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Post-Prostatectomy Epididymitis: A Bacteriological and Clinical Survey*
Vol. 104, July
THE JOURNAL OF UROLOGY
Copyright © 1970 by The Williams & Wilkins Co.
Printed in U.S.A.
POST-PROSTATECTOMY EPIDIDY:\IITIS: A BACTERIOLOGICAL AND CLINICAL SURVEY* A. DAVID BECK
AND
DAVIDE. TAYLOR
From the Departments of Urology and Bacteriology, Auckland Hospital, Auckland, New Zealand
Epididymitis is recognized as a possible complication of a prostatic operation. Several investigators suggest that epididymitis is caused by reflux of urine into the vas deferens. Rolnick1 first proposed such a mechanism but 0'Conor2 confirmed that bladder contents refluxed into the vas by finding silver solution in the vasa of 2 patients within 24 hours of instilling the solution into the bladder. Hanley 3 reported on the passage of urine from the severed end of the vas while Carlton and Leader 4 demonstrated filling of the vas radiographically during cystourethrography. Interruption of vasal continuity would seem to be a logical procedure to reduce the incidence of epididymitis. However, the value of vasectomy for all patients undergoing prostatectomy has been criticized. Some people believe that preoperative urinary infection may have already resulted in bacterial contamination of the epididymis.5-7 In our investigation a segment of one vas was excised and cultured for pathogenic bacteria and the contralateral vas was left intact to serve as a control. We will herein discuss the significance of urinary infection, instrumentation and vasal infection in the development of epididymitis. Accepted for publication June 11, 1969.
* This study was done by one of us (A. D.
1?-l
during the tenure of an Isaacs Medical J:e)lows~1_p. 1 Rolnick, H. C.: Pathology of ep1d1dym1t1s. Surg., Gynec. & Obst., 47: 806! 19?8, 2 O'Conor, V. J.: Silver solut10n rn the lumen of the vas after bladder instillation. J. Urol., 33: 422, 1935. . 3 Hanley, H. G.: Urinary fistula followrng scrotal vasectomy. Brit. J. Urol., 17: 54, 1945. 4 Carlton, C. E. and Leader, A ..J.: The cy~tourethrographic demonstration of retrogr3:de unr'.a~y flow in the vas deferens as a cause of ep1d1dym1 tis. J. Urol., 84: 123, 1960. 5 Haralambidis, G. and Spinelli, A. N.: Vasectomy: an evaluation. J. Urol., 89: 591! 1963. G Lynn, J.M. and Nesbit, R. l\!I.: Th~ 1:1flue'.1~e of vasectomy upon the incidence of ep1d1dym1t1s following transurethral prostatectomy. J. Urol., 59: 72, 1948. 7 Bohn, C. L. and Sji:iber~, J.: VasectOIJ?-Y: as. a prophylactic measure agarn~t ep1d1dym1t1s m surgical treatment of prostat1c hypertrophy and other urological diseases. Acta Chir. Scand., :113:
MATERIAL AND METHODS
Our series consisted of 100 consecutive patients undergoing suprapubic prostatectomy. Every patient who required preoperative urethral catheter drainage received nitrofurantoin which was discontinued on the day of operation. Bacteriological urinalysis was performed when the patient was admitted to the hospital, immediately before the operation and on the day of discharge from the hospital. At the commencement of the operation a segment of the left vas was excised through a small scrotal incision and sent for bacterial culture. Postoperatively 45 unselected patients were prescribed prophylactic antibiotic therapy (ampicillin). The minimum followup was 3 months during which time each patient was seen on at least 3 occasions. Bacteriological methods. Urine specimens were examined by microscopy and bacterial colony counts were performed by agar dilution techniques. Leukocyte counts of 2 or more cells per high power field and bacterial colony counts of 100,000 or more organisms per ml. indicated significant infection. Immediately after excision the vas was placed in 10 ml. thioglycollate broth and sent to the laboratory. The segment of vas was swabbed, inoculated onto other media and incubated at 37C for as long as 5 days. The media used were blood agar, incubated aerobically and anaerobically, MacConkey agar, glucose broth and the original thioglycollate broth. Media and methods of identification of the urinary and vasal bacteria cultured were those outlined by Cruickshank. 8 RESULTS
To facilitate interpretation of results the cases are presented in 3 groups: group 1-sterile urine at operation with no preoperative catheter, group 2-sterile urine at operation with preoperative 8 Cruickshank, R.: Medical Microbiology, 11th edit. Baltimore: The Williams and Wilkins Co.,
1965.
