Tuberculous Epididymitis With Abscess Formation
Severe tuberculous epididymo-orchitis with abscess formation can occur following intravesical bacille Calmette-Guérin (BCG) instillation for the management of recurrent superficial bladder cancers. The interval between treatment with BCG and the onset of related sequelae can be quite long. The finding of an epididymal inflammation or mass in patients who have received BCG instillation therapy (especially in those with a history of prostatic resection) should trigger suspicion for the possibility of a BCG tuberculous cause. Timely confirmation of the diagnosis and prompt initiation of appropriate antituberculous therapy may preclude further harm.
Intravesical instillation of bacille Calmette-Guérin (BCG) is one of the most effective and widely used treatments for carcinoma in situ and for recurrent superficial transitional cell carcinoma of the bladder.
Lamm reported, in a multi-institutional survey, the incidence of complications of BCG intravesical therapy in 2602 patients. Epididymo-orchitis was reported in only 10 patients (0.4%; range, 0.0% to 0.8%). Data from one manufacturer of BCG indicate that in 29,000 patients from 1991 to 1994, the incidence of epididymitis or epididymal abscess associated with intravesical BCG was 0.02% (R. Wittes, confidential communication, April 1995). DeKernion, commenting in the Journal of Urology, confirmed the infrequency of this complication: "I have never noted epididymo-orchitis as a consequence of [BCG] maintenance therapy, and it probably is a truly rare occurrence." Recognizing the marked infrequency of this side effect, but pointing out, nevertheless, the potential for harm, Lamm and coworkers observed: "In rare cases, abscess or even fistula formation has been described. Orchiectomy rarely may be required."
Encounters with BCG epididymitis continue to be reported anecdotally; most result in orchiectomy. In fact, the epididymis has proved to be the most common site for abscess formation following BCG intravesical therapy. Systemic immune reactions and directly disseminated BCG infection seem to play a role in the development of this scrotal complication. In one report, epididymal inflammation developed in the context of a fatal, systemic mycobacterial infection. (Lamm has named these overwhelming systemic reactions "BCG sepsis.")
Clinicians seem to be adequately informed regarding the life-threatening complications of BCG, including septicemia. Minor complications, which are more common, may be underreported because they are often self-limited. It is important to suspect BCG-induced epididymo-orchitis in patients treated with intravesical BCG in whom symptomatic testicular, epididymal, or spermatic cord lesions subsequently develop.
Chart reviews of 3 cases, supplemented by consultations with the patients' urologists, bacteriologists, and pathologists, provide clinically informative findings and insights.
Severe tuberculous epididymo-orchitis with abscess formation can occur following intravesical bacille Calmette-Guérin (BCG) instillation for the management of recurrent superficial bladder cancers. The interval between treatment with BCG and the onset of related sequelae can be quite long. The finding of an epididymal inflammation or mass in patients who have received BCG instillation therapy (especially in those with a history of prostatic resection) should trigger suspicion for the possibility of a BCG tuberculous cause. Timely confirmation of the diagnosis and prompt initiation of appropriate antituberculous therapy may preclude further harm.
Intravesical instillation of bacille Calmette-Guérin (BCG) is one of the most effective and widely used treatments for carcinoma in situ and for recurrent superficial transitional cell carcinoma of the bladder.
Lamm reported, in a multi-institutional survey, the incidence of complications of BCG intravesical therapy in 2602 patients. Epididymo-orchitis was reported in only 10 patients (0.4%; range, 0.0% to 0.8%). Data from one manufacturer of BCG indicate that in 29,000 patients from 1991 to 1994, the incidence of epididymitis or epididymal abscess associated with intravesical BCG was 0.02% (R. Wittes, confidential communication, April 1995). DeKernion, commenting in the Journal of Urology, confirmed the infrequency of this complication: "I have never noted epididymo-orchitis as a consequence of [BCG] maintenance therapy, and it probably is a truly rare occurrence." Recognizing the marked infrequency of this side effect, but pointing out, nevertheless, the potential for harm, Lamm and coworkers observed: "In rare cases, abscess or even fistula formation has been described. Orchiectomy rarely may be required."
Encounters with BCG epididymitis continue to be reported anecdotally; most result in orchiectomy. In fact, the epididymis has proved to be the most common site for abscess formation following BCG intravesical therapy. Systemic immune reactions and directly disseminated BCG infection seem to play a role in the development of this scrotal complication. In one report, epididymal inflammation developed in the context of a fatal, systemic mycobacterial infection. (Lamm has named these overwhelming systemic reactions "BCG sepsis.")
Clinicians seem to be adequately informed regarding the life-threatening complications of BCG, including septicemia. Minor complications, which are more common, may be underreported because they are often self-limited. It is important to suspect BCG-induced epididymo-orchitis in patients treated with intravesical BCG in whom symptomatic testicular, epididymal, or spermatic cord lesions subsequently develop.
Chart reviews of 3 cases, supplemented by consultations with the patients' urologists, bacteriologists, and pathologists, provide clinically informative findings and insights.
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