Epididymitis

Background
Adult testicle with epididymis (left is posterior): A. Head of epididymis, B. Body of epididymis, C. Tail of epididymis, and D. Vas deferens.
  • Often confused with testicular torsion
    • Cremasteric reflex intact in epididymitis
  • Sexually active men <35yo → consider chlamydia, gonorrhea
  • Not sexually active, age >35yo, or anal intercourse → also consider E. coli, pseudomonas, enterobacter, TB, syphilis
  • 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
  • Dysuria
  • Urinary frequency
  • Fever
  • Pain relieved with elevation of testicle (Prehn sign)
    • Sensitivity: 91.3%, specificity: 78.3. Does not rule out testicular torsion

Differential Diagnosis

Testicular Diagnoses

Evaluation

Workup
Acute epididymo-orchitis. Contrast-enhanced CT (a, b) shows thickened and engorged left spermatic cord, with inhomogeneous vascularisation of the ipsilateral epididymis (thin arrows) and testis (arrows). Ultrasound (c) reveals hypervascularisation of the epididymis (+).
  • 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

Antibiotics
  • For acute epididymitis likely caused by STI
  • For acute epididymitis most likely caused by STI and enteric organisms (MSM)
  • For acute epididymitis most likely caused by enteric organisms

Treat sexual partner if possible

  • If med adherence is an issue:

Pediatric Epididymitis[1]
  • 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:

Disposition
  • Admit for systemic signs (fever, chills, nausea/vomiting) or toxic appearance
  • Discharge with urology follow-up in 1 week if non-toxic

See Also

References
  1. Richman MN and Bukowski TP. Pediatric Epididymitis: Pathophysiology, Diagnosis, and Management. Infect Urol. 2001;14(2).
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