305, 1957.
143
144
BECK AND TAYLOR
1. Incidence of positive vas cultures and epididymitis in 100 patients following unilateral vasectomy
TABLE
Group
2 3
No. Pts. 21 47 32
Positive Vas Culture
2. Results of vas cultures and occurrence of epididymitis in 100 patients following unilateral vasectomy
TABLE
Vas Culture
Postop. Epididymitis
No.
(%)
No.
(%)
2 5 12
(9 5) (10.6) (37.5)
2 4
(9. 5) (8.5) (21. 9)
7
Sterile
Group
Infected
Epfdidy- Epididy- E ~?d mitis mitis P:U{tit 18
21 47 32
39
17
catheter and group 3-infected urine at operation with preoperative urethral catheter. The vasa of 19 patients yielded positive bacterial cultures (table 1). Two patients (9.5 per cent) in group 1 had bacteria cultured from their vasa. A coagulase positive Staphylococcus was cultured from 1 case and Proteus was cultured from the other. Both were possibly skin contaminants. The bacteria isolated from the vasa of all 5 patients (10.6 per cent) in group 2 were coagulase positive staphylococci. The incidence of positive vas cultures in group 3 was 37.5 per cent. The bacteria isolated were identical to those responsible for the urinary infection in 9 of 12 patients. Although postoperative epididymitis occurred in 13 patients, only 5 had it before their discharge from the hospital. Epididymal infection occurred on the ligated side in 1 patient and no case of bilateral epididymitis was seen. Provided the urine was sterile at the time of prostatectomy the incidence of epididymitis was not affected by catheterization (9.5 per cent in group 1 and 8.5 per cent in group 2). Of the 32 patients with preoperative urinary infections, 7 (21.9 per cent) later had epididymitis (table 1). The presence of pathogenic organisms in the vasa was associated with an increased incidence of postoperative epididymitis on the non-ligated, non-cultured side. Eighty-one patients had sterile vasa, 7 (8.6 per cent) of whom had epididymitis. Of the 19 patients with positive vas cultures, 6 (31.6 per cent) had epididymitis. The 1 patient who had epididymitis on the ligated side had a sterile vas and infected urine (table 2). The prophylactic use of ampicillin in 45 unselected patients had no effect on the incidence of epididymitis-13.7 per cent of the patients treated suffered this complication compared to 12.7 per cent of the patients who received no antibiotic therapy. These results are in accordance with those of Reeves and associates who found
Total
74
Total
Epididymitis
3• 13
100
• One patient had epididymitis on the ligated side.
