Epididymitis - Quick Consult
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Last Updated / Reviewed: June 2022
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Key History
Key Physical Exam
Classification Systems
Risk Factors for Epididymitis
Differential Diagnosis
Diagnostic Testing
Clinical Risk and Safety Pearls
Treatment
Complications
- Gradual onset of pain
- Abdominal or flank pain may precede scrotal pain
- Fever and chills
- Recent endourethral instrumentation
- Recent urinary tract infection
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- Scrotal discomfort or pain
- Scrotal edema
- Urethral discharge
- Urinary frequency, dysuria or urgency
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- Tender edematous epididymis
- Tender enlarged testicle
- Erythematous scrotum
- Swollen scrotum
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- Scrotal fluctuance
- Urethral discharge – 10%
- Fever
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Classified according to the bacteria involved and age of patient (generally):
- Sexually transmitted: usually men < 35 years old: C. trachomatis & N. gonorrhea
- Non-sexually transmitted: usually men > 35 years old: Coliforms
(e.g., E. coli)
& Pseudomonas most common; TB, syphilis: usually in men, and meningococcus
are also
seen.
- Anal intercourse or having urinary tract instrumentation: Enterobacteriaceae or
Pseudomonas
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- Amiodarone
- Anal intercourse
- HIV infection
- Immunosuppression
- Urethral catheterization
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- Prostatitis
- Severe Behçet’s disease
- Transurethral prostate (TURP) biopsy
- Unprotected sex
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- Urethral instrumentation or transurethral surgery
- Urethral stricture
- Urinary tract infection
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- Epididymal congestion following vasectomy
- Epididymal cyst
- Orchitis
- Spermatocele
- Testicular torsion
- Epididymal adenomatoid tumor
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- Epididymal rhabdomyosarcoma
- Hydrocele
- Testicular trauma
- Testicular tumor
- Torsion of appendix testis
- Varicocele
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Text / literature information and recommendations include:
- Labs:
- Urinalysis – 50% show pyuria or bacteriuria
- Gram stain of urethral discharge may demonstrate organisms
- Urethral culture or DNA probe: for Chlamydia trachomatis and Neisseria
gonorrhoeae
- CBC – leukocytosis
- Imaging studies: Typically used to distinguish torsion from epididymitis
- Doppler ultrasound is the most common study utilized for imaging of the
testicle
and differentiating between torsion and epididymitis.
- Small studies to date recognize a high degree of accuracy utilizing MRI when
it
is performed with contrast enhancement.
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- A patient with a painful testicle has a ‘seconds to minutes emergency’ requiring
immediate evaluation to identify and treat testicular torsion when present.
Testicular
torsion should always be considered in patients presenting with a scrotal
complaint.
- Fever, redness, or swelling suggests the possibility of a scrotal infection. The
most important infection to recognize is Fournier’s gangrene, a life
threatening,
rapidly progressive, multi-microbial infection often including gas-forming
bacteria.
Also consider the cellulitis or scrotal abscess.
- Epididymitis is the most frequent misdiagnosis in cases of testicular torsion.
The
delay caused by the misdiagnosis can result in testicular loss. It is important
to differentiate the conditions, and if unclear, obtain an imaging study.
- Torsion vs. Epididymitis Comparison Table
Torsion
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Epididymitis
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- Onset of pain: acute
- Vomiting and anorexia are common
- History of prior episodes
- Fever and dysuria unusual
- Cremasteric reflex absent
- Testicular lie: horizontal
- Negative Prehn’s sign
- No urethral discharge
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- Onset of pain: gradual
- Vomiting and anorexia are uncommon
- No history of prior episodes
- Fever in 14% to 28% of cases
- Cremasteric reflex present
- Testicular lie: vertical
- Positive Prehn’s sign
- Urethral discharge possible
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- It may be possible to differentiate tenderness in the epididymis versus testicle
torsion early in either process. However, later in the process diffuse
tenderness
when palpating either the epididymis or the testicle can occur with both
clinical
entities. In addition, although pyuria is most typical of epididymitis, it can
also
occur in late torsion, as inflammation becomes widespread.
- One group of researchers found that patients with 3 findings from the following
list had definite epididymitis, and those with 2 findings were probable cases of
epididymitis:
- Gradual onset of symptoms
- Recent urinary tract instrumentation or surgery
- Dysuria or recent urinary tract infection
- Significant elevation in temperature – over 101 F (38.3 F)
- Localized tenderness and induration of epididymis
- Abnormal urinalysis
- ALL pediatric (prepubertal) cases of epididymitis require immediate urology
consultation
because of high incidence of associated genitourinary anomalies.
- Patients discharged with a diagnosis of epididymitis should have a follow-up
appointment
with a private physician or specialist to evaluate for testicular tumor.
- Patients with epididymitis from a sexually transmitted disease have a 2-5 times
the risk of acquiring and transmitting the human immunodeficiency virus (HIV).
- Prehn’s sign – decreased pain with scrotal elevation or support. Prehn’s sign is
NOT reliable for distinguishing epididymitis from testicular torsion.
- Pain improves within 3 days of treatment. However, induration may take several
weeks
or months to resolve completely.
- Patients with epididymitis who are younger than 25 typically have Chlamydia
Trachomatis
or Neisseria Gonorrhoeae as the causative organism.
- Patients with epididymitis who are older than 35 typically have coliform
bacteria,
a pseudomonas species or occasionally staphylococcus as the causative organism.
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Common text / literature recommendations include:
- If unable to differentiate epididymitis from testicular torsion obtain an
immediate
urologic consultation.
- Appropriate empiric antibiotic therapy should be instituted even if gram stains
are negative.
- Provide analgesics for pain.
- Scrotal elevation significantly decreased the pain of epididymitis. Athletic
supporters
may provide symptomatic relief.
- Apply an ice pack to the painful area. It will reduce swelling and pain.
- Evaluation or referral for syphilis and HIV testing in cases caused by STD
- All pediatric cases of epididymitis require immediate urology consultation
because
of high incidence of associated genitourinary anomalies.
- Most cases of epididymitis can be managed on an outpatient bases with follow-up
with a urologist in 3 to 5 days. Inpatient treatment is rarely indicated except
in those patients who are septic, have systemic symptoms, or are unable to
tolerate
oral medication.
- The CDC recommendations for treatment are as follows:
- For acute epididymitis most likely caused by sexually-transmitted chlamydia
and gonorrhea:
- Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally
twice a day for 10 days
- For acute epididymitis most likely caused by sexually-transmitted chlamydia
and gonorrhea and enteric organisms (men who practice insertive anal sex):
- Ceftriaxone 250 mg IM in a single dose PLUS Levofloxacin 500 mg orally
once a day for 10 days OR Ofloxacin 300 mg orally twice a day for 10
days
- For acute epididymitis most likely caused by enteric organisms:
- Levofloxacin 500 mg orally once a day for 10 days OR Ofloxacin 300 mg
orally twice a day for 10 days
- Patients who have acute epididymitis, confirmed or suspected to be caused by N.
gonorrhoeae or C. trachomatis, should be instructed to refer sex partners for
evaluation
and treatment if their contact with the index patient was within the 60 days
preceding
onset of the patient’s symptoms.
- Patients should be instructed to avoid sexual intercourse until they and their
sex
partners are cured (i.e., until therapy is completed and patient and partners no
longer have symptoms).
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- Fournier’s gangrene – necrotizing synergistic infection
- Infertility
- Recurrent epididymitis
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