Fournier's gangrene: Presentation and predictors of mortality in Zaria, Nigeria

Background

Fournier's gangrene is an infectious urological emergency with associated morbidity and varying rates of mortality in the world. Various predictors of mortality such as advancing age, Fournier's Gangrene Severity Index (FGSI), anatomical extent of the disease, or presence of risk factors have been studied in the literature, though with conflicting results.

Aim

The aim of the study was to determine the presentation and predictors of mortality in our environment, Nigeria.

Patients and Methods

A review of medical records of all the patients managed from April 2012 to December 2018 at a tertiary referral center in Nigeria was conducted. Data on clinical presentation, FGSI, management, and outcome were retrieved and analyzed.

Statistical Analysis

Descriptive studies using mean and standard deviation were used for continuous variables, Fischer's exact test was used to compare categorical variables among survivors and nonsurvivors, and logistic regression analysis was used to describe the relationships of these variables with mortality.

Results

The mean age of the 31 patients was 60 ± 12 years. All were men, with 9 (29.0%) patients without clinical evidence of immunosuppression or predisposing factor (idiopathic). Fourteen (45%) had documented evidence of immunosuppression. All the patients had a polymicrobial infection; however, Escherichia coli was the most common organism cultured seen in 26 (83.9%) patients. The initial empirical antibiotic regimen of choice was a combination of intravenous ceftriaxone and metronidazole in 26 (83.8%) patients and intravenous ciprofloxacin and metronidazole in 5 (16.1%) patients. Mortality was recorded in three patients representing a rate of 9.6%. Anatomical extent of the disease, anemia requiring blood transfusion, severity of infection, and FGSI were all found to be the statistically significant variable of mortality in these patients using the Fischer exact test. Furthermore, on regression analysis only the FGSI and blood transfusion were significant with P < 0.05.

Conclusion

Fournier's gangrene is a disease of the older men with a higher mortality rate when the FGSI is >9 or anemia requiring blood transfusion is present.

Effects of pre- and post-pubertal dihydrotestosterone treatment on penile length in 5α-reductase type 2 deficiency

Steroid 5α-reductase type 2 deficiency (5αRD2) is a congenital disorder of sex development caused by impairment of conversion from testosterone (T) to 5α-dihydrotestosterone (DHT). DHT deficiency leads to various degrees of undervirilized external genitalia including micropenis, primarily correlated with mutations of the SRD5A2 gene that encodes 5α-reductase type 2. Four Japanese boys with isolated micropenis were diagnosed as 5αRD2 by elevated ratios of serum T/DHT, and decreased ratios of urinary 5α/5β-reduced steroid metabolites. Genetic analyses for SRD5A2 identified that the four patients shared a hypomorphic mutation R227Q that has a residual activity related to the mild-form of 5αRD2. For prepubertal micropenis, DHT was transdermally applied to the four patients at the ages of 4-11 year, increasing a median of stretched penile lengths (SPLs) from 2.6 cm (-2.5 SD) to 4.4 cm (-0.2 SD). Nevertheless, the post-pubertal penile growth was apparently retarded, despite normal levels of T secreted from well-developed testes. The second course of DHT treatment underwent at ages of 12-18 year, but unable to normalize SPLs at a range of 6.0 to 7.0 cm (-3.4 to -2.4 SD). The prostate volumes of two patients were variable at 8.1 and 21 cm³, and a sperm cell count of one patient was normal as young adult. DHT treatment contributes to development of the penis and prostate, which are favorable for the potential fertility of 5αRD2 adults. Meanwhile, the retarded penile growth and a risk of prostate overgrowth may complicate the post-pubertal management with DHT for 5αRD2 males.

Efficacy and Safety of Continuous Subcutaneous Infusion of Recombinant Human Gonadotropins for Congenital Micropenis during Early Infancy

BACKGROUND

Early postnatal administration of gonadotropins to infants with congenital hypogonadotropic hypogonadism (CHH) can mimic minipuberty, thereby increasing penile growth. We assessed the effects of gonadotropin infusion on stretched penile length (SPL) and hormone levels in infants with congenital micropenis.

METHODS

Single-center study including 6 males with micropenis in case of isolated CHH (n = 4), panhypopituitarism (n = 1), and partial androgen insensitivity syndrome (PAIS; n = 1). Patients were evaluated at baseline, monthly and at the end of the study through a clinical examination (SPL, testicular position and size), serum hormone assays (testosterone, luteinizing hormone, follicle-stimulating hormone, inhibin B, anti-Müllerian hormone [AMH]), and ultrasound of penis/testes.

