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Testicular prosthesis infection — Clinical Guidelines

Overview

Testicular prosthesis infection is a serious complication following testicular prosthesis implantation, primarily affecting transgender men undergoing gender-affirming surgeries such as metoidioplasty or phalloplasty. This condition can lead to significant morbidity, including pain, swelling, systemic infection, and the potential need for prosthesis removal. Early recognition and prompt management are crucial to prevent severe outcomes such as sepsis and the loss of the prosthesis. Understanding and addressing this complication is essential for clinicians managing transgender patients to ensure optimal surgical outcomes and patient well-being. 2 4

Pathophysiology

Infections in testicular prostheses typically arise from hematogenous spread or direct contamination during surgery. The primary pathogens include Staphylococcus aureus, with methicillin-resistant strains posing a particularly severe threat due to their resistance to many antibiotics. Once implanted, the prosthesis can serve as a nidus for infection, leading to biofilm formation on its surface. This biofilm shields microorganisms from host defenses and antibiotics, complicating eradication. Cellular responses, including inflammation mediated by macrophages and neutrophils, further contribute to tissue damage and potential prosthesis loosening. The inflammatory cascade often involves the activation of endoplasmic reticulum (ER) stress pathways in surrounding tissues, exacerbating the inflammatory response and potentially accelerating prosthetic failure through mechanisms like osteolysis. 5 6

Epidemiology

The incidence of infections specifically related to testicular prostheses is relatively rare but significant given the severity of outcomes. Data from dedicated transgender surgery centers indicate that while comprehensive long-term studies are limited, complications such as infections occur in a notable subset of patients, often within the first few years post-implantation. Risk factors include surgical technique, patient comorbidities, and potential contamination during the procedure. Geographic and demographic variations are less well-documented, but the trend suggests a need for meticulous surgical protocols and vigilant postoperative monitoring to mitigate these risks. 2 4

Clinical Presentation

Patients with infected testicular prostheses typically present with localized symptoms such as pain, swelling, redness, and warmth around the implant site. Systemic signs may include fever, malaise, and elevated inflammatory markers. Atypical presentations can include subtle symptoms that mimic other post-surgical complications, making early diagnosis challenging. Red-flag features include purulent discharge, significant systemic inflammatory response, and signs of sepsis, necessitating urgent evaluation and intervention. 2 4

Diagnosis

The diagnosis of testicular prosthesis infection involves a combination of clinical assessment and diagnostic imaging. Key steps include:

Clinical Evaluation: Presence of local signs (pain, swelling, erythema) and systemic symptoms (fever, malaise).

Laboratory Tests: Elevated white blood cell count, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) can indicate infection.

Imaging:

- CT Scan: Highly sensitive (94%) and specific (85%) for detecting high-grade infections, though less effective for low-grade infections. - MRI: Useful for detailed soft tissue assessment and identifying complications like abscess formation. - PET-CT: Can help in identifying areas of increased metabolic activity indicative of infection.

Microbiological Confirmation: Cultures from aspirated fluid or tissue samples are essential to identify the causative organism and guide antibiotic therapy.

Differential Diagnosis:

- Aseptic Foreign Body Reaction: Typically lacks systemic signs and responds to conservative management. - Cellulitis: Localized to skin and subcutaneous tissues without deep involvement. - Prosthetic Joint Infection: Different clinical context but shares diagnostic challenges.

(Evidence: Moderate) 1 8 10

Management

Initial Management

Conservative Antibiotic Therapy: Initiate broad-spectrum antibiotics based on local antibiogram, targeting common pathogens like Staphylococcus aureus. Adjust based on culture and sensitivity results.

- Drugs: Vancomycin, piperacillin-tazobactam, or ceftriaxone. - Dose: Vancomycin 15-20 mg/kg every 8-12 hours; piperacillin-tazobactam 4.5 g every 6-8 hours. - Duration: Typically 2-4 weeks, adjusted based on clinical response and microbiological data. - Monitoring: Regular blood cultures, inflammatory markers, and clinical assessment.

Advanced Management

Surgical Intervention:

- Debridement: Wide surgical debridement of infected tissue if conservative therapy fails. - Prosthesis Removal: Explantation of the infected prosthesis may be necessary in cases of deep infection or failure of medical management. - Reconstructive Surgery: Consider delayed reimplantation with appropriate antibiotic prophylaxis and possibly antibiotic-loaded cement beads post-debridement. - Bypass Techniques: Restoration of blood flow using in situ or extra-anatomic bypass techniques if vascular involvement is suspected.

Refractory Cases

Specialist Referral: Consult infectious disease specialists and vascular surgeons for complex cases.

Advanced Imaging and Monitoring: Continued use of PET-CT, MRI, and serial imaging to monitor infection resolution and prosthesis status.

Reimplantation: Consider reimplantation only after thorough resolution of infection, typically months post-explantation, with meticulous surgical technique and possibly antimicrobial surface modifications.

(Evidence: Moderate) 1 4 5

Complications

Systemic Infections: Sepsis, systemic inflammatory response syndrome (SIRS).

Local Complications: Abscess formation, fistula development, chronic pain.

Prosthetic Failure: Loosening, migration, or structural damage necessitating further surgical intervention.

Management Triggers: Persistent fever, increasing pain, signs of systemic toxicity, or imaging evidence of ongoing infection warrant immediate escalation of care.

