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Epididymitis

BASICS

DESCRIPTION

  • Inflammation of epididymis causing scrotal pain, swelling, induration, possible hydrocele.
  • Acute: pain <6 weeks; chronic: ≥6 weeks.
  • Involvement of testis = epididymo-orchitis.
  • Classification: infectious (bacterial, viral, fungal, parasitic) vs noninfectious (chemical, traumatic, autoimmune, idiopathic, industrial, vaso-epididymal reflux syndrome).
  • System affected: reproductive.

EPIDEMIOLOGY

  • Predominant age: younger sexually active men or older men with UTIs, BPH.
  • Male only.
  • Most common cause of acute scrotal pain in prepubertal boys (more common than torsion).
  • Incidence: 600,000 cases/year in US; 1/1000 adult males; 1.2/1000 boys aged 2-13 years.
  • Prevalence: common.

ETIOLOGY AND PATHOPHYSIOLOGY

Infectious

  • Retrograde urinary bacteria from prostate/urethra via ejaculatory ducts and vas deferens; rarely hematogenous.
  • Organisms vary by age.

Noninfectious

  • Often unknown etiology; may be trauma, autoimmune, vasculitis, chemical irritation from sterile urine reflux.
  • Reflux can occur after exercise with full bladder or prolonged sitting.
  • Urethritis/prostatitis can cause muscular rigidity, promoting reflux at ejaculatory ducts.
  • In <14 yrs, likely from anatomic abnormalities (VUR, ectopic ureter, rectourethral fistula) or postinfectious syndromes (Mycoplasma pneumoniae, enterovirus, adenovirus).
  • Henoch-Schönlein purpura can cause acute scrotal pain.
  • 14-35 yrs: Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium; enteric pathogens with anal intercourse.

  • 35 yrs: enteric bacteria, sometimes Staphylococcus aureus or epidermidis.

  • Elderly: often with obstruction (BPH), UTI, catheterization.
  • TB epididymitis possible (granulomatous, sterile pyuria, nodularity, hematogenous).
  • Other rare infections: syphilis, blastomycosis, coccidioidomycosis, cryptococcosis, brucellosis (endemic).
  • Drug-induced (amiodarone).

RISK FACTORS

  • UTI, prostatitis, indwelling catheters, instrumentation, strictures, biopsy, brachytherapy, anal intercourse, high-risk sex, physical strain, sedentary periods, bladder obstruction, immunosuppression (HIV), Behçet disease, presence of foreskin, constipation, occupations involving physical strain.

GENERAL PREVENTION

  • Safer sex practices.
  • Mumps vaccination.
  • Antibiotic prophylaxis for urethral procedures.
  • Early prostatitis/BPH treatment.
  • Vasectomy during transurethral surgery.
  • Avoid vigorous rectal exam during acute prostatitis.
  • Empty bladder prior to exertion.
  • Physical conditioning before intense activity.
  • Treat constipation.

COMMONLY ASSOCIATED CONDITIONS

  • Prostatitis, urethritis, orchitis, hematospermia, constipation, UTI.

DIAGNOSIS

HISTORY

  • Gradual onset scrotal pain, radiating to groin (1-2 days).
  • Urethral discharge, urinary symptoms (frequency, dysuria, hematuria).
  • Sexual history.
  • Fever in 11-19%.
  • Progression to hemiscrotal swelling, redness, testis indistinguishable from epididymis, scrotal wall thickening, hydrocele.

PHYSICAL EXAM

  • Tender epididymis, enlarged tail vs contralateral.
  • Prehn sign positive (pain relief with testicular elevation).
  • Absent cremasteric reflex suggests torsion.

DIFFERENTIAL DIAGNOSIS

  • Testicular or appendage torsion.
  • Orchitis, trauma.
  • Post-vasectomy congestion.
  • Malignancy, cysts, hernia, varicocele.
  • Henoch-Schönlein purpura vasculitis.

DIAGNOSTIC TESTS

  • Urinalysis, urine culture (first-void preferred).
  • Gram stain/culture of urethral discharge.
  • Urine testing for gonorrhea and chlamydia.
  • Elevated CRP helps differentiate from torsion.
  • Doppler US if torsion or mass suspected.
  • Pediatric imaging for anatomic anomalies.
  • Clinical diagnosis predominant.