RESULTS

In CHH, significant increases occurred in serum testosterone (from undetectable level to 3.5 ± 4.06 ng/mL [12.15 ± 14.09 nmol/L]), SPL (from 13.8 ± 4.5 to 42.6 ± 5 mm; p < 0.0001), inhibin B (from 94.8 ± 74.9 to 469.4 ± 282.5 pg/mL, p = 0.04), and AMH (from 49.6 ± 30.6 to 142 ± 76.5 ng/mL, p = 0.03). Micropenis was corrected in all patients, except one. On treatment, in the patient with PAIS, SPL was increased from 13 to 38 mm.

CONCLUSIONS

Early gonadotropin infusion is a safe, well-tolerated and effective treatment. The effect in PAIS has not been reported previously. Long-term follow-up is needed to assess the impact, if any, on future fertility and reproduction.
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[Optimization of modern conservative therapy of micropenis in hypogonadal men]

The study was aimed to the optimization of conservative therapy of micropenis in hypogonadal men using combination of traction therapy and androgen replacment therapy (ART) with injections of prolonged testosterone undecanoate (Nebido) and to evaluatiom of the safety of ART in terms of the risk of prostate cancer against the background of combined treatment of micropenis by both methods within 12 months. The study included 16 men aged 22-62 years with micropenis and hypogonadism. 10 men were diagnosed with primary hypogonadism, 6 men were diagnosed with secondary hypogonadism without reserve gonadal function; therefore, all 16 patients were treated with testosterone undecanoate 1000 mg intramuscularly according to the scheme: the second injection 6 weeks after the first injection, then each injection once a 12 weeks, the course of 12 months. During the first 3 months of ART, hypogonadism in all men was eliminated, but only at 6 month of ART, the length of the penis in the flaccid state at maximum extension increased from 5.8±1.2 to 8.3±1.2 cm (p<0.05), and the length of the erect penis - from 6.8±1.1 to 11.8±0.9 (p<0,05). At the next stage, from the 6th to the 12th month of ART, traction therapy was simultaneously carried out. At the end of the treatment, the length of the penis in the flaccid state at maximum extension increased by 58% of the original length, and in a state of erection - by 114% (p<0.05). During the 12 months of treatment, prostate volume in all men increased from 3.4±1.2 to 16.3±1.2 (p<0.05), which corresponds to the size of the prostate in healthy men. Total blood PSA level increased from 0.72±0.03 to 1.4±0.05 ng/ml (p<0.05), but it was in the acceptable range of reference values for healthy men during whole period of ART in all patients. Start therapy with prolonged testosterone undecanoate for 6 months significantly increases the efficiency of traction therapy in men with hypogonadism and micropenis, but for maintenance of the effect, ART should be continued during all period of treatment.

Human chorionic gonadotrophin (HCG) stimulation test and testosterone response in children with micropenis

BACKGROUND

Human chorionic gonadotropin (HCG) stimulation test is a reliable dynamic test for the evaluation of testicular function during childhood. A single dose of HCG injection at dose of 100 iu/kg is able to produce a progressive but modest rise in testosterone level for 72 to 120 hours in presence of a viable testicular Leydig cells.

OBJECTIVE

To describe pattern of testicular response to HCG stimulation in prepubertal children with micropenis seen at a paediatric endocrinology training centre.

METHODOLOGY

A retrospective review of all children seen over a fifteen months period and evaluated for micropenis using single dose HCG stimulation protocol. Information was retrieved from the clinic register and case notes of patients. Information retrieved includes age, anthropometry, associated clinical finding and results of stimulation test. Interpretation of test was as sited by Knorr and colleagues.

RESULTS

Six children with micropenis had HCG stimulation test. Mean age of children was 49.9 months age range 2 months to 84 months. Base line testosterone level ranged from 0 ng/ml to 0.35 ng/ml with a mean of 0.3 ng/ml. The mean testosterone level after HCG stimulation was 1.26 ng/ml and range between 0.35 and 3.2 ng/ml. Three subjects had normal increase in testosterone level post stimulation. There was no significant increase in mean stretched penile length of 0.4 cm.

