eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions
Epididymal Tuberculosis: Treatment & Medication
Updated: Nov 21, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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.
Adult
25 mg/kg/d PO; not to exceed 2 g PO qd
Pediatric
Administer as in adults
Reported to produce a pink-brown color with some urine test strips
Documented hypersensitivity; severe hepatic damage; acute gout
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.
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
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
Documented hypersensitivity; previous isoniazid-associated hepatic injury; severe adverse reactions to isoniazid such as drug fever, chills, or arthritis; acute liver disease
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.
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
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
Documented hypersensitivity
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.
Adult
15 mg/kg IV qd maximum 1 g
Pediatric
20-40 mg/kg IV qd maximum 1 g
Nephrotoxicity may be increased with aminoglycosides, cephalosporins, penicillins, amphotericin B, and loop diuretics
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
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
More on Epididymal Tuberculosis |
| Overview: Epididymal Tuberculosis |
| Differential Diagnoses & Workup: Epididymal Tuberculosis |
 Treatment & Medication: Epididymal Tuberculosis |
| Follow-up: Epididymal Tuberculosis |
| References |
| « Previous Page | Next Page » |
References
Madeb R, Marshall J, Nativ O, Erturk E. Epididymal tuberculosis: case report and review of the literature. Urology. Apr 2005;65(4):798. [Medline].
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].
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].
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].
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].
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].
Allen FJ, de Kock ML. Genito-urinary tuberculosis--experience with 52 urology inpatients. S Afr Med J. Dec 1993;83(12):903-7. [Medline].
Angulo JC, Ramirez JC, Esteban M, Sanchez-Chapado M. Perineal fistulization of genital tuberculosis. J Urol. May 1999;161(5):1576-7. [Medline].
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].
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].
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].
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].
Farer LS, Lowell AM, Meador MP. Extrapulmonary tuberculosis in the United States. Am J Epidemiol. Feb 1979;109(2):205-17. [Medline].
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].
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].
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].
Kim SH, Pollack HM, Cho KS, et al. Tuberculous epididymitis and epididymo-orchitis: sonographic findings. J Urol. Jul 1993;150(1):81-4. [Medline].
Kumar PV, Owji SM, Khezri AA. Tuberculous orchitis diagnosed by fine needle aspiration cytology. Acta Cytol. Nov-Dec 1996;40(6):1253-6. [Medline].
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].
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].
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].
Oben FT, Wright RD, Ahaghotu CA. Tuberculous epididymitis with extensive retroperitoneal and mediastinal involvement. Urology. Jul 2004;64(1):156-8. [Medline].
Ortona L, Federico G. Pulmonary and extrapulmonary tuberculosis. Rays. Jan-Mar 1998;23(1):64-77. [Medline].
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].
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].
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].
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].
Wolf JS, McAninch JW. Tuberculous epididymo-orchitis: diagnosis by fine needle aspiration. J Urol. Apr 1991;145(4):836-8. [Medline].
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].
Further Reading
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
