para>In prepubertal boys: Epididymitis is found to be the most common cause of acute scrotum-more common than testicular torsion.
Incidence
- Common (600,000 cases annually in the United States) (1)
- 1 in 1,000 males per year
Prevalence
Common
ETIOLOGY AND PATHOPHYSIOLOGY
- Infectious epididymitis
- Retrograde passage of urine or urinary bacteria from the prostate or urethra to the epididymis via the ejaculatory ducts and the vas deferens; rarely, hematogenous spread
- Causative organism is identified in 80% of patients and varies according to patient age.
- Sterile epididymitis
- Chemical epididymitis occurs when sterile urine flows backward from the urethra to the epididymis
- Can develop as a sequelae of strenuous exercise with a full bladder when urine is pushed through internal urethral sphincter (located at proximal end of prostatic urethra)
- Reflux of urine through orifice of ejaculatory ducts at verumontanum may occur with history of urethritis/prostatitis, as inflammation may produce rigidity in musculature surrounding orifice to ejaculatory ducts, holding them open.
- Exposure of epididymis to foreign fluid may produce inflammatory reaction within 24 hours.
- <35 years and sexually active
- Usually Chlamydia trachomatis or Neisseria gonorrhoeae
- Look for serous urethral discharge (chlamydia) or purulent discharge (gonorrhea)
- With anal intercourse, likely Escherichia coli or Haemophilus influenzae
- >35 years
- Coliform bacteria usually, but sometimes Staphylococcus aureus or Staphylococcus epidermidis
- In elderly men, often with distal urinary tract obstruction, benign prostatic hyperplasia (BPH), UTI, or catheterization
- Tuberculosis (TB), if sterile pyuria, nodularity of vas deferens (hematogenous spread), and recent infection. TB is the most common granulomatous disease affecting the epididymitis (2).
- Sterile urine reflux after transurethral prostatectomy
- Granulomatous reaction following BCG intravesical therapy for bladder cancer
- Prepubertal boys
- Usually coliform bacteria
- Evaluate for underlying congenital abnormalities, such as vesicoureteral reflux, ectopic ureter, or anorectal malformation (rectourethral fistula).
- Amiodarone may cause noninfectious epididymitis; resolves with decreasing drug dosage.
- Syphilis, blastomycosis, coccidioidomycosis, and cryptococcosis are rare causes, but brucellosis can be a common cause in endemic areas.
RISK FACTORS
- UTI
- Prostatitis
- Indwelling urethral catheter
- Urethral instrumentation or transurethral surgery
- Urethral or meatal stricture
- Transrectal prostate biopsy
- Prostate brachytherapy (seeds) for prostate cancer
- Anal intercourse
- High-risk sexual activity
- Strenuous physical activity
- Prolonged sedentary periods
- Bladder obstruction (benign prostatic hyperplasia, prostate cancer)
- HIV-immunosuppressed patient
- Severe Beh §et disease
- Presence of foreskin
- Constipation
- Sterile epididymitis
- Increased intra-abdominal pressure (due to frequent physical strain)
- Military recruits, especially who begin physically unprepared.
- Laborers; restaurant kitchen workers
- Full bladder during intense physical exertion
GENERAL PREVENTION
- Vasectomy or vasoligation during transurethral surgery
- Safer sexual practices
- Mumps vaccination
- Antibiotic prophylaxis for urethral manipulation
- Early treatment of prostatitis/BPH
- Avoid vigorous rectal exam with acute prostatitis.
- Emptying the bladder prior to physical exertion
- Physically conditioning the body prior to engaging in regular intense physical exertion
- Treat constipation.
COMMONLY ASSOCIATED CONDITIONS
- Prostatitis/urethritis/orchitis
- Hemospermia
- Constipation
- UTI
DIAGNOSIS
- Scrotal pain, sometimes radiating to the groin region, may begin acutely over several hours.
- Urethral discharge or symptoms of UTI, such as frequency of urination, dysuria, cloudy urine, or hematuria
- Initially, only the posterior-lying epididymis, usually the lowermost tail section, is very tender and indurated; will eventually progress to involvement of body and head of epididymis
- Elevation of the testes/epididymis reduces the discomfort (Prehn sign).
- Entire hemiscrotum becomes swollen and red; the testis becomes indistinguishable from the epididymis; the scrotal wall becomes thick and indurated; and reactive hydrocele may occur.
- Sterile epididymitis
- Unilateral scrotal pain and swelling preceded by several hours of intense physical exertion. Patient may recall full bladder prior to exertion.
