Introduction

Pyospermia is a medical condition where there are high numbers of white blood cells in semen. There is a presence of 1x10⁶   round cells/mL of white blood cells. The presence of white blood cells is a concern for inflammation and infection in the male reproductive tract. High concentrations of WBCs induce higher levels of oxidative stress, damaging sperm motility and fertilisation capacity.¹ Infection in the male reproductive tract can be caused due to various reasons such as Prostatitis, Epididymitis and seminal vesiculitis.  Almost 15% of all couples trying to conceive are affected by infertility, and most of them are connected to male factors.²

Prostatitis 

Prostatitis is a common urinary tract disease in men. Nearly half of all men suffer from symptoms of prostatitis at some stage of their lives. Prostatitis affects men of all ages, especially in the middle-aged group. Acute and chronic infection of the prostate are uncommon and can be caused by a wide range of organisms.  Bacterial prostatic infections are caused by Gram-negative rods. Prostatitis is caused by infection from Enterobacteriaceae, E.coli, Proteus, Klebsiella, Enterobacter, Serratia and Pseudomonas. Gram-positive organisms such as Enterococcus and Staphylococcus species, and sexually transmitted organisms such as Neisseria gonorrhoeae, chlamydia trachomatis, also cause Prostatitis.⁴

Symptoms of prostatitis

• Pain in the area between the scrotum and the rectum, called the perineum.

• Pain or discomfort of the penis or testicles.
• Painful ejaculation.
• Blood in the urine and cloudy urine. 
• Fever, chills, muscle aches, and other flu-like symptoms with acute bacterial prostatitis.

What is epididymitis?

 The epididymis is part of the genitourinary tract that includes testes, the vas deferens, the prostate, the urethra and the bladder. Epididymitis is inflammation of the epididymis that causes discomfort or pain in the scrotum, testicle. Most of the infections of the epididymis are due to the reverse flow of urine in elderly males or due to sexually transmitted diseases in younger males. Other causes of epididymitis include viral infections and drug-induced infections. Chlamydia and Neisseria also account for epididymitis. Epididymitis is caused by tuberculosis, E.coli, and sexually transmitted diseases. Epididymitis also occurs due to certain medications, such as amiodarone, used in the treatment of cardiac dysrhythmia.⁵

Symptoms of epididymitis

• Sudden or gradual pain in 1 or both of the testicles.
• Unilateral or bilateral scrotal pain 
• Fever and urethral  discharge 
• Dysuria
• Urinary frequency, urgency or incontinence of urine
• Build-up of fluid around testicle

What is seminal vasculitis?

Seminal vesiculitis is the term used to describe inflammation of the seminal vesicles. It is associated with infection in the male genital tract, prostatitis or epididymitis. It can be acute or chronic in nature. Patients with seminal vesiculitis present with painful ejaculation, pain in the lumbosacral region, and subfertility.⁶

Symptoms of seminal vesiculitis 

• Haematospermia
• Pain 
• Obstructive lower urinary tract symptoms
• Combined impact on semen parameters

Impact of epididymal infections on semen

Chronic Epididymitis may result in reduced sperm count and motility. Most cases of infection occur as a result of retrograde flow of urine, most commonly seen in elderly males. Epididymitis may still be caused by bacterial infections. Epididymitis may be caused by bacterial infections and inflammatory processes, like repeated running and jumping. Chemical epididymitis may occur as a result of exercising or sexual intercourse, resulting in retrograde flow of urine. Epididymitis may be caused by using certain medications, like amiodarone, used in the treatment of cardiac dysrhythmias. Viral infections in the testis can result in epididymo-orchitis.⁶

• Chronic epididymitis may result in reduced sperm motility and reduced sperm count
• Impaired sperm motility is associated with atypical staining behaviour of sperm tails
• Urinary tract infections can cause infection in the epididymis, leading to inflammation and potential fertility problems
• Structural abnormalities in the urinary tract or blockages in the epididymis can increase the risk of fertility issues

