II.3.4 Clinical Microbiology Summary II.3.4.2 Diagnosis of Pathogens in the Male

401
II.3.4 Clinical Microbiology
H. G. Schiefer, A. von Graevenitz
Summary
Common pathogens and unconventional, fastidious bacteria, viruses, fungi and parasites are causative agents in male urogenital diseases. Uropathogens and sexually transmissible organisms must be
considered. Diagnostic procedures and criteria for
aetiological classification in cases of balanitis, urethritis, prostatitis, epididymitis, orchitis and male
accessory gland infections are described and evaluated.
Of andrological importance are:
1. Infections of the male urogenital tract, frequently caused by sexually transmitted agents.
Occasionally, they have deleterious consequences for fertility, e.g. azoospermia that
follows epididymitis.
2. Agents (mostly viral) that cause systemic
disease and are excreted in semen, e.g. human
immunodeficiency virus (HIV), hepatitis B
virus (HBV) and cytomegalovirus (CMV).
II.3.4.1
Normal Flora of the Male Urogenital Tract
With the exception of the external genitalia and the anterior third of the urethra, the male urogenital tract is
devoid of microorganisms. The flora of the prepuce and
anterior urethra is complex and inconsistent. Species
and numbers depend on, among other things, age, personal hygiene, the patient’s history (sexually transmitted diseases, urinary tract infections or manipulations), sexual activity (abstinence, monogamous or
promiscuous relationships) and sexual practices (genital–genital, genital–anal, genital–oral). Beside microorganisms with low or no virulence for man one may
encounter facultatively pathogenic ones, albeit mostly
in small numbers.
Typical bacteria of the normal male urogenital tract
(Bowie et al. 1977; Schiefer 1998) are coagulase-negative Staphylococcus spp., viridans streptococci, Enterobacteriaceae spp., Acinetobacter spp., Corynebacterium
spp., Neisseria spp., Mycobacterium smegmatis, Peptostreptococcus spp., Bacteroides spp., Fusobacterium
spp., Mycoplasma spp., and Candida spp. So far, there
have been no data on possible viral or parasitic colonizers.
II.3.4.2
Diagnosis of Pathogens in the Male
Urogenital Tract
Obligately pathogenic microorganisms in the male
urogenital tract are Mycobacterium (M.) tuberculosis,
Neisseria (N.) gonorrhoeae, Chlamydia (C.) trachomatis, Treponema (T.) pallidum, Haemophilus (H.) ducreyi, Klebsiella (K.) [Calymmatobacterium (C.)] granulomatis, herpes simplex virus 2 (HSV-2), human papilloma viruses (HPV), and Trichomonas (T.) vaginalis. In
systemic disease human immunodeficiency viruses
(HIV), hepatitis B virus (HBV), hepatitis C virus
(HCV), hepatitis D virus (HDV), and cytomegalovirus
(CMV) may be excreted with semen, often in high concentrations.
The interpretation of microbiological findings with
regard to their relationship to clinical symptoms may
be quite difficult in individual cases, particularly if no
quantitative data are available. The finding of obligately
pathogenic microorganisms or of a large number of
facultatively pathogenic ones should be a sign of a
pathological process, although there are asymptomatic
carriers of N. gonorrhoeae, C. trachomatis, T. vaginalis
and HSV-2.
The multitude of potential microorganisms and the
difficulties in diagnosing some of them make it impossible to search every sample for all possible pathogens.
Ambiguous results obtained by routine microbiology
as well as scientific interest would call for a diagnostic
armamentarium that exceeds that used in routine microbiology.
Depending on the clinical picture, the preliminary
diagnosis and the organism(s) suspected, the following
samples can be considered:
1. Samples from prepuce and urethra, on cottontipped fine wire, or on small plastic loops. Swabs
or loops should be introduced 2 – 4 cm into the
urethra in order to obtain mucosal cells.
2. Impression smears, e.g. from the prepuce in cases
of balanitis, to be directly plated on media suitable
for culture of potential pathogens.
