Etiology of Epididymitis
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 years, most cases are due to a sexually transmitted pathogen, especially Neisseria gonorrhoeae or Chlamydia trachomatis. Infection may begin as urethritis Urethritis Bacterial urinary tract infections (UTIs) can involve the urethra, prostate, bladder, or kidneys. Symptoms may be absent or include urinary frequency, urgency, dysuria, lower abdominal pain... read more .
In men > 35 years, 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 United States except in immunocompromised (eg, HIV-infected) patients.
Viral causes (eg, cytomegalovirus infection Cytomegalovirus (CMV) Infection Cytomegalovirus (CMV, human herpesvirus type 5) can cause infections that have a wide range of severity. A syndrome of infectious mononucleosis that lacks severe pharyngitis is common. Severe... read more ) and mycotic causes (eg, actinomycosis Actinomycosis Actinomycosis is a chronic localized or hematogenous anaerobic infection caused by Actinomyces israelii and other species of Actinomyces. Findings are a local abscess with multiple... read more , blastomycosis Blastomycosis Blastomycosis is a pulmonary disease caused by inhaling spores of the dimorphic fungus Blastomyces dermatitidis. Occasionally, the fungi spread hematogenously, causing extrapulmonary... read more ) of epididymitis are rare in the United States 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 of Epididymitis
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 of Epididymitis
Sometimes urethral swab and urine culture
Diagnosis of epididymitis is confirmed by finding swelling and tenderness of the epididymis. However, unless findings are clearly isolated to the epididymis, testicular torsion Testicular Torsion Testicular torsion is an emergency condition due to rotation of the testis and consequent strangulation of its blood supply. Symptoms are acute scrotal pain and swelling, nausea, and vomiting... read more must also be considered, particularly in patients < 30 years; immediate color Doppler ultrasonography is indicated. A genitourinary consultation is indicated if the cause is unclear or the disorder is recurrent.
Pearls & Pitfalls
Urethritis Urethritis Bacterial urinary tract infections (UTIs) can involve the urethra, prostate, bladder, or kidneys. Symptoms may be absent or include urinary frequency, urgency, dysuria, lower abdominal pain... read more suggests that the cause of epididymitis is a sexually transmitted pathogen, and a urethral swab is sent for gonococcus and chlamydia nucleic acid amplification testing (NAAT) or culture. Otherwise, the infecting organism usually can be identified by urine culture. Urinalysis and culture are normal in nonbacterial causes.
Treatment of Epididymitis
Epididymitis treatment consists of 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 levofloxacin 500 mg orally once a day for 10 days. Alternatively, doxycycline 100 mg orally twice a day or sulfamethoxazole/trimethoprim double-strength (160/800 mg) orally twice a day may be used. Levofloxacin with a single dose of ceftriaxone 500 mg IM (1 g in patients > 150 kg) is preferred for patients who practice anal intercourse or if epididymitis is likely caused by enteric organisms. Doxycycline is preferred for patients with suspected gonorrhea or chlamydial acute epididymitis. A single dose of ceftriaxone 500 mg IM (1 g in patients ≥ 150 kg) should be added to oral antibiotics in men who practice insertive anal intercourse or if chlamydia or gonorrhea is suspected (1 Treatment reference Epididymitis is inflammation of the epididymis, occasionally accompanied by inflammation of the testis (epididymo-orchitis). Scrotal pain and swelling usually occur unilaterally. Diagnosis is... read more ). Ceftriaxone treatment also covers gram-negative bacteria (eg, E. coli).
If sepsis is suspected, an aminoglycoside such as tobramycin or a 3rd-generation cephalosporin such as ceftriaxone 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 Urethritis Bacterial urinary tract infections (UTIs) can involve the urethra, prostate, bladder, or kidneys. Symptoms may be absent or include urinary frequency, urgency, dysuria, lower abdominal pain... read more or prostatitis Prostatitis Prostatitis refers to a disparate group of prostate disorders that manifests with a combination of predominantly irritative or obstructive urinary symptoms and perineal pain. Some cases result... read more 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.
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 sulfamethoxazole/trimethoprim, ceftriaxone) and treat pain.
Drugs Mentioned In This Article
|Drug Name||Select Trade|
|Iquix, Levaquin, Levaquin Leva-Pak, Quixin|
|Acticlate, Adoxa, Adoxa Pak, Avidoxy, Doryx, Doxal, Doxy 100, LYMEPAK, Mondoxyne NL, Monodox, Morgidox 1x, Morgidox 2x , Okebo, Oracea, Oraxyl, Periostat, TARGADOX, Vibramycin, Vibra-Tabs|
|Primsol, Proloprim, TRIMPEX|
|Ceftrisol Plus, Rocephin|
|AK-Tob, BETHKIS, Kitabis Pak, Nebcin, Tobi, TOBI Podhaler, Tobrasol , Tobrex|