Epididymitis: Difference between revisions
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==Background==
==Background==
[[File:Gray1144.png|thumb|Scrotal anatomy]]
[[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.]]
*Often confused with testicular torsion
*Often confused with testicular torsion
**Cremasteric reflex intact
**Cremasteric reflex intact in epididymitis
*Sexually active men <35yo:
*Sexually active men <35yo → consider [[Chlamydia|chlamydia]], [[Gonorrhea|gonorrhea]]
**Consider chlamydia, gonorrhea
*Not sexually active, age >35yo, or anal intercourse → also consider E. coli, pseudomonas, enterobacter, TB, [[Syphilis|syphilis]]
*Not sexually active, age >35yo, or anal intercourse:
*Chemical epididymitis
**Also consider E. coli, pseudomonas, enterobacter, TB, syphilis
**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
*[[Dysuria]]
*Pain relieved with elevation of testicle (positive Prehn sign)
*Urinary frequency
*[[Fever]]
*Pain relieved with elevation of testicle (Prehn sign)
**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)
#Urine GC/Chlam (urethral discharge or age <40)
#Ultrasound for equivocal cases
#Older men should be evaluated for urinary retention
#Note that testicular tumors are frequently misdiagnosed as epididymitis


==DDx==
==Evaluation==
{{Template:Testicular DDX}}
===Workup===
[[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.]]
[[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 (+).]]
*[[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]]


==Treatment==
===[[Antibiotics]]===
#Scrotal elevation
{{Epididymitis antibiotics}}
#Analgesia
*If med adherence is an issue:
#Abx
**[[Ceftriaxone]] 250mg IM once '''AND'''
##Sexually transmitted (<40yo):
**Azithromycin 1 g PO once
###[[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: Cipro 500mg BID x 14d OR Ofloxacin 200mg BID x 14d
###IV: Piperacillin/taxobactam 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) or toxic appearance
##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 Torsion]]
*[[Testicular diagnoses]]
*[[Torsion of Testicular Appendages]]
*[[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]]

Revision as of 22:49, 11 November 2020

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

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:

Pediatric Epididymitis[2]

  • 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) or toxic appearance
  • 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. ↑ Richman MN and Bukowski TP. Pediatric Epididymitis: Pathophysiology, Diagnosis, and Management. Infect Urol. 2001;14(2).
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