3-Month-Old Boy With a Febrile Urinary Tract Infection

CASE SCENARIO 3-Month-Old Boy With a Febrile Urinary Tract Infection Ellen Shapiro, MD, FACS, FAAP Department of Urology, New York University School of Medicine, New York, NY [Rev Urol. 2003;5(4):241-244] © 2003 MedReviews, LLC CASE REPORT 3-month-old boy has a febrile urinary tract infection. The right kidney is duplicated and measures 5.5 cm with moderate dilation of the upper pole moiety and minimal dilation of the lower pole system (Figures 1 and 2). The left kidney is also duplicated (Figure 3). The left upper pole is moderately dilated, whereas the lower pole moiety is massively hydronephrotic with thin parenchyma. There is left ureteral dilation. The bladder shows evidence of bilateral ureteroceles (Figure 4). The voiding cystourethrogram shows right grade III-IV/V and left grade V/V vesicoureteral reflux associated with the lower pole moieties (Figure 5). The early phase of the MAG-3 (mercaptotriglycylglycine) scan shows no function of the left upper pole (Figure 6). The left lower pole moiety contributes less than 10% to the total renal function. The right upper pole moiety has no function, whereas the lower pole functions normally. Following parenteral antibiotic therapy, antibiotic prophylaxis is begun. Figure 1. Right renal sonogram shows significant hydronephrosis in the upper and lower pole moieties. Figure 3. Left renal sonogram shows massive hydronephrosis of the entire renal unit. Figure 2. Right renal sonogram shows marked calyceal dilation of the lower pole moiety. Figure 4. Bladder sonogram demonstrates bilateral ureteroceles. A VOL. 5 NO. 4 2003 REVIEWS IN UROLOGY 241 Case Scenario continued Figure 5. The postvoid film of the voiding cystourethrogram showing right grade III-IV/V and left grade V/V vesicoureteral reflux associated with the lower pole moieties. Figure 6. MAG-3 scan: The early phase shows no function of the right or left upper pole systems. Only minimal function is observed in the left lower pole. MANAGEMENT OPTIONS The next appropriate step is: ❑ 1. Incision of ureteroceles ❑ 2. Left nephrectomy only ❑ 3. Incision of right ureterocele and left nephrectomy ❑ 4. Left nephrectomy and right double-barrel reimplant ❑ 5. Left nephrectomy and right upper pole nephrectomy Vote online at www.medreviews.com; fax your response to MedReviews at (212) 971-4047; or e-mail your selection to dgern@medreviews.com. 242 VOL. 5 NO. 4 2003 REVIEWS IN UROLOGY Case Scenario Discussion of Last Issue’s Case Scenario IN THE LAST ISSUE, DR NIEDERBERGER AND DR MEACHAM PRESENTED THIS CASE REPORT: A 32-year-old man presents for evaluation following 2 years of unsuccessfully attempting to father a pregnancy. He has a completely negative medical and surgical history, is taking no medications, does not smoke, and consumes alcohol in moderation (averages 1 drink per week). Semen analyses, performed on 2 occasions, revealed ejaculate volumes of 1.4 mL and 1.7 mL, sperm concentrations of 4.5 million and 5.2 million sperm per mL, and motility of 46% and 43%. Serum hormone evaluation revealed a serum testosterone level (drawn at 8:30 AM) of 235 ng/dL (normal, 300-1000 ng/dL). Repeat morning serum testosterone was 217 ng/dL. Serum luteinizing hormone, follicle-stimulating hormone, and prolactin levels were all within the normal range. Physical examination revealed the testes to be descended bilaterally with moderately decreased size and consistency. There were no varicoceles present, and the vasa deferentia and epididymis glands were unremarkable to palpation. The prostate was normal to palpation, and the remainder of the physical examination was normal. Assessment of a spun urine sediment collected immediately following ejaculation revealed only occasional sperm. Transrectal sonographic imaging of the prostate and surrounding structures revealed no evidence of ejaculatory duct obstruction or other abnormality. The patient’s partner is a 29-year-old woman with no known fertility concerns. She reports regular menses, and her past medical history is negative for any surgical or medical conditions that might affect her fertility status. THE FOLLOWING MANAGEMENT OPTIONS WERE OFFERED: ❑ 1. Unilateral testis biopsy with subsequent therapy based on the histologic findings ❑ 2. Bilateral testis biopsy with subsequent therapy based on the findings in the most normal testis ❑ 3. Referral to a reproductive medicine specialist for discussion of assisted reproductive technologies, such as intrauterine insemination or in vitro fertilization ❑ 4. Initiation of testosterone supplementation sufficient to achieve a serum level of at least 300 ng/dL with repeat semen analysis performed in 3 weeks ❑ 5. Initiation of testosterone supplementation as described above with assessment of semen analysis performed in 4 months ❑ 6. Initiation of clomiphene citrate therapy at a dosage of 25 mg/d, with dosage adjustment to achieve a testosterone level of at least 300 ng/dL with repeat semen analysis performed in 4 months ❑ 7. Performance of color Doppler ultrasonography to assess the patient for the presence of subclinical varicocele AUTHORS’ DISCUSSION This patient presents with mildly decreased serum testosterone, reduced ejaculate volume, oligospermia, and minimally impaired sperm motility. Patients with decreased ejaculate volume may suffer from retrograde ejaculation or ejaculatory duct obstruction. Other less common causes include decreased androgen sta- tus and seminal vesical abnormalities, such as seminal vesical agenesis. Retrograde ejaculation was ruled out in this