Epididymitis

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Background

  • Often confused with testicular torsion
    • Cremasteric reflex intact in epididymitis
  • Sexually active men <35yo → consider chlamydia, gonorrhea
  • Not sexually active, age >35yo, or anal intercourse → also consider E. coli, pseudomonas, enterobacter, TB, syphilis
  • Chemical epididymitis
    • Consider in the patient with afib and testicular pain
    • Testicular pain and swelling in patients on amiodarone

Clinical Features

  • Pain of gradual onset, peaks at 24hr
  • Dysuria
  • Urinary frequency
  • Fever
  • Pain relieved with elevation of testicle (Prehn sign)
    • Sensitivity: 91.3%, specificity: 78.3. Does not rule out testicular torsion

Differential Diagnosis

Testicular Diagnoses

Evaluation

  • Urinalysis
    • Pyuria seen in half of cases
  • Urine culture (children, elderly men)
  • Urine GC/Chlam (urethral discharge or age <40)
  • Ultrasound for equivocal cases
  • Older men should be evaluated for urinary retention

Management

  • Scrotal elevation
  • Analgesia

Antibiotics

  • For acute epididymitis likely caused by STI
  • For acute epididymitis most likely caused by STI and enteric organisms (MSM)
  • For acute epididymitis most likely caused by enteric organisms

Treat sexual partner if possible

  • If med adherence is an issue:
    • Ceftriaxone 250mg IM once AND
    • Azithromycin 1 g PO once

Pediatric Epididymitis[1]

  • Rule out testicular torsion
  • Bed rest to ensure lymphatic drainage
  • Ice packs, acetaminophen, ibuprofen
  • Rarely oral narcotics
  • Pediatric urology follow up outpatient in non-toxic child for possible GU anatomical abnormalities
  • Antibiotics for 10-14 days, with urine culture sent:
    • Trimethroprim-sulfamethoxazole
    • Amoxicillin-clavulanate
    • Coverage for chlamydia and N. gonorrhoeae in suspected cases of sexual transmission
    • Avoid fluoroquinolones in pediatric patients
    • Severely ill or septic children:
      • First generation cephalosporin AND
      • Aminoglycoside

Disposition

  • Admit for systemic signs (fever, chills, nausea/vomiting) or toxic appearance
  • Discharge with urology follow-up in 1 week if non-toxic

See Also

References

  1. Richman MN and Bukowski TP. Pediatric Epididymitis: Pathophysiology, Diagnosis, and Management. Infect Urol. 2001;14(2).