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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 epididymyalgia
Epididymitis: Signs and Symptoms
- Testicular pain: tenderness of the epididymis
- Tender and swollen spermatic cord
- Swollen Scrotum, reddening and fever in case of 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 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 of N. Günther, Augsburg.
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
- 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.
- 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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Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
- 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