Basics
Description
Epididymitis
- Definition: Inflammation or infection of the epididymis
- Rare in prepubertal boys
- Pathogenesis:
- Initial stages:
- Cellular inflammation begins in vas deferens, descends to epididymis
- Acute phase:
- Epididymis is swollen and indurated in upper and lower poles.
- Spermatic cord thickened
- Testis may become edematous owing to passive congestion or inflammation.
- Resolution:
- May be complete without sequelae
- Peritubular fibrosis may develop, occluding ductules.
- Complications:
- 2/3 of men have atrophy due to partial vascular thrombosis of testicular artery.
- Abscess and infarction rare (5%)
- Incidence of infertility with unilateral epididymitis unknown:
- 50% with bilateral epididymitis
Orchitis
- Definition: Inflammation or infection of the testicle:
- Usually from direct extension of the same process within the epididymis
- Isolated testicular infection is rare:
- Can result from hematogenous spread of bacteria or following mumps infection
- Categories:
- Pyogenic bacterial orchitis secondary to bacterial involvement of epididymis
- Viral orchitis:
- Most commonly due to mumps
- Rare in prepubertal boys; occurs in 20-30% of postpubertal boys with mumps.
- Occurs 4-6 days after parotitis but can occur without parotitis.
- Unilateral in 70% of patients
- Usually resolution in 6-10 days
- 30-50% of testes involved have residual atrophy; rarely affects fertility
- Granulomatous orchitis:
- Syphilis
- Mycobacterium and fungal diseases
- Usually occurs in immunocompromised host
Etiology
Epididymitis
- Children:
- Most common in children <1 yr or between the ages of 12-15 yr
- Etiology identified in only 25% of prepubertal boys
- Coliform or pseudomonal UTI
- Sexually transmitted diseases rare in prepubertal males
- Associated with predisposing abnormalities of lower urinary tract
- Young men, age <35 yr:
- Usually sexually transmitted
- Chlamydia trachomatis (28-88%) with severe inflammation with minimal destruction
- Neisseria gonorrhea (3-28%)
- Coliform bacteria (7-24%):
- Highly destructive with tendency for abscess
- Coliform bacteria more common in insertive partners in anal intercourse
- Ureaplasma urealyticum (sole organism in only 6% of cases)
- Older men, age >35 yr:
- Commonly associated with underlying urologic pathology (benign prostatic hypertrophy, prostate cancer, strictures)
- May have acute or chronic bacterial prostatitis
- Coliform bacteria more common (23-67%), especially after instrumentation
- C. trachomatis (8-80%)
- Klebsiella and Pseudomonas species
- N. gonorrhea (15%)
- Gram-positive cocci
- Drug related:
- Amiodarone-induced epididymitis:
- Usually with amiodarone levels > therapeutic levels
- Granulomatous:
- Etiology maybe related to mycobacterial, syphilis, or fungal infections:
- Mycobacterium tuberculosis is the most common cause of granulomatous disease affecting the epididymis
- Suspect in HIV patients
- Urine cultures often negative for M. tuberculosis
- Vasculitis:
- Polyarteritis nodosa
- Beh §et disease
- Henoch-Sch ¶nlein purpura
Orchitis
- Pyogenic bacterial orchitis:
- Escherichia coli
- Klebsiella pneumoniae
- Pseudomonas aeruginosa
- Staphylococci
- Streptococci
- Viral orchitis:
- Mumps:
- 20% may develop epididymo-orchitis.
- Rarely associated with live-attenuated mumps vaccine
- Coxsackie A and lymphocytic choriomeningitis virus
- Granulomatous orchitis: Syphilis, mycobacterial and fungal diseases:
- Fungal orchitis:
- Blastomycosis in endemic regions
- Invasive candidal infections in immunosuppressed hosts
- Post-traumatic orchitis: Inflammation
Diagnosis
Signs and Symptoms
History
- Gradual onset of mild to moderate testicular or scrotal pain, usually unilateral
- Progressive scrotal swelling
- Dysuria (30%):
- Recent UTI
- History of abnormal bladder function
- Urethral discharge:
- Of patients with gonococcal epididymitis, 21-30% did not complain of urethral discharge.
