Learning Objectives
? Describe the clinical manifestations,
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methods of identification, CDC treatment
guidelines, prevention and follow up for
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epididymoorchitis.Anatomy review
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BladderSeminal vesicle
Vas deferens
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Epididymis
Testis
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Anatomy reviewA: Caput or head of
the epididymis
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B: Corpus or body of
the epididymis
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C: Cauda or tail of theepididymis
D: Vas deferens
E: Testicle
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Cleveland Clinic Center for Medical Art and Photography ? 2009
Risk Factors
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? Sexual intercourse with more than one
partner and not using condoms
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? Being uncircumcised? Recent surgery or a history of structural
problems in the urinary tract
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? Regular use of a urethral catheterCauses of acute epididymitis
? Among sexually active men aged <35 years
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? C. trachomatis or N. gonorrhoeae? Men who are the insertive partner during anal
intercourse:
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? Escherichia coli and Pseudomonas spp
? Men aged >35 years
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? Sexual y transmitted epididymitis is uncommon? Bacteriuria secondary to obstructive urinary
disease is more common
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Causes of chronic epididymitis? Inadequate treatment of acute epididymitis
? Recurrent epididymitis
? Granulomatous reaction
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? Mycobacterium tuberculosis (TB) is the most
common granulomatous disease affecting the
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epididymis? Chronic disease
Incidence
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? Epididymitis is most common in young menages 19 ? 35
? ~1 in 1000 men develop epididymitis
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annually
? Acute epididymitis accounts for >600,000
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medical visits per year in the U.S.? Patients with epididymitis secondary to a STI
have 2-5 times the risk of acquiring and
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transmitting HIV
Acute Epididymitis
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? Discomfort and/or pain in the scrotum,testicle, or epididymis lasts <6 week
? Usually caused by a bacterial infection
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Chronic Epididymitis
? Discomfort and/or pain in the scrotum,
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testicle, or epididymis lasting >6 weeks
? Pain may be constant or waxing and
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waning? Scrotum is not usually swollen but may be
indurated in long-standing cases
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Mumps Orchitis
? Fever, malaise &
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myalgia? Parotiditis typically
preceding onset of
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orchitis by 3-5 days
? Subclinical
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infectionsEpididymitis ? signs/symptoms
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? Heavy sensation in thetesticle area
? Painful scrotal swelling
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? Fever? Chills
? Testicle pain gets
worse with pressure
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? Lump in the testicle
Epididymitis ? signs/symptoms
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? Blood in the semen? Discharge from the
urethra
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? Pain or burning duringurination or ejaculation
? Discomfort in the lower
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abdomen or pelvis
Diagnosis
? Urine R/M
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? Urine C/S
? Urethral swab
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? intracellular gram-negative diplococci, -N.gonorrhoeae
? only WBCs - C. trachomatis
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? Scrotal USG( rule out testicular torsion)
Epididymitis ? diagnosis
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? Gram stain of urethral secretionsdemonstrating 5 WBC per oil immersion
field
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? Positive leukocyte esterase test on first-
void urine
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? Culture, nucleic acid hybridization tests,and NAATs are available for the detection
of both N. gonorrhoeae and C. trachomatis
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Epididymitis ? diagnosis? Physical exam
? Additional tests:
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? Complete blood count? Doppler ultrasound
? Testicular scan (nuclear medicine scan)
? Urinalysis and culture
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Acute Epididymitis vs Testicular TorsionAcute Epididymitis
Testicular Torsion
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? Gradual onset of scrotal pain ? Sudden onset of scrotal pain
(days)
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(hours)? Normal cremasteric reflex
? Abnormal cremasteric reflex
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? Usually no nausea & vomiting ? Nausea & vomiting common
? More common in sexually
? More common in adolescents
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active men
and in men without evidence of
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inflammation or infection? HPI & exam support a
? HPI & exam do not support a
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diagnosis of urethritis or
diagnosis of urethritis or UTI
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urinary-tract infection? Surgical emergency
? Empiric treatment & follow-up
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Epididymitis ? treatment? Empiric treatment is indicated before
laboratory results are available
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? Goals of treatment of acute epididymitis
caused by C. trachomatis or N.
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gonorrhoeae:? Microbiological cure of infection
? Improvement of signs & symptoms
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? Prevent transmission to others
? Reduce potential complications
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Epididymitis ? treatment? Recommended Regimens:
? Ceftriaxone 250mg IM in a single dose PLUS
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? Doxycycline 100mg PO BID x 10 daysFor acute epididymitis most likely caused by enteric
organisms:
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? Levofloxacin 500mg PO once daily x 10 days
OR
? Ofloxacin 300mg PO BID x 10 days
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Source: Centers for Disease Control and Prevention (CDC). Epididymitis. In: Sexual y transmitted diseases treatment
guidelines, 2010. MMWR Recomm Rep. 2010 Dec 17;59(RR-12):67-9.
Epididymitis ? follow up
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? Pain improves within 1-3 days
? Induration can last a few weeks-months to
resolve
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? Swelling and tenderness that persists after
completion of treatment should be evaluated
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comprehensively? Evaluate for formation of an epididymal
abscess or a testicular abscess
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Epididymitis ? complications
Complications of epididymitis:
? Abscess in the scrotum
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? Chronic epididymitis? Fistula on the skin of the scrotum
(cutaneous scrotal fistula)
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? Death of testicular tissue due to lack ofblood (testicular infarction)
? Sepsis & infertility
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Epididymitis ? prevention? Practicing safe sex
? Treating sexual partners as a contact to
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epididymitis? Repeat screening for STI ~ 2 months after
initial testing for re-infection
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? Abstain from sex until the individual & sex
partners have completed treatment
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References? Centers for Disease Control and Prevention (CDC). Epididymitis. In:
Sexual y transmitted diseases treatment guidelines, 2010. MMWR
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Recomm Rep. 2010 Dec 17;59(RR-12):67-9.
? Nickel JC. Inflammatory Conditions of the Male GenitourinaryTract:
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Prostatitis, and Related Conditions, Orchitis, Epididymitis. In: Wein AJ,ed. Campbel -Walsh Urology. 10th ed. Philadelphia, Pa: Saunders
Elsevier; 2011:chap 11.
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? Trojian TH, Lishnak TS, Heiman D. American Family Physician. 2009
Apr 1;79(7):583-7. Epididymitis and orchitis: an overview.
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? Walker NA, Chal acombe B. Practitioner. 2013 Apr;257(1760):21-5, 2-3.Managing epididymo-orchitis in general practice.