epididymitis

Introduction

Inflammation/infection of the epididymis.

Etiology

• mechanism
  • inflammation leading to epididymal swelling & induration
  • progression of disease from lower to upper pole
  • tunica vaginalis secretes a serous fluid (inflammatory hydrocele) that becomes purulent
  • spermatic cord thickens
  • testes becomes swollen from passive congestion
• sexually transmitted
  • Chlamydia trachomatis
  • Neisseria gonorrhoeae
  • Ureaplasma urealyticum
  • gram-negative rods including E coli (anal intercourse, homosexual men)
• anatomic anomalies
  • age > 35 years
    • prostatectomy, prostatitis, benign prostatic hypertrophy (BPH)
    • higher voiding pressures may cause reflux
  • children
    • pathologic connections from gastrointestinal or urinary tract
    • usually present early in life
  • etiologic agents
    • Escherichia coli
    • Pseudomonas
• amiodarone

Clinical manifestations

• epididymal swelling & tenderness
• scrotal erythema & edema
  • hydrocele
  • pain & swelling of ipsilateral testis & spermatic cord
  • pain localizes to the superior & posterior ipsilateral testicle
  • pain is subacute
• inguinal pain (Chlamydia)
• fever (up to 104 F)
• urethral discharge:
  • 2 days (Neisseria) to 5 weeks (Chlamydia) after sexual transmission depending upon etiologic agent
• dysuria (30% of patients)
• abdominal pain/tenderness
• massaging prostate may exacerbate epididymitis
• signs & symptoms of concurrent prostatitis
• epididymis difficult to distinguish from testes
• pain relieved by elevating the testicle onto the pubic symphysis (Prehn's sign +)

Laboratory

• complete blood count (CBC)
• urethral smear: gram stain
  • gram-negative intracellular diplococci is evidence of Neisseria gonorrhoeae
  • > WBC/hpf without bacteria suggests non-gonococcal urethritis, generally Chlamydia
• screen men with epididymitis for Chlamydia trachomatis & Neisseria gonorrhoeae
  • Neisseria gonorrhoeae DNA (urine, urethral)
  • Chlamydia trachomatis DNA (urine, urethral)
• culture of urethral discharge
• urinalysis
  • pyruria
  • perform after collection of urethral discharge for smear & culture, since urination may wash out urethra
• urine culture if indicated by urinalysis

Radiology

• voiding cystourethrogram if positive urine culture
• ultrasound of scrotum
  • blood flow to epididymis is normal or increased
  • Doppler (compression of testicular artery at external ring decreases pulse & increases flow to inflamed side
  • only if diagnosis in question (generally a clinical diagnosis)
• radionuclide scanning

Differential diagnosis

• torsion of spermatic cord
  • age group 9-15
  • pain exacerbated by elevating the testicle onto the pubic symphysis (Prehn's sign -)
• torsion of testicular appendage
  • blue discoloration seen on testicle through skin
• varicocele - negative Prehn's sign, no fever, chronic, scrotal mass ('bag of worms') increases with standing, transillumination negative
• incarcerated inguinal hernia
• testicular trauma
• testicular tumor
  • generally painless
  • hemorrhage within tumor may distend tunica albuginea causing pain
• mumps orchitis
• secondary syphilis - 8 to 10 years after initial infection
• tuberculosis epididymitis
  • generally painless
  • little or no fever
  • prostatic induration & thickened ipsilateral seminal vesicle
  • epididymis distinguishable from testes
• Cryptococcus
• Brucella

Management

• general
  • non-steroidal anti-inflammatory agents (NSAIDs)
  • lidocaine local injection (20 cc, 1%) into spermatic cord at pubic tubercle (just above testicle) over external ring
  • sexually transmitted disease
    • treat partners
    • look for other sexually transmitted diseases
• antibiotics
  • empiric
    • ceftriaxone (Rocephin) 250 mg IM single dose plus doxycycline 100 mg BID for 10 days
      • ceftriaxone plus fluoroquinolone in older men & men who engage in anal intercourse (risk of enteric pathogen)
    • levofloxacin for 10 days treatment of choice in men > 35 years of age at low risk for sexually-transmitted disease
  • Neisseria gonorrhoeae
    • ceftriaxone (Rocephin) 250 mg IM
    • ampicillin 500 mg PO QID for 10 days
  • Chlamydia trachomatis
    • doxycycline 100 mg PO BID for 10 days
    • ofloxacin (Floxin) 300 mg PO BID for 10 days
    • erythromycin 500 mg PO QID for 10 days
    • continue treatment beyond 10 days if still symptomatic
  • other bacterial etiologies
    • ciprofloxacin (Cipro) 500 mg PO BID for 10 days
    • Bactrim DS PO BID for 10 days
    • IV aminoglycoside
    • if swelling & pain continue, extend treatment
• patient education
  • avoid sexual activity & physical strain
  • bed rest with scrotal elevation (use towel) for 3-4 days
  • roomy athletic supporter
  • ice in early phase, heat in later phase
• complications
  • testicular atrophy occurs in 2/3 of men with epididymitis, perhaps secondary to thrombosis of testicular artery
  • infertility occurs in 50% of men with bilateral epididymitis
  • abscess 5%
  • infarction 5%
  • chronic epididymitis
• follow-up

More general terms

• male genital disease
• urogenital infection

Additional terms

• benign prostatic hyperplasia (BPH)
• epididymis
• orchitis
• Prehn's sign
• prostadynia (prostatosis)