EPIDIDYMITIS

The 5 Minute Urology Consult 3rd Ed.

Jonathan H. Huang, MD

Wayland Hsiao, MD

BASICS

DESCRIPTION

• Epididymitis is an inflammatory condition of the epididymis

– Acute epididymitis is a clinical syndrome consisting of pain, swelling, and inflammation of the epididymis that lasts <6 wk

Usually infectious but occasionally inflammatory due to trauma or other cause

– Chronic epididymitis is characterized by a ≥6-wk history of symptoms of discomfort and/or pain in the scrotum, testicle, or epididymis

• Infectious epididymitis is often associated with orchitis

– Left untreated localized infectious epididymitis can lead to more extensive infection to include the testicle

• Thought to be the most common cause of scrotal pain in men

EPIDEMIOLOGY (1)

Incidence

Estimated at 1 in 100 males in the United States

Prevalence

• 42% of cases are in males 20–39 yr old

• Reported from infancy to the elderly population

RISK FACTORS

• High-risk sexual behavior (multiple sexual partners, sex without condoms)

• Poor hygiene

• Being uncircumcised

• Instrumentation or manipulation of the genitourinary tract

– Catheterization, transurethral surgery

• Urinary tract obstruction (benign prostate hypertrophy, urethral strictures, bladder cancer, prostate cancer)

• Amiodarone usage

• Tuberculosis (TB)

• Treatment with Bacillus Calmette–Guérin (BCG) for superficial bladder cancer

• Systemic inflammatory diseases (Behçet disease, sarcoidosis)

Genetics

N/A

PATHOPHYSIOLOGY

• Acute infectious epididymitis (<6-wk duration) is often due to retrograde spread of infection toward the epididymis

– Infants and children

Associated with congenital genitourinary abnormalities

Reactive process after a nongenitourinary viral infection

– Sexually active males

Associated with sexually transmitted diseases (STDs), often Neisseria gonorrhoeae and Chlamydia trachomatis

– Elderly males

Associated with urinary stasis from benign prostate hypertrophy and catheterization

• Other infectious causes:

– Bacterial

Escherichia coli, Salmonella enterica, Ureaplasma urealyticum, Corynebacterium pseudotuberculosis, Mycoplasma genitalium, Brucella ovis, Pseudomonas species, Toxoplasma species

– Fungal (more common with HIV)

Cryptococcus species

– Filarial

Wucheria bancrofti

– Viral (more common with HIV)

Cytomegalovirus

• Noninfectious epididymitis

– Trauma

– Amiodarone usage

Antiamiodarone antibodies interact with the elevated concentration of amiodarone in the epididymis, leading to inflammation

– Behçet disease

Etiology of epididymitis is unclear

– Sarcoidosis

Noncaseating granulomas in the epididymis lead to inflammation

• Chronic epididymitis (>6-wk duration)

– Inadequately treated acute epididymitis

– Postvasectomy syndrome

Reported in 1 in 100 males

• TB

– Suspected to be due to hematogenous spread; usually a chronic granulomatous reaction

• BCG treatment for superficial bladder cancer can lead to epididymitis

ASSOCIATED CONDITIONS

• Orchitis

• Hydrocele

• Immunosuppression

GENERAL PREVENTION

• Condom usage

• Proper hygiene

• Avoiding unnecessary instrumentation of the genitourinary tract

ALERT

Emergency evaluation for testicular torsion is indicated when the onset of pain is sudden, pain is severe, or the test results available during the initial examination do not support a diagnosis of infection.

DIAGNOSIS

HISTORY

• Testicular pain

– Gradually worsens in epididymitis

– Rapid onset and intense in testicular torsion

• Sexual intercourse without condom including anal receptive unprotected sex

• Instrumentation of the genitourinary tract

• Review of systems may help elucidate other causes (ie, amiodarone usage, TB, Behçet disease, sarcoidosis)

• Chronic Epididymitis Symptom Index (CESI) has been described for cases that last >3 mo

PHYSICAL EXAM

• Epididymal tenderness

– Positive in 90–97% of patients

– Ipsilateral and contralateral testicle may be involved

– Spermatic cord may be involved

• Erythema of the scrotum

• Fever

• Genital exam

– Lesions related to STDs

– Urethral discharge

– Ulcerations from Behçet disease

– Hydrocele

A reactive process sometimes related to the epididymal inflammation

• Prostate exam

– Rule out prostatitis, especially in males with chronic epididymitis

• Prehn sign

– Used to rule out testicular torsion

– Alleviation of pain, with elevation of the testicle, is more consistent with epididymitis (negative Prehn sign)

– Only positive in 8% of children with epididymitis

DIAGNOSTIC TESTS & INTERPRETATION

Lab (3)

• Used to rule in a source of infection

• Urethral exudate

– Gram stain with at least 5 white blood cells (WBC) per oil immersion field

Gram-negative bacilli is suggestive of E. coli infection and underlying cystitis

Intracellular gram-negative diplococci suggests a diagnosis of N. gonorrhoeae infection

Findings of only WBC are suggestive of C. trachomatis in 2/3 of cases

– Send for culture and sensitivity

• Urine analysis

– Assess for leukocyte esterase or at least 10 WBC per high power field

• Urine culture (midstream clean catch)

– Send for culture and sensitivity

• C-reactive protein

– Acute phase protein that is elevated in epididymitis

– Sensitivity of 96.2%; specificity of 94.2%

• When an STD is suspected, the patient should be screened for other STDs, including human immunodeficiency virus (HIV)

