Epididymitis

Background

• Often confused with testicular torsion
  • Cremasteric reflex intact in epididymitis
• Sexually active men <35yo:
  • Consider chlamydia, gonorrhea
• Not sexually active, age >35yo, or anal intercourse:
  • Also consider E. coli, pseudomonas, enterobacter, TB, syphilis
  • Chemical epididymitis
  • Consider in the patient with afib and testicular pain
  • Testicular pain and swelling in patients on amiodarone

Clinical Features

• Pain of gradual onset, peaks at 24hr
• Dysuria
• Urinary frequency
• Fever
• Pain relieved with elevation of testicle (Prehn sign)
  • Sensitivity: 91.3%, specificity: 78.3. Does not rule out testicular torsion

Differential Diagnosis

Testicular Diagnoses

• Testicular torsion
• Epididymitis
• Orchitis
• Torsion of testicular appendage
• Scrotal abscess
• Fournier gangrene
• Hydrocele
• Indirect inguinal hernia
• Hematocele
• Spermatocele
• Testicular trauma
• Testicular rupture
• Varicocele
• Inguinal lymph node (Lymphadenitis)
• Testicular tumor
• Cellulitis
• Tinea cruris

Evaluation

• Urinalysis
  • Pyuria seen in half of cases
• Urine culture (children, elderly men)
• Urine GC/Chlam (urethral discharge or age <40)
• Ultrasound for equivocal cases
• Older men should be evaluated for urinary retention

Management

• Scrotal elevation
• Analgesia

Antibiotics

• For acute epididymitis likely caused by STI
  • Ceftriaxone 250 mg IM in a single dose PLUS
  • Doxycycline 100 mg orally twice a day for 10 days

• For acute epididymitis most likely caused by STI and enteric organisms (MSM)
  • Ceftriaxone 250 mg IM in a single dose PLUS
  • Levofloxacin 500 mg orally once a day for 10 days OR
  • Ofloxacin 300 mg orally twice a day for 10 days

• For acute epididymitis most likely caused by enteric organisms
  • Levofloxacin 500 mg orally once daily for 10 days OR
  • Ofloxacin 300 mg orally twice a day for 10 days

Treat sexual partner if possible

• If med adherence is an issue:
  • Ceftriaxone 250mg IM once
  • PLUS azithromycin 1 g PO once

Pediatric Epididymitis

• Rule out testicular torsion
• Bed rest to ensure lymphatic drainage
• Ice packs, acetaminophen, ibuprofen
• Rarely oral narcotics
• Pediatric urology follow up outpatient in non-toxic child for possible GU anatomical abnormalities
• Antibiotics for 10-14 days, with urine culture sent:
  • Trimethroprim-sulfamethoxazole
  • Amoxicillin-clavulanate
  • Coverage for chlamydia and N. gonorrhoeae in suspected cases of sexual transmission
  • Avoid fluoroquinolones in pediatric patients
  • Severely ill or septic children:
    • At least, first generation cephalosporin
    • PLUS aminoglycoside

Disposition

• Admit for:
  • Systemic signs of toxicity (fever, chills, nausea/vomiting)
• Discharge with urology follow-up in 1 week if non-toxic

See Also

• Testicular diagnoses
• Traumatic epididymitis

References

Authors

Ross Donaldson, Kevin Lu, Jordan Swartz, Michael Holtz, Daniel Eggeman, Mark Russell, Daniel Ostermayer, Babak Missaghi, Claire, Neil Young, Felipe A. Sanchez