Epididymitis
Cheryl A. Glass
Definition
Epididymitis is acute infection of the epididymis, the coiled segment of the spermatic duct that connects the efferent duct from the posterior aspect of the testicle to the vas deferens. Epididymitis is commonly found to develop during strenuous exertion in conjunction with a full bladder. Testicular torsion should be considered in all cases—this is a surgical emergency.
A.Acute epididymitis lasts less than 6 weeks duration of symptoms:
1.Acute epididymitis often involves the testis (epididymo-orchitis).
B.Chronic epididymitis lasts more than 6 weeks duration of symptoms:
1.Inflammation chronic.
2.Obstructive chronic.
3.Chronic epididymalgia.
Incidence
A.Epididymitis is the fifth most common urologic diagnosis in men aged 18 to 50 years. There are approximately 600,000 medical visits per year related to epididymitis. An estimated 1 in 1,000 men develops epididymitis annually. Chronic epididymitis may account for up to 80% of scrotal pain noted in the outpatient setting.
Pathogenesis
A.The exact pathophysiology is unclear. The cause may be the retrograde passage of infected urine from the prostatic urethra to the epididymis from the ejaculatory ducts and vas deferens. Reflux may be induced by having the patient perform Valsalva or may be from strenuous exertion. Pathogens include Chlamydia trachomatis, Neisseria gonorrhea, Escherichia coli, Proteus species, Klebsiella species, Pseudomonas, Mycoplasma species, and Treponema pallidum.
Predisposing Factors
A.Age:
1.Age younger than 35 years is generally associated with urethritis with the following organisms:
a.C. trachomatis (chlamydia).
b.N. gonorrhoeae (gonorrhea).
2.Benign prostatic hyperplasia (BPH) is more common for men older than 35 years and common organisms include the following:
a.Escherichia coli.
b.Pseudomonas species.
c.Proteus species.
d.Klebsiella species.
3.The older population of men usually has nonsexual epididymitis related to urinary tract instrumentation, surgery, and immunosuppression.
B.Men having sex with men (MSM) who are the insertive partner during anal intercourse have epididymitis with the following organisms:
1.E. coli.
2.Pseudomonas.
3.Coliform bacteria.
C.Urinary tract infections (UTIs).
D.Tuberculosis (TB; should be considered if there is a history of or recent exposure to).
E.Vasectomy.
F.Indwelling urethral catheter.
G.Urethral stricture.
H.Amiodarone—high drug concentrations (dosedependent).
I.Prolonged sitting (sedentary job, travel).
J.Mumps.
Common Complaints
A.Swelling and tenderness of the scrotum (usually located on one side).
B.Fever.
C.Chronic epididymitis:
1.Epididymal pain and inflammation that last more than 6 weeks.
2.May be accompanied by scrotal induration.
Other Signs and Symptoms
A.Gradual onset of localized, unilateral testicular pain. The patient may get relief with elevation of the scrotum, which is a positive Prehn’s sign.
B.Urethral discharge.
C.Dysuria.
D.Hematuria.
E.Fever and chills (in only 25% of adults with acute epididymitis).
Subjective Data
A.Elicit the onset, duration, and course of the patient’s symptoms.
B.Review the patient’s history for vasectomy or trauma to the groin.
C.Are there any other symptoms, including fever, dysuria, or discharge?
D.What helps relieve the pain? Ask about elevating the scrotum.
E.Does the patient’s sexual partner(s) have any symptoms or discharge?
F.Has there been any recent instrumentation or catheterization?
G.Is the pain unilateral or bilateral?
H.Review medication history for amiodarone.
I.Does the patient have a recent TB exposure?
Physical Examination
A.Check temperature, blood pressure (BP), and pulse.
B.Inspection:
1.Examine the patient generally for discomfort before and during examination.
2.Check the urethral meatus for discharge. Retract foreskin (if present) and assess for hygiene and smegma. Check the shaft of the penis, glans, and prepuce for lesions.
3.Check the inguinal and femoral areas for bulges and hernias; have the patient bear down and cough, and reexamine him.
C.Palpate:
1.Palpate testes and epididymides for inflammation, tenderness, and masses. In chronic cases, epididymis feels firm and lumpy. Vas deferens may be beaded.
2.Check Prehn’s sign by elevating the affected hemiscrotum. This action relieves the pain of epididymitis but exacerbates the pain of torsion.
3.Elicit a cremasteric reflex. Stroking the inner thigh should result in rise of the testicle and scrotum on the affected side. A normal cremasteric reflex indicates that testicular torsion is less likely.
4.Palpate scrotum for hydrocele or varicocele.
5.Check for costovertebral angle (CVA) tenderness.