prophylactic antibiotics relatively ineffective in preventing epididymitis after prostatectomy. 9 Complications of vasectomy. A small hematoma, requiring no treatment, developed at the site of the scrotal incision in 3 patients. Vasitis was observed in 1 patient. The only other complication was a minor infection of the scrotal wound. None of these complications caused extra hospitalization of any patient. DISCUSSION
The recorded incidence of epididymitis following vasectomy ranges from 3.7 to 13.6 per cent. 10 , 11 When vasectomy is omitted the incidence rises to between 14.9 and 39 per cent. 12 , 13 These figures support the protagonists of routine vasectomy. In our series one testicle served as a control to assess the prophylactic value of vasectomy. That 12 of the 13 cases of epididymitis occurred on the non-ligated side is further evidence of the advantages of vasal ligation. In a similar study of 194 patients, the majority treated by periurethral prostatectomy, 12 had epididy9 Reeves, J. F., Scott, R., Jr. and Scott, F. B.: Prevention of epididymitis after prostatectomy by prophylactic antibiotics and partial vasectomy. J. Urol., 92: 528, 1964. 10 Schmidt, S. S. and Hinman, F.: The effect of vasectomy upon incidence of epididymitis after prostatectomy; and analysis of 810 operations. J. Urol., 63: 872, 1950. 11 Crabtree, E. G. and Brodny, M. L.: Vasectomy in prostatic surgery; a review of 141 consecutive prostatectomies. Trans. Amer. Ass. Genito-Urin. Surg., 23: 383, 1930. 12 Abeshouse, B. and Lerman, S.: Vasectomy in the prevention of epididymitis following prostatic surgery. Urol. & Cutan. Rev., 54: 385, 1950. 13 Alyea, E. P.: Vasa-ligation a preventive of epididymitis before and after prostatectomy. J. Urol., 19: 65, 1928.
POST-PROSTATECTOMY EPIDIDYMITIS
mitis on the non-ligated side, 3 were bilateral and none were restricted to the ligated side. 14 Only 5 of 13 cases of epididymitis in our series occurred before discharge from the hospital. The average interval between operation and the development of this complication was 2.8 weeks. Therefore, any investigation designed to determine the incidence of postoperative epididymitis should extend beyond the immediate postoperative period. 15 Organisms isolated from the majority of cases with positive vas cultures, excluding those attributed to operative contamination, were identical to those found in urine specimens. This is evidence that infected urine can reflux into the vas deferens and offers a plausible explanation for the development of epididymitis in such cases. Provided the urine remained sterile, the presence of an indwelling urethral catheter had little effect on the incidence of postoperative epididymitis occurring on the non-ligated side. In the presence of infected urine, 37 .5 per cent of the vas cultures were positive which agrees closely with other reports following culture of both vasa. 16 , 17 Vasectomy afforded protection to the ligated testicle of 14 Graham, J. B. and Grayhack, J. T.: Epididymitis following unilateral vasectomy and prostatic surgery. J. Urol., 87: 582, 1962. 15 Presman, D. and Rolnick, D.: Retropubic prostatectomy: mortality, complications and functional end results. J. Urol., 88: 814, 1962. 16 Kendall, A. R.: Rationale of prophylactic vasectomy. J. Urol., 89: 712, 1963. 17 Kreutzmann, H. A. R.: Studies of infections of the vas deferens. J. Urol., 39: 123, 1938.
145
all patients whose urine and ipsilateral vasa were infected. In contrast, 30 per cent of those patients with infected vasa at operation had epididymitis on the non-ligated side. These results indicate that prophylactic vasectomy is of value even when the vas is infected assuming that the bacterial flora of both vasa are the same. 16 The 1 patient who had epididymitis on the ligated side had infected urine, although culture of the excised vas yielded no bacteria. This is thought to be a laboratory error. Seven patients whose left vas was sterile had epididymitis on the right side and all had postoperative urinary infections. It is possible that the reflux of sterile urine into the vas initiated a chemical inflammation though the reflux of infected urine, after prostatectomy, cannot be excluded. 18 However, vasectomy afforded protection to the ligated testicles of all patients who had urinary infections postoperatively. The presence of pathogenic bacteria in both the vas deferens and urine does not mean that the subsequent development of epididymitis is inevitable. Vasectomy affords a significant degree of protection to the ligated testicle. The results of our series, despite the minor complications which occasionally followed vasal ligation, strongly suggest that bilateral vasectomy is a simple and reliable method of reducing the incidence of epididymitis in all patients undergoing prostatectomy. 18 Graves, IL S. and Engel, W. J.: Experimental production of epididymitis with sterile urine; clinical implications. J. Urol., 64: 601, 1950.