3. Urogenital secretions, e.g. urethral discharge or
prostatic fluid, obtained by means of a calibrated
loop and placed into defined volumes (2 ml) of liquid transport media, e.g. trypticase soy broth with
0.5 % bovine serum albumin.
4. Ejaculate. The patient should urinate first in order
to eliminate part of the urethral flora. After cleansing prepuce and hands, the fluid is obtained by
masturbation. Ejaculate culture is indicated after
II.3
402
II.3 Diagnostic Tools
& 106 peroxidase-positive leukocytes per ml have
been detected by cytological analysis of semen. Attention: ejaculate may be contaminated by urethral
flora (WHO 1999; Rowe et al. 2000).
5. Urine. For the diagnosis of extracellular microorganisms in urethritis and prostatitis, fractionated
samples, e.g. those obtained by the “fourspecimen-test” (Brunner et al. 1983; Weidner et al.
1987, 1994; Schiefer et al. 1993), should be obtained. For some nonculture tests, e.g. enzymelinked immunosorbent assay (ELISA) or molecular
biological techniques [ligase or polymerase chain
reactions (LCR, PCR)], a portion of 20 – 30 ml,
obtained approximately 2 h after the last voiding,
may be used following centrifugation.
6. Immunological tests. A systemic immune response
is tested in blood serum. Urogenital secreta may
be used for testing the local immune response
(Mestecky and Fultz 1999).
7. Biopsy, aspirated material, or scrapings. They can
be used to detect intra- and extracellularly growing
microorganisms by means of light or electron
microscopy, culture or nucleic acid hybridization/
amplification (Krieger et al. 1996b; Isenberg 1998;
Tanner et al. 1999; Murray et al. 2003).
II.3
To ensure the survival of fastidious microorganisms
that may be killed by drying or low temperatures, samples should be inoculated immediately on culture media or into special transport media, depending on the
organisms to be cultured. Semen contains antibacterial
factors, among them Zn-containing proteins, and proteases, and should be diluted before inoculation with
the same or double volume of phosphate-buffered
0.145 M NaCl or of transport medium and should be
homogenized on a vortex mixer. Prior to inoculation of
cell cultures the homogenate should be centrifuged,
and only the pellet should be used (Howell et al. 1986).
To obtain cell counts, defined volumes of secretions
are used for culture so that the number of colonies, with
the dilution factor taken into account, reflects the number of organisms per millilitre.
Various methods can be used to detect facultatively
or obligately pathogenic microorganisms. Three levels
of diagnostic workup will be distinguished, depending
on the degree of diagnostic difficulty, personnel training, available instrumentation and reagents. For a critical analysis of the individual methods, we refer to Murray et al. (2003).
The standard diagnosis of urogenital infections (level II) for conventional bacteria and fungi involves culture of defined volumes of secretions, other samples in
liquid transport media, or urine on the usual general/
selective/indicator/fungal media, e.g. sheep blood,
MacConkey, bromothymol blue-lactose-cystine (Sandys 1960), and Sabouraud plates. Incubation is for
Level I:
Light microscopy, simple staining techniques,
use of commercial media and simple identification techniques
Level II: Culture and identification of microorganisms on
various commercial and noncommercial media.
Use of fluorescein- and peroxidase-labelled antibodies. ELISAs
Level III: Special research techniques. Electron microscopy. Molecular techniques to detect and identify
microorganisms: hybridization, nucleic acid amplification (PCR, LCR); amplification of the 16 S
rRNA gene (rDNA) using specific or universal
primers; sequencing (Krieger et al. 1996b; Isenberg 1998; Tanner et al. 1999; Murray et al. 2003).
24 – 48 h at 37 °C (72 h at 30 °C for fungal media). If obligately pathogenic and facultatively pathogenic microorganisms in significant numbers are found, they
should be tested for antibiotic susceptibility (Isenberg
1998; Murray et al. 2003).
II.3.4.2.1
Neisseria (N.) gonorrhoeae
The usual procedures are: microscopy of the material
stained with Gram, methylene blue (I) or with fluorescein-labelled antibodies (II), and culture of fresh material (if possible, at body temperature) on modified Thayer–Martin selective medium (I) with subsequent colony identification (II) by patterns of acid production
from glucose, maltose, lactose and fructose, or by coagglutination with antibody-labelled staphylococci (II).
