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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
Non-sexually transmitted form
In men age 35 years and older, associated with urinary tract infections and prostatitis
Caused by enteric gram-negative rods
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Symptoms may follow chronic dysfunctional voiding, urinary retention, urethral catheter placement, 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
Generally cause painless enlargement of the testis
Urinalysis is negative
Examination reveals normal epididymis
Scrotal ultrasound may be helpful in defining pathology
Testicular torsion
Distal ureteral stone
Often presents with referred pain into ipsilateral groin and scrotum
Scrotum is not tender to palpation
Scrotal ultrasound is normal
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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)
Non-sexually transmitted form
Perform urinalysis
Results may show pyuria, bacteriuria, hematuria
Urine cultures may reveal pathogen
Scrotal ultrasound may aid diagnosis if examination is difficult because of a large hydrocele or because questions exist about diagnosis
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Sexually transmitted
Ceftriaxone, 500 mg by intramuscular injection once plus doxycycline, 100 mg orally twice daily for 10 days
Any sexual partners from the preceding 60 days must be evaluated and treated as well
Men who practice insertive anal intercourse should receive ceftriaxone, 500 mg, by intramuscular injection once and levofloxacin, 500 mg orally once daily for 10 days to cover sexually transmitted and enteric organisms
Non-sexually transmitted
Bed rest and ice with scrotal elevation during the acute phase
Prompt treatment usually results in a favorable outcome
Symptoms and signs of epididymitis that do not subside within 3 days require re-evaluation of the diagnosis and therapy
If significant scrotal swelling has developed, this ...