THE JOURNAL OF UROLOGY
Copyright © 1970 by The Williams & Wilkins Co.
Printed in U.S.A.
POST-PROSTATECTOMY EPIDIDY:\IITIS: A BACTERIOLOGICAL AND CLINICAL SURVEY* A. DAVID BECK
AND
DAVIDE. TAYLOR
From the Departments of Urology and Bacteriology, Auckland Hospital, Auckland, New Zealand
Epididymitis is recognized as a possible complication of a prostatic operation. Several investigators suggest that epididymitis is caused by reflux of urine into the vas deferens. Rolnick1 first proposed such a mechanism but 0'Conor2 confirmed that bladder contents refluxed into the vas by finding silver solution in the vasa of 2 patients within 24 hours of instilling the solution into the bladder. Hanley 3 reported on the passage of urine from the severed end of the vas while Carlton and Leader 4 demonstrated filling of the vas radiographically during cystourethrography. Interruption of vasal continuity would seem to be a logical procedure to reduce the incidence of epididymitis. However, the value of vasectomy for all patients undergoing prostatectomy has been criticized. Some people believe that preoperative urinary infection may have already resulted in bacterial contamination of the epididymis.5-7 In our investigation a segment of one vas was excised and cultured for pathogenic bacteria and the contralateral vas was left intact to serve as a control. We will herein discuss the significance of urinary infection, instrumentation and vasal infection in the development of epididymitis. Accepted for publication June 11, 1969.
* This study was done by one of us (A. D.
1?-l
during the tenure of an Isaacs Medical J:e)lows~1_p. 1 Rolnick, H. C.: Pathology of ep1d1dym1t1s. Surg., Gynec. & Obst., 47: 806! 19?8, 2 O'Conor, V. J.: Silver solut10n rn the lumen of the vas after bladder instillation. J. Urol., 33: 422, 1935. . 3 Hanley, H. G.: Urinary fistula followrng scrotal vasectomy. Brit. J. Urol., 17: 54, 1945. 4 Carlton, C. E. and Leader, A ..J.: The cy~tourethrographic demonstration of retrogr3:de unr'.a~y flow in the vas deferens as a cause of ep1d1dym1 tis. J. Urol., 84: 123, 1960. 5 Haralambidis, G. and Spinelli, A. N.: Vasectomy: an evaluation. J. Urol., 89: 591! 1963. G Lynn, J.M. and Nesbit, R. l\!I.: Th~ 1:1flue'.1~e of vasectomy upon the incidence of ep1d1dym1t1s following transurethral prostatectomy. J. Urol., 59: 72, 1948. 7 Bohn, C. L. and Sji:iber~, J.: VasectOIJ?-Y: as. a prophylactic measure agarn~t ep1d1dym1t1s m surgical treatment of prostat1c hypertrophy and other urological diseases. Acta Chir. Scand., :113:
MATERIAL AND METHODS
Our series consisted of 100 consecutive patients undergoing suprapubic prostatectomy. Every patient who required preoperative urethral catheter drainage received nitrofurantoin which was discontinued on the day of operation. Bacteriological urinalysis was performed when the patient was admitted to the hospital, immediately before the operation and on the day of discharge from the hospital. At the commencement of the operation a segment of the left vas was excised through a small scrotal incision and sent for bacterial culture. Postoperatively 45 unselected patients were prescribed prophylactic antibiotic therapy (ampicillin). The minimum followup was 3 months during which time each patient was seen on at least 3 occasions. Bacteriological methods. Urine specimens were examined by microscopy and bacterial colony counts were performed by agar dilution techniques. Leukocyte counts of 2 or more cells per high power field and bacterial colony counts of 100,000 or more organisms per ml. indicated significant infection. Immediately after excision the vas was placed in 10 ml. thioglycollate broth and sent to the laboratory. The segment of vas was swabbed, inoculated onto other media and incubated at 37C for as long as 5 days. The media used were blood agar, incubated aerobically and anaerobically, MacConkey agar, glucose broth and the original thioglycollate broth. Media and methods of identification of the urinary and vasal bacteria cultured were those outlined by Cruickshank. 8 RESULTS
To facilitate interpretation of results the cases are presented in 3 groups: group 1-sterile urine at operation with no preoperative catheter, group 2-sterile urine at operation with preoperative 8 Cruickshank, R.: Medical Microbiology, 11th edit. Baltimore: The Williams and Wilkins Co.,
1965.