More recent and more sensitive procedures involve
nucleic acid hybridization/amplification (III). The possible presence of q -lactamase should always be
checked, e.g. by a nitrocefin test (important if no standardized test system for penicillin susceptibility is
available) (Isenberg 1998; Murray et al. 2003).
II.3.4.2.2
Treponema (T.) pallidum
The serous fluid obtained from the primary lesion is
examined by dark-field microscopy (I) or after staining
with fluorescein-labelled antibodies (II). Later stages
have to be diagnosed serologically (II) by means of
treponema-specific tests [e.g., Treponema pallidum
hemagglutination (TPHA) test, fluorescent treponemal
antibody absorption (FTA-ABS) test] and treponemanonspecific tests (e.g. VDRL or RPR card test). Antibodies develop slowly and can be detected at the earliest 2 – 3 weeks following infection. Approximately
12 weeks after infection, often in the secondary stage,
almost all infected individuals will show a positive reaction (Isenberg 1998; Murray et al. 2003).
II.3.4 Clinical Microbiology
II.3.4.2.3
Mycobacterium (M.) tuberculosis
II.3.4.2.6
Haemophilus (H.) ducreyi
Since saprophytic mycobacteria (e.g. M. smegmatis)
frequently occur on the prepuce, the finding of acidfast bacteria (II) in urine, prostatic secretions and semen has to be interpreted with caution. The microbiological diagnosis is based on culture (II) or nucleic acid
hybridization/amplification (III). Mycobacteria can also be stained in biopsy samples (Isenberg 1998; Murray
et al. 2003).
The usual techniques are direct microscopy (I) of
smears stained by Gram or Giemsa (I) and culture (II)
on selective and enrichment media (Murray et al.
2003). A PCR (III) has been established as well (Murray
et al. 2003).
II.3.4.2.4
Chlamydia (C.) trachomatis
403
II.3.4.2.7
Enterobacteriaceae spp.
Enterobacteriaceae spp. are cultured on selective media
and identified according to biochemical reactions
(Isenberg 1998; Murray et al. 2003). For the detection of
Klebsiella (K.) [Calymmatobacterium (C.)] granulomatis, the most important technique is direct microscopy
of Giemsa- or Wright-stained smears (I). Co-cultivation with monocytes and Hep-2 cells is possible (Kharsany et al 1996; Murray et al. 2003).
The usual diagnostic tools are direct microscopy of elementary bodies using fluorescein-tagged antibodies
(II), culture in cycloheximide-treated McCoy or BGMK
cells (II), ELISA (II), and the more sensitive nucleic acid hybridization/amplification (III) (Isenberg 1998;
Murray et al. 2003). The use of urine samples for the diagnosis of C. trachomatis infections is effective, but
urine samples should be used in addition to conventional swabs instead of replacing them (Jensen et al.
2003). The microimmunofluorescence (MIF) test is
valuable in the diagnosis of urogenital infections but is
expensive and labour-intensive while the complement
fixation (CF) test yields reliable results only for lymphogranuloma venereum. The value of Chlamydia-specific antibodies (IgM, IgG, IgA) in the diagnosis of urogenital infections using indirect immunofluorescence
(IF) and immunoperoxidase (IPO) methods (II) is limited since these antibodies are genus-specific and thus
will also be elevated in infections with Chlamydophila
pneumoniae (Tuuminen et al. 2000). IgA levels in urogenital secretions may, in the future, be of more than
academic interest (Mestecky and Fultz 1999).
Corynebacterium (C.) spp. (e.g. C. glucuronolyticum,
which is identical to C. seminale) are cultured on blood
agar and speciated according to biochemical reactions
(II) (Funke et al. 1995; Riegel et al. 1995; Murray et al.
2003).
II.3.4.2.5
Mycoplasma spp.
