BCG Related Infections

Dear Dr. Lamm,

I am an 78 year old retired general surgeon in Dallas, Texas, with transitional cell carcinoma in situ of my urinary bladder and, now, probable BCG-related right epididymo orchitis.  I have undergone induction BCG treatment as per your protocol, followed by maintenance Rx. consisting of one bladder irrigation with BCG once monthly.  My care has been under the direction of a board certified urologist (Michael Gross, M.D.) a member of Dr. Mel Kadesky's urology group.   I am now NED according to repeat cystograms and biopsies at three-month intervals that have shown no residual malignancy in either of the last two exams.  FISH tests to date have been non diagnostic because of insufficient cells to examine.  Altogether, I have been NED eight months after one induction course of BCG followed by maintenance as described above.  For the past six months the irrigations have been associated with significant pain and swelling of my right testicle.  I have had no symptoms of BCG systemic sepsis.  Recently, I developed a right scrotal fistula.  It is, perhaps, significant that 20 years ago I had a TUIP to release a bladder neck stricture and excision of multiple bladder diverticulae.  Several years later, I underwent a left epididymectomy to remove a large spermatocele.  There is, therefore, no epididymus on the left but there is one on the right where the abscess and fistula are located.

I have recently been placed on treatment for the tubercular left epidymo-orchitis with Isoniazid 300 mgm, Rifampin 600 mgm, and Ethambutal 1200 mgm daily.  A year of treatment is planned.  Abscess cultures are pending.  I am totally asymptomatic except for a mass in my left scrotum and a small amount of clear liquid drainage from the fistula.  

My urologist has never seen this type of complication from BCG therapy.  Apparently there is no one in Dallas who has any experience with this complication.  That is why I am turning to you for advice.  

To begin with, my urologist tells me I must forego any further BCG therapy.  I am most reluctant to do this.  If the epididymus became infected could the previous TUIP have set the stage for this complication by allowing retrograde flow of the irrigation fluid into the prostate and thence to the epididymis?  If so, could this source of infection be eliminated by a right epididymectomy and orchiectomy and allow for resumption of BCG?  As noted I have previously undergone a left epididymectomy.

Finally, do you have any suggestions about how to improve the results of the FISH tests?  At this point I face loss of maintenance treatment with BCG irrigations as well as absence of diagnostic quality FISH tests to monitor for recurrent disease.  I would be most grateful for your suggestions.

Very truly yours,

John H. Cottey, M.D.

Dear Dr. Cottey,


You are absolutely correct. The problem can be solved, I believe, with a right epedidymectomy (on your antibiotics).  This will speed your recovery, reduce the amount of time you need to be on TB antibiotics, and allow you to continue on BCG as needed.  This is a recognized complication of BCG therapy, and yes, it is related to reflux down the vas.  The "good" news is that not only are you cancer free, but the infection will reduce the amount of BCG maintenance you need in the future.  When you do return to BCG maintenance, I strongly suggest reduced dose. 
FISH and cytology can be improved by doing a bladder wash at the time of cystoscopy.  We start with a small (20cc) volume of saline and use all the residual urine in the specimen.  We also wash the prostatic urethra, which is at risk for developing CIS in the ducts.
Best regards,
Don Lamm, MD