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For further information, see CMDT Part 23-03: Genitourinary Tract Infections

Key Features

  • Painful enlargement of the epididymis, relieved by scrotal elevation

  • Fever and irritative voiding symptoms are common

  • In advanced cases, infection can spread to the testis and the entire scrotal contents become tender to palpation

  • Sexually transmitted form

    • Typically in men under age 35

    • Associated with urethritis

    • Caused by Chlamydia trachomatis or Neisseria gonorrhoeae

  • Nonsexually transmitted form

    • In men aged 35 years and older, associated with urinary tract infections and prostatitis

    • Caused by enteric gram-negative rods

Clinical Findings

  • Symptoms may follow chronic dysfunctional voiding, urinary retention, sexual activity or trauma

  • Associated symptoms of urethritis (pain at the tip of the penis and urethral discharge) or cystitis (irritative voiding symptoms)

  • Pain in the scrotum may radiate along the spermatic cord or to the flank

  • Scrotal swelling and tenderness are usually apparent

  • Severe cases may develop systemic symptoms such as fever

  • Early in the course, the epididymis may be distinguishable from the testis; however, later the two may appear as one enlarged, tender mass

  • A reactive hydrocele may develop

  • The prostate may be tender on rectal examination

  • Differential diagnosis

    • Tumors of the testis

    • Testicular torsion

    • Distal ureteral stone

Diagnosis

  • Complete blood count: leukocytosis and left shift

  • Sexually transmitted form

    • Perform Gram stain of urethral discharge

    • Results may show white cells and gram-negative intracellular diplococci (N gonorrhoeae) or white cells without visible organisms (nongonococcal urethritis, C trachomatis)

  • Nonsexually transmitted form

    • Perform urinalysis

    • Results may show pyuria, bacteriuria, hematuria

    • Urine cultures may reveal pathogen

Treatment

  • Sexually transmitted

    • Intramuscular injection of ceftriaxone plus 10 days of oral doxycycline

    • Any sexual partners from the preceding 60 days must be evaluated and treated as well

    • Men who practice insertive anal intercourse receive a single intramuscular injection of ceftriaxone (250 mg) and 10 days of a fluoroquinolone (ciproflxacin 500 mg twice daily) to cover sexually transmitted and enteric organisms

  • Nonsexually transmitted

    • Treated for 10 days with a fluoroquinolone, at which time evaluation of the urinary tract is warranted to identify underlying disease

  • Evaluate urinary tract to identify underlying disease

  • Bed rest and ice with scrotal elevation

  • Prompt treatment usually results in a favorable outcome

  • Symptoms and signs of epididymitis that do not subside within 3 days require reevaluation of the diagnosis and therapy

  • If significant scrotal swelling has developed, this may take 4 weeks to resolve

  • Delayed or inadequate treatment may result in epididymo-orchitis, decreased fertility, abscess formation

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