Aktuelle Aspekte der Epididymo-Orchitis

 

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Zusammenfassung

Hintergrund: Bei der akuten Epididymitis handelt es sich um eine Entzündung des Nebenhodens. Diese tritt typischerweise unilateral auf und kann ohne adäquate Therapie auf den Hoden übergreifen, sodass oft von einer Epididymo-orchitis gesprochen wird. Mit zunehmendem technischen Fortschritt gelingt eine immer genauere Untersuchung der Begleiterscheinungen wie Ejakulatveränderungen und des ursächlichen Erregerspektrums, welches von sexuell übertragbaren Erregern, wie Chlamydien und Gonokokken, hin zu Enterobakterien und selten Virusinfektionen reicht. Diese Aspekte, sowie weitere Erkenntnisse der letzten Jahrzehnte sollen hier zusammenfassend beschrieben werden.

Patienten/Methoden: Selektive Literaturrecherche via Medline der letzten 40 Jahre.

Ergebnisse: Die akute Epididymitis ist mit ca. 400 Fällen bei 100 000 Männern pro Jahr die häufigste Urogenitalinfektion. Betroffen sind alle Altersgruppen, einschließlich Kinder. Obwohl ätiologisch die bakterielle Aszension von wesentlicher Relevanz ist, berichten nur ca. 30% der Männer über eine Dysurie bzw. Urethritis. Bei jungen, sexuell aktiven Männern lassen sich auch bei unauffälliger Sexualanamnese regelmäßig sexuell übertragbare Erreger neben den typischen Enterobakterien finden. Falls eine epididymale Abszedierung auftritt, bildet sich diese in 88% vollständig unter konservativer Therapie zurück, sodass von einer Operation in aller Regel abgesehen werden kann. Hinsichtlich der antimikrobiellen Therapie sind insbesondere Patienten mit Dauerkatheterversorgung als Risikopatienten zu betrachten, da diese oftmals multiresistente Erreger aufweisen. Hier empfiehlt sich bis zum Erhalt des Antibiogramms eine initiale empirische Kombination mittels Fluorchinolon und Cephalosporin der dritten Generation. Eine postinflammatorische Subfertilität entwickelt sich bei rund 40% der Männer, wobei pathologische Ejakulatveränderungen verstärkt bei Nachweis von Hämolysin A-exprimierenden E.coli-Bakterien zu beobachten sind. Allerdings scheint es keinen Hinweis auf eine Verminderung des Hodenvolumens bei adäquater antimikrobieller Therapie zu geben. Rezidive erleiden ca. 10% der Männer. Hier sollte eine subvesikale Obstruktion diagnostisch abgeklärt werden, ggfs. kann auch eine prophylaktische Vasektomie diskutiert werden sollte.

Schlussfolgerungen: Die Übersichtsarbeit stellt wichtige Aspekte der akuten Epididymitis dar, die zunehmend auch Berücksichtigung in aktuellen Leitlinien finden.

Abstract

Background: Acute epididymitis is an inflammation of the epididymis. It mostly occurs unilaterally and may spread to the testis (‘epididymo-orchitis’) if untreated. Increasing technological advances allow for an even more detailed examination of concurrent symptoms such as ejaculate changes and the whole spectrum of pathogenic agents, which ranges from sexually transmitted pathogens such as Chlamydia and gonococci to enterobacteria and, rarely, viruses. This review summarises major aspects of the disease including the latest scientific findings.

Methods: A selective literature search including the last 40 years was performed via Medline.

Results: With about 400 cases a year in 100 000 men, acute epididymitis is the most common urogenital infection in men. It occurs across all age groups including children. Despite the fact that bacterial ascension is aetiologically of utmost relevance, only one out of three men reports signs of dysuria or urethritis. In young, sexually active men, sexually transmitted pathogens are regularly found in addition to the characteristic enterobacteriae, even if these men have an unremarkable sexual history. 88% of epididymal abscess formations can be successfully treated without surgery. Patients with indwelling urethral catheters are at a high risk of multiple drug resistance and should be treated empirically with both a fluoroquinolone and a third-generation cephalosporin until antimicrobial susceptibility testing has been completed. About 40 out of 100 patients develop post-inflammatory sub-fertility. Here, virulence factors like haemolysin A produced by uropathogenic E. coli have a negative impact on semen parameters compared to those patients suffering from epididymitis induced by haemolysin A negative strains. With adequate antibiotic treatment there is no evidence for testicular atrophy. Only one out of 10 men relapses. These cases should be examined thoroughly for subvesical obstruction. Some of them may benefit from prophylactic vasectomy.

Conclusions: This review presents key aspects of acute epididymitis, which are increasingly adopted in updated guidelines.

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