Epididymitis

Background

• Often confused with testicular torsion
  • Cremasteric reflex intact
• Sexually active men <35yo:
  • Consider chlamydia, gonorrhea
• Not sexually active, age >35yo, or anal intercourse:
  • Also consider E. coli, pseudomonas, enterobacter, TB, syphilis

Diagnosis

• Pain of gradual onset, peaks at 24hr
  • Dysuria, frequency, fever
• Pain relieved with elevation of testicle (positive Prehn sign)

Work-Up

• UA
  • Pyuria seen in half of cases
• Ucx (children, elderly men)
• Urine GC/Chlam (urethral discharge or age <40)
• Ultrasound for equivocal cases
• Older men should be evaluated for urinary retention

Differential Diagnosis

Testicular Diagnoses

• Scrotal cellulitis
• Epididymitis
• Fournier gangrene
• Hematocele
• Hydrocele
  • Hydrocele (peds)
• Indirect inguinal hernia
• Inguinal lymph node (Lymphadenitis)
• Orchitis
• Scrotal abscess
• Spermatocele
• Tinea cruris
• Testicular rupture
• Testicular torsion
• Testicular trauma
• Testicular tumor
• Torsion of testicular appendage
• Varicocele
• Pyocele
• Testicular malignancy
• Scrotal wall hematoma

Treatment

1. Scrotal elevation
2. Analgesia
3. Antibiotics
   1. Sexually transmitted (<40yo):
      1. Ceftriaxone 250mg IM x1 for GC, AND
      2. Doxycycline 100 mg BID x10d for chlamydia
   2. Men > 40yrs old, History of anal intercourse or non-sexually active:
      1. PO: Ciprofloxacin 500mg BID x 14d OR ofloxacin 200mg BID x 14d
      2. IV: Piperacillin/Tazobactam 3.375g IV q6 or Ampicillin/Sulbactam 3g IV q6

Treat sexual partner if possible

Disposition

• Admit for:
  • Systemic signs of toxicity (fever, chills, N/V)
• Discharge with urology follow-up in 1 week if non-toxic

See Also

• Testicular Diagnoses
• Traumatic Epididymitis

Source

• Anatomical Approach to Scrotal Emergencies: A New Paradigm for the Diagnosis and Treatment of the Acute Scrotum. The Internet Journal of Urology 2010 : Volume 6 Number 2. Sardar Ali. Khan
• CDC Guidelines http://www.cdc.gov/std/treatment/2010/epididymitis.htm