CONCLUSION

HCG stimulation is an important test to determine Leydig cell function and testosterone secretion in children with micropenis. 3 (50%) including a cryptochid child showed normal rise in testosterone level post HCG stimulation. The normal response indicates a normal leydig cell function and possible presence of viable testicular tissues in the cryptochid.

Bancroftian filariasis in 12 villages in Kwale district, Coast province, Kenya — variation in clinical and parasitological patterns

As part of a larger study on the effects of permethrin-impregnated bednets on the transmission of Wuchereria bancrofti, subjects from 12 villages in the Coastal province of Kenya, south of Mombasa, were investigated. The aims were to update the epidemiological data and elucidate the spatial distribution of W. bancrofti infection. Samples of night blood from all the villagers aged i 1 year were checked for the parasite, and all the adult villagers (aged >/= 15 years) were clinically examined for elephantiasis and, if male, for hydrocele. Overall, 16.0% of the 6531 villagers checked for microfilariae (mff) were found microfilaraemic, although the prevalence of microfilaraemia in each village varied from 8.1%-27.4%. The geometric mean intensity of infection among the microfilaraemic was 322 mff/ml blood. At village level, intensity of the microfilaraemia was positively correlated with prevalence, indicating that transmission has a major influence on the prevalence of microfilaraemia. Clinical examination of 2481 adults revealed that 2.9% had elephantiasis of the leg and that 19.9% of the adult men (10.8%-30.1% of the men investigated in each village) had hydrocele. Although the overall prevalence of microfilaraemia in the study villages had not changed much since earlier studies in the 1970s, both prevalence and intensity varied distinctly between the study villages. Such geographical variation over relatively short distances appears to be a common but seldom demonstrated feature in the epidemiology of bancroftian filariasis, and the focal nature of the geographical distribution should be carefully considered by those mapping the disease.

PROBABILITY OF SPERM RECOVERY IN NON-OBSTRUCTIVE AZOOSPERMIC PATIENTS PRESENTING WITH TESTES VOLUME LESS THAN 10 ml/FSH LEVEL EXCEEDING 20 mIU/ml

We evaluated the sperm recovery rate in non-obstructive azoospermia (NOA) patients presenting with bilateral testicular atrophy characterized by testes volume of less than 10ml and FSH levels exceeding 20 mIU/ml (group NOA-1), and compared the results to those NOA cases displaying unilateral testis volume exceeding 10 ml or FSH levels less than 20 mIU/ml (group NOA-2). Sperm retrieval was conducted in 261 azoospermic patients from April 1995 to December 2002. Forty-six NOA-1 and 37 NOA-2 individuals underwent microdissection TESE or 3-4 standard biopsies. Sperm recovery was achieved in 11 (24%) and 12 (32%) cases in NOA-1 and NOA-2, respectively. All couples received ICSI. Four clinical pregnancies (36.3%) in NOA-1 and two (17%) in NOA-2 resulted. Five subsequent healthy deliveries were obtained. NOA patients presenting with bilateral severe atrophic testes volume and obviously elevated FSH levels exhibited approximately 24% probability of sperm recovery. On the other hand, NOA characterized by testicular atrophy or elevated FSH levels displayed probability of approximately 32%. Differences in sperm recovery were not evident between NOA-1 and NOA-2. No successful pre-operative predictors of sperm recovery were identified.

Diagnostic utility of serologic markers for genital chlamydial infection in STD patients in Chennai, India

OBJECTIVES

To evaluate the diagnostic utility of serological markers for C. trachomatis in different clinical groups of STD patients.

METHODS

Blood and genital swab specimens were collected from symptomatic STD patients (n=143) attending the STD out patient clinic at the Institute of STDs, Government General hospital, Chennai who enrolled for the study. Serological determination for IgM, IgA and IgG antibodies to C. trachomatis was done using commercial kits. PCR analysis was performed on genital swab samples by using plasmid and major outer membrane protein (MOMP) based primers and patients who were positive by both PCR assays were considered as proven cases of C. trachomatis infection. The serological marker positivity was analysed with PCR positivity.

RESULTS

Serologic positivity by IgM, IgA and IgG was 22.4%, 28.7% and 58.7% respectively. The PCR analysis showed 44 (30.8%) cases with confirmed C. trachomatis infection. Seropositivity for IgM (34.1% (15/44) vs. 17.2% (17/99); P<0.05) as well as for IgA (40.9% (18/44) vs. 23.2% (23/99); P<0.05) significantly correlated to PCR positivity, while significant correlation was not seen with IgG positivity. The overall seropositivity (IgM/IgA/IgG) in the study population was 68.5%.

