Introduction

Pyospermia, also known as leukocytospermia, refers to the presence of an elevated number of white blood cells (WBCs) in the semen, typically exceeding 1 million WBCs per millilitre.¹ It typically indicates inflammation or infection of the male urogenital tract. Hence, it is essential to be aware of the symptoms of pyospermia, as it affects male fertility and overall reproductive well-being.^1,3,4 This article aims to provide a summary of pyospermia, its likely cause, and various symptoms, including pain, discharge, and fever. By knowing these likely signs, one can be empowered to seek medical help sooner, thus acquiring a clear diagnosis and proper remedy.

Understanding pyospermia

Definition and causes

Pyospermia refers to an abnormally high WBC count in semen (1 × 10⁶ or more leukocytes per millilitre of semen).¹ It is usually an indication of inflammation or infection of the male reproductive tract, and can be caused by a number of factors, such as viral or bacterial infections, sexually transmitted infections (STIs), and inflammatory conditions of the prostate, epididymis, or other structures of the male genital tract.

Prevalence and risk factors

Prevalence of pyospermia is highly variable, with studies reporting rates ranging between 2% and 40% in men undergoing fertility assessment.⁴ Risk factors for pyospermia include:

• Sexual habits: Engaging in unprotected sex increases the risk of STI acquisition, hence facilitating causative infections of pyospermia
• Habits of an individual: Cigarette smoking and alcohol abuse have been found to be associated with an increased risk of pyospermia
• Medical history: A history of urogenital infection or inflammation could predispose an individual to pyospermia

Impact on male fertility and reproductive health

Pyospermia negatively affects male fertility by undermining sperm quality and functionality. Increased WBC count in semen can lead to excessive production of reactive oxygen species (ROS), which may damage sperm DNA, reduce motility, and reduce overall fertilisation potential. Therefore, treatment of pyospermia is important in achieving optimal reproductive health. 

Common symptoms of pyospermia

While pyospermia in itself is often asymptomatic, it is typically accompanied by conditions that present with a range of symptoms.

Pain and discomfort

• Pain or discomfort in the scrotum or testicles: Pain or discomfort in the scrotum may be due to epididymal or testicular inflammation or infection, which are caused by bacterial infections such as STIs, these manifest as testicular aches, tenderness and swelling³ 
• Dysuria or pain on ejaculation: Pain upon urination (dysuria) or ejaculation may be due to infection of the urethra or prostate. Urethritis is commonly caused by STIs such as Chlamydia trachomatis or Neisseria gonorrhoeae, which can lead to a burning sensation during urination³

Genital discharge

• Abnormal penile discharge: The presence of abnormal discharge from the penis, coloured and of a different consistency, can imply an underlying infection³
• Bad-smelling or thicker semen: A change in consistency or odour of the semen, with an offensive smell or thickened consistency, can imply an inflammatory process or infection³

Fever and systemic symptoms

• Low-grade to high fever: Infections as a result of pyospermia can induce systemic symptoms, including mild to high fever^1,3
• Fatigue, chills, or malaise: The infections leading to pyospermia can produce nonspecific symptoms of discomfort, fatigue, or chills

Urinary symptoms

• Frequent urination: More frequent urination is produced by prostatitis or urinary tract infection
• Burning or painful sensation during urination: Painful urination or dysuria may be caused by urinary tract infections or as a sign of inflammation³

Underlying conditions that may cause pyospermia symptoms

Sexually transmitted infections (STIs)

STIs such as trichomoniasis, gonorrhea, and chlamydia can cause reproductive tract inflammation, which can subsequently result in pyospermia. It can also be accompanied by sensations of discomfort, burning, and discharge.

Prostatitis

Prostatitis is also a common condition associated with pyospermia and several symptoms. Bacterial prostatitis, typically caused by common urinary tract pathogens or sexually transmitted diseases, is often associated with pelvic pain, dysuria and painful ejaculation, frequency and urgency of micturition, and sometimes fever and rigours.³ Chronic prostatitis/chronic pelvic pain syndrome is a more complex syndrome involving prostate inflammation and pelvic pain in the absence of characteristically distinct bacterial infection, but also possibly with related leukocytospermia and pain.

