1.Introduction
Infections of the male genitourinary tract are considered to be one of the causes of male infertility that can be corrected. In this paper, urethritis, prostatitis, orchitis and epididymitis are classified as male accessory gonadal infections according to WHO guidelines. However, there is a lack of clear information to confirm that these diseases have a negative impact on sperm quality.
2. Urethritis
There are various pathogens of UTIs from sexual contact, the most common being chlamydia, mycoplasma and gonococcus. Non-infectious causes of UTIs include allergic reactions, trauma and various operational stimuli. Urethral discharge and dyspareunia are the most prominent symptoms of acute UTIs.
Diagnosis relies on urethral smear and initial urinalysis. The diagnosis is confirmed if the urethral smear reveals more than 4 granulocytes per high magnification field (1000x) or more than 15 granulocytes per high magnification field (400x) on a 3 ml initial urine sediment smear. In the case of urethritis, the examination of the patient’s fertility is inaccurate because the inflammatory material in the anterior urethra interferes with the semen analysis.
The effect of UTI on semen quality and fertility is unclear due to the contamination of semen from inflammatory material in the urethra.
It is debated whether sexually transmitted microorganisms impair sperm function, but it can cause urethral strictures or lesions at the posterior urethral seminal mound leading to obstruction and ejaculation disorders, which can impair male fertility.
Treatment of sexually transmitted diseases can follow the guidelines established by the Centers for Disease Control and Prevention in Atlanta, GA. In most patients, the pathogen is not known at the time of diagnosis and treatment is empirical. A single dose of fluoroquinolone may be given followed by 2 weeks of doxycycline, and these treatments are effective against both gonococci and mycoplasma/chlamydia.
3. Prostatitis
Prostatitis is the most common urological disease in men under 50 years of age and was previously classified into 4 major categories.
-Acute bacterial prostatitis and prostate abscesses.
-chronic bacterial prostatitis.
-non-bacterial prostatitis.
-Prostatodynia.
1) Classification
In order to better define and understand prostatitis, the National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK) has introduced a new classification of prostatitis (Table 9).
Table 9 New NIDDK classification criteria for prostatitis
Category (new) Description
? Acute bacterial prostatitis Acute prostate infection
Ⅱ Chronic bacterial prostatitis Recurrent prostate infection
III chronic non-bacterial prostatitis Pelvic pain syndrome without evidence of infection
IIIA inflammatory Semen, EPS, urine with WBC after massage
IIIB non-inflammatory Semen, EPS, post-massage urine without WBC
Ⅳ asymptomatic prostatitis No subjective symptoms, due to inflammation found in prostate biopsy or WBC in EPS or semen found during examination for other diseases
4.Testiculitis
When the testes are inflamed, the inside and outside of the varicocele are filled with white blood cells and their secretions, leading to sclerosis of the tubules. Inflammation can cause pain and swelling. Chronic inflammation of the varicocele can lead to impairment of sperm production, which can result in a decrease in both the quantity and quality of sperm.
It is generally believed that orchitis may be an important cause of spermatogenic blockage, but it is reversible. Testicular inflammation can lead to testicular atrophy.
1) Diagnosis
Patients with orchitis of the epididymis usually have unilateral scrotal pain, and the diagnosis relies on history and palpation. Ultrasonography will reveal a swollen and enlarged testicle, and its ultrasound features can rule out other diseases. Semen analysis including leukocyte analysis will suggest a persistent inflammatory response and most patients, especially those with acute epididymitis, will have a temporary decrease in sperm count and sperm forward motility, with obstructive azoospermia being a rarer complication. Mumps complicated by orchitis may cause bilateral testicular atrophy, leading to testicular azoospermia. However, when sarcoidosis orchitis occurs, sperm-binding autoantibodies are present.
2) Treatment
Standardized treatment protocols have been developed only for acute bacterial epididymal orchitis and atopic granulomatous orchitis (Table 10), and several protocols are thought to improve inflammatory lesions. Unfortunately there is a lack of evaluation of the effects of corticosteroids, nonsteroidal analgesics such as dichlorfenac, anti-inflammatory pain and acetylsalicylic acid on the male reproductive system. The application of gonadotropin-releasing hormone (GnRH) to prevent the damage of inflammation on spermatogenesis remains to be confirmed by further clinical trials. Some reports have confirmed that the application of interferon alpha-2b can prevent testicular atrophy and azoospermia caused by mumps complicated by orchitis. In the treatment of idiopathic granulomatous orchitis, surgical removal of the affected testis is an option.