II.3.4.2.10
Gardnerella (G.) vaginalis
At least four mycoplasmas may colonize the urogenital
tract: Mycoplasma (M.) fermentans, M. hominis, M. genitalium and Ureaplasma (U.) urealyticum. Only the
latter three have pathogenic significance. Direct microscopy is unreliable. The usual diagnostic procedure
(II) involves inoculation into solid media and in liquid
enrichment and indicator media (Schiefer et al. 1993;
Isenberg 1998; Schiefer 1998; Murray et al. 2003). Identification is based on the use of biochemical tests or
fluorescein-labelled antibodies. Only semiquantitative
analysis will lead to useful results. Serological tests are
useless. M. genitalium can be detected by PCR or by
primary culture on Vero cells, with subsequent culture
in liquid and on solid media (Jensen et al. 1993, 1996;
Taylor-Robinson 1996; Dupin et al. 2003).
The usual diagnostic tools are direct microscopy of
Gram-stained smears and culture on selective media
(II). Specific DNA probes have also been developed
(Murray et al. 2003).
II.3.4.2.8
Streptococcus (S.) spp. and Enterococcus (E.) spp.
Streptococcus (S.) spp. and Enterococcus (E.) spp. are
cultured on nonselective/selective media. Streptococci
may be grouped by immunological techniques (II)
(Murray et al. 2003).
II.3.4.2.9
Corynebacterium (C.) spp.
II.3.4.2.11
Anaerobes
Culture is performed by means of the usual anaerobic
methods (II). Identification and quantification of the
numerous anaerobes in the male urogenital tract are
time- and labour-intensive and are rarely performed
because of the questionable aetiological significance of
these organisms (Eggert-Kruse et al. 1995; Isenberg
1998; Murray et al. 2003).
II.3
404
II.3 Diagnostic Tools
II.3.4.2.12
Herpes Simplex Virus 2 (HSV-2)
II.3.4.2.18
Trichomonas vaginalis
In smears of mucocutaneous lesions HSV antigen can
be detected by ELISA (II). Cell culture allows for identification with fluorescein-labelled antibodies (III). HSV
genome sequences can be amplified by type-specific
PCR and detected by hybridization (III). Serology
yields useful results only in primary infections and in
older patients (Isenberg 1998; Murray et al. 2003).
The method of choice is direct, if possible, dark-field
microscopy (I) following suspension of the material in
0.145 M NaCl. The most sensitive detection method is
culture, with subsequent microscopy of the (motile)
trophozoites (II) (Isenberg 1998; Murray et al. 2003).
II.3.4.2.13
Papilloma Viruses (HPV)
The diagnosis is a clinical one, to be confirmed by histopathology (III). Viruses are detected by nucleic acid
hybridization or by PCR amplification of DNA obtained from biopsy samples (III) (Isenberg 1998; Murray et al. 2003).
II.3.4.2.14
Cytomegalovirus (CMV)
Cytomegalovirus (CMV) can be cultured in cell lines
and detected with immunofluorescence techniques.
The methods of choice, however, are detection by PCR
(III) and by the presence of specific antibodies (Isenberg 1998; Murray et al. 2003).
II.3.4.2.15
Hepatitis Viruses
Important in this connection are HBV and, more rarely,
HCV and HDV. Stage-specific diagnostic tests [antigens and antibodies, genome amplification by PCR
(III)] are reviewed elsewhere (Isenberg 1998; Murray et
al. 2003).
II.3.4.2.16
Human Immunodeficiency Viruses (HIV-1, HIV-2)
The usual method is serology for anti-HIV-antibodies
by means of ELISA and immunoblot (III). These antibodies can be detected in most patients within
6 – 12 weeks and in > 95 % within 6 months following
infection. Viral culture of lymphocytes and of various
secretions is also possible, as is the detection of the HIV
genome by PCR (III) (Isenberg 1998; Murray et al.
2003).
II.3
II.3.4.2.17
Yeasts
Standard methods are direct microscopy (I) and culture on selective media (II) (Isenberg 1998; Murray et
al. 2003).
II.3.4.3
Microbiological Examinations in the Diagnosis
of Male Urogenital Infections
II.3.4.3.1
Balanitis
Samples are swabbings or impression smears. The most
frequent agents are Enterobacteriaceae spp., Streptococcus spp. (groups A, B), coagulase-positive Staphylococcus spp., Gardnerella vaginalis, HSV, Candida spp.
and Trichomonas vaginalis (Schiefer 1998).
