Tb epididymitis, By Emad M.Qasem

Hints about tuberculosis , Epididymis anatomy and functions, Epididymis infection with TB, Incidence, Clinical picture and complications of it, Hints about the diagnosis and treatment

Presented in the department of Urology, Sohag school of medicine

1. TB
Epididymis
Highlight on
By:
EmadM. Qasem

2. Intended learning outcomes (IlOs)
•To learn the anatomy and physiology of epididymis.
•To learn hints about TB.
•To know about the incidence and clinical picture of
TB epididymitis.
•To know the investigations used for diagnosis.
•What is the treatment of TB Epididymitis.

3. What about Epididymis ?!
And TB ?!

4. Epididymis
•a long, coiled tube on posterior aspect that stores
sperm and transports it from the testes.
•These arethe head,
body,andtail.
•surrounding and separating
the epididymis from the
testis is the tunica vaginalis.
Fig. 1.

5. Epididymis function
stores sperm until it
is ready to undergo
maturation.
the sperm matures.
This maturation takes
approximately one
week.
connects to the
ductusdeferens
or vas deferens.
Fig. 2.
1.Sperm Storage.
2.Sperm Maturation.
3.Fluid resorption.

6. Epididymis Blood Supply
•Deferential artery (a branch of superior vesical
artery)
•cremastericartery (a branch of inferior epigastric
artery) supply the epididymis.

7. Mycobacterium tuberculosis.
•TheZiehl-Neelsen stain, or
acid-fast stain, is used in
staining it.
Fig. 3. 4. 5.
•Cultured on TheLöwenstein
–Jensen medium.
•TheMantouxtest
(tuberculin sensitivity
test) is a screening tool

8. Epididymitis

9. Epididymitis
•Inflammation or infection of the epididymis.
•It is the most common cause of intrascrotal swelling.
•Orchitisis less common, and rarely occurs in isolation
(except for some viral infections)
ChronicAcute
May last for 3months or moreLess than 6 weeks symptoms
0.9%of men presenting with
urogenitalproblems

10. Tuberculous Epididymitis
•about 90%of cases presenting as
chronic epididymo-orchitis can be attributed to
tuberculosis.
•The most common manifestation of genitourinary
tuberculosis in males is epididymitis with or without
orchitis

11. Tuberculous Epididymitis
•Tuberculosis of epididymis and testes is
the third commonest site of extrapulmonary
tuberculosisafter lymph nodes and bone
tuberculosis respectively.
•Genitourinary TB = (20 –73 %) of all extrapulmonary
TB.
•22% of these cases are epididymo-orchitis

12. Route of infection
•Secondary blood borne spread from a
primary pulmonary lesion.
•This haematogenousspread results in genital lesions
with or without any renal lesions.
•Genital disease may arise by antegradeinfection
from the kidneys

13. Route of infection
•haematogenousseeding or directextension from
neighboring foci in the genital tract.
•Apparent veneraltransmission from a woman
with pelvic tuberculosis has also been reported

14. Facts
•the tail of epididymisis the most affected part
•it is most vascular
•its relation with the vas deferens to be involved with
urinary reflux

15. Clinical Picture and
Investigations

16. History
•It is likely to present in patients from
1.high prevalence countries
2.with a previous historyof TB
3.patients with immunodeficiency.

17. Symptoms
•Symptoms suggestive of tuberculousinfection
1.Usually unilateral.
2.subacute/chronic onset
3.painless or painful scrotal swelling
4.associated with systemic symptoms of TB
5.a scrotal sinus
6.thickened scrotal skin.
7.Case would be recurrent.

18. Symptoms
Fig. 10.

19. Signs
•Tendernessto palpation on the affected side.
•Palpable swelling of the epididymis, starting with the
tail (Nodularityat the base of left scrotum)
•There may also be urethral discharge
•secondary hydrocele
•erythemaand/or oedemaof the scrotum on the
affected side
•pyrexia.

20. Investigations
•Diagnostic tests
1.Mycobacterialsmear and
culture.
•FNAC
•Good starting test for
evaluation of scrotal
swellings.
2. EpididymalBiopsy.
as we know, fine needle
aspiration is contraindicated in a
patient presenting
with a painless scrotal tumor,
because if a malignancy is
proven later, possible lymphatic
spread of malignant cells may
occur during aspiration
cytology.

21. Other Lab. Investigations
•The Mantouxtest ( no important role)
•Nucleic acid amplification test
sensitivityof 87–100%
a specificity of 92.2–98%
Detect the genes that confer resistance to
drugs.
•Urine analysis ( often UTI associated, Sterile pyria)

22. Other Lab. Investigations
•Semen cultures
•A minority of patients may have positive semen
cultures

23. Radiological examination
•Ultrasonography
•diffuse heterogenous
hypoechoicenlarged
epididymis
•focal nodular hypoechoic
lesion within it.
•due to caseatingnecrosis,
granulomasand fibrosis.
Fig. 6.