305, 1957.
143
144
BECK AND TAYLOR
1. Incidence of positive vas cultures and epididymitis in 100 patients following unilateral vasectomy
TABLE
Group
2 3
No. Pts. 21 47 32
Positive Vas Culture
2. Results of vas cultures and occurrence of epididymitis in 100 patients following unilateral vasectomy
TABLE
Vas Culture
Postop. Epididymitis
No.
(%)
No.
(%)
2 5 12
(9 5) (10.6) (37.5)
2 4
(9. 5) (8.5) (21. 9)
7
Sterile
Group
Infected
Epfdidy- Epididy- E ~?d mitis mitis P:U{tit 18
21 47 32
39
17
catheter and group 3-infected urine at operation with preoperative urethral catheter. The vasa of 19 patients yielded positive bacterial cultures (table 1). Two patients (9.5 per cent) in group 1 had bacteria cultured from their vasa. A coagulase positive Staphylococcus was cultured from 1 case and Proteus was cultured from the other. Both were possibly skin contaminants. The bacteria isolated from the vasa of all 5 patients (10.6 per cent) in group 2 were coagulase positive staphylococci. The incidence of positive vas cultures in group 3 was 37.5 per cent. The bacteria isolated were identical to those responsible for the urinary infection in 9 of 12 patients. Although postoperative epididymitis occurred in 13 patients, only 5 had it before their discharge from the hospital. Epididymal infection occurred on the ligated side in 1 patient and no case of bilateral epididymitis was seen. Provided the urine was sterile at the time of prostatectomy the incidence of epididymitis was not affected by catheterization (9.5 per cent in group 1 and 8.5 per cent in group 2). Of the 32 patients with preoperative urinary infections, 7 (21.9 per cent) later had epididymitis (table 1). The presence of pathogenic organisms in the vasa was associated with an increased incidence of postoperative epididymitis on the non-ligated, non-cultured side. Eighty-one patients had sterile vasa, 7 (8.6 per cent) of whom had epididymitis. Of the 19 patients with positive vas cultures, 6 (31.6 per cent) had epididymitis. The 1 patient who had epididymitis on the ligated side had a sterile vas and infected urine (table 2). The prophylactic use of ampicillin in 45 unselected patients had no effect on the incidence of epididymitis-13.7 per cent of the patients treated suffered this complication compared to 12.7 per cent of the patients who received no antibiotic therapy. These results are in accordance with those of Reeves and associates who found
Total
74
Total
Epididymitis
3• 13
100
• One patient had epididymitis on the ligated side.