6.Examine the abdomen for masses, urinary distension, tenderness, and organomegaly.
7.Palpate lymph nodes in the groin.
8.Evaluate for an inguinal hernia.
D.Rectal exam: Check for symmetry, swelling, tenderness, and enlarged prostate.
Diagnostic Tests
A.Gram stain of urethral secretions.
B.Urinalysis and urine cultures:
1.Positive leukocyte esterase test (LET) on first-void urine.
2.Microscopic examination of sediment from a spunfirst void urine demonstrating >10 white blood cells (WBC) per high-power field.
3.Urine testing for gonorrhea and chlamydia culture by nucleic acid amplification tests (NAATs).
C.Urethra swab (before void, after prostate massage) for gonorrhea and chlamydia culture.
D.In patients older than 40, express prostatic secretions.
E.TB skin test to rule out TB.
F.Complete blood count (CBC).
Differential Diagnoses
A.Epididymitis:
1.Bacterial.
2.Viral epididymo-orchitis (mumps and Haemophilus influenzae).
B.Testicular torsion (surgical emergency).
C.Testicular tumor.
D.Prostatitis.
E.Incarcerated inguinal hernia.
F.Orchitis (occurs with parotitis).
G.Trauma.
H.Vasectomy side effect.
I.Folliculitis.
J.Herpes outbreak.
Plan
A.General interventions:
1.Encourage and stress the importance of adequate fluid intake.
2.Stress the importance of taking all antibiotics as directed. Complete resolution of discomfort might not occur until a few weeks after completion of the antibiotic regimen.
B.
See Section III: Patient Teaching Guide Epipdymitis.
C.Pharmaceutical therapy:
1.Antibiotic therapy (both partners must be treated for a STI). Treat empirically until laboratory test results are available.
2.Acute epididymitis should be treated for 10 days (see Table 15.2).
3.Chronic epididymitis should be treated for 4 to 6 weeks for bacterial pathogens, especially chlamydia.
4.Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management.
5.Antitubercular treatment per CDC guidelines. www.cdc.gov/tb/topic/treatment/tbdisease.htm
6.Amiodarone epididymitis usually responds to a dosage reduction or discontinuation.
Follow-Up
A.See the patient within 72 hours of initiation of treatment if the symptoms fail to improve. Signs and symptoms of epididymitis that do not subside within 3 days require reevaluation of the diagnosis and therapy.
1.Pain typically improves within 1 to 3 days but may take up to 2 to 4 weeks.
2.Inadequate treatment can result in abscess formation and decreased fertility.
3.Men who experience swelling and tenderness that persists after completion of antimicrobial therapy should be evaluated for alternative diagnoses, including tumor, abscess, infarction, testicular cancer, tuberculosis, and fungal epididymitis.
B.Culture urine at the end of treatment (test of cure).
C.Treat both partners for sexually transmitted infections (STIs); test for all STIs and do not just focus on chlamydia and gonorrhea.
TABLE 15.2 The 2015 CDC Recommendation Regimens for Acute Epididymitis
CDC, Centers for Disease Control and Prevention; IM, intramuscular.
Source: From Centers for Disease Control and Prevention. (2015). 2015 sexually transmitted diseases treatment guidelines: Epididymitis. Retrieved from https://www.cdc.gov/std/tg2015/epididymitis.htm
D.Consider testing for HIV.
E.Tuberculous epididymitis should be suspected if clinical signs worsen despite appropriate antibiotic therapy.
F.Men older than 50 years should be evaluated for urethral obstruction secondary to prostatic enlargement.
G.Men with HIV who have uncomplicated acute epididymitis should receive the same treatment regimen as those who are HIV negative. Acute epididymitis in men with HIV infections may have other etiologies including cytomegalovirus (CMV), salmonella, toxoplasmosis, Ureaplasma urealyticum, Corynebacterium sp., Mycoplasma sp., and Mima polymorpha. Fungi and mycobacteria also are more likely to cause acute epididymitis in men with HIV infection than in those who are immunocompetent.
Emergent Issues/Instructions
A.Obtain an immediate consultation with a urologist if testicular torsion, scrotal abscess, or failed medical treatment is suspected.
Consultation/Referral
A.Consult a physician for the following:
1.Intravenous pyelography (IVP).
2.Doppler ultrasonography.
3.Scrotal ultrasonography.
4.Radionuclide scrotal imaging.
Individual Considerations
A.Partner:
1.Treat sexual partners for STI.
2.Consider testing for HIV.
B.Geriatrics:
1.Pharmacologic caution in geriatrics:
a.Fluoroquinolone use in the elderly has the potential to cause neuropsychiatric symptoms, including seizures to worsening dementia.