patient via assessment of a post-ejaculatory urine specimen, which revealed only rare sperm. Patients with ejaculatory duct obstruction typically have midline prostatic cysts, dilated seminal vesicles, or dilated ejaculatory VOL. 5 NO. 4 2003 REVIEWS IN UROLOGY 243 Case Scenario continued ducts that can be visualized via transrectal sonography.1 Such findings were absent in this patient. This patient’s abnormal androgen status, as reflected by a decreased serum testosterone level, may be contributing to reduced ejaculate volume. In regard to diagnostic studies, performance of either unilateral or bilateral testis biopsy in this patient would not be an appropriate next step. Testis biopsy is used almost exclusively in the assessment and treatment of the azoospermic patient. The primary objective of testis biopsy is to differentiate azoospermic patients with ductal obstruction from those who have intrinsic testicular failure, such as hypospermatogenesis, maturation arrest, or Sertoli cell only syndrome. Among patients found to have intrinsic testicular failure, testis biopsy also provides tissue for use in attempted sperm extraction. If found, such sperm can potentially be used in the performance of in vitro fertilization (IVF) using intracytoplasmic sperm injection. In this oligospermic patient, there are no histologic findings on testis biopsy that would suggest a treatable cause of decreased semen quality. Clearly, it would be inappropriate to give this patient testosterone supplementation. Administration of exogenous testosterone is associated with a marked decrease in spermatogenesis. This is the result of suppression of luteinizing hormone (LH) and follicle-stimulating hormone production by the pituitary secondary to negative feedback from the supplemental testosterone. Decreased circulating LH leads to a decline in endogenous testosterone production with a concomitant decrease in intratesticular testosterone levels. Spermatogenesis, which requires high levels of intratesticular testosterone, therefore drops dramatically for the duration of testosterone therapy. Although the repair of clinically detectable varicoceles is generally felt to be an important modality in the management of subfertile men, such is not the case with subclinical varicoceles. Minimally dilated veins can often be detected sonographically in both fertile and infertile men. However, it is doubtful that the ligation of such veins would improve fertility. Among men with diminished sperm concentrations and decreased testosterone levels, an alternative to supplemental testosterone is administration of clomiphene citrate. By blocking the negative feedback of testosterone on the hypothalamus and pituitary, clomiphene increases LH production and, thus, boosts production of testosterone in most men. Although the efficacy of clomiphene therapy in this setting has not been established by randomized, prospec- 244 VOL. 5 NO. 4 2003 REVIEWS IN UROLOGY tive trials, it may be of use in some patients. If clomiphene administration is elected, 25 mg/d is a reasonable starting dosage. Serum testosterone should be assessed approximately 1 month after initiation of therapy, with adjustment of dosage to achieve testosterone levels within the highnormal range. Semen analysis should be reassessed in approximately 4 months. If properly assessed, many patients suffering from male infertility are found to have correctable abnormalities. In some cases, however, no correctable lesion can be identified. In such cases, consideration should be given to the use of assisted reproductive technologies (ART). The least expensive and invasive form of ART is semen processing combined with intrauterine insemination (IUI). The basis for this practice is the observation that only a small fraction of sperm that are deposited in the vagina during intercourse subsequently progress to the level of the internal cervical opening. IUI allows deposition of the sperm directly into the uterine cavity. Prior to performance of IUI, it is necessary to separate the sperm from the seminal plasma by centrifugation. The sperm are then resuspended in a physiologic sperm wash medium and placed through the cervix into the uterus. This must be done to remove prostaglandins found in the seminal plasma, which can lead to severe uterine cramping. It is generally felt that IUI is most effective when more than 5 million motile sperm are present in the processed specimen. This technique is most useful when specific barriers to conception are present, such as hypospadias (leading to deposition of the ejaculate outside the vagina), cervical stenosis, or retrograde ejaculation. Still, in the presence of uncorrectable male factor infertility when adequate motile sperm are present, 4 to 6 cycles of IUI is a reasonable next step. If pregnancy is not achieved in 4 to 6 cycles, the couple may want to consider IVF. For cases in which the number of motile sperm is quite small, or if the couple fails to achieve fertilization through conventional in vitro techniques, intracytoplasmic sperm injection (ICSI) may be of added benefit. In this procedure, an individual sperm is injected into each egg to facilitate the fertilization process. With the use of ICSI, the IVF team literally needs only 1 motile sperm per ovum. This technology has dramatically enhanced the ability of couples suffering from profound male factor infertility to achieve conception. Reference 1. Meacham RB, Hellerstein DK, Lipshultz LI. Evaluation and treatment of ejaculatory duct obstruction in the infertile male. Fertil Steril. 1993;59:393-397.