CONCLUSIONS

The observations of the present study indicate a high exposure rate to chlamydial infection in STD clinic patients in India. The study also suggests the usefulness of serology instead of PCR to trace chlamydial etiology, especially in deep-seated upper genital tract diseases and to facilitate better clinical management as there was good correlation between serology and PCR positivity.

Vascular endothelial growth factor and monocyte chemoattractant protein-1 in Behçet's patients with venous thrombosis

OBJECTIVE

Vascular lesions can involve both arterial and venous systems which are often the major causes complicating the disease course of Behçet's disease (BD). Vascular endothelial growth factor (VEGF) is a stimulant of angiogenesis secondary to ischemia while monocyte chemoattractant protein 1 (MCP-1) is induced by shear stresses leading to vascular collateral development. MCP-1 has been also shown to contribute to the recanalization of venous thrombi. Tumor necrosis factor-alpha (TNF-alpha) is known to play a major role in the pathogenesis of BD. Furthermore, up-regulation of secreted MCP-1 and VEGF was observed following stimulation with TNF-alpha. In view of the above functions of VEGF, MCP-1 and TNF-alpha, we hypothesized that these factors may be important in the pathogenesis of thrombosis seen in BD.

METHODS

A total of 36 patients with a diagnosis of BD were studied. BD patients were separated into 3 groups with respect to vascular involvement. Group BD-AT (n = 9) with acute thrombosis, BD-CT (n = 12) with chronic thrombosis and BD-MC (n = 15) with mucocutaneous involvement only. The control group (group H) was comprised of 20 healthy persons. In addition, patients with acute, DC-AT (n= 11) and patients with chronic DC-CT (n = 9) thrombosis without BD served as disease controls. Serum measurements of VEGF MCP-1 and TNF-alpha were performed by quantitative sandwich ELISA. The acute phase reactants, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were also measured.

RESULTS

The levels of VEGF were significantly higher in the patients in group BD-AT than either in group BD-CT or BD-MC (p = 0.03 and p < 0.001, respectively). However, no significant difference was found for VEGF levels of thrombotic patients regarding the cause (BD-AT vs. DC-AT, p = 0.063; BD-CT vs. DC-CT, p = 0.084) or the stage of thrombosis (DC-AT vs. DC-CT, p > 0.05). Both BD patients and disease controls with acute thrombosis had significantly higher levels of MCP-1 as compared to corresponding chronic thrombosis patients (BD-AT vs. DC-CT; p < 0.001; DC-AT vs. DC-CT, p < 0.001). Patients with BD and disease controls had significantly higher serum TNF-alpha level when compared with healthy subjects. No significant difference with respect to serum TNF-alpha level was noted when patient subgroups with BD and disease controls were compared with each other Serum levels of VEGF, MCP-1, and TNF-alpha were not found to be correlated with either ESR or CRP (p > 0.05).

CONCLUSIONS

Increased levels of VEGF and MCP-1 detected in BD thrombosis suggest the possible role of those angiogenic cytokines in the pathogenesis. Although not specific for BD, detection of VEGF or MCP-1 levels seems to serve as an assay for differentiation of BD patients with acute thrombosis from chronic.

[Pathogenetic mechanisms of infectious-inflammatory and thrombohemorrhagic complications of transurethral prostatic resection]

The role of hemostatic disorders and alterations in urine proteolytic activity in pathogenesis of infectious-inflammatory and thrombohemorrhagic complications of prostatic transurethral resection (PTR) was studied. Hemostasis and urine proteolytic activity were investigated with biochemical and coagulological tests in 54 patients with benign prostatic hyperplasia (BPH) before and after PTR. Significant hypercoagulation in early postoperative period found in the examinees promoted formation of inflammation-related contaminated dense protein products which serve a source of permanent reinfection. The patients had low proteolytic activity of the urine caused by renal dysfunction as a result of abnormal urodynamics in this disease. Thus, hemostatic disorders and subnormal proteolytic activity of the urine are essential factors in pathogenesis of infectious-inflammatory and thrombohemorrhagic complications of PTR. The conceptual scheme of postoperative complications pathogenesis in BPH patients subjected to PTR is proposed.

