Experimental male genital tuberculosis, the possibility of lymphatic spread

Unilateral Testicular Infarction a Very Rare Complication of Genital Tuberculosis: A Case Report and Literature Review

Background

Genitourinary tuberculosis is the second most common form of extrapulmonary tuberculosis in developing countries. Isolated genital TB is rare, but testicular infarction is an unusual complication of delayed management, in which surgical intervention is warranted.

Case Presentation

A 29-year-old male non-smoker presents with painful left scrotal pain of 21 days. Initially managed with intravenous antibiotics, the disease progressed and resulted in testicular infarction. Left orchiectomy was performed, and the specimen was sent for histopathological examination, which revealed features consistent with a testicular tuberculous abscess.

Conclusion

Tuberculous epididymo-orchitis (TBEO) with testicular infarction was unusual. It is prudent to consider this in patients presenting with long-standing urinary symptoms, particularly in those unresponsive to the initial antibiotic therapy. It requires a high index of suspicion, especially in TB endemic areas.

Genital tuberculosis: current status of diagnosis and management

Genitourinary Tuberculosis (GUTB) is the second most common extra-pulmonary manifestation of tuberculosis (Tb) and an isolated involvement of genital organs is reported in 5–30% of the cases. Genital involvement results from primary reactivation of latent bacilli either in the epididymis or the prostate or by secondary spread from the already infected urinary organs. The epididymis are the commonest involved organs affected primarily by a hematogenous mode of spread. Tb is characterized by extensive destruction and fibrosis, thus an early diagnosis may prevent function and organ loss. The gold standard for diagnosis is the isolation and culture of mycobacterium tuberculosis bacilli and in the cases of suspected GUTB, it is commonly looked for in the urinary samples. All body fluid specimens from possible sites of infection and aspirates from nodules must also be subjected to examination. Radiologic investigations including ultrasonography and contrast imaging may provide supportive evidence. Anti-tubercular chemotherapy is the first line of management for all forms of genital Tb and a 6 months course is the standard of care. Most patients with tubercular epididymo-orchitis respond to antitubercular therapy but may require open or percutaneous drainage. Infertility resulting from the tubercular affliction of the genitalia is multifactorial in origin and may persist even after successful chemotherapy. Multiple organ involvement with obstruction at several sites is characteristic and most of these cases are not amenable to surgical reconstruction. Thus, assisted reproduction is usually required. Post treatment, regular annual follow up is recommended even though, with the current multi drug therapy, the chances of relapse are low.

Silent testicular metastasis from carcinoma of the prostate

Secondary testicular tumours are rare, but metastasis of prostatic carcinoma to the testis is being reported more frequently. While this may not reflect a true increased incidence, more cases are detected by bilateral orchiectomy. Of 916 patients with carcinoma of the prostate diagnosed and treated over a period of 10 years, 124 underwent bilateral orchiectomy. Three patients were found to have testicular metastasis, 1 being bilateral. The route of spread seems to be through the lumen and/or lymphatics of the vas deferens. Although it is a sign of advanced disease, the prognostic significance is undetermined.

Metastases to the spermatic cord, epididymis and testicles from carcinoma of the prostate--five cases

In five out of 80 patients, orchiectomized in the course of treatment for prostatic carcinoma, metastatic growth in testicles, epididymis and/or spermatic cord was found. Two patients had bilateral metastases. Metastatic spread to scrotal organs seems to be more common than earlier thought. The most common way of dissemination is probably by lymphatic extension. Scrotal spread is a sign of advanced disease.

Tuberculous prostatitis

A study of 5 patients with tuberculosis prostatitis revealed that (1) there is a greater chance of striking a noncaseating granuloma than a caseating lesion by needle biospy when both are present; (2) the absence of caseation on biopsy does not necessarily rule out tuberculosis; and (3) special stains may be negative for tuberculosis because of the small size of the tissue sample. Thus, if the clinical suspicion of tuberculous prostatitis is high and if noncaseating lesions are found, a second biopsy specimen should be taken for culture only.

Experimental male genital tuberculosis-appraisal of protective value of BCG vaccination

As part of an experimental study of the spread of urogenital tuberculosis, the development of tuberculous infection was compared in vaccinated and non-vaccinated guinea pigs after challenge with Mycobacterium tuberculosis strain H37Rv into the seminal vesicle. The animals were saccrified 35 days after challenge. Morphological observations indicate that tuberculous infection in an immunized animal is retarded, but spreads by the same routes as in an nonimmunized animal. On microbial enumeration significantly lower numbers of organisms were recovered from the inoculated seminal vesicle and regional iliac lymph nodes of the BCG-vaccinated guinea pigs.

Male genital tuberculosis-the possibility of lymphatic spread. A case report

A 52-year old man with recurrent, persistent tuberculosis developed a tuberculous epididymitis. No inflammatory changes were found in the ductus deferens. It is likely that spread of infection from the prostate to the epididymis occurred via the lymphatics in the funiculus spermaticus.

Spread of tuberculosis from obstructed and non-obstructed upper urinary tract

As part of an experimental study of the spread of urogenital tuberculosis, male guinea pigs were inoculated with tubercle bacilli (H37Rv) in the upper part of the ureter. Half of the animals were prepared by ligature of the ureter below the injection site prior to inoculation. Spread of the infection to the lower urinary tract and the genitalia occurred whether the ureter was intact or ligated. It is concluded that lymphatic spread is possible and seems to be more common than urinary (canalicular) spread.