Epididymitis, Acute

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