C3 in seminal plasma has no additional informative value in the diagnosis of infection/inflammation of the male genital tract

The objective of this study was to determine the clinical significance of complement fraction C3 (C3c) in seminal plasma. Therefore 120 samples from randomly chosen subfertile males without signs of genital tract infection were screened for C3 and for seminal leucocytes as markers for subclinical infection/inflammation. A comprehensive semen evaluation included sperm analysis, sperm migration testing, immunocytochemical round cell differentiation to determine seminal leucocyte counts and the leucocyte ratio and semen cultures, in aliquots of the same ejaculates. C3 concentrations were significantly correlated with leucocyte counts per ml (P < 0.002) and per ejaculate (P < 0.001), and with the leucocyte ratio (P < 0.001). No association of C3 concentrations with semen quality or with the bacterial colonization of semen samples was found. The significant association with seminal leucocytes suggests that C3 might be used as an additional marker for silent male genital tract infection. In comparison with semen leucocytes, C3 screening does not reveal any further information about semen quality or infection/inflammation pathogenesis of the male genital tract.

[Significance of neutrophil elastase in diagnosis of male genital tract infection]

Neutrophil Elastase(NE) is a kind of neutral proteinase. Its value in the diagnosis of male genital tract infection has attracted increasing attention in recent years. NE has special diagnostic value in screening the typical genital tract infection caused by Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma urealyticum and Trichomonas, as well as other kinds of genital infection, such as leukocytospermia and periorchitis. NE has been considered as a specific marker of the male genital tract infection.

Value of acute-phase proteins in the differential diagnosis of acute scrotum

OBJECTIVES

The evaluation of patients with an acute scrotum is primarily based on physical examination, imaging studies, as well as blood and urine tests. However, the differential diagnosis may be difficult in some cases. In a retrospective study, we investigated the value of acutephase proteins in serum and plasma from patients with an acute scrotum.

METHODS

A total of 104 patients (epididymitis n=52, testicular tumor n=17, testicular torsion n = 11, other conditions n = 24) with an acute scrotum were included in this study. In all patients the acute-phase proteins C-reactive protein (CRP), haptoglobin, alpha1-acid glycoprotein and transferrin in serum as well as fibrinogen in plasma were determined by turbidimetric analysis. The results were compared to the clinical findings, routine blood and urine tests and ultrasound.

RESULTS

Patients with an epididymitis showed at least a 4-fold elevation of CRP except for 2 cases (median 63.2 mg/l). In these patients, the sensitivity of CRP was 96.2%, the specificity 94.2%, the negative predictive value 94.2% and the positive predictive value 94.3%. Patients with a testicular tumor had no significant elevation of CRP (median 9 mg/l) as well as those with a testicular torsion (median 5 mg/l) except for 1 patient. The difference between patients with epididymitis and those with noninflammatory conditions was statistically significant (p<0.001, Kruskal-Wallis test and Tukey-Kramer test). The remaining parameters (haptoglobin, fibrinogen, a1-acid glycoprotein, transferrin, white blood count, body temperature and ultrasound) were less sensitive and specific.

CONCLUSIONS

Acute-phase proteins (especially C-reactive protein) are helpful in differentiating epididymitis from noninflammatory conditions like testicular torsion or tumor. Turbidimetric analysis of these proteins is rapid, easy and inexpensive.

Assessment of seminiferous tubule function (anti-müllerian hormone)

Anti-müllerian hormone (AMH) is specifically produced by Sertoli cells in the male. The testes express a high level of AMH from early fetal life, driven by the transcription factors SOX9, SF1, WT1 and GATA4, until puberty, when AMH is downregulated by testosterone and meiosis. When androgen negative effect is absent, follicle-stimulating hormone increases the secretion of AMH. Serum AMH determination is useful in the evaluation of children with non-palpable gonads, with or without ambiguous genitalia. It signals the existence of functional testicular tissue and allows a distinction to be made between gonadal dysgenesis and dissociated tubular-interstitial dysfunction. Serum AMH is a useful marker in the follow-up of male patients with precocious puberty or hypogonadotrophic hypogonadism, as well as of patients with sex cord stromal tumours of the gonads. Finally, AMH determination on the seminal plasma of men with non-obstructive azoospermia may be used as a marker of the existence of testicular spermatozoa when intracytoplasmic sperm injection is considered.