II.3.4.3.2
Urethritis
Evidence of & 4 granulocytes per microscopic field
(1000×) in the smear of urethral discharge, or of & 15
granulocytes per microscopic field (400×) in the smear
of the sediment of 3 ml of a first voided urine portion
(VB1 = voided bladder urine 1) is indicative (Schiefer
1998).
Urethral discharge and the first voided portion of
urine (VB1) are examined separately for common bacteria, gonococci, mycoplasmas, C. trachomatis, T. vaginalis, and Candida spp. Semiquantitative methods
should be employed for common bacteria, mycoplasmas and yeasts.
Aetiological classification is based on the following
criteria (Schiefer 1998):
1. (Quantitative) evidence of significantly high
numbers of “conventional” bacteria, Candida spp.
Mycoplasma spp., i.e. & 104 organisms per ml of
urethral discharge, and & 103 organisms per ml of
VB1.
2. (Qualitative) evidence of gonococci, C. trachomatis, T. vaginalis.
Patients suffering from chronic urethritis without discharge pose particular diagnostic problems. They
should be examined for a possible “early morning urethral discharge” which can be observed prior to voiding
morning urine. In addition, VB1 should be examined
for granulocytes.
The most frequent agents of male urethritis are N.
gonorrhoeae, C. trachomatis, M. genitalium and U. urealyticum. Mixed infections are common. Other micro-
II.3.4 Clinical Microbiology
organisms (Enterobacteriaceae spp., Streptococcus spp.,
Staphylococcus aureus, Corynebacterium glucuronolyticum, Bacteroides ureolyticus, M. hominis, Candida
spp., HSV, T. vaginalis) are rare (Brunner et al. 1983;
Hawkins et al. 1988; Jensen et al. 1993, 1996; Funke et al.
1995; Riegel et al. 1995; Schiefer 1998).
II.3.4.3.3
Prostatitis
This multifaceted syndrome has been classified by
Drach et al. (1978) into acute bacterial, chronic bacterial and “abacterial” prostatitis, which have to be separated from prostatodynia in which prostatic secretions
do not show signs of inflammation and do not yield infectious agents.
Difficulties in the separation of infectious, inflammatory, and noninflammatory forms have led to a new
classification (Krieger et al. 1996a) based on symptomatology. It differentiates between:
1. Acute bacterial prostatitis, i.e. acute infection of
the prostate.
2. Chronic bacterial prostatitis, i.e. recurrent prostatic infection.
3. Chronic prostatitis/chronic pelvic pain syndrome
(no conventional microorganisms can be detected
although symptoms are present) subdivided into:
3a. Inflammatory subtype (elevated leukocyte
numbers in ejaculate, prostatic secretions, or
urine after prostatic massage).
3b. Noninflammatory subtype (no leukocytes in
the samples mentioned above).
4. Asymptomatic inflammatory prostatitis [no subjective symptoms but leukocytes in prostatic biopsy material and/or elevated leukocytes in ejaculate,
prostatic secretions, or urine after prostatic massage, i.e. procedures performed after other pathologies, e.g., elevated prostate-specific antigen (PSA)
levels, have been detected].
For the rare febrile acute bacterial prostatitis (category 1)
microbiology of a urine sample should suffice. Prostatic massage is strictly contraindicated since it may induce sepsis.
Prostatitis (categories 2 – 4) is diagnosed according
to the localization protocol of the “four–specimen–
test” (Schiefer et al. 1993; Weidner et al. 1994; Schiefer
1998). The first voided urine portion (VB1) and the
second voided (bladder) urine portion (VB2) are
obtained separately. Following prostatic massage,
expressed prostatic secretions (EPS) or, if the former
are not available in sufficient amounts, urethral swabs
are obtained. Then the patient urinates again and, as
the fourth fraction, urine after prostatic massage
(VB3) is obtained. Generally, ejaculate is also examined.
