PEDIATRIC UROLOGY

Inflammation of the Testis and Epidididymis in an Otherwise Healthy Child: Is it a True Bacterial Urinary Tract Infection?
Halachmi S, Toubi A, Meretyk S
Department of Urology, Rambam Medical Center, The Faculty of Medicine, Technion-Israeli Institute of Technology, Haifa, Israel
J Pediatr Urol. 2006; 2:386-9.

• Purpose: The exact etiology of acute gonadal inflammation (EO) in children is unknown. Bacterial infection and underlying urological abnormalities are thought to be the main causes, and hence antibiotic treatment and further invasive urinary tract imaging studies are usually recommended. The purpose of this study was to assess the role of bacterial infection in pediatric acute EO.
• Materials and Methods: We retrospectively searched our electronic medical archive for children under the age of 18 years with the diagnosis of acute EO between 1997 and 2002. Patients’ charts were retrieved and reviewed for clinical and laboratory data.
• Results: During 1997–2002, 193 patients with acute EO were treated. There were two subgroups according to the results of urinary cultures: 182 children (94.3%) had negative urine cultures and 11 (5.7%) had positive cultures. In the negative culture group, the mean age was 9.8 ± 3.2 years (0.5–17). Medical history for urological disease was negative in all patients. Presenting symptom was scrotal pain in 165 (90.7%), and only three patients (1.6%) had accompanying urinary symptoms. Physical examination was normal besides tender gonad. Urinalysis was completely normal in 169 (92.9%) patients. Scrotal Doppler ultrasound (US) demonstrated non-specific inflammatory process in 146 patients (80%), in nine (5%) torsion of the appendix testis was documented and in 27 (14.8%) scrotal US was normal. Follow up was available in 40% all of whom had an uneventful recovery with normal physical examination. In the positive culture group of 11 patients, the mean age was 11 ± 6.7 years (3 months to 16 years), and eight patients (73%) had a known congenital urological abnormality. Presenting symptom was pain in five (45.4%) and pain with swelling in six (55.6%). Accompanying dysuria, frequency and urgency occurred in eight (72.7%) patients. Urinalysis was abnormal in 10 (90.9%). US demonstrated increased blood flow to the gonad in 10 (90.9%).
• Conclusions: Negative history for urological disease, absence of urinary symptoms and normal urinalysis make the diagnosis of bacterial EO unlikely. In this setting, once testicular torsion was excluded, there is no justification for antimicrobial treatment or further imaging of the urinary tract.
  
  
• Editorial Comment
  This manuscript looks at patients under 18 years of age, between 1997 and 2002. They presented with the diagnosis of inflammation of the testis and epididymis. Charts were reviewed from children under the age of 18 from 1997 to 2002 and 193 patients were evaluated. They were divided into two groups, positive cultures and negative cultures. Hundred and eighty-two patients had negative cultures with a mean age of 9.8. The most common symptom in the culture negative group was scrotal pain and only 3 patients in this group had any urinary symptoms. Nearly 93% of these children had normal urinalysis with the other 13 children having scattered red cells or white cells. None was positive for protein, nitrites or leukocyte esterase. 80% of these culture-negative patients had ultrasounds of the scrotum with 9 patients having torsion of the appendix testis and follow up in 40% of the patients showed a normal physical exam. Eleven patients in the second group had positive urine cultures with a median age of 11 years. Five patients presented with pain and 6 with testicular swelling. The urinalysis was positive including red cells, white cells, protein nitrites and leukocyte esterase in 10 of the 11 patients with cultures being positive in all 11.
  The authors rightly point out that only a minority of patients have positive urine cultures when epididymo-orchitis is suspected and question whether antibiotics should be included as part of the treatment of patients whose urinalyses are negative.
  The conclusion was that patients with a non-bacterial epididymo-orchitis are usually pre-pubertal children without positive history for urologic disease. Their presentation is without urinary symptoms yet there is no justification for antibiotic therapy or urinary tract imaging. They did caution that non-verbal children and infants might need to be excluded.
  A few decades ago, urology textbooks suggested that epididymo-orchitis was due to urologic abnormalities such as ectopic ureters and that the entire urinary tract needed to be imaged. It is becoming more and more clear that the majority of epididymo-orchitis is not bacterial in origin and probably has a significant viral component. Somekh et al. (1) had a nice manuscript suggesting that a viral etiology may often be the cause. It is recognized that anti-inflammatory medications should be the main stay of treatment rather than antibiotics in epididymo-orchitis in kids.

Reference
1. Somekh E, Gorenstein A, Serour F: Acute epididymitis in boys: evidence of post-infectious etiology. J Urol. 2004; 171: 391-4.

Dr. Brent W. Snow
University of Utah Health Sci Ctr
Division of Urology
Salt Lake City, Utah, USA