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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 epididymalgia: chronic pain felt in the epididymis
Epididymitis: Signs and Symptoms
- Testicular pain: tenderness of the epididymis
- Tender and swollen spermatic cord
- Scrotal swelling and redness
- Intact cremasteric reflex, the Prehn sign is not reliable, should be positive (lifting of the testis alleviates the pain).
- fever indicates advanced infection.
- Complications: abscess, urosepsis, Fournier gangrene.
Diagnosis of Epididymitis
Urethral swab and PCR testing for gonorrhea or chlamydial infection if STD are possible.
- Urine sediment: leukocyturia.
- Urine culture: can identify the pathogen, but is negative at 40–90% of patients.
Testicular Ultrasound Imaging
Testicular ultrasound examination 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).
Doppler ultrasound is important for the exclusion of a testicular torsion. Typical findings for an epididymitis are increased testicular perfusion and an enlarged epididymis.
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 should be chosen.
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
- 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 ropivacaine
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:
Ciprofloxacin 500 mg 1-0-1 or other quinolone for at least 10 days. Alternatives are aminopenicillins with penicillinase inhibitor or oral cephalosporins, if necessary correction of the antibiotic depending on urine culture result.
- 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.
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ReferencesLuzzi 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