Epididymitis

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Epididymitis
Other namesInflammation of the epididymis [1]
Acute epididymitis, low mag.jpg
Acute epididymitis with abundant fibrinopurulent exudate in the tubules.
Pronunciation
Specialty Urology, infectious disease
Symptoms Pain in the back of the testicle, swelling of the testicle, burning with urination, frequent urination [1]
Complications Infertility, chronic pain [1]
Usual onsetOver a day or two [1]
TypesAcute (< 6 weeks), chronic (>12 weeks) [1]
Causes Gonorrhea, chlamydia, enteric bacteria, reflux of urine [1]
Diagnostic method Based on symptoms, ultrasound [1]
Differential diagnosis Testicular torsion, inguinal hernia, testicular cancer, orchitis [1] [2]
Treatment Pain medications, antibiotics, elevation [1]
Medication NSAIDs, ceftriaxone and doxycycline, ofloxacin [1]
Frequency600,000 per year (age 15-35, US) [2]

Epididymitis is a medical condition characterized by inflammation of the epididymis, a curved structure at the back of the testicle. [1] Onset of pain is typically over a day or two. [1] The pain may improve with raising the testicle. [1] Other symptoms may include swelling of the testicle, burning with urination, or frequent urination. [1] Inflammation of the testicle is commonly also present. [1]

Contents

In those who are young and sexually active, gonorrhea and chlamydia are frequently the underlying cause. [1] In older males and men who practice insertive anal sex, enteric bacteria are a common cause. [1] Diagnosis is typically based on symptoms. [1] Conditions that may result in similar symptoms include testicular torsion, inguinal hernia, and testicular cancer. [1] Ultrasound can be useful if the diagnosis is unclear. [1]

Treatment may include pain medications, NSAIDs, and elevation. [1] Recommended antibiotics in those who are young and sexually active are ceftriaxone and doxycycline. [1] Among those who are older, ofloxacin may be used. [1] Complications include infertility and chronic pain. [1] People aged 15 to 35 are most commonly affected, with about 600,000 people within this age group affected per year in the United States. [2]

Signs and symptoms

Adult human testicle with epididymis: A. Head of epididymis, B. Body of epididymis, C. Tail of epididymis, and D. Vas deferens Epididymis-KDS.jpg
Adult human testicle with epididymis: A. Head of epididymis, B. Body of epididymis, C. Tail of epididymis, and D. Vas deferens

Those aged 15 to 35 are most commonly affected. [2] The acute form usually develops over the course of several days, with pain and swelling frequently in only one testis, which will hang low in the scrotum. [3] There will often be a recent history of dysuria or urethral discharge. [3] Fever is also a common symptom. In the chronic version, the patient may have painful point tenderness but may or may not have an irregular epididymis upon palpation, though palpation may reveal an indurated epididymis. A scrotal ultrasound may reveal problems with the epididymis, but such an ultrasound may also show nothing unusual. The majority of patients who present with chronic epididymitis have had symptoms for over five years. [4] : p.311 

Complications

Untreated, acute epididymitis's major complications are abscess formation and testicular infarction. Chronic epididymitis can lead to permanent damage or even destruction of the epididymis and testicle (resulting in infertility and/or hypogonadism), and infection may spread to any other organ or system of the body. Chronic pain is also an associated complication for untreated chronic epididymitis. [5]

Causes

Though urinary tract infections in men are rare, bacterial infection is the most common cause of acute epididymitis. [6] The bacteria in the urethra back-track through the urinary and reproductive structures to the epididymis. In rare circumstances, the infection reaches the epididymis via the bloodstream. [7]

In sexually active men, Chlamydia trachomatis is responsible for two-thirds of acute cases, followed by Neisseria gonorrhoeae and E. coli (or other bacteria that cause urinary tract infection). Particularly among men over age 35 in whom the cause is E. coli, epididymitis is commonly due to urinary tract obstruction. [3] [8] Less common microbes include Ureaplasma , Mycobacterium, and cytomegalovirus , or Cryptococcus in patients with HIV infection. E. coli is more common in boys before puberty, the elderly, and men who have sex with men. In the majority of cases in which bacteria are the cause, only one side of the scrotum or the other is the locus of pain. [9]

Non-infectious causes are also possible. Reflux of sterile urine (urine without bacteria) through the ejaculatory ducts may cause inflammation with obstruction. In children, it may be a response following an infection with enterovirus, adenovirus or Mycoplasma pneumoniae . Rare non-infectious causes of chronic epididymitis include sarcoidosis (more prevalent in black men) and Behçet's disease. [4] : p.311 

