Key History

Key Physical Exam

Classification Systems

• Sexually transmitted - usually men < 35 years old: C. trachomatis & N. gonorrhea
• Non-sexually transmitted - usually men > 35 years old: Coliforms (e.g., E. coli) & Pseudomonas most common; TB, syphilis: usually in men, and meningococcus are also seen.
• Anal intercourse or having urinary tract instrumentation: Enterobacteriaceae or Pseudomonas

Risk Factors for Epididymitis

Differential Diagnosis

Diagnostic Testing

1. Labs:
• Urinalysis – 50% show pyuria or bacteriuria
• Gram stain of urethral discharge may demonstrate organisms
• Urethral culture or DNA probe: for Chlamydia trachomatis and Neisseria gonorrhoeae
• CBC – leukocytosis
2. Imaging studies: Typically used to distinguish torsion from epididymitis
• Color Doppler ultrasound is the most common study utilized for imaging of the testicle and differentiating between torsion and epididymitis.
• Small studies to date recognize a high degree of accuracy utilizing MRI when it is performed with contrast enhancement.

Clinical Risk and Safety Pearls

• A patient with a painful testicle has a “seconds to minutes emergency” requiring immediate evaluation to identify and treat testicular torsion when present. Testicular torsion should always be considered in patients presenting with a scrotal complaint.
• Fever, redness or swelling suggests the possibility of a scrotal infection. The most important infection to recognize is Fournier’s gangrene, a life-threatening, rapidly progressive, multi-microbial infection often including gas-forming bacteria. Also consider cellulitis or scrotal abscess.
• Epididymitis is the most frequent misdiagnosis in cases of testicular torsion. The delay caused by the misdiagnosis can result in testicular loss. It is important to differentiate the conditions, and if unclear, obtain an imaging study.

• It may be possible to differentiate tenderness in the epididymis versus testicle torsion early in either process. However, later in the process, diffuse tenderness when palpating either the epididymis or the testicle can occur with both clinical entities. In addition, although pyuria is most typical of epididymitis, it can also occur in late torsion as inflammation becomes widespread.
• ALL pediatric (prepubertal) cases of epididymitis require immediate urology consultation because of the high incidence of associated genitourinary anomalies.
• Patients discharged with a diagnosis of epididymitis should have a follow-up appointment with a private physician or specialist to evaluate for testicular tumor.
• Patients with epididymitis from a sexually transmitted disease have 2-5 times the risk of acquiring and transmitting the human immunodeficiency virus (HIV).
• Prehn’s sign – decreased pain with scrotal elevation or support. Prehn’s sign is NOT reliable for distinguishing epididymitis from testicular torsion.
• Pain improves within 3 days of treatment. However, induration may take several weeks or months to resolve completely.
• Patients with epididymitis who are younger than 25 typically have Chlamydia Trachomatis or Neisseria Gonorrhoeae as the causative organism.
• Patients with epididymitis who are older than 35 typically have coliform bacteria, a pseudomonas species, or occasionally staphylococcus as the causative organism.

Treatment

1. If unable to differentiate epididymitis from testicular torsion, obtain an immediate urologic consultation.
2. Appropriate empiric antibiotic therapy should be instituted even if gram stains are negative.
3. Provide analgesics for pain.
4. Scrotal elevation significantly decreased the pain of epididymitis. Athletic supporters may provide symptomatic relief.
5. Apply an ice pack to the painful area. It will reduce swelling and pain.
6. Provide evaluation or referral for syphilis and HIV testing in cases caused by STD.
7. All pediatric cases of epididymitis require immediate urology consultation because of the high incidence of associated genitourinary anomalies.
8. Most cases of epididymitis can be managed on an outpatient basis with follow-up with a urologist in 3 to 5 days. Inpatient treatment is rarely indicated except in those patients who are septic, have systemic symptoms, or are unable to tolerate oral medication.
9. The CDC recommendations for treatment are as follows:
• For acute epididymitis most likely caused by Chlamydia trachomatis or Neisseria gonorrhoeae:
1. Ceftriaxone 500 mg intramuscularly (IM) in a single dose (1 g for persons weighing ≥150 kg)
2. Doxycycline 100 mg orally twice daily for 10 days
• For acute epididymitis most likely caused by Chlamydia trachomatis, Neisseria gonorrhoeae, or enteric organisms (e.g., in men who practice insertive anal sex):
1. Ceftriaxone 500 mg IM in a single dose (1 g for persons weighing ≥150 kg)
2. Levofloxacin 500 mg orally once daily for 10 days
• For acute epididymitis most likely caused by enteric organisms only (e.g., in men over 35 years or those with recent urinary tract instrumentation):
1. Levofloxacin 500 mg orally once daily for 10 days
10. Patients who have acute epididymitis, either confirmed or suspected to be caused by N. gonorrhoeae or C. trachomatis, should be instructed to refer sex partners for evaluation and treatment if their contact with the index patient was within the 60 days preceding onset of the patient’s symptoms.
11. Patients should be instructed to avoid sexual intercourse until they and their sex partners are cured (i.e., until therapy is completed and patient and partners no longer have symptoms).

Complications

• Fournier’s gangrene – necrotizing synergistic infection
• Infertility
• Recurrent epididymitis