Epididymitis
Background
- Inflammation/infection of the epididymis; due to retrograde ascent of pathogens (usually bacterial), the type of which is associated with age
- Sexually active men <35yo → consider STI organisms including chlamydia, gonorrhea
- Not sexually active, age >35yo, or anal intercourse → consider E. coli, pseudomonas, enterobacter, TB, syphilis
- Progression of epididymitis results in epididymo-orchitis, now involving testes; isolated bacterial orchitis is rare
- Often confused with testicular torsion
- Cremasteric reflex intact in epididymitis, usually absent in torsion
- Epidididymitis typically more gradual onset and has concurrent lower urinary tract complaints
- Torsion rarer with older men
- 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
- Can radiate to inguinal and lower abdominal areas
- Dysuria or urinary frequency/urgency
- Fever
- Tenderness of epididymis and/or scrotum, overlying erythema or induration
- Positive Prehn sign: Pain relieved with elevation of testicle
- Sensitivity: 91.3%, specificity: 78.3. Does not rule out testicular torsion
Differential Diagnosis
Testicular Diagnoses
- Scrotal cellulitis
- Epididymitis
- Fournier gangrene
- Hematocele
- Hydrocele
- Indirect inguinal hernia
- Inguinal lymph node (Lymphadenitis)
- Orchitis
- Scrotal abscess
- Spermatocele
- Tinea cruris
- Testicular rupture
- Testicular torsion
- Testicular trauma
- Testicular tumor
- Torsion of testicular appendage
- Varicocele
- Pyocele
- Testicular malignancy
- Scrotal wall hematoma
Evaluation
Workup
- 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
Diagnosis
- Based on clinical exam or ultrasound
Management
- Scrotal elevation
- Analgesia
Antibiotics
- For acute epididymitis likely caused by STI [1]
- Ceftriaxone 500 mg IM in a single dose PLUS
- Doxycycline 100 mg orally twice a day for 10 days
- For acute epididymitis most likely caused by STI and enteric organisms (MSM)
- Ceftriaxone 500 mg IM in a single dose PLUS
- Levofloxacin 500 mg orally once a day for 10 days
- For acute epididymitis most likely caused by enteric organisms
- Levofloxacin 500 mg orally once daily for 10 days
For persons weighing ≥150 kg, 1 g of ceftriaxone should be administered.
- If med adherence is an issue [2]
- Ceftriaxone 500mg IM once AND
- Azithromycin 1 g PO once
Pediatric Epididymitis[3]
- 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), septic or toxic appearance, epididymal or testicular abscess formation, failure of outpt ABX
- Discharge with urology follow-up in 1 week if non-toxic
See Also
References
- ↑ https://www.cdc.gov/std/treatment-guidelines/epididymitis.htm
- ↑ CDC 2022 guidelines
- ↑ Richman MN and Bukowski TP. Pediatric Epididymitis: Pathophysiology, Diagnosis, and Management. Infect Urol. 2001;14(2).