Andor teratozoospermia

Any of the following combination

• 1 factor A + 1 factor C 1 factor B + 1 factor C

Ejaculate signs Leukocyte > 1x106/ml Culture with significant growth of pathogenic bacteria Abnormal appearance, increased viscosity and pH, and/or abnormal biochemistry of the seminal plasma

Prostatic fluid

Abnormal prostatic expression fluid and/or abnormal urine after prostatic massage

Clinical history

Positive history for urinary infection, epididymitis, and/or sexual transmitted diseases

Physical signs

Thickened or tender epididymis, tender vas deferens, and/or abnormal digital rectal examination

Fig. 25.1 Conventional WHO criteria to diagnose male accessory gland infections (MAGI) [10]

problem solving. The diagnostic workup linked to the original classifications is the corollary of these points of views. Therefore, both classifications should be maintained, though with a different field of application.

Among microbials, some Gram-negative bacteria such as Enterobacteriaceae (Escherichia coli, Klebsiella sp., Proteus, Serratia, Pseudomonas sp., etc.) have been recognized as known prostate pathogens (category II, NIH classification) because of their strong association with a clear positive clinical history (prior and/ or recurrent urinary tract infection, sexually transmitted disease, congenital urogenital abnormalities) and some urogenital abnormalities at the physical examination. On the other hand, the only presence of some microorganisms is interpreted by a number of investigators as "probable" or "possible" prostate infection when, respectively, Gram-positive pathogens (Enterococcus sp.,

Streptococcus viridans, and Streptococcus pyogens, and Staphylococcus aureus) are present, or when coagulase-negative pathogens (Staphylococcus epidermidis), Chlamydia trachomatis, Ureaplasma urealyticum, anaerobes are present.

The major difficulty in interpreting microbiological findings is the presence of contaminating, indigenous microbial flora, inhibitory substances known to be in the prostatic secretions and/or previous antibiotic treatments. Thus, the diagnosis of bacterial prostatitis may be confirmed by quantitative bacteriological cultures in the semen (>103 pathogenic bacteria or >104 nonpathogenic bacteria in the seminal plasma diluted 1:2 with saline solution) [11] or segmented cultures, such as the four [12] or the two [13] glass test.

On the other hand, although theoretically the WHO definition of MAGI includes different diagnostic entities [prostatitis, prostatovesiculitis (PV), prostatovesiculoe-pididymitis (PVE)], practically it recognizes only the negative role of one gland (prostate) (identified by the factors of the group B) and one factor (infectious noxae: bacteria, C. trachomatis, U. urealyticum) on male reproductive function and fertility. Thus, the WHO conventional criteria, though not entirely coherent with the definition of MAGI which should include different diagnostic entities, represent a clinical aid to diagnose a prostate infection, but underestimate the important role of the chronic inflammatory response in terms of leukocytospermia and its products (ROS, cytokines) which, on the contrary, have been shown to play a relevant role.

Moreover, although acute or chronic bacterial prostatitis accounts for a low number of cases (5-10%) [7] , MAGI has been reported to be present in a wide range (1.615%) of male infertile patients attending various infertility clinics [14-17]. Therefore, chronic, mainly symptomless MAGI may contribute to infertility to a various extent depending on the site of infection 49, 18-204 and/or on the host's inflammatory response in terms of leukocytospermia and leukocyte products: ROS [19-22] and/or cytokines [23-25]. Thus, the broad range of prevalence and the open debate with pros and cons on the role of MAGI in male infertility [26] relate to various factors:

1. Different consulting physician speciality, which has an impact on the workup of the infertile patient with MAGI

2. Incomplete and not well-defined diagnosis; for example, "sperm infection" is an improperly used laboratory definition, and it should be correctly replaced by the male diagnostic category defined conventionally as MAGI

3. Lack of appropriate morphostructural evaluation of the gland(s) involved in the inflammatory process

4. The highest estimated prevalence may be found in those studies which include patients who require specific andrological clinical counseling for persistent infection (even after antimicrobials) and/or previous assisted reproduction program failure

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