Imaging (4,5)

• Color Doppler scrotal ultrasound (US)

– Hyperemia and swelling in epididymitis

Sensitivity of 70%; specificity of 88%

Negative US, when positive clinical findings, should not necessarily alter management

– Decreased blood flow in testicular torsion

Sensitivity of 100%

– May identify an abscess

• Radionuclide imaging with Tc-99m pertechnetate

– High sensitivity and specificity in differentiating testicular torsion from epididymitis

– Rarely used in the United States

Diagnostic Procedures/Surgery

• Testicular exploration

– Not used as 1st-line diagnostic procedure

– Used when clinical suspicion for testicular torsion is high

• In infants and children with epididymitis, up to 75% have genitourinary abnormalities

– Renal ultrasound and voiding cystourethrography are recommended when there are clinical signs of epididymitis and a positive urine culture

Pathologic Findings

• Inflammation

• Infection

• Possible fibrosis

DIFFERENTIAL DIAGNOSIS

• Abscess

• Chronic pelvic pain syndrome

• Epididymitis (acute vs. chronic)

• Interstitial cystitis

• Orchitis

• Partial spermatic cord torsion

• Prostatitis

• Referred pain (inguinal hernia renal colic, aneurysm, hip pain, lower back pain)

• Spermatocele

• Testicular cancer

• Testicular torsion

• Varicocele

TREATMENT

GENERAL MEASURES

• Acute epididymitis

– Treat infections

– Decrease inflammation (NSAIDs)

– Pain control (NSAIDs, prescription pain medications)

– Scrotal support

– Ice/heat based on response

– Avoid sexual activity for at least 1 wk following the initiation of therapy and until symptoms resolved

• Chronic epididymitis

– Course of antibiotics is appropriate initially; if no relief observation and reassurance are recommended for mild symptoms

– Scrotal support

– Avoid aggravating activities

– Local heat therapy/Sitz baths

MEDICATION (1)

First Line

• For infections tailor therapy to age and history

– Ciprofloxacin and other quinolones are no longer recommended for gonococcal/nongonococcal infections due to resistance

• Empiric therapy to treat N. gonorrhea and C. trachomatis should be initiated pending lab results

– Ceftriaxone 250 mg intramuscularly in a single dose along with either

Azithromycin 1 g PO × 1 dose OR

Doxycycline 100 mg orally BID for 10 days

• Epididymitis due to enteric organisms

– Levofloxacin 500 mg orally once daily for 10 days or ofloxacin 300 mg orally twice daily for 10 days

• Epididymitis due to TB

– Systemic antibiotics based on most current CDC guidelines or local guidelines if available local guidelines

• Epididymitis due to intravesical BCG

– Fluoroquinolone (eg, levofloxacin 500 mg once daily)

Second Line

N/A

SURGERY/OTHER PROCEDURES

• Drainage if abscess present

• Epididymectomy (2)

– Not used as 1st-line treatment

– Reserved for severe acute or chronic epididymitis/epididymalgia

– Patient needs to understand that there is only at best a 50% chance of pain relief

– Outcomes appear improved in the setting of postvasectomy chronic epididymitis

– Fertility issues need to be addressed

• Testicular denervation

– Not widely used

– Reserved for patients who failed conservative management

– Pain relief noted in 71% of cases

ADDITIONAL TREATMENT

Radiation Therapy

N/A

Additional Therapies

• Scrotal elevation

• Limitation of activity

• Ice packs

Complementary & Alternative Therapies

N/A

ONGOING CARE

PROGNOSIS

• Pain often improves within 48–72 hr after treatment of acute epididymitis

– Induration may remain for up to 4 wk

• Chronic cases can be difficult to treat

COMPLICATIONS

• Chronic or recurrent epididymitis

• Epididymal and/or testicular abscess

• Infertility

• Testicular atrophy

• Fournier gangrene

FOLLOW-UP

Patient Monitoring

• Patients should follow up within 3–7 days after initiation of treatment, especially if symptoms have not improved

• Infants and children may need to be assessed for genitourinary abnormalities

• Elderly males may need to be assessed for urinary tract obstructions

• Screening and treatment of partners for STDs

Patient Resources

Urology Care Foundation. http://www.urologyhealth.org/urology/index.cfm?article=114

REFERENCES

1. Centers for Disease Control and Prevention. Epididymitis. MMWR. 2010;59(No. RR-12):67–69.

2. Hori S, Sengupta A, Shukla CJ, et al. Long-term outcome of epididymectomy for the management of chronic epididymal pain. J Urol. 2009;182:1407–1412.

3. Tracy CR, Steers WD, Costabile R. Diagnosis and management of epididymitis. Urol Clin N Am. 2008;35:101–108.

4. Wu HC, Sun SS, Kao A, et al. Comparison of radionuclide imaging and ultrasonography in the differentiation of acute testicular torsion and inflammatory testicular disease. Clin Nucl Med. 2002;27:490–493.

5. Yin S, Trainor JL. Diagnosis and management of testicular torsion, torsion of the appendix testis, and epididymitis. Clin Pediatr Emerg Med. 2009;10:38–44.

ADDITIONAL READING

N/A

See Also (Topic, Algorithm, Media)

• Acute Scrotum

• Acute Scrotum Algorithm