TREATMENT

GENERAL MEASURES

  • Bed rest, scrotal elevation/support, ice.
  • Avoid constipation.
  • Spermatic cord block for severe pain.
  • Noninfectious epididymitis: avoid strenuous activity, valsalva; empty bladder before exertion.

MEDICATION

First Line

  • Age <35 & sexually active: doxycycline 100 mg PO BID ×10 days + ceftriaxone 500 mg IM (1 g if >150 kg). Treat sexual partners.
  • Age ≥35 & non-STD: levofloxacin 500 mg PO daily ×10 days (note FDA fluoroquinolone warnings).
  • Anal intercourse: ceftriaxone 500 mg IM + fluoroquinolone.
  • NSAIDs for pain; steroids if NSAIDs not tolerated; opioids for severe pain.
  • Septic/toxic: 3rd generation cephalosporin or aminoglycoside.
  • Behçet/sarcoid/Henoch-Schönlein: steroids recommended.

Second Line

  • TMP-SMX double strength PO BID ×10-14 days; consider rifampin or vancomycin as needed.

PEDIATRIC

  • Postinfectious inflammation treated with anti-inflammatories/analgesics.
  • Antibiotics reserved for infants with positive urine cultures.

ISSUES FOR REFERRAL

  • Urgent US or ER referral if torsion suspected.
  • <14 yrs: urology referral for possible urogenital abnormalities.
  • Failed medical therapy: urology referral for anatomic or chemical epididymitis.
  • HIV/immunocompromised: consider additional infections (CMV, salmonella, toxoplasmosis, etc.).

SURGERY/OTHER PROCEDURES

  • Vasostomy for drainage in severe/refractory cases.
  • Scrotal exploration if diagnosis unclear.
  • Abscess drainage, epididymectomy, orchidectomy for refractory suppurative cases.
  • Surgery for anatomic correction.

INPATIENT CARE

  • Indicated for intractable pain, sepsis, abscess, vomiting, surgery, purulent drainage.

ONGOING CARE

FOLLOW-UP

  • Routine follow-up 1 week; earlier if no improvement (72 hrs).
  • Persistent swelling/tenderness post-antibiotics evaluated for abscess, tumor, infarction, TB, fungal infection.
  • Noninfectious: follow-up in 4 weeks to assess NSAIDs/lifestyle efficacy.

DIET

  • Treat constipation with high-fiber diet/prevention.

PATIENT EDUCATION

  • Complete antibiotic course even if asymptomatic.
  • Early recognition/treatment of UTI or prostatitis.
  • Safer sex, abstain until treatment and partner treated.
  • Repeat STI testing at 3 months if STI identified.
  • Treat and refer partners for STI evaluation and treatment.

PROGNOSIS

  • Pain improves in 1-3 days; induration may take weeks/months.
  • Bilateral involvement may cause sterility.
  • Noninfectious usually resolves <1 week.

COMPLICATIONS

  • Recurrent epididymitis, infertility, oligospermia, testicular necrosis/atrophy, secondary abscess, Fournier gangrene.

REFERENCES

  1. Trojian TH, Lishnak TS, Heiman D. Epididymitis and orchitis: overview. Am Fam Physician. 2009;79(7):583-587.
  2. McConaghy JR, Panchal B. Epididymitis overview. Am Fam Physician. 2016;94(9):723-726.
  3. Tekgül S, Dogan HS, Kocvara R, et al. EAU Pediatric Urology Guidelines. 2016.
  4. Workowski KA, Bachmann LH, Chan PA, et al. STI Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187.

CODES

  • ICD10 N45.1 Epididymitis
  • ICD10 N45.2 Orchitis
  • ICD10 N45.3 Epididymo-orchitis

CLINICAL PEARLS

  • Epididymitis pain is gradual onset, tenderness posterior to testis.
  • Torsion has rapid onset, elevated testis, absent cremasteric reflex, decreased Doppler flow.
  • Prostatic massage contraindicated in epididymitis (risk of sepsis).
  • Noninfectious epididymitis is diagnosis of exclusion; infectious causes predominate.