Overview

Pyospermia (py-oh-sper-mia) refers to an abnormally elevated presence of white blood cells (leukocytes) in semen, affecting those assigned male at birth (AMAB). Leukocytes (loo-koh-cytes) are important cells in the body’s immune system that help to fight infections. While a small number of leukocytes in the semen is normal, an abnormal level can indicate an underlying infection and result in fertility issues if left untreated.¹ In this article, we will look at infectious causes of pyospermia and explore how antibiotics are utilised in treating this.

Understanding infectious pyospermia

An infectious disease is a disease caused by harmful pathogens (germs) that enter the body and multiply to cause infections, such as bacteria, viruses or fungi. These are contagious diseases that can spread from person to person, or through contaminated food, water, or vectors (living organisms). This differs from non-infectious diseases (also known as non-communicable diseases), which aren’t contagious and are usually caused by genetics, environmental factors or a combination of both.

While pyospermia itself is not contagious, infectious pyospermia can be attributed to infectious diseases caused by contagious microorganisms in the reproductive or urinary system. Infections in the reproductive or urinary system can lead to pyospermia. Common causes include:²

• Sexually transmitted infections (STIs)
• Bacterial infections, e.g. urinary tract infections (UTI)
• Chronic prostatitis (long-term inflammation of the prostate)

Inflammation is the body’s natural response to damage caused by harmful pathogens. When an infection occurs, leukocytes are recruited to the site to help fight it. They release reactive oxygen species (ROS), a powerful substance that destroys infection-causing microorganisms.³ However, in the process of fighting infections, high levels of ROS can harm healthy cells, such as sperm cells, known as oxidative stress. Oxidative stress promotes detrimental changes to the function, motility (movement) and overall quality of sperm, making it harder for sperm to reach and fertilise an egg successfully during conception.⁴ ROS can contribute to:

• Damaged sperm DNA
• Sperm membrane destruction
• Impaired sperm motility

If you are experiencing symptoms such as pain, swelling, abnormal semen colour and difficulty conceiving, seek medical advice.

Diagnosing pyospermia

Identifying the infection

If you are experiencing symptoms, a sample of semen would be requested for examination. A diagnosis is made in the presence of more than 1 million leukocytes in 1 mL of ejaculate.⁴ Bacterial culturing of semen, urine and prostate fluid can assist in identifying any bacteria causing the infection. STI testing can also help identify whether pyospermia is caused by sexually transmitted bacteria.

Importance of targeted treatment

It is important to pinpoint the cause of pyospermia and provide specific treatments accurately. The overuse of unnecessary antibiotics increases the chance of antibiotic resistance, which is when bacteria stops responding to antibiotics, and they can no longer be killed by them. If antibiotics are ineffective, they may not clear the infection and can lead to the recurrence of the disease.

Antibiotic treatment strategies

Choosing the right antibiotic

Current management of infectious pyospermia focuses on eliminating the root cause. Some studies have observed that the use of antibiotics has improved sperm health parameters such as concentration, motility and volume.⁵ Healthcare professionals select the appropriate antibiotics using culture test results that identify the specific bacteria present and choose the corresponding antibiotic. The type of antibiotic chosen also takes individual patient factors into consideration, such as allergies or interference with other medications.

Commonly used antibiotics

Here are some commonly used antibiotics. If appropriate, a combination of these can be used.

Fluoroquinolones 

Fluoroquinolones (e.g. ciprofloxacin, levofloxacin) are broad-spectrum antibiotics, meaning they are effective against a wide range of bacteria. They can be used to treat various urogenital infections, showing promising results when treating bacterial prostatitis and lower urinary tract infections.⁶ While effective, guidelines state that they must only be prescribed when other commonly recommended antibiotics are inappropriate, due to a risk of severe irreversible side effects, including nerve damage and tendon rupture.⁷

Tetracyclines

Tetracyclines (e.g. doxycycline) are bacteriostatic antibiotics, meaning they prevent bacteria from multiplying, but don’t necessarily kill them. This is achieved by interfering with mechanisms that bacteria use to produce proteins necessary for growth and multiplication, thereby preventing the bacteria from reproducing.⁸ However, the use of tetracyclines is not advised during pregnancy; tetracycline use during the last half of pregnancy increases the risk of defects in tooth development, such as permanent yellow-gray-brown discolouration of the teeth and enamel hypoplasia (not having enough tooth enamel to protect the teeth) in the developing baby. 

Macrolides

Macrolides (e.g. azithromycin) are bacteriostatic agents which inhibit protein synthesis, similar to tetracyclines. They are often prescribed to treat chlamydia or gonorrhea infections. Erythromycin is a type of macrolide that can be taken during pregnancy, providing an alternative treatment option if suitable.

