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Epididymitis

by Patrick J. Shenot, MD

Epididymitis is inflammation of the epididymis, occasionally accompanied by inflammation of the testis (epididymo-orchitis). Scrotal pain and swelling usually occur unilaterally. Diagnosis is based on physical examination. Treatment is with antibiotics, analgesics, and scrotal support.

Etiology

Bacterial

Most epididymitis (and epididymo-orchitis) is caused by bacteria. When inflammation involves the vas deferens, vasitis ensues. When all spermatic cord structures also are involved, the diagnosis is funiculitis. Rarely, epididymal abscess, scrotal extra-epididymal abscess, pyocele (accumulation of pus within a hydrocele), or testicular infarction occurs.

In men < 35 yr, most cases are due to a sexually transmitted pathogen, especially Neisseria gonorrhoeae or Chlamydia trachomatis. Infection may begin as urethritis. In men > 35 yr, most cases are due to gram-negative coliform bacilli and typically occur in patients with urologic abnormalities, indwelling catheters, or recent urologic procedures. Tuberculous epididymitis and syphilitic gummas are rare in the US except in immunocompromised (eg, HIV-infected) patients.


Nonbacterial

Viral causes (eg, cytomegalovirus infection) and mycotic causes (eg, actinomycosis, blastomycosis) are rare in the US except in immunocompromised (eg, HIV-infected) patients. Epididymitis and epididymo-orchitis of noninfectious etiology may be due to chemical irritation secondary to a retrograde flow of urine into the epididymis, which may occur with Valsalva maneuver (eg, with heavy lifting) or after local trauma.


Symptoms and Signs

Scrotal pain occurs in both bacterial and nonbacterial epididymitis. Pain can be severe and is sometimes referred to the abdomen. In bacterial epididymitis, patients may also have fever, nausea, or urinary symptoms. Urethral discharge may be present if the cause is urethritis.

Physical examination reveals swelling, induration, marked tenderness, and sometimes erythema of a portion of or all of the affected epididymis and, sometimes, the adjacent testis. Sepsis is suggested by fever, tachycardia, hypotension, and a toxic appearance.

Diagnosis

  • Clinical evaluation

  • Sometimes urethral swab and urine culture

Diagnosis is confirmed by finding swelling and tenderness of the epididymis. However, unless findings are clearly isolated to the epididymis, testicular torsion (see Testicular Torsion) must also be considered, particularly in patients < 30 yr; immediate color Doppler ultrasonography is indicated. A GU consultation is indicated if the cause is unclear or the disorder is recurrent.

Pearls & Pitfalls

  • In males with acute scrotal pain, exclude testicular torsion unless findings are clearly limited to the epididymis.

Urethritis suggests that the cause of epididymitis is a sexually transmitted pathogen, and a urethral swab is sent for gonococcus and chlamydia culture or PCR. Otherwise, the infecting organism usually can be identified by urine culture. Urinalysis and culture are normal in nonbacterial causes.

Treatment

  • Antibiotics

  • Supportive measures

Treatment consists of bed rest, scrotal elevation (eg, with a jockstrap when upright) to decrease repetitive, minor bumps, scrotal ice packs, anti-inflammatory analgesics, and a broad-spectrum antibiotic such as ciprofloxacin 500 mg po bid or levofloxacin 500 mg po once/day for 21 to 30 days. Alternatively, doxycycline 100 mg po bid or trimethoprim/sulfamethoxazole double-strength (160/800 mg) po bid may by used. If sepsis is suspected, an aminoglycoside such as tobramycin 1 mg/kg IV q 8 h or a 3rd-generation cephalosporin such as ceftriaxone 1 to 2 g IV once/day may be useful until the infecting organism and its sensitivities are known. Abscess and pyocele usually require surgical drainage.

Recurrent bacterial epididymitis secondary to incurable chronic urethritis or prostatitis occasionally can be prevented by vasectomy. An epididymectomy, occasionally done for chronic epididymitis, may not relieve symptoms. Patients who must continuously wear an indwelling urethral catheter are prone to develop recurrent epididymitis and epididymo-orchitis. In such cases, placement of a suprapubic cystostomy or institution of a self-catheterization regimen may be useful.

Treatment of nonbacterial epididymitis includes the above general measures, but antimicrobial therapy is not warranted. Nerve block of the spermatic cord with local anesthesia can relieve symptoms in severe, persistent cases.

Key Points

  • The most common causes of epididymitis are bacteria: Neisseria gonorrhoeae and Chlamydia trachomatis in younger men and adolescents, and gram-negative coliform bacilli in older men.

  • Tenderness affects the epididymis and often the testis.

  • Diagnose epididymitis clinically and exclude testicular torsion by clinical findings or, if necessary, by color Doppler ultrasonography.

  • For most cases, give antibiotics (eg, for outpatient treatment, a fluoroquinolone, doxycycline, or trimethoprim/sulfamethoxazole) and treat pain.

Resources In This Article

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • PERIOSTAT, VIBRAMYCIN
  • ROCEPHIN
  • IQUIX, LEVAQUIN, QUIXIN
  • CILOXAN, CIPRO
  • No US brand name
  • TOBI, TOBREX

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