Epididymitis
Background
- 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
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 r/o testicular torsion
Differential Diagnosis
Testicular Diagnoses
- Scrotal cellulitis
- Epididymitis
- Fournier gangrene
- Hematocele
- Hydrocele
- 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
Diagnosis
- 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
Treatment
- Scrotal elevation
- Analgesia
Antibiotics
- For acute epididymitis likely caused by STI [1]
- 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 compliance an issue:
- Ceftriaxone 250 mg IM once
- PLUS azithromycin 1 g PO once
Disposition
- Admit for:
- Systemic signs of toxicity (fever, chills, N/V)
- Discharge with urology follow-up in 1 week if non-toxic