Failure to establish chronic infection of the reproductive tract of the male horse with a South African asinine strain of equine arteritis virus (EAV)

Eight sexually mature horse stallions were inoculated intranasally with a South African asinine strain of EAV, a strain that was isolated from the semen of a donkey carrier. All horses developed fever, with maximum rectal temperatures of 38.9-39.9 degrees C recorded 3-6 d post challenge. Six horses showed very mild clinical signs of equine viral arteritis and two were asymptomatic. The virus was recovered from the nasopharynxes of six horses 2-7 d after inoculation, and from buffy-coat samples of all horses, 2-11 d after inoculation. Seroconversion to EAV was detected on days 8 and 10 and peak serum-virus-neutralizing antibody titres ranging from log10 1.2-1.8, on days 14-20 after challenge. The titres varied from log10 0.9-1.2 after about 10 weeks, when the experiment was terminated. In three stallions euthanased on days 5, 7 and 9 after challenge, virus was detected inconsistently in different parts of the reproductive tract and urine. No virus was isolated from the tissues of the reproductive tract collected from stallions on days 16, 23 and 68 after challenge. Five stallions were bred to six seronegative mares between 13 and 34 d post challenge. No clinical signs of EAV were observed, and neither was seroconversion detected in any of the mares after mating. No virus was recovered from semen samples collected at the time of breeding. The results of this study demonstrated that the tissues of the reproductive tracts of the stallions did not become persistently infected with a South African asinine strain of EAV.

[Usefulness of counting leukocytes and round cells in determination of bacterial infection of semen in infertile men]

The authors measured efficiency of the determination of bacterial infection from the semen of infertile men. They compared the correlation of counts of bacteria with white blood cells (peroxidase method) and round cells in ejaculate. Seminal white blood cells counts (more than 1 x 10(5)/ml) correlated well with bacteriospermia (more than 1000 cells/ml), R = 0.4741, p = 0.0007. Determination of round cells in semen has no clinical value in prediction of seminal infection, R = 0.0153, p = 0.6022.

Outcome prediction in patients with Fournier's gangrene

We treated 30 patients with Fournier's gangrene during a 15-year period. Data were collected on demographics, medical history, admission signs and symptoms, physical examination, admission laboratory studies and bacteriology. The timing and degree of surgical débridement as well as antibiotic therapy were also reviewed. The extent of disease was calculated from body surface area nomograms. Data were stratified according to the outcomes of death (13 patients) or survival (17). Patients who survived were significantly younger (53 years old, range 23 to 90) than those who died (71 years old, range 53 to 83, p = 0.004). Admission laboratory parameters that were statistically related to outcome included hematocrit, blood urea nitrogen, calcium, albumin, alkaline phosphatase and cholesterol levels. White blood count, platelets, potassium, bicarbonate, blood urea nitrogen, total protein, albumin and lactic dehydrogenase levels 1 week following hospitalization were also associated with outcome. The greater mean extent of body surface area involved among patients who died was not statistically different from that of those who lived (7.16 and 4.32%, respectively, p = 0.1). The number of surgical débridements did not seem to influence outcome. To assess better the physiological profile of the patients in both outcome categories, the acute physiology and chronic health evaluation II severity score was modified to create a Fournier's gangrene severity index. The mean Fournier's gangrene severity index for survivors was 6.9 +/- 0.9 compared to 13.5 +/- 1.5 for nonsurvivors. Regression analysis demonstrated a strong correlation between Fournier's gangrene severity index and death rate (correlation coefficient = 0.934, p = 0.005). Using a Fournier's gangrene severity index threshold value of 9, there was a 75% probability of death with a score greater than 9, while a score of 9 or less was associated with a 78% probability of survival (p = 0.008). In conclusion, Fournier's gangrene is an infectious disease affecting an ever aging population of patients. Deviation from homeostasis is the most important parameter predictive of outcome and not the extent of disease or performance of surgical débridement. The Fournier's gangrene severity index is an objective and simple method to quantify the extent of metabolic aberration that may be used to predict outcome. We recommend the use of the Fournier's gangrene severity index when evaluating therapeutic options and reporting results.

Nonbacterial pyospermia: a consequence of clomiphene citrate therapy

OBJECTIVE

Since the development of nonbacterial pyospermia in previously nonpyospermic men treated with clomiphene citrate (CC) has been observed, and nonbacterial prostatitis has been after antiestrogen treatment in an animal model, we sought characterize the occurrence of nonbacterial pyospermia in men treated with CC.

PATIENTS AND METHODS

Forty-two nonpyospermic men with low serum testosterone levels treated with 25 mg CC/day were retrospectively compared to 27 untreated nonpyospermic men referred for infertility evaluation.