24. Radiological examination
•The tail of the
epididymis:
•markedly
enlarged,
heterogeneous
and hyper
vascular
Fig. 7.

25. Radiological examination
•CT scan
•Cases may be
presented with
non-tender scrotal
swelling
Fig. 9.

26. Radiological examination
•MRI
•enlarged left testis.
•Granulomatous
tissue located
centrally cannot be
clearly discriminated
from testicular
tissue, although it
seems slightly
hypointense
compared to the
peripheral testicular
tissue.
Fig. 8.

27. Other Radiological examination
•Chest X-Ray
•An abnormal chest radiograph revealing evidence of
quiescent or active pulmonary disease may be
present in some of the patients
•sputum microscopy must be carried out as routine.

28. Biopsy (diagnostic)
Fig. 11.

29. Complications and treatment

30. Complications
•atrophy (shrinkage) of the testicles
•fistula (abnormal passageway) in the scrotum
•testicular infraction (death of testicular tissue)
•infertility

31. Treatment
•Drug treatment
•6months of
treatment should be
effective.
•all four drugs are used for
2months
•‘maintenance phase’,
in which a combination of
rifampicinand isoniazidis
used for 4months
•Surgical treatment
•Surgery is an adjunct
method to drug
treatment for
GUTB, particularly for
extensive disease.
•excision of affected
tissue.
•a reconstructive therapy.

32. Drug treatment
Fig. 12.

33. Surgical treatment
•An epididymectomy
•required if a caseatingabscess does not respond to
medical treatment.
•testicular atrophy can occur in 6% of patients after
epididymectomy,

34. Surgical treatment
•If a testicular mass is not reduced in size within
3months of TB chemotherapy, the presence of a
neoplasm should be considered.
•Even if mycobacterialcultures were positive, as TB
and neoplasm can coexist.

35. Surgical treatment
•A 10-year study of 101 patients with confirmed GUTB
from Korea showed that more than 50% of these
patients required surgical intervention in addition to
medical treatment.
•Surgical interventions included nephrectomy,
epididymectomyand stenting.

36. Surgical treatment
Fig. 13.

37. References
1.Anatomy: http://www.healthline.com/human-body-maps/epididymis
2.Clinical Infectious diseases, by David Schlossberg, Ebookon:
http://bit.ly/1WIQaQm
3.Blood supply: http://radiopaedia.org/articles/epididymis
4.Tuberculous Epididymo-OrchitisTreated with Intermittent Therapy : A Case Report
: http://medind.nic.in/iac/t02/i1/iact02i1p51o.pdf
5.http://patient.info/doctor/epididymo-orchitis-pro
6.GranulomatousEpididymitis” possibly due to TB By BijanSadri fromTehran
University of Medical Sciences Dr. Gillian Lieberman Harvard Medical School
Nove, http://eradiology.bidmc.harvard.edu/LearningLab/genito/Sadri.pdf
7.http://www.healthline.com/health/epididymitis#TestsandDiagnosis4

38. Publications used as reference
1.Tuberculous Epididymo-OrchitisTreated with Intermittent Therapy : A
Case Report Sanjay Rajpal1, V.K. Dhingra2, M. Malik3, Raj Kumar4
2.“GranulomatousEpididymitis” possibly due to TB By BijanSadri from
Tehran University of Medical Sciences , Dr. Gillian Lieberman Harvard
Medical School.
3.Etiology and management of genitourinary tuberculosis Aula Abbaraand
Robert N. Davidson. Nature Review urology 2011.
4.Isolated tuberculousepididymitis presenting as a painless scrotal tumor
Victor Ka-SiongKho, Pei-HuiChan* 2010.

39. Figures
1.Fig. 1.: http://medicine.academic.ru/pictures/medicine/536.jpg
2.Fig. 2.: http://img.medscapestatic.com/pi/meds/ckb/68/39568tn.jpg
3.Fig. 3.:
https://en.wikipedia.org/wiki/Ziehl%E2%80%93Neelsen_stain#/media/File:Mycobacterium_t
uberculosis_Ziehl-Neelsen_stain_02.jpg
4.Fig. 4.: https://en.wikipedia.org/wiki/Löwenstein–
Jensen_medium#/media/File:LJ_medium.JPG
5.Fig. 5.:
https://en.wikipedia.org/wiki/Mantoux_test#/media/File:Mantoux_tuberculin_skin_test.jpg
6.Fig. 6. 7.: GranulomatousEpididymitis” possibly due to TB By BijanSadri fromTehran
University of Medical Sciences
7.Fig. 8: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031331/
8.Fig. 9. 10. 11. 13.: Isolated tuberculousepididymitis presenting as a painless scrotal tumor
http://homepage.vghtpe.gov.tw/~jcma/75/6/292.pdf
9.Fig. 12.: https://xa.yimg.com/kq/groups/23987713/425775974/name/tb+urin%C3%A1ria.pdf