Any form of epididymitis can be caused by genito-urinary surgery, including prostatectomy and urinary catheterization. Congestive epididymitis is a long-term complication of vasectomy. [10] [11] Chemical epididymitis may also result from drugs such as amiodarone. [12]

Diagnosis

Doppler ultrasound of epididymitis, seen as a substantial increase in blood flow in the left epididymis (top image), while it is normal in the right (bottom image). The thickness of the epididymis (between yellow crosses) is only slightly increased. Ultrasonography of epididymitis.jpg
Doppler ultrasound of epididymitis, seen as a substantial increase in blood flow in the left epididymis (top image), while it is normal in the right (bottom image). The thickness of the epididymis (between yellow crosses) is only slightly increased.

Diagnosis is typically based on symptoms. [1] Conditions that may result in similar symptoms include testicular torsion, inguinal hernia, and testicular cancer. [1] Ultrasound can be useful if the diagnosis is unclear. [1]

Epididymitis usually has a gradual onset. Typical findings are redness, warmth and swelling of the scrotum, with tenderness behind the testicle, away from the middle (this is the normal position of the epididymis relative to the testicle). The cremasteric reflex (elevation of the testicle in response to stroking the upper inner thigh) remains normal. [1] This is a useful sign to distinguish it from testicular torsion. If there is pain relieved by elevation of the testicle, this is called Prehn's sign, which is, however, non-specific and is not useful for diagnosis. [13] Before the advent of sophisticated medical imaging techniques, surgical exploration was the standard of care. Today, Doppler ultrasound is a common test: it can demonstrate areas of blood flow and can distinguish clearly between epididymitis and torsion. However, as torsion and other sources of testicular pain can often be determined by palpation alone, some studies have suggested that the only real benefit of an ultrasound is to assure the person that they do not have testicular cancer. [14] : p.237  Nuclear testicular blood flow testing is rarely used.[ citation needed ]

Additional tests may be necessary to identify underlying causes. In younger children, a urinary tract anomaly is frequently found. In sexually active men, tests for sexually transmitted infections may be done. These may include microscopy and culture of a first void urine sample, Gram stain and culture of fluid or a swab from the urethra, nucleic acid amplification tests (to amplify and detect microbial DNA or other nucleic acids) or tests for syphilis and HIV.

Classification

Histopathology image of inflamed epididymis and testis Suppurative epidydimo orchitis histopathology.jpg
Histopathology image of inflamed epididymis and testis

Epididymitis can be classified as acute, subacute, and chronic, depending on the duration of symptoms. [6]

Chronic epididymitis

Scrotal ultrasound showing calcifications and cysts in a case of chronic epididymis. Epididymal calcifications and cyst.jpg
Scrotal ultrasound showing calcifications and cysts in a case of chronic epididymis.

Chronic epididymitis is epididymitis that is present for more than 3 months. Chronic epididymitis is characterized by inflammation even when there is no infection present. Tests are needed to distinguish chronic epididymitis from a range of other disorders that can cause constant scrotal pain including testicular cancer (though this is often painless), enlarged scrotal veins (varicocele), calcifications, [15] and a possible cyst within the epididymis. Some research has found that as much as 80% of visits to a urologist for scrotal pain are for chronic epididymitis. [4] : p.311  As a further complication, the nerves in the scrotal area are closely connected to those of the abdomen, sometimes causing abdominal pain similar to a hernia (see referred pain).

Chronic epididymitis is most commonly associated with lower back pain, and the onset of pain often co-occurs with activity that stresses the low back (i.e., heavy lifting, long periods of car driving, poor posture while sitting, or any other activity that interferes with the normal curve of the lumbar lordosis region). [14] : p.237 

Treatment

In both the acute and chronic forms, antibiotics are used if an infection is suspected. The treatment of choice is often azithromycin and cefixime to cover both gonorrhoeae and chlamydia. Fluoroquinolones are no longer recommended due to widespread resistance of gonorrhoeae to this class. [8] Doxycycline may be used as an alternative to azithromycin. In chronic epididymitis, a four- to six-week course of antibiotics may be prescribed to ensure the complete eradication of any possible bacterial cause, especially the various chlamydiae.

