Epididymitis

Background

1. acute scrotal pain is a common reason for ER visit
2. epididymitis is entity most often confused with testicular torsion
3. sexually active men <35yo: Chlamydia trachomatis, Neisseria gonorrhea
4. men engaging in anal intercourse, non sexually active and/or >35, also consider: E. Coli, Pseudomonas, Enterobacteraciaceae, TB, syphilis

Diagnosis

1. pain of gradual onset, peak at 24 hours
2. cremasteric reflex intact
3. pain relieved with elevation of testicle (positive Prehn sign)
4. US shows scrotal wall thickening and hyperemia, possible reactive hydrocele or pyocele
5. UA may show pyuria but absence does not rule out disease

Work-Up

1. UA, Urine culture
2. urethral gram stain, culture, chlamydia, gonorrhea
3. testicular US

DDx

1. testicular torsion
2. torsion of testicular appendage
3. testicular tumor
4. orchitis
5. scrotal abscess
6. indirect inguinal hernia

Treatment

1. scrotal elevation
2. analgesia
3. antibiotics:
   1. sexually transmitted (<35yo):
      1. ceftriaxone 250mg IM x1 or cipro 500mg PO x1 for gonorrhea
      2. doxycycline 100mg PO BID x 14 days for chlamydia
   2. anal intercourse, nonsexually active, instrumentation and/or >35yo:
      1. cipro 500mg PO BID x 14 days OR Ofloxacin 200mg PO BID x 14 days
      2. IV: piperacillin/taxobactam 3.375g IV q6 or ampicillin/sulbactam 3g IV q6
4. treat sexual partner

Disposition

1. admit for systemic signs of toxicity (fever, chills, nausea, vomiting)
2. discharge home with follow up in one week if non toxic

See Also

testicular torsion

torsion of the testicular appendage

Source

Anatomical Approach to Scrotal Emergencies: A New Paradigm for the Diagnosis and Treatment of the Acute Scrotum. The Internet Journal of Urology 2010 : Volume 6 Number 2. Sardar Ali. KhanRosens