Table 10 Treatment of epididymal orchitis
Condition Treatment
Acute bacterial epididymitis testicularis
Gonococcal Tetracyclines
Chlamydia trachomatis Tetracyclines
Escherichia coli Fluoroquinolone
Mumps complicated by orchitis Interferon alpha-2b
Non-specific chronic epididymitis orchitis Steroidal and non-steroidal analgesics
Granulomatous (idiopathic) orchitis Removal of the affected testicle
Idiopathic orchitis Treatment according to the appropriate disease
5. Epididymitis
Epididymitis usually causes unilateral, rapid onset pain and swelling, and in most cases affects both testes, called epididymitis. In sexually active young patients under the age of 35, the most common organisms causing epididymitis are Chlamydia trachomatis or gonococcus. Epididymitis transmitted through sexual contact is usually accompanied by urethritis. Non-sexually transmitted epididymitis is usually associated with a urinary tract infection. These epididymitis tend to occur in patients over 35 years of age who have had recent urethral instrumentation or urethral surgery, or who have a urethral malformation.
1) Diagnosis
In acute epididymitis, the inflammation and swelling usually begins in the caudal part of the epididymis and then spreads to the rest of the epididymis and the testes. Although epididymitis transmitted through sexual contact has a history of smut, it can be up to several months away from the onset of the disease. The causative organism of epididymitis can be determined by a urethral smear and a Gram stain of the middle urine. A urethral smear from a patient with gonorrhea will reveal intracellular Gram negative diplococci. A urethral smear with only leukocytes is usually a sign of non-gonococcal urethritis, and chlamydia can be isolated in approximately two-thirds of these patients.
Semen analysis: Semen analysis including leukocyte analysis may suggest the persistence of inflammation, and most patients will have a temporary decrease in sperm count and forward motility, which may be related to impaired sperm quality due to ipsilateral concurrent orchitis. (Table 11)
Table 11 Effect of acute epididymitis on semen parameters
Author Adverse reaction
Density Viability Morphology Notes
Ludwig and Haselberger ＋ ＋ ＋ 19 of 22 patients had spermatozoa
Berger et al. ＋
Weidner et al. ＋ ＋ ＋ 3 out of 70 patients with azoospermia
Haidl + + chronic infection; macrophage increase
Cooper et al Reduced epididymal markers: alpha-glucosidase, levocannabinoids
Improper management of bilateral epididymitis can produce epididymal duct stenosis, reduced sperm count, and even azoospermia, and it is unclear how much azoospermia is caused by epididymitis.
2) Treatment
Antibiotics can be applied even before the culture results are available. The treatment of epididymitis can achieve the following results.
-removal of the infecting microorganism.
-Improvement of signs and symptoms.
-prevention of spread.
-reduction of complications such as infertility or chronic pain.
When epididymitis is clearly or suspected to be caused by gonococcal or chlamydial infection, their sexual partners should be advised to be examined and treated.
6. Conclusion
UTI and prostatitis do not always lead to reduced fertility or infertility, and in most patients, general semen analysis does not reflect a clear association between accessory gonadal infection and decreased sperm quality. In addition, antibiotic therapy usually only destroys microorganisms and does not help with inflammatory changes or reverse functional defects and anatomical abnormalities.
7. Recommended protocol
Most patients with DD acute urethritis have an unclear etiology at the time of diagnosis, which can then be administered empirically by giving a single dose of fluoroquinolone followed by 2 weeks of doxycycline. This treatment is effective against both gonococci and mycoplasma or chlamydia.
DD Only antibiotic treatment of chronic bacterial prostatitis has been shown to be effective in improving symptoms, eliminating microorganisms, and reducing inflammatory parameters of the cells and body fluids in the secretions of the genitourinary tract.
DD Although antibiotic treatment of male accessory gonadal infections can improve sperm quality, it does not always improve pregnancy rates.
DDefinitely or suspected epididymitis caused by gonococcal or chlamydial infection, their sexual partners should be advised to be examined and treated.