AJR Am J Roentgenol. Jun 2001;176(6):1459-66. [Medline].

21. O'Connell HE, Russell JM, Schultz TC. Delayed epididymitis following intravesical bacillus Calmette-Guerin administration. Aust N Z J Surg. Jan 1993;63(1):70-2. [Medline].

22. Oben FT, Wright RD, Ahaghotu CA. Tuberculous epididymitis with extensive retroperitoneal and mediastinal involvement. Urology. Jul 2004;64(1):156-8. [Medline].

23. Ortona L, Federico G. Pulmonary and extrapulmonary tuberculosis. Rays. Jan-Mar 1998;23(1):64-77. [Medline].

24. Petersen L, Mommsen S, Pallisgaard G. Male genitourinary tuberculosis. Report of 12 cases and review of the literature. Scand J Urol Nephrol. 1993;27(3):425-8. [Medline].

25. Schubert GE, Haltaufderheide T, Golz R. Frequency of urogenital tuberculosis in an unselected autopsy series from 1928 to 1949 and 1976 to 1989. Eur Urol. 1992;21(3):216-23. [Medline].

26. Small PM, Schecter GF, Goodman PC, et al. Treatment of tuberculosis in patients with advanced human immunodeficiency virus infection. N Engl J Med. Jan 31 1991;324(5):289-94. [Medline].

27. Türkvatan A, Kelahmet E, Yazgan C, Olcer T. Sonographic findings in tuberculous epididymo-orchitis. J Clin Ultrasound. Jul-Aug 2004;32(6):302-5. [Medline].

28. Wolf JS, McAninch JW. Tuberculous epididymo-orchitis: diagnosis by fine needle aspiration. J Urol. Apr 1991;145(4):836-8. [Medline].

29. Yang DM, Chang MS, Oh YH, et al. Chronic tuberculous epididymitis: color Doppler US findings with histopathologic correlation. Abdom Imaging. Sep-Oct 2000;25(5):559-62. [Medline].

Keywords

epididymal tuberculosis, epididymal TB, tuberculous epididymitis, genital tuberculosis, genital TB, genitourinary tuberculosis, genitourinary TB, mycobacterial tuberculosis, Mycobacterium tuberculosis, MTB, granulomas, extrapulmonary tuberculosis, nonpulmonary tuberculosis, extrapulmonary TB, nonpulmonary TB, male genital tuberculosis, male genital TB

Contributor Information and Disclosures

Author

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Medical Editor

Martha K Terris, MD, FACS, Professor, Department of Surgery, Medical College of Georgia
Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Urological Association, New York Academy of Sciences, and Society of University Urologists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

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