SIGNS AND SYMPTOMS 
History
- Gradual onset of mild to moderate testicular or scrotal pain, usually unilateral
- Progressive scrotal swelling
- Dysuria (30%):
- Recent UTI
- History of abnormal bladder function
- Urethral discharge:
- Of patients with gonococcal epididymitis, 21–30% did not complain of urethral discharge.
- No demonstrable urethral discharge in 50%
- Fever (14–28%)
- Recent urethral instrumentation or catheterization
Physical Exam
- Tenderness in groin, lower abdomen, or scrotum
- Scrotal skin commonly erythematous and warm
- Early:
- May feel swollen, indurated epididymis
- Later:
- May not be able to distinguish epididymis from testis
- Spermatic cord may be edematous.
- Intact cremasteric reflex
- Prehn sign:
- Pain relief with testicular elevation
- Commonly observed but not specific
- Coexistent prostatitis is rare (8%).
- Pyogenic bacterial orchitis:
- Patients usually are acutely ill.
- Fever
- Intense discomfort, swelling of testicle
- Often reactive hydrocele
ESSENTIAL WORKUP
- Must differentiate from testicular torsion
- Early consultation with urologist if strong suspicion of testicular torsion
DIAGNOSIS TESTS & INTERPRETATION
Lab
- CBC:
- Urinalysis and culture:
- Positive leukocyte esterase on first-void urine or > 10 WBC per high-power field on first-void urine sediment
- 15–50% of patients with epididymo-orchitis have pyuria.
- 24% of patients have positive urine bacterial cultures.
- Urethral swab (50–73% have demonstrable urethritis despite minority of symptoms)
- Gram stain and culture or DNA amplification for C. trachomatis/N. gonorrhea
- Avoid bladder emptying within 2 hr of tests (lowers sensitivity).
- Especially for postpubertal and sexually active
- Blood culture if systemically ill
Imaging
- US: Color Doppler imaging:
- 82–100% sensitivity, 100% specificity in detecting testicular torsion or decreased blood flow
- Epididymo-orchitis:
- Hyperemia
- Increased vascularity and blood flow
- Advantages:
- Can evaluate for epididymitis or other causes of scrotal pain
- 70% sensitivity, 88% specificity for epididymitis
- Disadvantages:
- Highly examiner dependent
- Difficult in infants or children
- Testicular scintigraphy:
- Radionuclide study to assess perfusion
- 90–100% sensitivity, 89–97% specificity in detecting testicular torsion
- Inflammatory processes have increased flow and uptake.
- Not routinely available at many institutions
Diagnostic Procedures/Surgery
Surgical exploration indications:
- Scrotal abscess
- If torsion cannot be excluded
- Suspected or proved ischemia caused by severe epididymitis
- Patient with solitary testicle
- Scrotal fixation: Indicates severe inflammation and potential suppuration
DIFFERENTIAL DIAGNOSIS
- Testicular torsion
- Testicular tumor
- Torsion of testicular appendages
- Trauma to scrotum
- Acute hernia
- Acute hydrocele
[Outline]
PRE-HOSPITAL
- IV access
- IV fluids, especially if systemically ill
INITIAL STABILIZATION/THERAPY
- IV access
- IV fluids, especially if systemically ill
ED TREATMENT/PROCEDURES
- Antibiotics:
- Cover for chlamydial and gonococcal etiologies if adult or presumed sexually transmitted
- Cover for coliform etiology:
- Child, or adult > 35 yr of age
- Insertive partner in anal intercourse
- Presumed nonsexually transmitted
- Bed rest, scrotal support, ice packs
- Analgesics and anti-inflammatories
MEDICATION
- Age < 35 yr or sexually active postpubertal males:
- Age > 35 yr or insertive partners in anal intercourse or negative culture/DNA amplification for C. trachomatis/N. gonorrhea or allergy to cephalosporins/tetracyclines:
Pediatric Considerations
- Bacterial epididymitis is uncommon in prepubertal boys and antibiotic regimens are not well established.
- If concurrent UTI:
- TMP–SMX: 4 mg/kg TMP and 20 mg/kg SMX BID for 10 days
- Avoid quinolones and tetracyclines in children
[Outline]
DISPOSITION
Admission Criteria
- Surgical indications present
- Older age group if it is the only way to ensure appropriate workup:
- Many will have underlying urologic pathology.
- Systemically ill, fever, nausea, vomiting
- Scrotal abscess
- Intractable pain
Discharge Criteria
- Fails to meet admission criteria
- Patient with good follow-up
- Able to take oral antibiotics
Issues for Referral
- Children need workup for urologic abnormalities:
- Voiding cystourethrography, renal US
- If bacteriuria present, exam of lower tract with cystoscopy after treatment completed
FOLLOW-UP RECOMMENDATIONS
- Failure to improve within 3 days of commencing antibiotics warrants urologic evaluation.
- Persistence of symptoms after full antibiotic course warrants search for other causes of epididymitis:
- TB or fungal epididymitis, scrotal abscess, tumor, infarction.
- Sexual partners of patients with suspected or confirmed C. trachomatis/N. gonorrhea should be tested/treated.
- Children need urology consult for evaluation of structural urogenital abnormalities.
[Outline]
- Brenner JS, Ojo A. Causes of scrotal pain in children and adolescents. UpToDate. Available at www.uptodate.com. Accessed on January 30, 2013.
- Ching CB, Sabanegh ES. Epididymitis. eMedicine. Available at emedicine.medscape.com/article/436154-overview. Accessed on January 30, 2013.
- Tekgül S, Riedmiller H, Gerharz E, et al. European Society for Paediatric Urology and European Association of Urology. Guidelines on paediatric urology. Available at http://www.uroweb.org/gls/pdf/19_Paediatric_Urology.pdf.
- Tracy CR, Steers WD, Costabile R. Diagnosis and management of epididymitis. Urol Clin North Am. 2008;35(1):101–108.
- Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1–110.
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