RESULTS

Spontaneous nonbacterial pyospermia developed in CC-treated men [14.3%] at rate nearly twice that observed in controls [7.4%]. Serum testosterone increased in CC-treated men, both pyospermic and nonpyospermic. However, only CC-treated, nonpyospermic men demonstrated improvement in semen characteristics. CC-treated men who developed pyospermia were older than nonpyospermic men [pyospermic, 41.7 +/- 8.1 years; nonpyospermic, 35.6 +/- 4.9 years-P < .01). Men over 35 years of age were over six times as likely to develop pyospermia as men under 35 years of age (P < .05). Eight nonpyospermic, CC-treated men (8/36, 22.2%) have contributed to pregnancies leading to live births, whereas no pyospermic man has done so.

CONCLUSION

These findings support an association between a nonbacterial inflammatory response of the human male reproductive tract and CC treatment. This pyospermia may occur without significant deterioration of semen characteristics and with an appropriate response to treatment in terms of serum testosterone level. Men over the age of 35 are statistically more likely to develop pyospermia with this therapy. Our results suggest that clomiphene citrate-associated pyospermia has a negative effect on male fertility.

History and physical examination

In summary, the history and physical examination provide a valuable overview of a patient's condition and clues as to the causes. Typically, the most important features are evidence of gynecomastia, completeness of genital development and virilization, testicular size and consistency, and condition of the prostate gland. Preliminary laboratory evaluation is usually done at the conclusion of the initial evaluation and generally includes a total or free testosterone level, a semen analysis, urinalysis, and screening profiles for blood count, liver and renal function, and serum electrolytes. A more detailed hormonal evaluation would include gonadotropins, luteinizing hormone and follicle-stimulating hormone, prolactin, estradiol, and possibly thyroid studies. With this information complete, the astute clinician can develop a working diagnosis and plan for further evaluation or referral to a specialist.

Serum antisperm antibodies in men with vas deferens obstruction caused by childhood inguinal herniorrhaphy

OBJECTIVE

To study the incidence of serum antisperm antibodies in patients with vas deferens obstruction caused by childhood inguinal herniorrhaphy.

DESIGN

Retrospective.

SETTING

Kansai Medical University and Kyoto University Hospital.

PATIENTS

Thirteen patients with vas deferens obstruction caused by childhood inguinal herniorrhaphy.

MAIN OUTCOME MEASURES

Indirect immunobead test for serum antisperm antibodies.

RESULTS

Of 13 patients, 7 (54%) and 2 (15%) tested positive for immunoglobulin (Ig)G and IgA class antisperm antibodies, respectively; all patients tested negative for IgM class antibodies. The incidence of antisperm antibodies was not different between the patients with possible epididymal obstruction and those without epididymal obstruction.

CONCLUSIONS

A significant percentage of patients with vasal obstruction caused by infant inguinal herniorrhaphy have serum antisperm antibodies despite the absence of sperm granulomas.

Immunoglobulins and immunoglobulin-containing cells in the reproductive tracts of rams naturally infected with Brucella ovis

Thirteen rams with serological evidence of Brucella ovis exposure (CFT of 1:8 or greater), but with no or only mild epididymitis, were selected from a ram flock. Serum, semen, preputial washings and fluids from the accessory sex glands (ASGF) and testis and epididymis (TEF) were examined and immunoglobulin (Ig) concentrations estimated. Genital tissues were examined histologically and the percentages of class specific immunoglobulin containing cells (ICC) determined. Eleven of these rams had histological evidence of active inflammation consistent with B. ovis infection; the organisam was cultured from the semen of 7. IgA concentration was high in semen (mean +/- standard deviation of 5.03 +/- 1.78 mg/ml) and ASGF (9.18 +/- 7.28 mg/ml). These levels were much higher than those recorded in noninfected rams. IgA concentration was low in serum (0.78 +/- 0.55 mg/ml) and TEF (0.59 +/- 0.78 mg/ml). The concentrations of IgG1, IgG2 and IgM were low in all genital fluids sampled and not significantly different from those recorded in noninfected rams. This indicated that infection with B. ovis results in a pronounced IgA response in secretions, mostly from the accessory sex glands. Examinations of ICC, however, revealed that the plasma cell infiltrates of the epididymis, vas deferens, ampulla and seminal vesicle were predominantly IgG-containing (92.4, 97.2, 79.4 and 91.9% respectively). Fewer IgM-containing cells were scattered throughout these tissues, constituting 3.9, 6.3, 0.3 and 6.5% of all ICC, respectively. IgA-containing cells were most frequently seen in the ampulla (9.6% of ICC) where they were located directly beneath the epithelium, suggesting the ampulla as the most prominant location for the local production of IgA.(ABSTRACT TRUNCATED AT 250 WORDS)

