Epididymitis: Difference between revisions
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==Background==
==Background==
*Often confused with testicular torsion
[[File:Gray1144.png|thumb|Scrotal anatomy]]
**Cremasteric reflex intact
[[File:Epididymis-KDS.jpg|thumb|Adult testicle with epididymis (left is posterior): A. Head of epididymis, B. Body of epididymis, C. Tail of epididymis, and D. Vas deferens.]]
*Sexually active men <35yo:
*Inflammation/infection of the epididymis; due to retrograde ascent of pathogens (usually bacterial), the type of which is associated with age
**Consider chlamydia, gonorrhea
**Sexually active men <35yo → consider STI organisms including [[Chlamydia|chlamydia]], [[Gonorrhea|gonorrhea]]
*Not sexually active, age >35yo, or anal intercourse:
**Not sexually active, age >35yo, or anal intercourse → consider [[E. coli]], [[pseudomonas]], [[enterobacter]], [[TB]], [[Syphilis|syphilis]]
**Also consider E. coli, pseudomonas, enterobacter, TB, syphilis
*Progression of epididymitis results in epididymo-orchitis, now involving testes; isolated bacterial orchitis is rare
*Often confused with [[testicular torsion]]
**Cremasteric reflex intact in epididymitis, usually absent in torsion
**Epidididymitis typically more gradual onset and has concurrent lower urinary tract complaints
**Torsion rarer with older men
*Chemical epididymitis
**Consider in the patient with [[afib]] and testicular pain
**Testicular pain and swelling in patients on [[Amiodarone|amiodarone]]


==Diagnosis==
==Clinical Features==
*Pain of gradual onset, peaks at 24hr
*Pain of gradual onset, peaks at 24hr
**Dysuria, frequency, fever
**Can radiate to inguinal and lower abdominal areas
*Pain relieved with elevation of testicle (positive Prehn sign)
*[[Dysuria]] or urinary frequency/urgency
*[[Fever]]
*Tenderness of epididymis and/or scrotum, overlying erythema or induration
*Positive Prehn sign: Pain relieved with elevation of testicle
**Sensitivity: 91.3%, specificity: 78.3. Does not rule out testicular torsion


==Work-Up==
==Differential Diagnosis==
#UA
{{Template:Testicular DDX}}
##Pyuria seen in half of cases
 
#Ucx (children, elderly men)
==Evaluation==
#Urine GC/Chlam (urethral discharge or age <40)
===Workup===
#Ultrasound for equivocal cases
[[File:Ultrasonography of epididymitis.jpg|thumb|Doppler ultrasound of epididymitis, seen as a substantial increase in blood flow in the left epididymis (top image), while it is normal in the right (bottom image). The thickness of the epididymis (between yellow crosses) is only slightly increased.]]
#Older men should be evaluated for urinary retention
[[File:PMC5028337 13244 2016 503 Fig17 HTML.png|thumb|Acute epididymo-orchitis. Contrast-enhanced CT (a, b) shows thickened and engorged left spermatic cord, with inhomogeneous vascularisation of the ipsilateral epididymis (thin arrows) and testis (arrows). Ultrasound (c) reveals hypervascularisation of the epididymis (+).]]
#Note that testicular tumors are frequently misdiagnosed as epididymitis
*[[Urinalysis]]
**Pyuria seen in half of cases
*Urine culture (children, elderly men)
*Urine [[GC]]/[[Chlam]] (urethral discharge or age <40)
*Ultrasound for equivocal cases
*Older men should be evaluated for urinary retention
 
===Diagnosis===
*Based on clinical exam or ultrasound
 
==Management==
*Scrotal elevation
*[[Analgesia]]


==DDx==
===[[Antibiotics]]===
{{Template:Testicular DDX}}
{{Epididymitis antibiotics}}


==Treatment==
*If med adherence is an issue <ref>CDC 2022 guidelines</ref>
#Scrotal elevation
**[[Ceftriaxone]] 500mg IM once '''AND'''
#Analgesia
**Azithromycin 1 g PO once
#Abx
##Sexually transmitted (<40yo):
###[[Ceftriaxone]] 250mg IM x1 for [[GC]] AND:
###[[Doxycycline]] 100 mg BID x10d for [[chlamydia]]
##Men > 40yrs old, History of anal intercourse or non-sexually active:
###PO: [[Ciprofloxacin]] 500mg BID x 14d OR [[ofloxacin]] 200mg BID x 14d
###IV: [[Piperacillin/Tazobactam]] 3.375g IV q6 or [[Ampicillin/Sulbactam]] 3g IV q6