- No symptoms of infection
Pediatric Considerations
In prepubertal patients, may be postinfectious inflammatory condition; treat with anti-inflammatories, analgesics.
Antibiotic therapy can be reserved for young infants and those with pyuria or positive urine cultures (3).
Bacteremia from H. influenzae infection may produce acute epididymitis.
In adolescent males, particularly age >13 years, must rule out testicular torsion.
History not helpful in distinguishing epididymitis from testicular torsion
Geriatric Considerations
Diabetics with sensory neuropathy may have no pain despite severe infection/abscess.
PHYSICAL EXAM
- The tail of the epididymis is larger in comparison with the contralateral side.
- Epididymis is markedly tender to palpation.
- Absence of a cremasteric reflex should raise suspicion for testicular torsion.
DIFFERENTIAL DIAGNOSIS
- Epididymal congestion following vasectomy
- Testicular torsion
- Torsion of testicular appendages
- Orchitis
- Testicular malignancy
- Testicular trauma
- Epididymal cyst
- Inguinal hernia
- Urethritis
- Spermatocele
- Hydrocele
- Hematocele
- Varicocele
- Epididymal adenomatoid tumor
- Epididymal rhabdomyosarcoma
- Vasculitis (Henoch-Sch ¶nlein purpura)
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
- All suspected cases should be evaluated for objective evidence of inflammation by one of the following:
- Urinalysis preferably on first-void urine to evaluate for positive leukocyte esterase
- Gram stain urethral discharge. ≥2 WBC per oil immersion field. Also for evaluation of presence or absence of gonococcal infection
- Microscopic examination of sediment from a spun first-void urine with ≥10 WBC per high power field.
- Urine culture, preferably first-void
- Urine GC/chlamydia testing by NAAT for all suspected cases (2)[A].
- CRP >24 mg/L suggestive of epididymitis (4)[C]
- Urinalysis clear and culture-negative suggest sterile epididymitis.
- If testicular torsion cannot be excluded (especially in children), Doppler ultrasound is test of choice (1).
- In adult men, Doppler ultrasound: sensitivity and specificity of 100% in evaluation of acute scrotum (5)
Pediatric Considerations
Further radiographic imaging in children should be done to rule out anatomic abnormalities.
Diagnostic Procedures/Other
This is a clinical diagnosis.
TREATMENT
GENERAL MEASURES
- Bed rest or restriction on activity
- Athletic scrotal supporter
- Scrotal elevation
- Ice pack wrapped in towel
- Avoid constipation.
- Spermatic cord block with local anesthesia in severe cases
- If chemical epididymitis
- No strenuous physical activity and avoidance of any Valsalva maneuvers for several weeks.
- Empty bladder prior to strenuous exercises
MEDICATION
First Line
- <35 years, or suspected STD etiology: doxycycline 100 mg PO BID for 10 days (C. trachomatis coverage) PLUS ceftriaxone 250 mg IM for 1 (N. gonorrhoeae coverage). Refer sexual partner(s) for evaluation and treatment if contact within 60 days of the onset of symptoms (2)[A].
- ≥35 years, not suspecting STD etiology with suspected enteric organism (i.e., bacteriuria due to bladder outlet obstruction, prostate biopsy, urinary instrumentation, systemic disease, and/or immunosuppression)
- Levofloxacin (Levaquin) 500 mg/day PO for 10 days OR
- Ofloxacin 300 mg PO BID for 10 days (2)[A]
- Men who are at risk for both STD and enteric organism (i.e., men who have sex with men who report insertive anal intercourse): ceftriaxone 250 mg IM for 1 plus fluoroquinolone as above (2)[A].
- Analgesia (infectious and chemical epididymitis)
- NSAIDs (e.g., naproxen or ibuprofen) for mild to moderate pain
- Consider corticosteroid if patient cannot tolerate NSAID.
- Acetaminophen-codeine or acetaminophen-oxycodone for moderate to severe pain
- Septic or toxic patient
- 3rd-generation cephalosporin or aminoglycoside
- For Beh §et, sarcoid, Henoch-Sch ¶nlein purpura
- Corticosteroids, such as methylprednisolone, 40 mg/day recommended
Second Line
- Trimethoprim-sulfamethoxazole (Bactrim, Septra) double-strength PO BID for 10 to 14 days; increasing bacterial resistance may limit effectiveness.
- Add rifampin (rifampicin) or vancomycin, as required.
ISSUES FOR REFERRAL
- If suspicion is high for testicular torsion or cancer, consult a urologist.
