Epididymitis: Difference between revisions

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==Background==
==Background==
*Often confused with testicular torsion
*Often confused with testicular torsion
**Cremasteric reflex intact
**Cremasteric reflex intact in epididymitis
*Sexually active men <35yo:
*Sexually active men <35yo → consider [[Chlamydia|chlamydia]], [[Gonorrhea|gonorrhea]]
**Consider chlamydia, gonorrhea
*Not sexually active, age >35yo, or anal intercourse → also consider E. coli, pseudomonas, enterobacter, TB, [[Syphilis|syphilis]]
*Not sexually active, age >35yo, or anal intercourse:
*Chemical epididymitis
**Also consider E. coli, pseudomonas, enterobacter, TB, syphilis
**Consider in the patient with afib and testicular pain
**Testicular pain and swelling in patients on [[Amiodarone|amiodarone]]


==Diagnosis==
==Clinical Features==
*Pain of gradual onset, peaks at 24hr
*Pain of gradual onset, peaks at 24hr
**Dysuria, frequency, fever
*[[Dysuria]]
*Pain relieved with elevation of testicle (positive Prehn sign)
*Urinary frequency
*[[Fever]]
*Pain relieved with elevation of testicle (Prehn sign)
**Sensitivity: 91.3%, specificity: 78.3. Does not rule out testicular torsion


==Work-Up==
==Differential Diagnosis==
*UA
{{Template:Testicular DDX}}
 
==Evaluation==
*[[Urinalysis]]
**Pyuria seen in half of cases
**Pyuria seen in half of cases
*Ucx (children, elderly men)
*Urine culture (children, elderly men)
*Urine [[GC]]/[[Chlam]] (urethral discharge or age <40)
*Urine [[GC]]/[[Chlam]] (urethral discharge or age <40)
*Ultrasound for equivocal cases
*Ultrasound for equivocal cases
*Older men should be evaluated for urinary retention
*Older men should be evaluated for urinary retention


==Differential Diagnosis==
==Management==
{{Template:Testicular DDX}}
*Scrotal elevation
*Analgesia


==Treatment==
===[[Antibiotics]]===
#Scrotal elevation
{{Epididymitis antibiotics}}
#Analgesia
*If med adherence is an issue:
#[[Antibiotics]]
**[[Ceftriaxone]] 250mg IM once '''AND'''
##Sexually transmitted (<40yo):
**Azithromycin 1 g PO once
###[[Ceftriaxone]] 250mg IM x1 for [[GC]], AND
###[[Doxycycline]] 100 mg BID x10d for [[chlamydia]]
##Men > 40yrs old, History of anal intercourse or non-sexually active:
###PO: [[Ciprofloxacin]] 500mg BID x 14d OR [[ofloxacin]] 200mg BID x 14d
###IV: [[Piperacillin/Tazobactam]] 3.375g IV q6 or [[Ampicillin/Sulbactam]] 3g IV q6


''Treat sexual partner if possible''
===Pediatric Epididymitis<ref>Richman MN and Bukowski TP. Pediatric Epididymitis: Pathophysiology, Diagnosis, and Management. Infect Urol. 2001;14(2).</ref>===
*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==
==Disposition==
*Admit for:
*Admit for systemic signs (fever, chills, nausea/vomiting) or toxic appearance
**Systemic signs of toxicity (fever, chills, N/V)
*Discharge with urology follow-up in 1 week if non-toxic
*Discharge with urology follow-up in 1 week if non-toxic


==See Also==
==See Also==
*[[Testicular Diagnoses]]
*[[Testicular diagnoses]]
*[[Traumatic Epididymitis]]
*[[Traumatic epididymitis]]


==Source==
==References==
*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. Khan
<References/>
*CDC Guidelines http://www.cdc.gov/std/treatment/2010/epididymitis.htm


[[Category:GU]]
[[Category:Urology]]
[[Category:ID]]
[[Category:ID]]

Revision as of 06:29, 7 July 2017

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 [1]
  • For acute epididymitis most likely caused by STI and enteric organisms (MSM)
  • For acute epididymitis most likely caused by enteric organisms

For persons weighing ≥150 kg, 1 g of ceftriaxone should be administered.

  • If med adherence is an issue:

Pediatric Epididymitis[2]

  • 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. https://www.cdc.gov/std/treatment-guidelines/epididymitis.htm
  2. Richman MN and Bukowski TP. Pediatric Epididymitis: Pathophysiology, Diagnosis, and Management. Infect Urol. 2001;14(2).