Epididymitis

Review Literature: (Luzzi and O'Brien, 2001).

Definition, Classification and Etiology of Epididymitis

Acute or chronic inflammation of the epididymis of various etiologies:

Bacterial epididymitis
- Epididymitis secondary to urinary tract infection: E. coli, Proteus, Klebsiella, Pseudomonas, Staphylococci
- Epididymitis secondary to sexually transmitted diseases: Chlamydia, Neisseria
- Tuberculosis: rare cause (hematogenous manifestation)
Nonbacterial infectious epididymitis: viral, fungal or parasitic etiology
Noninfectious epididymitis: traumatic etiology, autoimmune, amiodarone-induced or idiopathic
Chronic epididymitis: duration longer than six weeks
Chronic epididymyalgia

Epididymitis: Signs and Symptoms

Testicular pain: tenderness of the epididymis
Tender and swollen spermatic cord
Swollen Scrotum, reddening and fever with advanced inflammation
Intact cremasteric reflex, Prehn's sign is not reliable, should be positive (lifting of the testis alleviates the pain).

Diagnosis of Epididymitis

Urine analysis:

Urine sediment: leukocyturia.
Urine culture: can identify the pathogen, but is negative at 40–90% of patients.

Ultrasound imaging

Ultrasound imaging is mandatory for differential diagnosis to testicular torsion. In epididymitis, ultrasound imaging shows an enlarged epididymis, often together with a hydrozele [ultrasound imaging: epididymitis]. It is important to rule out abscess formation, involvement of the testicular parenchyma and rule out testicular torsion with Doppler ultrasound (see below).

Ultrasound imaging of epididymitis: typical signs are an enlarged epididymis with a hydrocele. By courtesy, N. Günther, Augsburg.

Doppler ultrasound:

Typical findings for an epididymitis are increased testicular perfusion and an enlarged epididymis. Doppler ultrasound is important for the exclusion of a testicular torsion; however, a false-positive detection of testicular blood flow is possible. An arterial Doppler signal in the testicle should disappear by the compression of the spermatic cord at the external inguinal ring. If the signal is not affected with compression of the spermatic cord, a scrotal vessel is transmitting the Doppler signal.

Surgical Exploration of the Scrotum

In the slightest doubt about the diagnosis of epididymitis, a surgical exploration of the scrotum must be done to exclude testicular torsion. When a testicular tumor might be possible, an inguinal approach to the testis is necessary.

Diagnosing voiding dysfunction

Uroflowmetry, exclusion of residual urine in the bladder, retrograde urethrography and/or cystogram should be performed after healed epididymitis, if a voiding dysfunction is suspected. Voiding dysfunctions are most likely in children and in elderly patients with epididymitis.

Treatment of Epididymitis

Symptomatic Treatment

Bed rest
Elevation and cooling of the testes
Anti-inflammatory drugs such as Dicloenac 75 mg 1-0-1
For the sudden relieve of strong pain: nerve block of the spermatic cord at the external inguinal ring with a long-acting local anesthetic such as bupivacaine

Antibiotic Treatment of Epididymitis

After obtaining a urine culture a calculated antibiotic treatment is initiated:

Suspected sexually transmitted epididymitis:

Ciprofloxacin 500 mg p.o. or ofloxacin 300 mg p.o. or ceftriaxone 250 mg i.m. once followed by doxycycline 100 mg p.o. 1-0-1 for at least 7 days. Alternatives: azithromycin 1 g p.o. once a week.

Epididymitis secondary to urinary tract infection:

Cefuroxim 500 mg 1-0-1 or ciprofloxacin 500 mg 1-0-1 or other quinolone for at least 10 days.

Surgical Therapy

Epididymectomy: indicated in epididymitis refractory to antibiotic treatment or chronic epididymitis. Local complications are frequent (recurrent infections, impaired wound healing, loss of testicle)
Orchiectomy: indicated in epididymo-orchitis, abscess formation and in epididymitis refractory to antibiotic treatment as an alternative to epididymectomy.

Testis, anatomy

Index

Mumps orchitis

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References

Luzzi und O’Brien 2001 LUZZI, G. A. ; O’BRIEN, T. S.:: Acute epididymitis.
In: BJU Int
87 (2001), Nr. 8, S. 747–55

Deutsche Version: Epididymitis: Ursachen und Therapie

Last update:

Dr. med. Dirk Manski (E-Mail)