Impact of epididymal infections on semen

1. Reduced sperm count ( oligospermia): Acute epididymitis is one of the most common diseases related to male inflammation. Men with epididymitis usually present with impaired semen quality and high white blood cells. The sperm protein composition changed significantly in patients after epididymitis, which is one of the factors contributing to infertility. Sperm concentrations of <15 million /ml or total count less than 39 million /ejaculate are classified as oligospermic
2. Impaired sperm motility (Asthenozoospermia) -  A  condition defined as low sperm motility with less than 32 per cent progressive motility in a semen sample¹¹
3. Abnormal sperm morphology (Teratozoospermia)- A condition of abnormal sperm morphology defined as less than 4 % spermatozoa with normal morphology³
4. Azoospermia is the absence of spermatozoa in the ejaculate. True azoospermia can be observed in cases of chromosomal abnormalities or testicular hypoplasia. It is usually associated with bilateral blockage of the ampulla of the ductus deferens
5. Pyospermia ( Leukocytospermia)- Pyospermia is suspected based on the presence of white blood cells and excessive inflammation, which impact semen parameters and fertilisation capability. High concentrations of WBCs induce higher levels of oxidative stress, which leads to a decrease in the motility of the sperm and fertilization capability¹

Diagnosis 

• Semen analysis ( to check WBC count, motility, morphology, sperm concentration)
• Scrotal ultrasound to detect swelling, Abscess or obstruction.
• Urine bacterial cultures should be performed for all men to evaluate the presence of genitourinary organisms to check antibiotic susceptibility.
• Microbiological testing 

Management and treatment

Acute infectious epididymitis 

1. Acute epididymitis can be treated on an outpatient basis by an antibiotic regimen; referral to a specialist is required in case of severe pain or fever in case of diagnosis such as torsion, testicular infarction and abscess.
2. For acute epididymitis caused by chlamydia or gonorrhoea, ceftriaxone 500mg and Doxycycline 100mg orally 2 times /day for 10 days is recommended.
3. Rest and scrotal elevation 
4. NSAIDS for pain and swelling 

Chronic epididymitis 

1. Neuropathic pain management eg amitriptyline, gabapentin.
2. Surgical treatment. If an abscess is formed, surgery might be required to drain it . Sometimes the whole part of the epididymis has to be removed surgically.

Other management considerations 

All men with acute epididymitis should be tested for HIV and syphilis.

Men who have suspected infections with gonorrhoea and chlamydia should be advised to abstain from sexual intercourse.

Follow up 

Men who experience swelling and tenderness that persist after completion of antimicrobial therapy should be assessed for alternative diagnoses such as tumour, abscess, infarction, testicular cancer, Tuberculosis and fungal epididymitis.

FAQs

Does leukocytospermia prevent having children?

Many of the patients are likely to get pregnant through a variety of methods, including natural conception, IVF, and IUI.

What causes leukocytospermia?

Leukocytospermia is a result of infection and inflammation along the genitourinary tract, particularly along the testis, prostate gland, and seminal vesicles. Long-term abstinence from ejaculation can increase the number of leukocytes in semen. Leukocytes in the semen can also be due to certain autoimmune conditions, strictures and varicoceles.

What are anti -sperm antibodies?

Many people carry antibodies that cause their sperm to be destroyed, resulting in infertility.

What happens when the Epididymis tube becomes blocked?

When the epididymis tube becomes infected, it blocks the sperm's journey through it, thus inhibiting its transmission. About one-third of epididymitis patients have antisperm antibodies, which result in infertility.

What is semen?

Semen is a thick, sticky, whitish-grey fluid of the male reproductive system. It contains sperm. It also has components that help nourish sperm and fluids that make it easier to deposit towards the back of the vagina and fertilise the egg.

Where is semen stored?

A  tube at the back of the testicle stores sperm until it matures. Sperm then combines with seminal vesicle fluid to create Semen.

What is semen made of?

Semen mainly consists of water, Mucus, and plasma.

Summary 

Epididymitis can negatively impact semen parameters, especially if not treated. Early diagnosis and appropriate medical intervention are key to preserving fertility.

This article explores the link between epididymal infections—particularly epididymitis—and their detrimental effects on semen quality and male fertility. Pyospermia (leukocytospermia), characterised by high white blood cell (WBC) counts in semen, is a key indicator of inflammation or infection in the male reproductive tract. Common causes include infections such as prostatitis, epididymitis, and seminal vesiculitis, often triggered by bacteria (e.g., E. coli, Chlamydia, Neisseria) or viruses (e.g., mumps).

Epididymal infections can result in:

• Reduced sperm count (oligospermia)
• Poor sperm motility (asthenozoospermia)
• Abnormal morphology (teratozoospermia)
• Azoospermia (absence of sperm)
• Pyospermia (presence of excess WBCs)

These conditions are primarily diagnosed through semen analysis, scrotal ultrasound, and urine cultures. Acute cases are managed with antibiotics, rest, and pain relief, while chronic cases may require neuropathic pain management or surgical intervention. If untreated, epididymitis can cause permanent damage to sperm quality, contributing to male infertility.

Early diagnosis and targeted treatment are essential for preserving reproductive health in men.