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For further information, see CMDT Part 25-03: 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

  • Non-sexually transmitted form

    • In men age 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, 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

      • Acute onset of symptoms and negative urinalysis

      • Prehn sign (elevation of scrotum improves pain from epididymitis) is suggestive but not reliable

    • Distal ureteral stone

      • Often presents with referred pain into ipsilateral groin and scrotum

      • Scrotum is not tender to palpation

      • Scrotal ultrasound is normal

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)

  • 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

TREATMENT

  • 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

    • Treated with levofloxacin, 500 mg orally once daily for 10 days

  • 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 ...

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