''Treat sexual partner if possible''
===Pediatric Epididymitis<ref>Richman MN and Bukowski TP. Pediatric Epididymitis: Pathophysiology, Diagnosis, and Management. Infect Urol. 2001;14(2).</ref>===
*Rule out testicular torsion
*Bed rest to ensure lymphatic drainage
*Ice packs, acetaminophen, ibuprofen
*Rarely oral narcotics
*Pediatric urology follow up outpatient in non-toxic child for possible GU anatomical abnormalities
*Antibiotics for 10-14 days, with urine culture sent:
**[[Trimethroprim-sulfamethoxazole]]
**[[Amoxicillin-clavulanate]]
**Coverage for chlamydia and [[N. gonorrhoeae]] in suspected cases of sexual transmission
**Avoid fluoroquinolones in pediatric patients
**Severely ill or septic children:
***First generation [[cephalosporin]] '''AND''' [[Aminoglycoside]]


==Disposition==
==Disposition==
#Admit for:
*Admit for systemic signs (fever, chills, nausea/vomiting), septic or toxic appearance, epididymal or testicular abscess formation, failure of outpt ABX
##Systemic signs of toxicity (fever, chills, N/V)
*Discharge with urology follow-up in 1 week if non-toxic
#D/c w/ urology f/u in 1wk if non toxic


==See Also==
==See Also==
*[[Testicular Pain]]
*[[Testicular diagnoses]]
*[[Traumatic Epididymitis]]
*[[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
==References==
<References/>


[[Category:GU]]
[[Category:Urology]]
[[Category:ID]]
[[Category:ID]]

Latest revision as of 18:03, 15 June 2024

Background

Scrotal anatomy
Adult testicle with epididymis (left is posterior): A. Head of epididymis, B. Body of epididymis, C. Tail of epididymis, and D. Vas deferens.
  • Inflammation/infection of the epididymis; due to retrograde ascent of pathogens (usually bacterial), the type of which is associated with age
  • Progression of epididymitis results in epididymo-orchitis, now involving testes; isolated bacterial orchitis is rare
  • Often confused with testicular torsion
    • Cremasteric reflex intact in epididymitis, usually absent in torsion
    • Epidididymitis typically more gradual onset and has concurrent lower urinary tract complaints
    • Torsion rarer with older men
  • Chemical epididymitis
    • Consider in the patient with afib and testicular pain
    • Testicular pain and swelling in patients on amiodarone

Clinical Features

  • Pain of gradual onset, peaks at 24hr
    • Can radiate to inguinal and lower abdominal areas
  • Dysuria or urinary frequency/urgency
  • Fever
  • Tenderness of epididymis and/or scrotum, overlying erythema or induration
  • Positive Prehn sign: Pain relieved with elevation of testicle
    • Sensitivity: 91.3%, specificity: 78.3. Does not rule out testicular torsion

Differential Diagnosis

Testicular Diagnoses

Evaluation

Workup

Doppler ultrasound of epididymitis, seen as a substantial increase in blood flow in the left epididymis (top image), while it is normal in the right (bottom image). The thickness of the epididymis (between yellow crosses) is only slightly increased.
Acute epididymo-orchitis. Contrast-enhanced CT (a, b) shows thickened and engorged left spermatic cord, with inhomogeneous vascularisation of the ipsilateral epididymis (thin arrows) and testis (arrows). Ultrasound (c) reveals hypervascularisation of the epididymis (+).
  • Urinalysis
    • Pyuria seen in half of cases
  • Urine culture (children, elderly men)
  • Urine GC/Chlam (urethral discharge or age <40)
  • Ultrasound for equivocal cases
  • Older men should be evaluated for urinary retention

Diagnosis

  • Based on clinical exam or ultrasound

Management

Antibiotics

  • For acute epididymitis likely caused by STI [1]
  • For acute epididymitis most likely caused by STI and enteric organisms (MSM)
  • For acute epididymitis most likely caused by enteric organisms

For persons weighing ≥150 kg, 1 g of ceftriaxone should be administered.

  • If med adherence is an issue [2]

Pediatric Epididymitis[3]

  • Rule out testicular torsion
  • Bed rest to ensure lymphatic drainage
  • Ice packs, acetaminophen, ibuprofen
  • Rarely oral narcotics
  • Pediatric urology follow up outpatient in non-toxic child for possible GU anatomical abnormalities
  • Antibiotics for 10-14 days, with urine culture sent:

Disposition

  • Admit for systemic signs (fever, chills, nausea/vomiting), septic or toxic appearance, epididymal or testicular abscess formation, failure of outpt ABX
  • Discharge with urology follow-up in 1 week if non-toxic

See Also

References

  1. ↑ https://www.cdc.gov/std/treatment-guidelines/epididymitis.htm
  2. ↑ CDC 2022 guidelines
  3. ↑ Richman MN and Bukowski TP. Pediatric Epididymitis: Pathophysiology, Diagnosis, and Management. Infect Urol. 2001;14(2).
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