This report discusses the case of a 79-year-old man who developed a urethral injury after implantation of an inflatable prosthesis, resulting in recurrent urinary tract infections. The patient had pain and swelling in the scrotum, as well as abdominal and suprapubic pain and rebound. He was diagnosed with epididymitis orchiditis, penile prosthesis, and pelvic abscess, and was treated with cephalexin. The patient was admitted for a urology consultation and his hospital stay was uneventful.
Epididymitis orchitis (EO) is inflammation of both the epididymis and the ipsilateral testicle. This condition is uncommon, with 600,000 cases of epididymitis reported annually in the United States, and it primarily affects men between the ages of 18 and 35. . Orchitis is much rarer. One outpatient study found that orchitis occurs in 58% of cases in which men develop epididymitis . EO can be caused by pathogens, bacterial or viral, the most common of which are Chlamydia trachomatis And the Neisseria gonorrhoeae. Men younger than 14 and older than 35 are less likely to get EO from sexually transmitted bacteria and usually develop common urinary tract pathogens such as Escherichia coli . Men with a UTI often have major complaints of scrotal pain and symptoms of a lower urinary tract infection (UTI).
Risk factors associated with EO include a history of epididymitis, unprotected sexual intercourse, prolonged use of a Foley catheter, bladder outlet obstruction, and lack of immunization against measles, mumps, and rubella. Cases of EO have also been attributed to urological organs . A physical exam can help differentiate EO from testicular torsion, which occurs frequently. While acute pain in the testicles and scrotum is a common symptom of EO and torsion, the symptoms of UTI found in EO including fever, hematuria, and dysuria are unlikely with testicular torsion. Moreover, the inguinal region can be searched for hernias or tender lymph nodes, indicating an inflammatory response during play, suggesting epididymitis or orchitis. Another physical examination result may be a thin spermatic cord, confirming epididymitis .
When the results of the physical examination are unclear or additional testing is required, Gram stain and urethral secretion culture are recommended. Sample polymerase chain reaction assays can then be used to identify the pathogen causing the infection. Ultrasound may also be used to visualize the Doppler wave pulse. Ultrasound imaging provides information about whether blood flow is restricted. In this case, doctors can easily attribute the patient’s pain to testicular torsion. On the contrary, if there is an increase in the pulsation of the wave, this indicates an enlarged epididymis or epididymitis [4,5]. The urgency of EO diagnosis is important; If left untreated, it can lead to infertility.
Penile prostheses are a viable option for patients with erectile dysfunction. These devices allow penetrative sexual activity without affecting the ability to urinate or ejaculate, nor do they interfere with sexual sensation or orgasm. . The most dreaded complication is infection, although the incidence of coated implants is lower . A patient and partner satisfaction study of two-part penile implants (such as the one obtained by our patient) revealed good satisfaction for both parties. . We present the case of an elderly man with EO after urinary injury from a penile prosthesis.
A 79-year-old man presented to the emergency department with left lower quadrant and left suprapubic region, left scrotal pain, and dysuria that began four days before presentation. The patient had an inflatable prosthesis in place. The patient reported that a few months ago he entered into urinary retention and had a traumatic catheter placed. Placement of the catheter became more difficult due to his prosthetic limb. He ended up with a urethral injury. Since that time, he has had problems with recurrent UTIs. He suffers from benign prostatic hyperplasia who underwent transurethral resection of the prostate. He was being treated with cephalexin for a urinary tract infection. He denied having any fever, chills, chest pain, shortness of breath, nausea, vomiting, diarrhea or headache. His previous medical history was significant for hypertension, dyslipidemia, gastroesophageal reflux disease, squamous cell carcinoma, and melanoma. Previous surgical history was significant in hernia surgery, penile implants, and knee surgery. He is a former smoker and does not drink. His vital signs were as follows: blood pressure of 146/88 mm Hg, temperature of 97.7 degrees Fahrenheit, pulse of 77 beats per minute, and a respiratory rate of 17 breaths per minute saturated at 97% over room air.
Physical examination was significant for abdominal and suprapubic pain and rebound. Examination of the genitourinary system revealed swelling in the scrotum. Urinalysis revealed moderate blood and significant leukoesterase. The remainder of the laboratory evaluation was unremarkable (Table 1).
Scrotal ultrasound revealed no ultrasound evidence of testicular torsion. The results were consistent with the EO on the left side. A complex medium-sized left hydrocele was seen. Mild to moderate bilateral testicular atrophy has also been observed. Heterozygous testicular echo may be based on atrophy (Fig 1).
A CT scan of the abdomen and pelvis revealed a large, well-defined fluid collection in the lower right pelvic region adjacent to the bladder, surrounding the penile prosthesis catheter (Fig. 2).
The patient was treated conservatively with intravenous antibiotics according to the advice of the urological service and did not require any surgical intervention. He was discharged from home the next day for an outpatient follow-up.
EO treatment can be determined by the pathogen causing the infection. Patients aged 14-35 years with a potential for gonococcal or chlamydial infection should receive a single dose of 250 mg of ceftriaxone and 100 mg of doxycycline twice daily. . For patients whose infection can be attributed to coliform bacteria, most of whom are patients under 14 years of age and over 35 years of age, 300 mg of ofloxacin twice daily for 10 days or 500 mg of levofloxacin once daily for 10 days is recommended. .
In addition to antibiotics, it is recommended that patients limit their activity, use cold compresses, and try to elevate the scrotum. Follow-up is suggested for up to seven days after patient assessment and initial treatment. The pain is expected to subside within one to three days, and patients over 50 years of age should be evaluated for urethral obstruction due to an enlarged prostate. . The importance of completing the entire course of antibiotic therapy should be emphasized to patients.
In the general population of patients with EO, trauma to the urinary tract devices is uncommon. A study of 58 cases in Nigeria found that only three cases could be attributed to trauma/hardware (5.2%). While this aetiology described only a small number of patients, the study ultimately suggested that in older men, urinary tract and instrumentation surgery are expected risk factors for UTIs and UTIs. .
When EO is observed in the presence of a penile prosthesis, concern about injury to the prosthesis itself must be considered. The most important risk factors in this scenario are diabetes mellitus and revision surgery Our patient had neither. Furthermore, it was not evidence of any systemic signs of sepsis (normal vital signs and no leukocytosis). In the case of our patient, the urological service decided on conservative management with a course of intravenous antibiotics. If opting to remove the prosthesis, the options would include immediate re-implantation of a new device (called a “post-implant companion”) or revision surgery at a later date. The challenge with delayed re-implantation is fibrosis of the canal and shortening of the penis, but it is considered safer for the patient .
The causes of EO often vary in patients with age. Additional risk factors such as comorbidities, urinary tract devices, and penis prostheses should also be considered. The mainstay of urogenital infection are antibiotics that target the infection, followed by consideration of implant removal where appropriate.