Inflammation of the epididymis – is an important cause of morbidity and is the fifth most frequent urological diagnosis in men aged 18 to 50 years.
Epididymitis must be differentiated from testicular torsion, which is a true urological emergency.
Signs and symptoms
The following history findings are associated with acute epididymitis and orchitis:
- Gradual onset of scrotal pain and swelling, often developing over several days (as opposed to hours of testicular torsion).
- Generally located on 1 side.
- Dysuria, frequent or urgent.
- Fever and chills (in only 25% of adults with acute epididymitis, but in up to 71% of children with the condition).
- Usually, there is no nausea or vomiting (in contrast to testicular torsion).
- Urethral discharge preceding the onset of acute epididymitis (in some cases)
The following history findings are associated with chronic epididymitis:
- Prolonged history (> 6 weeks) of pain.
- Scrotum that is not usually swollen but can be hardened in long-standing cases.
- The following history findings are associated with mumps orchitis:
- Fever, malaise and myalgia (common).
- Parotiditis typically preceding the onset of orchitis for 3-5 days.
- Subclinical infections (30-40% of patients).
The findings of the physical examination may not distinguish acute epididymitis from testicular torsion and may include the following:
- Softness and induration occur first in the epididymal tail and then spread.
- Elevation of the affected hemiscrotum.
- Normal creosotetic reflex.
- Erythema and mild scrotal cellulitis.
- Reactive hydrocele (in patients with advanced epididymo-orchitis).
- Bacterial prostatitis or seminal vesiculitis (in postpubertal individuals).
- With tuberculosis, focal epididymitis, a draining sinus, or a flange of the vas deferens.
- In children, an underlying congenital anomaly of the urogenital tract.
The findings associated with orchitis may include the following:
- Testicular enlargement, hardening, and reactive hydrocele (common).
- Epididymis not predator.
- In 20-40% of cases, association with acute epididymitis.
The following laboratory studies may be indicated for suspected epididymitis:
- Urinalysis: Pyuria or bacteriuria (50%); Urine culture indicated for prepubertal and elderly patients.
- Complete blood count: leukocytosis.
- Gram stain of urethral discharge, if present.
- Urethral culture, nucleic acid hybridization and nucleic acid amplification tests to facilitate the detection of Neisseria gonorrhoeae and Chlamydia trachomatis.
- Realization of (or derivation) of syphilis and HIV tests in patients with a sexually transmitted etiology.
The use of C-reactive protein and the rate of erythrocyte sedimentation to differentiate epididymitis from other causes of the acute scrotum is being investigated.
Imaging studies that can be considered to evaluate structural abnormalities and help distinguish acute epididymitis from testicular torsion include the following:
- Cytourethrogram of cancellation.
- Retrograde urethrography.
- Abdominal / pelvic ultrasonography.
- Radionuclide scan and scintigraphy.
- In tuberculous epididymitis, chest x-ray, computerized tomography or excretory urography.
Other measures that may be useful for the evaluation are the following:
- Scrotal exploration or aspiration.
- Management of the situation.
The pharmacological treatment of epididymitis may include the following:
In chronic epididymitis, a 4-6 week test of antibiotics effective against bacterial pathogens (especially chlamydiae).
In the treatment of epididymitis secondary to Chlamydia trachomatis or Neisseria gonorrhoeae, the treatment of all sexual partners.
In prepubertal patients with epididymitis, antibiotic therapy only for the young and those with pyuria or the positive findings of the urine culture.
In addition to antibiotics (except in viral epididymitis), the pillars of supportive therapy for acute epididymitis and orchitis are the following:
- Reduction of physical activity.
- Scrotal support and elevation.
- Ice compresses.
- Anti-inflammatory agents.
- Analgesics, including nerve blocks.
- Avoidance of urethral instrumentation.
- Sitz baths.
Surgical options include the following:
Epididimotomy: It is performed infrequently in patients with acute suppurative epididymitis.
Epididymectomy: Usually reserved for refractory cases.
Orchiectomy: Indicated only for patients with relentless epididymal pain.
Skeletalization of the spermatic cord by subaginal varicocelectomy: Performed in rare cases of refractory pain due to chronic epididymitis and orchialgia.
Epididymitis is defined as the inflammation of the epididymis, the narrowly spiral segment of the spermatic duct that connects the efferent duct of the posterior aspect of each testicle to its respective vas deferens.
It is a major cause of morbidity and is commonly observed by urologists, emergency medicine physicians, and primary care physicians.
Epididymitis is the fifth most common urological diagnosis in men aged 18 to 50 years. It is an important entity to differentiate from testicular torsion, which is a true urological emergency.
Acute epididymitis is characterized by the appearance of epididymal pain and inflammation over a period of several days.
Chronic epididymitis is characterized by pain and epididymal inflammation lasting more than 6 weeks and may be accompanied by scrotal induration.
Although epididymitis can often be an infectious process, cultures commonly fail to demonstrate any identifiable infection.
The infection that is severe and extends to the adjacent testicle is called an acute epididymal-orchitis.
It should be noted that idiopathic scrotal pain and orchialgia can be misdiagnosed as epididymitis.
However, with proper evaluation and careful physical examination, these entities can distinguish themselves and obtain an adequate diagnosis.
The complications associated with acute epididymitis and bacterial orchitis are the following:
- Scrotal abscess and picocele.
- Testicular infarction: inflammation of the cord can limit the blood flow of the testicular artery.
- Fertility problems
- Testicular atrophy
- Cutaneous fistulization due to rupture of an abscess (observed especially in tuberculosis).
- Recurrence, chronic epididymitis and orchialgia.
With respect to the last point above, the true local pain can be distinguished from the pain referred to by injection of the spermatic cord with 1% lidocaine.
Refractory pain that is not improved by analgesics has also been managed by denervation of the spermatic cord.
Generally and when it is detected in time, epididymitis can be combated and treated, generating positive expectations in patients.