Epididymitis

Epididymitis refers to inflammation of the epididymis and is most frequently linked to bacterial infections and can cause severe scrotal enlargement and fever.³

Urinary tract infections (UTIs)

UTIs have the ability to travel from the bladder to the reproductive system, resulting in murky or unpleasant-smelling semen and painful urination.

Autoimmune conditions

When the immune system unintentionally targets the sperm cells, conditions like antisperm antibody syndrome develop, which can cause inflammation and pyospermia.

When to seek medical attention

Men with repeated symptoms should undergo medical evaluation by a physician. Pyospermia can cause infertility, and there is an imperative need to receive treatment to improve reproductive health. Symptoms suggestive of an imperative necessity for prompt medical attention include:

• Repeating genitalia pain or swelling
• Profuse fever and rigours
• Semen colour, odour, or texture alteration
• Presence of blood in the semen or urine
• Painful micturition or being unable to urinate/empty the bladder

Diagnostic approaches

Semen analysis

Semen is tested for infection, sperm quality, and WBC count. Pyospermia is indicated by a WBC count of more than 1 million cells/mL.⁵

Urine and blood tests

Urinalysis will confirm the occurrence of a urinary tract infection, which may be associated with inflammation in the genitalia.¹ Blood tests may be undertaken to detect signs of systemic infection, including elevated WBC counts or markers of inflammation such as C-reactive protein (CRP).¹ If an STI is suspected, additional urine or blood tests may be carried out to screen for pathogens such as Chlamydia and Gonorrhoea are warranted.³

Ultrasound or imaging tests

Prostate and scrotal transrectal ultrasounds are useful for detecting and evaluating inflammation or structural abnormalities in the reproductive organs.³

Treatment options

Treatment of pyospermia is primarily focused on the management of the causative agent and its associated symptoms.

Antibiotics for infections

If infections due to bacteria are found during diagnosis of pyospermia, antibiotics such as ciprofloxacin or doxycycline are administered to eradicate the infection.^3,5 Depending on the location and intensity of the infection, treatment usually lasts anywhere from a few days to several weeks.^1,3 

Anti-inflammatory medications

Where there is no detected bacterial infection or as an adjuvant to antibacterial therapy, non-steroidal anti-inflammatory drugs (NSAIDs) or selective cyclooxygenase-2 (COX-2) inhibitors such as celecoxib, can be used to reduce the discomfort and inflammation associated with pyospermia.^1,3 These medications have the ability to alleviate the inflammatory lesions and potentially improve semen quality.³

Lifestyle changes and supportive care

• Hydration: Infections can be cleared up by consuming sufficient water, hence maintaining adequate hydration can aid in the treatment or prevention of pyospermia
• Reducing alcohol and smoking: Reproductive health can be enhanced by quitting alcohol and smoking³
• Safe sexual practices: The use of condoms lowers the risk of STIs that cause pyospermia

Summary

Pyospermia, defined as an elevated white blood cell count in semen, can manifest through a variety of symptoms including pain and discomfort in the testes or upon urination/ejaculation, abnormal genital discharge, fever and systemic symptoms of infection, and urinary symptoms. These symptoms generally point to underlying prostatitis, epididymitis, sexually transmitted infections, or urinary tract infections, which cause an inflammatory response in the male genital tract.

It is important to identify these symptoms and receive timely medical evaluation. Adequate diagnosis, which may involve semen analysis, urine and blood tests, and sometimes semen culture and imaging, is crucial in uncovering the underlying cause of pyospermia. Appropriate further treatment, which may vary from antibiotics, anti-inflammatory agents, lifestyle changes, or antioxidants, may result in relief of symptoms, improvement in underlying pathology, and potentially also in semen quality and fertility outcomes.

By highlighting the symptoms of pyospermia and urging individuals to be more proactive about their health, we can encourage earlier diagnosis and treatment, and ultimately contribute to better management of male reproductive health.