(Evidence: Moderate) 1 2

Prognosis & Follow-up

The prognosis for patients with testicular prosthesis infections varies based on the severity and timeliness of intervention. Early diagnosis and aggressive management generally yield better outcomes, with lower risks of systemic complications and prosthesis-related morbidity. Prognostic indicators include prompt surgical intervention, successful eradication of infection, and absence of underlying comorbidities. Follow-up should include regular clinical assessments, imaging studies to monitor prosthesis integrity, and laboratory tests to ensure resolution of inflammatory markers. Recommended intervals are typically every 3-6 months initially, tapering to annually if stable. 2 4

(Evidence: Moderate) 2 4

Special Populations

Transgender Men: Higher risk due to specific surgical contexts (metoidioplasty, phalloplasty). Close postoperative monitoring is crucial.

Comorbidities: Patients with diabetes, immunosuppression, or chronic skin conditions may have increased susceptibility to infections and require tailored prophylactic measures.

Surgical Technique: Variations in surgical approach and experience can influence infection rates, highlighting the importance of standardized protocols and experienced surgical teams.

(Evidence: Moderate) 2 4

Key Recommendations

Early Clinical Surveillance: Regular follow-up visits post-implantation to detect early signs of infection. (Evidence: Moderate) 2

Prompt Diagnostic Workup: Utilize imaging (CT, MRI) and microbiological cultures for definitive diagnosis. (Evidence: Moderate) 1 8

Antibiotic Therapy Based on Culture Sensitivity: Initiate targeted antibiotic therapy guided by microbiological results. (Evidence: Moderate) 1

Surgical Intervention for Persistent Infections: Consider debridement and prosthesis removal if medical management fails. (Evidence: Moderate) 1 4

Delayed Reimplantation After Infection Resolution: Reassess candidacy for reimplantation only after thorough infection clearance and appropriate intervals. (Evidence: Moderate) 4

Multidisciplinary Care: Involve infectious disease specialists and vascular surgeons for complex cases. (Evidence: Expert opinion) 1

Enhanced Surgical Techniques: Employ meticulous surgical techniques and sterile protocols to minimize infection risk. (Evidence: Expert opinion) 2

Close Monitoring of Comorbidities: Tailor prophylactic measures for patients with underlying conditions predisposing to infections. (Evidence: Moderate) 2

Patient Education: Inform patients about signs of infection and the importance of prompt reporting. (Evidence: Expert opinion) 2

Long-term Follow-up: Schedule regular follow-up assessments to monitor prosthesis status and overall health. (Evidence: Moderate) 2 4

References

1 Andercou O, Marian D, Olteanu G, Stancu B, Cucuruz B, Noppeney T. Complex treatment of vascular prostheses infections. Medicine 2018. link 2 Briles B, Crane C, Santucci R. Long-term Fate of Testis Prosthesis After Metoidioplasty and Phalloplasty. Urology 2025. link 3 Bauer SJ, Mehdiani A, Sugimura Y, Immohr MB, Wollgarten L, Antoch G et al.. Twisting is key: Removing an infected nitinol wire braided uncovered stent from the aortic arch and the descending aorta. Multimedia manual of cardiothoracic surgery : MMCTS 2022. link 4 Pigot GLS, Al-Tamimi M, Ronkes B, van der Sluis TM, Özer M, Smit JM et al.. Surgical Outcomes of Neoscrotal Augmentation with Testicular Prostheses in Transgender Men. The journal of sexual medicine 2019. link 5 Hisata Y, Hashizume K, Tanigawa K, Miura T, Odate T, Tasaki Y et al.. Vacuum-assisted closure therapy for salvaging a methicillin-resistant Staphylococcus aureus-infected prosthetic graft. Asian journal of surgery 2014. link 6 Wang R, Wang Z, Ma Y, Liu G, Shi H, Chen J et al.. Particle-induced osteolysis mediated by endoplasmic reticulum stress in prosthesis loosening. Biomaterials 2013. link 7 Scerba M, Podlaha J, Kriz Z, Krejci Z. Infection of vascular prosthesis in aortofemoral area. Bratislavske lekarske listy 2007. link 8 Pakos EE, Fotopoulos AD, Stafilas KS, Gavriilidis I, Al Boukarali G, Tsiouris S et al.. Use of (99m)Tc-sulesomab for the diagnosis of prosthesis infection after total joint arthroplasty. The Journal of international medical research 2007. link 9 Pakos EE, Trikalinos TA, Fotopoulos AD, Ioannidis JP. Prosthesis infection: diagnosis after total joint arthroplasty with antigranulocyte scintigraphy with 99mTc-labeled monoclonal antibodies--a meta-analysis. Radiology 2007. link 10 Stádler P, Bìlohlávek O, Spacek M, Michálek P. Diagnosis of vascular prosthesis infection with FDG-PET/CT. Journal of vascular surgery 2004. link 11 Morawietz L, Gehrke T, Frommelt L, Gratze P, Bosio A, Möller J et al.. Differential gene expression in the periprosthetic membrane: lubricin as a new possible pathogenetic factor in prosthesis loosening. Virchows Archiv : an international journal of pathology 2003. link 12 Satoh S, Elstrodt J, Hinrichs WL, Feijen J, Wildevuur CR. Prevention of infection in a porous tracheal prosthesis by omental wrapping. ASAIO transactions 1990. link 13 Lattimer JK, Stalnecker MC. Tissue expansion of underdeveloped scrotum to accommodate large testicular prosthesis. A technique. Urology 1989. link90056-3)

Testicular prosthesis infection