The diagnosis of prostatitis sensu stricto (categories
2, 3a and 4) is based on the detection of purulent prostatic secretions. If urethritis and urinary tract infections can be excluded, the presence of & 10 granulocytes per microscopic field (1000×) in prostatic secretions is suggestive, while & 20 granulocytes per microscopic field (1000×) is proof of prostatitis, as are
& 10 granulocytes per microscopic field (400×) in the
cytocentrifugate of 3 ml of urine voided after prostatic
massage (VB3) (Schiefer et al. 1993; Weidner et al. 1994;
Schiefer 1998).
The optimal diagnostic strategy to differentiate between categories 3a (inflammatory) and 3b (noninflammatory) requires the evaluation of white blood
cells in semen in addition to the traditional EPS examination. The presence of & 106 peroxidase-positive leukocytes per millilitre of ejaculate is considered representative of “significant leukocytospermia” indicating
category 3a (Krieger et al. 2000).
Microbiological examination includes: (1) a semiquantitative analysis of Gram-positive and Gram-negative bacteria, mycoplasmas and yeasts in all fractions;
(2) a qualitative examination for C. trachomatis and
N. gonorrhoeae in the urethral swab after prostatic
massage; and (3) microscopy for T. vaginalis. In case of
clinical suspicion, morning urine and ejaculate are cultured for M. tuberculosis.
A shorter test comparing semiquantitatively urine
cultures before and after prostatic massage would simplify the diagnosis (Nickel 1998).
The aetiological diagnosis of prostatitis requires either qualitative detection of gonococci, chlamydiae or
trichomonads, or the presence of “conventional” bacteria, mycoplasmas, or yeasts at & 104/ml in EPS and
& 103/ml in VB3, and e 103/ml in VB1 and VB2 (“prostatitis pattern”) (Weidner et al. 1991, 1994; Schiefer et
al. 1993).
The most important agents of acute and chronic
bacterial prostatitis are Gram-negative bacteria (Escherichia coli in 80 %, but also Klebsiella spp., Enterobacter
spp., Proteus spp., Pseudomonas spp.), Enterococcus
spp.; rarely, Staphylococcus aureus, N. gonorrhoeae,
Candida spp., T. vaginalis (causing mostly urethroprostatitis) and M. tuberculosis (in chronic prostatitis).
Yeast infections of the prostate, e.g. those due to Cryptococcus neoformans or Candida spp., are found in immunocompromised patients. The etiological role of
C. trachomatis, U. urealyticum and viruses has not yet
been elucidated (Weidner et al. 1991, 1994; TaylorRobinson 1996; Schiefer 1998).
Inconsistent microbiological findings are frequent
and are probably due to a focal localization of prostatitis (Weidner et al. 1991, 1994).
In the search for possible bacterial agents of chronic
prostatitis/chronic pelvic pain syndrome (category 3)
amplification of the 16 S rRNA gene (rDNA) has been
405
II.3
406
II.3 Diagnostic Tools
tried using universal and bacteria-specific primers
(Tanner et al. 1999; Krieger et al. 2000). This procedure
is still in the research domain. However, preliminary
data suggest that patients with the inflammatory subtype (category 3a) are significantly more likely to have
bacterial DNA in their prostatic parenchyma than
those with the noninflammatory subtype (category 3b)
(Krieger et al. 1996b).
II.3.4.3.4
Epididymitis
Age and history of the patient are of particular importance in the diagnosis of epididymitis (Weidner et al.
1987). In younger patients with urethral discharge and
no difficulty voiding, diagnostic procedures resemble
those used in cases of urethritis. In patients without
urethral discharge, diagnostic procedures follow the
“four-specimen-test” (Weidner et al. 1987). In all other
cases, particularly in patients over 35 years and in those
with bladder outlet disturbances, a urinary tract infection should be suspected. In case of chronic epididymitis, morning urine (× 3), ejaculate and urine voided after prostatic massage should be examined for M. tuberculosis (Weidner et al. 1987; Schiefer 1998).
In younger (< 35 years), sexually active men without
difficulty voiding, epididymitis is mostly caused by N.
gonorrhoeae or C. trachomatis. Elderly men and those
with bladder outlet disturbances have mostly urinary
tract infections with bacteria identical to those causing
epididymitis, i.e. E. coli, Pseudomonas aeruginosa,
Enterococcus spp. and M. tuberculosis (Schiefer 1998).