- No demonstrable urethral discharge in 50%
- Fever (14-28%)
- Recent urethral instrumentation or catheterization
Physical Exam
- Tenderness in groin, lower abdomen, or scrotum
- Scrotal skin commonly erythematous and warm
- Early:
- May feel swollen, indurated epididymis
- Later:
- May not be able to distinguish epididymis from testis
- Spermatic cord may be edematous.
- Intact cremasteric reflex
- Prehn sign:
- Pain relief with testicular elevation
- Commonly observed but not specific
- Coexistent prostatitis is rare (8%).
- Pyogenic bacterial orchitis:
- Patients usually are acutely ill.
- Fever
- Intense discomfort, swelling of testicle
- Often reactive hydrocele
Essential Workup
- Must differentiate from testicular torsion
- Early consultation with urologist if strong suspicion of testicular torsion
Diagnosis Tests & Interpretation
Lab
- CBC:
- Often leukocytosis in the range of 10,000-30,000/mm3
- Urinalysis and culture:
- Positive leukocyte esterase on first-void urine or >10 WBC per high-power field on first-void urine sediment
- 15-50% of patients with epididymo-orchitis have pyuria.
- 24% of patients have positive urine bacterial cultures.
- Urethral swab (50-73% have demonstrable urethritis despite minority of symptoms)
- Gram stain and culture or DNA amplification for C. trachomatis/N. gonorrhea
- Avoid bladder emptying within 2 hr of tests (lowers sensitivity).
- Especially for postpubertal and sexually active
- Blood culture if systemically ill
Imaging
- US: Color Doppler imaging:
- 82-100% sensitivity, 100% specificity in detecting testicular torsion or decreased blood flow
- Epididymo-orchitis:
- Hyperemia
- Increased vascularity and blood flow
- Advantages:
- Can evaluate for epididymitis or other causes of scrotal pain
- 70% sensitivity, 88% specificity for epididymitis
- Disadvantages:
- Highly examiner dependent
- Difficult in infants or children
- Testicular scintigraphy:
- Radionuclide study to assess perfusion
- 90-100% sensitivity, 89-97% specificity in detecting testicular torsion
- Inflammatory processes have increased flow and uptake.
- Not routinely available at many institutions
Diagnostic Procedures/Surgery
Surgical exploration indications:
- Scrotal abscess
- If torsion cannot be excluded
- Suspected or proved ischemia caused by severe epididymitis
- Patient with solitary testicle
- Scrotal fixation: Indicates severe inflammation and potential suppuration
Differential Diagnosis
- Testicular torsion
- Testicular tumor
- Torsion of testicular appendages
- Trauma to scrotum
- Acute hernia
- Acute hydrocele
Treatment
Pre-Hospital
- IV access
- IV fluids, especially if systemically ill
Initial Stabilization/Therapy
- IV access
- IV fluids, especially if systemically ill
Ed Treatment/Procedures
- Antibiotics:
- Cover for chlamydial and gonococcal etiologies if adult or presumed sexually transmitted
- Cover for coliform etiology:
- Child, or adult >35 yr of age
- Insertive partner in anal intercourse
- Presumed nonsexually transmitted
- Bed rest, scrotal support, ice packs
- Analgesics and anti-inflammatories
Medication
- Age <35 yr or sexually active postpubertal males:
- Ceftriaxone 250 mg IM once + doxycycline 100 mg PO BID for 10 days:
- May substitute azithromycin 1 g PO once for doxycycline if tetracycline allergy
- Quinolones no longer recommended if suspect N. gonorrhea
- Age >35 yr or insertive partners in anal intercourse or negative culture/DNA amplification for C. trachomatis/N. gonorrhea or allergy to cephalosporins/tetracyclines:
- Ofloxacin 300 mg PO BID or levofloxacin 500 mg/d PO for 10 days
- Bacterial epididymitis is uncommon in prepubertal boys and antibiotic regimens are not well established.