prophylactic antibiotics relatively ineffective in preventing epididymitis after prostatectomy. 9 Complications of vasectomy. A small hematoma, requiring no treatment, developed at the site of the scrotal incision in 3 patients. Vasitis was observed in 1 patient. The only other complication was a minor infection of the scrotal wound. None of these complications caused extra hospitalization of any patient. DISCUSSION
The recorded incidence of epididymitis following vasectomy ranges from 3.7 to 13.6 per cent. 10 , 11 When vasectomy is omitted the incidence rises to between 14.9 and 39 per cent. 12 , 13 These figures support the protagonists of routine vasectomy. In our series one testicle served as a control to assess the prophylactic value of vasectomy. That 12 of the 13 cases of epididymitis occurred on the non-ligated side is further evidence of the advantages of vasal ligation. In a similar study of 194 patients, the majority treated by periurethral prostatectomy, 12 had epididy9 Reeves, J. F., Scott, R., Jr. and Scott, F. B.: Prevention of epididymitis after prostatectomy by prophylactic antibiotics and partial vasectomy. J. Urol., 92: 528, 1964. 10 Schmidt, S. S. and Hinman, F.: The effect of vasectomy upon incidence of epididymitis after prostatectomy; and analysis of 810 operations. J. Urol., 63: 872, 1950. 11 Crabtree, E. G. and Brodny, M. L.: Vasectomy in prostatic surgery; a review of 141 consecutive prostatectomies. Trans. Amer. Ass. Genito-Urin. Surg., 23: 383, 1930. 12 Abeshouse, B. and Lerman, S.: Vasectomy in the prevention of epididymitis following prostatic surgery. Urol. & Cutan. Rev., 54: 385, 1950. 13 Alyea, E. P.: Vasa-ligation a preventive of epididymitis before and after prostatectomy. J. Urol., 19: 65, 1928.
POST-PROSTATECTOMY EPIDIDYMITIS
mitis on the non-ligated side, 3 were bilateral and none were restricted to the ligated side. 14 Only 5 of 13 cases of epididymitis in our series occurred before discharge from the hospital. The average interval between operation and the development of this complication was 2.8 weeks. Therefore, any investigation designed to determine the incidence of postoperative epididymitis should extend beyond the immediate postoperative period. 15 Organisms isolated from the majority of cases with positive vas cultures, excluding those attributed to operative contamination, were identical to those found in urine specimens. This is evidence that infected urine can reflux into the vas deferens and offers a plausible explanation for the development of epididymitis in such cases. Provided the urine remained sterile, the presence of an indwelling urethral catheter had little effect on the incidence of postoperative epididymitis occurring on the non-ligated side. In the presence of infected urine, 37 .5 per cent of the vas cultures were positive which agrees closely with other reports following culture of both vasa. 16 , 17 Vasectomy afforded protection to the ligated testicle of 14 Graham, J. B. and Grayhack, J. T.: Epididymitis following unilateral vasectomy and prostatic surgery. J. Urol., 87: 582, 1962. 15 Presman, D. and Rolnick, D.: Retropubic prostatectomy: mortality, complications and functional end results. J. Urol., 88: 814, 1962. 16 Kendall, A. R.: Rationale of prophylactic vasectomy. J. Urol., 89: 712, 1963. 17 Kreutzmann, H. A. R.: Studies of infections of the vas deferens. J. Urol., 39: 123, 1938.
145
all patients whose urine and ipsilateral vasa were infected. In contrast, 30 per cent of those patients with infected vasa at operation had epididymitis on the non-ligated side. These results indicate that prophylactic vasectomy is of value even when the vas is infected assuming that the bacterial flora of both vasa are the same. 16 The 1 patient who had epididymitis on the ligated side had infected urine, although culture of the excised vas yielded no bacteria. This is thought to be a laboratory error. Seven patients whose left vas was sterile had epididymitis on the right side and all had postoperative urinary infections. It is possible that the reflux of sterile urine into the vas initiated a chemical inflammation though the reflux of infected urine, after prostatectomy, cannot be excluded. 18 However, vasectomy afforded protection to the ligated testicles of all patients who had urinary infections postoperatively. The presence of pathogenic bacteria in both the vas deferens and urine does not mean that the subsequent development of epididymitis is inevitable. Vasectomy affords a significant degree of protection to the ligated testicle. The results of our series, despite the minor complications which occasionally followed vasal ligation, strongly suggest that bilateral vasectomy is a simple and reliable method of reducing the incidence of epididymitis in all patients undergoing prostatectomy. 18 Graves, IL S. and Engel, W. J.: Experimental production of epididymitis with sterile urine; clinical implications. J. Urol., 64: 601, 1950.