For cases caused by enteric organisms (such as E. coli), ofloxacin or levofloxacin are recommended. [8]

In children, fluoroquinolones and doxycycline are best avoided. Since bacteria that cause urinary tract infections are often the cause of epididymitis in children, co-trimoxazole or suited penicillins (for example, cephalexin) can be used.[ citation needed ]

Household remedies such as elevation of the scrotum and cold compresses applied regularly to the scrotum may relieve the pain in acute cases. Painkillers or anti-inflammatory drugs are often used for treatment of both chronic and acute forms. Hospitalisation is indicated for severe cases, and check-ups can ensure the infection has cleared up. Surgical removal of the epididymis is rarely necessary, causes sterility, and only gives relief from pain in approximately 50% of cases. [5] However, in acute suppurating epididymitis (acute epididymitis with a discharge of pus), an epididymotomy may be recommended; in refractory cases, a full epididymectomy may be required. In cases with unrelenting testicular pain, removal of the entire testicle—orchiectomy—may also be warranted.

It is generally believed that most cases of chronic epididymitis will eventually "burn out" of patient's system if left untreated, though this might take years or even decades. [5] However, some prostate-related medications have proven effective in treating chronic epididymitis, including doxazosin. [16]

Epidemiology

Epididymitis makes up 1 in 144 visits for medical care (0.69 percent) in men 18 to 50 years old or 600,000 cases in males between 18 and 35 in the United States. [6]

It occurs primarily in those 16 to 30 years of age and 51 to 70 years. [6] As of 2008, there appears to be an increase in incidence in the United States that parallels an increase in reported cases of chlamydia and gonorrhea. [8]

Related Research Articles

Urethritis is the inflammation of the urethra. The most common symptoms include painful or difficult urination and urethral discharge. It is a commonly treatable condition usually caused by infection with bacteria. This bacterial infection is often sexually transmitted, but not in every instance; it can be idiopathic, for example. Some incidence of urethritis can appear asymptomatic as well.

<span class="mw-page-title-main">Urinary tract infection</span> Infection that affects part of the urinary tract

A urinary tract infection (UTI) is an infection that affects a part of the urinary tract. When it affects the lower urinary tract it is known as a bladder infection (cystitis) and when it affects the upper urinary tract it is known as a kidney infection (pyelonephritis). Symptoms from a lower urinary tract infection include pain with urination, frequent urination, and feeling the need to urinate despite having an empty bladder. Symptoms of a kidney infection include fever and flank pain usually in addition to the symptoms of a lower UTI. Rarely the urine may appear bloody. In the very old and the very young, symptoms may be vague or non-specific.

<span class="mw-page-title-main">Mumps</span> Human disease caused by paramyxovirus

Mumps is a highly contagious viral disease caused by the mumps virus. Initial symptoms of mumps are non-specific and include fever, headache, malaise, muscle pain, and loss of appetite. These symptoms are usually followed by painful swelling around the side of the face, which is the most common symptom of a mumps infection. Symptoms typically occur 16 to 18 days after exposure to the virus. About one third of people with a mumps infection do not have any symptoms (asymptomatic).

<span class="mw-page-title-main">Testicular torsion</span> Medical condition

Testicular torsion occurs when the spermatic cord twists, cutting off the blood supply to the testicle. The most common symptom in children is sudden, severe testicular pain. The testicle may be higher than usual in the scrotum and vomiting may occur. In newborns, pain is often absent and instead the scrotum may become discolored or the testicle may disappear from its usual place.

<span class="mw-page-title-main">Testicular self-examination</span>

Testicular self-examination (TSE) is a procedure where a man examines his own testicles and scrotum for possible lumps or swelling. It is usually undertaken at home while standing in front of a mirror and after having a warm bath or shower. Monthly self-examination of the testicles starting at puberty may be an effective way of detecting testicular cancer at an early, potentially treatable stage, which can lead to a 5-year survival rate of 98%. In men aged 15 to 40, testicular cancer is the most common cancer, and the annual rate of increase over the last 10 years in cases of testicular cancer has been shown to be approximately 1% each year. Testicular cancer typically presents with a painless testicular swelling or lump or any change in shape or texture of the testicles.

Orchitis is inflammation of the testicles. It can also involve swelling, pains and frequent infection, particularly of the epididymis, as in epididymitis. The term is from the Ancient Greek ὄρχις meaning "testicle"; same root as orchid.

<span class="mw-page-title-main">Spermatocele</span> Medical condition

Spermatocele is a fluid-filled cyst that develops in the epididymis. The fluid is usually a clear or milky white color and may contain sperm. Spermatoceles are typically filled with spermatozoa and they can vary in size from several millimeters to many centimeters. Small spermatoceles are relatively common, occurring in an estimated 30 percent of males. They are generally not painful. However, some people may experience discomfort such as a dull pain in the scrotum from larger spermatoceles. They are not cancerous, nor do they cause an increased risk of testicular cancer. Additionally, unlike varicoceles, they do not reduce fertility.

