Author:
Matthew D.Cook
Kevin R.Weaver
Description
- Definition: Inflammation or infection of the epididymis
- Rare in prepubertal boys
- Pathogenesis:
- Initial stages:
- Cellular inflammation begins in vas deferens, descends to epididymis
- Acute phase:
- Epididymis is swollen and indurated in upper and lower poles
- Spermatic cord thickened
- Testis may become edematous owing to passive congestion or inflammation
- Resolution:
- May be complete without sequelae
- Peritubular fibrosis may develop, occluding ductules
- Complications:
- 2/3 of men have atrophy due to partial vascular thrombosis of testicular artery
- Abscess and infarction rare (5%)
- Incidence of infertility with unilateral epididymitis unknown:
- 50% with bilateral epididymitis
Orchitis
- Definition: Inflammation or infection of the testicle:
- Usually from direct extension of the same process within the epididymis
- Isolated testicular infection is rare:
- Can result from hematogenous spread of bacteria or following mumps infection
- Categories:
- Pyogenic bacterial orchitis secondary to bacterial involvement of epididymis
- Viral orchitis:
- Most commonly due to mumps
- Rare in prepubertal boys; occurs in 20-30% of postpubertal boys with mumps
- Occurs 4-6 d after parotitis but can occur without parotitis
- Unilateral in 70% of patients
- Usually resolution in 6-10 d
- 30-50% of testes involved have residual atrophy; rarely affects fertility
- Granulomatous orchitis:
- Syphilis
- Mycobacterium and fungal diseases
- Usually occurs in immunocompromised host
Etiology
Epididymitis
- Children:
- Most common in children <1 yr or between the ages of 12-15 yr
- Etiology identified in only 25% of prepubertal boys
- Coliform or pseudomonal UTI
- Sexually transmitted diseases rare in prepubertal males
- Associated with predisposing abnormalities of lower urinary tract
- Young men, age <35 yr:
- Usually sexually transmitted
- Chlamydia trachomatis (28-88%) with severe inflammation with minimal destruction
- Neisseria gonorrhoeae (3-28%)
- Coliform bacteria (7-24%):
- Highly destructive with tendency for abscess
- Coliform bacteria more common in insertive partners in anal intercourse
- Ureaplasma urealyticum (sole organism in only 6% of cases)
- Older men, age >35 yr:
- Commonly associated with underlying urologic pathology (benign prostatic hypertrophy, prostate cancer, strictures)
- May have acute or chronic bacterial prostatitis
- Coliform bacteria more common (23-67%), especially after instrumentation
- C. trachomatis (8-80%)
- Klebsiella and Pseudomonas species
- N. gonorrhoeae (15%)
- Gram-positive cocci
- Drug related:
- Amiodarone-induced epididymitis:
- Usually with amiodarone levels > therapeutic levels
- Granulomatous:
- Etiology maybe related to mycobacterial, syphilis, or fungal infections:
- Mycobacterium tuberculosis is the most common cause of granulomatous disease affecting the epididymis
- Suspect in HIV patients
- Urine cultures often negative for M. tuberculosis
- Vasculitis:
- Polyarteritis nodosa
- Behçet disease
- Henoch-Schönlein purpura
Orchitis
- Pyogenic bacterial orchitis:
- Escherichia coli
- Klebsiella pneumoniae
- Pseudomonas aeruginosa
- Staphylococci
- Streptococci
- Viral orchitis:
- 20% may develop epididymo-orchitis
- Rarely associated with live-attenuated mumps vaccine
- Coxsackie A and lymphocytic choriomeningitis virus
- Granulomatous orchitis: Syphilis, mycobacterial and fungal diseases:
- Fungal orchitis:
- Blastomycosis in endemic regions
- Invasive cand idal infections in immunosuppressed hosts
- Post-traumatic orchitis: Inflammation
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
Diagnostic Tests & Interpretation
Lab
- 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
- Nucleic acid amplification test (NAAT) for gonorrhea and chlamydia:
- Urine is preferred specimen
- Avoid bladder emptying within 2 hr of tests (lowers sensitivity)
- Especially for postpubertal and sexually active
- Urethral secretion Gram stain with ≥2 WBCs per immersion oil field (establishes urethritis) with WBC containing intracellular gram-negative diplococci (establishes gonococcal infection)
- 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
Prehospital
- 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 presumed sexually transmitted
- Cover for coliform etiology:
- Child, or adult >35 yr of age
- Insertive partner in anal intercourse
- Presumed nonsexually transmitted
- Recent GU instrumentation (prostate biopsy, vasectomy)
- Bed rest, scrotal support, ice packs
- Analgesics and anti-inflammatories
Medication
- Age <35 yr or presumed sexually transmitted gonorrhea or chlamydia:
- Ceftriaxone 250 mg IM once + doxycycline 100 mg PO b.i.d for 10 d
- Age >35 yr or recent GU instrumentation or negative NAAT for C. trachomatis/N. gonorrhoeae or allergy to cephalosporins/tetracyclines:
- Ofloxacin 300 mg PO b.i.d or levofloxacin 500 mg/d PO for 10 d
- Bacterial epididymitis is uncommon in prepubertal boys and antibiotic regimens are not well established
- Avoid quinolones and tetracyclines in children
- Insertive partners in anal intercourse:
- Ceftriaxone 250 mg IM once + ofloxacin 300 mg PO b.i.d or levofloxacin 500 mg/d PO for 10 d
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 d 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. gonorrhoeae should be tested/treated
- Children need urology consult for evaluation of structural urogenital abnormalities
- BrennerJS, OjoA. Causes of scrotal pain in children and adolescents . UpToDate. Available at www.uptodate.com. Accessed on March 6, 2018.
- ChingCB, SabaneghES. Epididymitis. eMedicine . Available at emedicine.medscape.com/article/436154-overview. Accessed on March 6, 2018.
- TekgülS, DolanHS, HoebekeP, et al. European Society for Paediatric Urology and European Association of Urology. EAU Guidelines on paediatric urology . Available at http://uroweb.org/wp-content/uploads/EAU-Guidelines-Paediatric-Urology-2016-1.pdf
- TracyCR, SteersWD, CostabileR. Diagnosis and management of epididymitis . Urol Clin North Am. 2008;35(1):101-108.
- WorkowskiKA, BolanGA; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2015 . MMWR Recomm Rep. 2015;64(3):1-140.
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