Beta-lactams

Beta-lactams (e.g., amoxicillin, cephalosporins) are used for a specific type of bacteria called gram-positive bacteria, which have a thick bacterial cell wall made from peptidoglycans, and no outer membrane. They are bactericidal agents, meaning they kill bacteria directly. Beta lactams kill bacteria by interrupting the formation of the peptidoglycan cell wall. This weakens the structural integrity of the bacterial cell, as peptidoglycan is the primary cell wall component with no structural support from an outer membrane.⁹ Uses of beta-lactams include treating STIs such as syphilis and gonorrhea, or UTIs, but are usually not used as a first-line treatment due to increasing resistance and higher recurrence rates than other treatments.¹⁰

Aminoglycosides

Aminoglycosides (e.g., Gentamicin, Amikacin) are potent bactericidal agents used to treat severe or resistant infections caused by gram-negative or some gram-positive bacteria. They are often administered as an injection or intravenously in hospitals. Aminoglycosides are known to be effective against UTIs caused by gram-negative bacteria that are resistant to multiple drugs, but are not commonly used due to concerns about potential kidney damage.¹¹

Treatment, duration and effectiveness

A typical course length of antibiotics can vary depending on the type and severity of the infection, as well as patient factors. For example, uncomplicated UTIs may be cleared with a 3-day course, whereas cases of chronic prostatitis may require a treatment course of 4 to 6 weeks.¹² Generally, the shortest course of treatment possible to fully clear the infection is recommended to reduce side effects and resistance. You must complete the full prescribed course of antibiotics to further prevent developing resistance and reduce the chance of recurrence. This ensures the infection can be treated fully, making any potential future treatments easier. The effectiveness of the treatment can be monitored by repeating semen analysis to investigate for improvement.

Antibiotic resistance and treatment failures

Unfortunately, treatments are not always successful. If the wrong antibiotic is chosen, the specific bacteria can’t be killed effectively. Additionally, not taking your antibiotics properly or stopping them too soon, as mentioned, can lead to persistent infection, as some bacteria may remain and multiply. Furthermore, some bacteria are more naturally resistant due to various mechanisms. For instance, some bacteria form protective layers called biofilms, making them more resistant to killing.

If the initial antibiotics don’t work, culture-guided treatments can be adjusted based on the type of bacteria and which antibiotics they are susceptible to. Sometimes, severe infections may require hospitalisation and treatment intravenously.

To prevent resistance, you should avoid taking unnecessary antibiotics. Taking antibiotics exactly as prescribed is the most effective way to treat an infection.

Addressing recurrent infections

Sometimes, recurrence may occur, meaning the disease returns. An untreated partner can reinfect you with an STI following treatment. Some infections may also persist despite treatment, such as in cases of chronic prostatitis. Furthermore, underlying health issues that weaken the immune system can make infections harder to clear, such as diabetes.

If recurrence is suspected, reevaluation of the antibiotic choice can be helpful, as switching to a different class of antibiotic may be more effective than the original treatment. If pyospermia is attributed to an STI, both partners must be treated, as reinfection following treatment is common. Additionally, some evidence suggests long-term  (8+ weeks) use of Doxycycline as a prevention tool for recurrent STIs is generally safe.¹³

Supporting antibiotic treatment

Lifestyle modifications

Lifestyle factors can aid antibiotic treatment. Drinking plenty of water helps to flush out bacteria, while avoiding alcohol reduces bladder irritation. Eating a healthy diet can facilitate good immune function and support gut microbiota (helpful bacteria that live inside of us).

Practising safe sex by using protection such as condoms can prevent infection or reinfection.

Alternative and complementary treatments

Anti-inflammatory medicines (NSAIDs) such as ibuprofen can be used alongside antibiotics to ease inflammation and reduce symptoms. However, if in doubt, check with a healthcare professional if you are concerned about if and how these drugs may interact.

Incorporating probiotics (good bacteria and yeasts) into your diet through yoghurts or supplements helps to maintain a healthy microbiome in the gut and reproductive tract by counteracting imbalances caused by antibiotics, which usually worsen symptoms.

The use of herbal and natural remedies may serve as a useful tool to support treatment. Some evidence suggests zinc or cranberry extract may have antioxidant properties to ease symptoms by counteracting oxidative stress.¹⁴ However, these should be used in conjunction with antibiotics rather than as a single treatment.

Summary

Infectious causes of pyospermia can be treated with a variety of different antibiotics. It is essential that an accurate, early diagnosis is made to select the best treatment and eliminate the infection fully and efficiently. Targeted antibiotic treatment also reduces the likelihood of antibiotic resistance, which makes it harder to treat any potential future infections. 

If you are experiencing persistent symptoms, consult with a healthcare professional. Healthcare professionals can provide assistance in uncovering the root cause of pyospermia, followed by tailored treatments and advice to treat the underlying infection, decreasing the number of leukocytes in semen and decreasing the chance of pyospermia-related fertility issues.