<span class="mw-page-title-main">Testicular atrophy</span> Reduction in the size and function of the testicles

Testicular atrophy is a medical condition in which one or both testicles diminish in size and may be accompanied by reduced testicular function. Testicular atrophy is not related to the temporary shrinkage of the surrounding scrotum, which might occur in response to cold temperature.

<span class="mw-page-title-main">Polyorchidism</span> Medical condition

Polyorchidism is the incidence of more than two testicles. It is a very rare congenital disorder, with fewer than 200 cases reported in medical literature and six cases in veterinary literature.

<span class="mw-page-title-main">Hydrocele</span> Accumulation of fluid in a body cavity

A hydrocele is an accumulation of serous fluid in a body cavity. A hydrocele testis, the most common form of hydrocele, is the accumulation of fluids around a testicle. It is often caused by fluid collecting within a layer wrapped around the testicle, called the tunica vaginalis, which is derived from peritoneum. Provided there is no hernia present, it goes away without treatment in the first year. Although hydroceles usually develop in males, rare instances have been described in females in the canal of Nuck.

<span class="mw-page-title-main">Hematocele</span> Medical condition

A hematocele is a collections of blood in a body cavity or potential space. The term most commonly refers to the collection of blood in the tunica vaginalis around the testes, known as a scrotal hematocele. Hematoceles can also occur in the abdominal cavity and other body cavities. Hematoceles are rare, making them harder to diagnose and treat. They are very common especially as slowly growing masses in the scrotum usually in men older than 50 years.

<span class="mw-page-title-main">Testicular pain</span> Medical condition

Testicular pain, also known as scrotal pain, occurs when part or all of either one or both testicles hurt. Pain in the scrotum is also often included. Testicular pain may be of sudden onset or of long duration.

<span class="mw-page-title-main">Prehn's sign</span> Medical sign for testicular pain

Prehn's sign is a medical diagnostic indicator that was once believed to help determine whether the presenting testicular pain is caused by acute epididymitis or from testicular torsion. Although elevation of the scrotum when differentiating epididymitis from testicular torsion is of clinical value, Prehn's sign has been shown to be inferior to Doppler ultrasound to rule out testicular torsion.

<span class="mw-page-title-main">Chronic testicular pain</span> Medical condition

Chronic testicular pain is long-term pain of the testes. It is considered chronic if it has persisted for more than three months. Chronic testicular pain may be caused by injury, infection, surgery, cancer, varicocele, or testicular torsion, and is a possible complication after vasectomy. IgG4-related disease is a more recently identified cause of chronic orchialgia.

<span class="mw-page-title-main">Acute prostatitis</span> Serious bacterial infection of the prostate gland

Acute prostatitis is a serious bacterial infection of the prostate gland. This infection is a medical emergency. It should be distinguished from other forms of prostatitis such as chronic bacterial prostatitis and chronic pelvic pain syndrome (CPPS).

<span class="mw-page-title-main">Sperm granuloma</span> Lump of extravasated sperm found in some vasectomized men

A sperm granuloma is a lump of leaked sperm that appears along the vasa deferentia or epididymides in vasectomized individuals. While the majority of sperm granulomas are present along the vas deferens, the rest of them form at the epididymis. Sperm granulomas range in size, from one millimeter to one centimeter. They consist of a central mass of degenerating sperm surrounded by tissue containing blood vessels and immune system cells. Sperm granulomas may also have a yellow, white, or cream colored center when cut open. While some sperm granulomas can be painful, most of them are painless and asymptomatic. Sperm granulomas can appear as a result of surgery, trauma, or an infection. They can appear as early as four days after surgery and fully formed ones can appear as late as 208 days later.

Urologic diseases or conditions include urinary tract infections, kidney stones, bladder control problems, and prostate problems, among others. Some urologic conditions do not affect a person for that long and some are lifetime conditions. Kidney diseases are normally investigated and treated by nephrologists, while the specialty of urology deals with problems in the other organs. Gynecologists may deal with problems of incontinence in women.

<span class="mw-page-title-main">Scrotal ultrasound</span> Medical ultrasound examination of the scrotum.

Scrotalultrasound is a medical ultrasound examination of the scrotum. It is used in the evaluation of testicular pain, and can help identify solid masses.