- If concurrent UTI:
- TMP-SMX: 4 mg/kg TMP and 20 mg/kg SMX BID for 10 days
- Avoid quinolones and tetracyclines in children
Follow-Up
Disposition
Admission Criteria
- Surgical indications present
- Older age group if it is the only way to ensure appropriate workup:
- Many will have underlying urologic pathology.
- Systemically ill, fever, nausea, vomiting
- Scrotal abscess
- Intractable pain
Discharge Criteria
- Fails to meet admission criteria
- Patient with good follow-up
- Able to take oral antibiotics
Issues for Referral
- Children need workup for urologic abnormalities:
- Voiding cystourethrography, renal US
- If bacteriuria present, exam of lower tract with cystoscopy after treatment completed
Follow-Up Recommendations
- Failure to improve within 3 days of commencing antibiotics warrants urologic evaluation.
- Persistence of symptoms after full antibiotic course warrants search for other causes of epididymitis:
- TB or fungal epididymitis, scrotal abscess, tumor, infarction.
- Sexual partners of patients with suspected or confirmed C. trachomatis/N. gonorrhea should be tested/treated.
- Children need urology consult for evaluation of structural urogenital abnormalities.
Pearls and Pitfalls
- Testicular torsion should be ruled out in all cases of new-onset testicular pain.
- Epididymitis usually due to STD in sexually active men <35 yr
- Epididymitis usually due to coliform bacteria in men >35 yr
- Antibiotic treatment is started immediately and empirically based on clinical picture.
Additional Reading
- Brenner JS, Ojo A. Causes of scrotal pain in children and adolescents. UpToDate. Available at www.uptodate.com. Accessed on January 30, 2013.
- Ching CB, Sabanegh ES. Epididymitis. eMedicine. Available at emedicine.medscape.com/article/436154-overview. Accessed on January 30, 2013.
- Tekg ¼l S, Riedmiller H, Gerharz E, et al. European Societyfor Paediatric Urology and European Association of Urology. Guidelines on paediatric urology. Available at http://www.uroweb.org/gls/pdf/19_Paediatric_Urology.pdf.
- Tracy CR, Steers WD, Costabile R. Diagnosis and management of epididymitis. Urol Clin North Am. 2008;35(1):101-108.
- Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-110.
See Also (Topic, Algorithm, Electronic Media Element)
- Gonococcal Disease
- Prostatitis
- Testicular Torsion
- Urethritis
Codes
ICD9
- 604.90 Orchitis and epididymitis, unspecified
- 604.91 Orchitis and epididymitis in diseases classified elsewhere
- 604.99 Other orchitis, epididymitis, and epididymo-orchitis, without mention of abscess
- 604.0 Orchitis, epididymitis, and epididymo-orchitis, with abscess
- 072.0 Mumps orchitis
- 604.9 Other orchitis, epididymitis, and epididymo-orchitis, without mention of abscess
- 604 Orchitis and epididymitis
ICD10
- N45.1 Epididymitis
- N45.2 Orchitis
- N45.3 Epididymo-orchitis
- N45.4 Abscess of epididymis or testis
- B26.0 Mumps orchitis
- N45 Orchitis and epididymitis
SNOMED
- 31070006 Epididymitis (disorder)
- 274718005 Orchitis (disorder)
- 197983000 Orchitis and epididymitis (disorder)
- 27141002 Epididymo-orchitis with abscess (disorder)
- 236766009 Gonococcal epididymitis (disorder)
- 236771002 Mumps epididymo-orchitis (disorder)
- 43491000 Acute epididymitis
- 45082006 Acute orchitis (disorder)
- 50390006 Non-specific granulomatous orchitis (disorder)