Zinc and genital infections

The zinc status of 19 patients with chronic or recurrent genital infections and 18 patients with non-recurrent genital infections was assessed by measuring plasma and leucocyte zinc concentrations. Neither group of patients had plasma or leucocyte zinc concentrations that differed significantly from those of matched healthy controls. Each of six patients with chronic candidiasis had anergy to candidal antigen, as shown by delayed cutaneous hypersensitivity to intradermal injection of the antigen, but their zinc status was normal. This study provided no evidence of zinc deficiency in this small number of patients with acute non-recurrent or chronic recurrent genital infections.

[Local morphological and functional changes in patients with obstructed testicular excretory ducts]

Following a short introduction to the physiology and function of gonads in men, the authors present their material and exploration methods. the study covered 39 patients with azoospermia of obstructive origin. The obstruction of v. deferens developed in 29 patients after a non-specific inflammatory reaction, in 7 patients after a trauma, in 2 patients after vasectomy, and one patient was a case of congenital anomaly. Concentrations of FSH and ICSH in the plasma of the patients studied did not show any major deviations. Histological analysis showed normal morphological spermatids and primary spermatocytes with degenerative changes in later stages in 29 patients. In the remaining 10 patients, most probably due to the inflammatory reaction and as the result of congenital anomaly, the destruction of the germinal epithelium was evident. Spermagglutinins in the serum of the patients were detected in 56.8%. Such a high percentage of antispermatic agglutinins is meant to be the result of obstruction and the presence of the inflammatory agent.

[Hormone determinations in andrology]

The measurements of the pituitary and peripheral plasma hormone values represent an important part in the andrological armamentarium. The basal plasma hormone levels in different urological and andrological disorders are demonstrated as well as the interpretation of the LH-RH test in Sertoli-cell-only- and Klinefelter's syndrome. Our days endocrinological diagnostic procedures are based on the determination of important hormonal parameters.

Alpha-fetoprotein and human chorionic gonadotropin in the management of testicular tumors

Alpha-fetoprotein and human chorionic gonadotropin levels were measured by radioimmunoassays in 260 patients with genitourinary diseases, including 93 patients with testicular tumors. Elevations of alpha-fetoprotein and human chorionic gonadotropin were associated only with non-seminomatous germ cell testicular tumors. Our 32-month experience with serial measurements of the 2 markers in patients with these tumors shows that alpha-fetoprotein and human chorionic gonadotropin must be determined and that together they serve as accurate and sensitive indicators of metastases and are helpful in determining the effectiveness of therapy. However, they have limited value in the differential diagnosis of scrotal masses.

Typing Herpesvirus hominis antibodies and isolates by inhibition of the indirect hemagglutination reaction

Inhibition of the indirect hemagglutination reaction (IHA inhibition) was compared to several other methods for type-specific identification of Herpesvirus hominis (HVH) antibodies and isolates. The method appears to have the greatest value for typing antibodies for HVH type 1 and HVH type 2 in human sera; identification of antibody type was relatively simple and results were definitive. The IHA-inhibition test permitted serological diagnosis of HVH type 2 infection in three young adults with meningoencephalitis, thus extending the mounting evidence that nervous system involvement with this virus type is not limited to neonatal infections. II/I indexes of neutralizing or IHA antibody gave an accurate indication of the presence of HVH type 2 antibody in those sera containing type 2 antibody by IHA inhibition, but they indicated the presence of HVH type 2 antibody in one-half or more of the sera shown to contain only HVH type 1 antibody by IHA inhibition. For typing HVH isolates, the IHA-inhibition test gave results identical to those obtained by direct fluorescent-antibody staining using cross-absorbed conjugates, but the IHA-inhibition test was much more cumbersome and time-consuming to perform than was direct fluorescent-antibody staining. A microneutralization technique for virus typing also gave results identical to those obtained with direct fluorescent-antibody staining and IHA inhibition. However, typing HVH isolates by plaque size or the differential effect of incubation temperature was found to be less definitive and accurate.