Male genital examination is a physical examination of the genital in males to detect ailments and to assess sexual development, and is normally a component of an annual physical examination. The examination includes checking the penis, scrotum, and urethral meatus. A comprehensive assessment of the male genitals assesses the pubic hair based on Sexual Maturity Rating and the size of the testicles and penis. The exam can also be conducted to verify a person's age and biological sex. The genitourinary system can also be assessed as part of the male genital examination. During a genital examination, the doctor can detect any of the following: structural abnormalities, urethral opening abnormalities, problems related to not being circumcised, lumps, tumors, redness, excoriation, edema, lesions, swelling, cancer, hair-related issues, and many others. In some instances where a physical examination of the male genitals is not sufficient to diagnose an individual, then an internal genital examination using imaging or ultrasounds will be needed for further evaluation.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 McConaghy, JR; Panchal, B (1 November 2016). "Epididymitis: An Overview". American Family Physician. 94 (9): 723–726. PMID   27929243.
  2. 1 2 3 4 Trojian, TH; Lishnak, TS; Heiman, D (1 April 2009). "Epididymitis and orchitis: an overview". American Family Physician. 79 (7): 583–7. PMID   19378875.
  3. 1 2 3 Brown, Jeremy (2008). Oxford American Handbook of Emergency Medicine. New York: Oxford University. p. 992. ISBN   978-0-19-518924-7.
  4. 1 2 3 Kavoussi, Parviz K.; Costabile, Raymond A. (2011). "Disorders of scrotal contents: orchitis, epididimytis, testicular torsion, torsion of the appendages, and Fournier's gangrene". In Chapple, Christopher R.; Steers, William D. (eds.). Practical urology: essential principles and practice. London: Springer-Verlag. ISBN   978-1-84882-033-3.
  5. 1 2 3 Nickel, J. Curtis; Beiko, Darren T. (2007). "Chapter 23:prostatitis, orchitis, and epididymitis". In Schrier, Robert W. (ed.). Diseases of the kidney and urinary tract . Vol. 1 (Eighth ed.). Philadelphia: Lippincott Williams & Wilkins. p. 645. ISBN   978-0-7817-9307-0.
  6. 1 2 3 4 Trojian TH, Lishnak TS, Heiman D (April 2009). "Epididymitis and orchitis: an overview". Am Fam Physician. 79 (7): 583–7. PMID   19378875.
  7. ↑ "Epididymitis and Orchitis". The Lecturio Medical Concept Library. Retrieved 19 July 2021.
  8. 1 2 3 4 Smith DM (September 1, 2008). "A Really Big Pain: Acute Epididymitis". The AIDS Reader.
  9. ↑ Marr, Lisa (2007). Sexually Transmitted Diseases: A Physician Tells You What You Need to Know (Second ed.). Johns Hopkins University. ISBN   9780801886591.
  10. ↑ Schwingl PJ, Guess HA (2000). "Safety and effectiveness of vasectomy". Fertil. Steril. 73 (5): 923–36. CiteSeerX   10.1.1.494.1247 . doi:10.1016/S0015-0282(00)00482-9. PMID   10785217.
  11. ↑ Raspa RF (1993). "Complications of vasectomy". American Family Physician. 48 (7): 1264–8. PMID   8237740.
  12. ↑ Ibsen HH, Frandsen F, Brandrup F, Møller M (August 1989). "Epididymitis caused by treatment with amiodarone". Genitourin Med. 65 (4): 257–8. doi:10.1136/sti.65.4.257. PMC   1194364 . PMID   2807285.
  13. ↑ "Diagnosis and Treatment of the Acute Scrotum - February 15, 1999 - American Academy of Family Physicians". Archived from the original on June 6, 2011. Retrieved May 19, 2008.
  14. 1 2 Granitisioti, P. (2008). "Scrotal pain conditions". In Baranowski, Andrew Paul; Abrams, Paul; Fall, Magnus (eds.). Urogenital pain in clinical practice. New York: Informa Healthcare USA. ISBN   978-0849399329.
  15. ↑ Matt A. Morgan and Yuranga Weerakkody. "Epididymal calcification". Radiopaedia . Retrieved 2018-05-21.
  16. ↑ Zhou, YC; Xia GS; Xue YY; Zhang XD; Zheng LW; Jin BF (2010–2012). "Kidney-tonifying and dampness-expelling Chinese herbal medicine combined with doxazosin for the treatment of chronic epididymitis". Zhonghua Nan Ke Xue (in Chinese). 16 (12): 1143–6. PMID   21348207. Archived from the original on 2013-07-31.

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