II.3.4.3.5
Orchitis
Orchitis is a complication of many systemic bacterial
infections, e.g. those due to Salmonella typhi, Brucella
spp., M. tuberculosis, M. leprae, Coxiella burnetii, or of
viral infections caused by the mumps virus, echo and
arboviruses, the virus of lymphocytic choriomeningitis, and of Plasmodium spp. Clinical symptoms provide
the clue (Schiefer 1998).
II.3.4.3.6
Male Accessory Gland Infections (MAGI)
II.3
Ejaculate originates from the testicles and epididymis
(approx. 5 %), the prostate (approx. 30 %), the seminal
vesicles (approx. 60 %), and the bulbourethral and urethral glands (approx. 5 %). The finding, on cytochemical and biochemical analysis of semen, of & 106 peroxidase-positive leukocytes/ml (“significant leukocytospermia”), & 230 ng elastase/ml and & 0.01 mg C3c
complement/ml is indicative of an inflammation of the
male accessory glands (“prostato-seminal vesiculitis”,
“male adnexitis”, “epididymo-prostato-vesiculitis”) as
long as urethritis and urinary tract infections have
been ruled out. Such findings call for microbiological
analysis of the ejaculate (Ludwig et al. 1998; WHO 1999;
Rowe et al. 2000), whereby growth of & 103/ml of potentially pathogenic bacteria, particularly of Gram-negative rods, is considered “significant bacteriospermia”
(WHO 1999; Rowe et al. 2000). Localization of the inflammatory focus cannot be accomplished by culture of
the ejaculate but rather requires a “four-specimen-test”
(Schiefer et al. 1993; Weidner et al. 1994; Schiefer 1998).
Analysis of various ejaculate fractions (“split ejaculate”) – i.e. of the first fraction (approx. 0.6 ml) from the
testicles and the epididymis, a second intermediate
fraction (approx. 1.0 ml), and a third fraction from the
seminal vesicles – allows, at best, an orientation.
II.3.4.3.7
Ejaculate as a Carrier of Microorganisms
Besides spermatozoa and cells of spermatogenesis ejaculate contains cells and secretions from epididymis,
prostate, seminal vesicles and ejaculatory ducts. It is also mostly contaminated with organisms from the urethral residual flora. Localized or generalized infections
can render ejaculate highly infectious. Obligate pathogens such as N. gonorrhoeae, C. trachomatis, T. vaginalis and facultatively pathogenic organisms such as M.
hominis, U. urealyticum, group B streptococci and Enterobacteriaceae spp. can be detected in ejaculates.
They attach to spermatozoa (Friberg et al. 1985) and
can thus infect the female genital tract, particularly the
endometrium and the tubal epithelium. Ejaculate may
also transmit viruses, in particular HIV-1 and HIV-2,
CMV, HBV and HPV (Craig et al. 1977; Mascola and
Guinan 1986; Kashube et al. 1999).
Bacteria and viruses will not be killed by cryopreservation. Special precautionary measures are, therefore,
necessary for semen used for artificial insemination.
The donors are usually young, sexually active, unmarried men carrying a high risk of sexually transmitted
disease(s). Men with histories of homosexual and prostitute encounters, frequently changing sexual partners,
sexually transmitted diseases, drug abuse and blood
transfusions to themselves or their partners should not
be semen donors. Urogenital infection with HIV-1,
HIV-2, CMV, HBV, HCV, HSV-2, HPV, T. pallidum, C.
trachomatis, N. gonorrhoeae, M. hominis, U. urealyticum, group B streptococci and T. vaginalis are absolute
or relative criteria for exclusion. Since the necessary
tests cannot be completed on the day of semen donation, semen has to be cryopreserved and should only be
used for insemination if tests on the donor have yielded
negative findings 180 days later (Craig et al. 1977; Mascola and Guinan 1986; Liesnard 1998; British Andrology Society 1999).
II.3.4 Clinical Microbiology
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