- Epididymitis in prepubertal boys requires a urology referral due to high incidence of associated urogenital abnormalities.
- If medical management fails, should be referred to urologist to rule out anatomic abnormality or chemical epididymitis.
SURGERY/OTHER PROCEDURES
- Vasostomy to drain infected material if severe or refractory case
- Scrotal exploration if unable clinically to distinguish between epididymitis and testicular torsion
- Drainage of abscesses, epididymectomy (acute suppurative), or epididymo-orchiectomy in severe cases refractory to antibiotics
- Surgery to correct underlying anatomic abnormality or obstruction
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Intractable pain
- Sepsis
- Abscess
- Persistent vomiting
- Scheduled surgery
- Purulent drainage
- Most cases can be managed with outpatient care
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- Return to office if symptoms fail to improve within 72 hours of treatment for reevaluation of diagnosis and therapy (2).
- In chemical epididymitis, follow up in 4 weeks to assess efficacy of NSAIDs and lifestyle changes.
DIET
If constipation is contributing to pain or chemical epididymitis, then consider constipation prevention and/or treatment.
PATIENT EDUCATION
- Stress completing course of antibiotics, even when asymptomatic
- Early recognition and treatment of UTI or prostatitis
- Safer sexual practices
- If chemical epididymitis, then educate on noninfectious etiology and proper lifestyle changes.
PROGNOSIS
- Pain improves within 1 to 3 days, but induration may take several weeks/months to completely resolve.
- If bilateral involvement, sterility may result.
- In chemical epididymitis, symptoms usually resolve in <1 week.
COMPLICATIONS
- Recurrent epididymitis
- Infertility
- Oligospermia
- Testicular necrosis or atrophy
- Secondary abscess formation
- Fournier gangrene (necrotizing synergistic infection)
REFERENCES
11 Trojian TH, Lishnak TS, Heiman D. Epididymitis and orchitis: an overview. Am Fam Physician. 2009;79(7):583-587.22 Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137.33 Santillanes G, Gausche-Hill M, Lewis RJ. Are antibiotics necessary for pediatric epididymitis? Pediatr Emerg Care. 2011;27(3):174-178.44 Crawford P, Crop JA. Evaluation of scrotal masses. Am Fam Physician. 2014;89(9):723-727.55 Rizvi SA, Ahmad I, Siddiqui MA, et al. Role of color Doppler ultrasonography in evaluation of scrotal swellings: pattern of disease in 120 patients with review of literature. Urol J. 2011;8(1):60-65.
ADDITIONAL READING
- Akinci E, Bodur H, Cevik MA, et al. A complication of brucellosis: epididymoorchitis. Int J Infect Dis. 2006;10(2):171-177.
- Bennett RT, Gill B, Kogan SJ. Epididymitis in children: the circumcision factor? J Urol. 1998;160(5):1842-1844.
- Somekh E, Gorenstein A, Serour F. Acute epididymitis in boys: evidence of a post-infectious etiology. J Urol. 2004;171(1):391-394.
- Tracy CR, Steers WD, Costabile R. Diagnosis and management of epididymitis. Urol Clin North Am. 2008;35(1):101-108; vii.
- Wolin LH. On the etiology of epididymitis. J Urol. 1971;105(4):531-533.
CODES
ICD10
- N45.1 Epididymitis
- N45.3 Epididymo-orchitis
- N45.4 Abscess of epididymis or testis
- N45.2 Orchitis
ICD9
- 604.90 Orchitis and epididymitis, unspecified
- 604.99 Other orchitis, epididymitis, and epididymo-orchitis, without mention of abscess
- 604.91 Orchitis and epididymitis in diseases classified elsewhere
SNOMED
- 31070006 Epididymitis (disorder)
- 43491000 Acute epididymitis
- 236768005 Chronic epididymitis
- 197994001 epididymitis associated with another disorder (disorder)
CLINICAL PEARLS
- With epididymitis, the pain is gradual in onset and the tenderness is mostly posterior to the testis. With testicular torsion, the symptoms are quite rapid in onset, the testis will be higher in the scrotum and may have a transverse lie, and the cremasteric reflex will be absent. The absence of leukocytes on urine analysis and decreased blood flow on scrotal ultrasound with Doppler will suggest torsion.
- Prostatic massage is contraindicated in epididymitis because of the risk for worsening local infection and the potential for sepsis are increased with acute prostatitis.
- Chemical epididymitis is a clinical diagnosis of exclusion, and infectious causes are much more common; but certain occupations, such as soldiers and laborers, must be considered.