Epididymitis

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.

• Often confused with testicular torsion
  • Cremasteric reflex intact in epididymitis
• Sexually active men <35yo → consider chlamydia, gonorrhea
• Not sexually active, age >35yo, or anal intercourse → also consider E. coli, pseudomonas, enterobacter, TB, syphilis
• 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
• Dysuria
• Urinary frequency
• Fever
• Pain relieved with elevation of testicle (Prehn sign)
  • Sensitivity: 91.3%, specificity: 78.3. Does not rule out testicular torsion

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

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

• Scrotal elevation
• Analgesia

Antibiotics

• For acute epididymitis likely caused by STI
  • Ceftriaxone 500 mg IM in a single dose PLUS
  • Doxycycline 100 mg orally twice a day for 10 days

• For acute epididymitis most likely caused by STI and enteric organisms (MSM)
  • Ceftriaxone 500 mg IM in a single dose PLUS
  • Levofloxacin 500 mg orally once a day for 10 days

• For acute epididymitis most likely caused by enteric organisms
  • Levofloxacin 500 mg orally once daily for 10 days

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

• If med adherence is an issue:
  • Ceftriaxone 250mg IM once AND
  • Azithromycin 1 g PO once

Pediatric Epididymitis

• 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

• Admit for systemic signs (fever, chills, nausea/vomiting) or toxic appearance
• Discharge with urology follow-up in 1 week if non-toxic

See Also

• Testicular diagnoses
• Traumatic epididymitis