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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 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:

Urethral swab and PCR testing for gonorrhea or chlamydial infection if STD are possible.

Urine analysis:

• 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).

Ultrasound imaging of epididymitis: typical signs are an enlarged epididymis with a hydrocele. With kind permission, N. Wagner, Augsburg.

Doppler ultrasound:

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

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 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.

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.

References

  Deutsche Version: Epididymitis: Ursachen und Therapie