Download MBBS Urology Presentations 8 Epididymoorchitis Lecture Notes

Epididymoorchitis : spectrum and

management

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Department of Urology

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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Bladder

Seminal vesicle

Vas deferens

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Epididymis

Testis

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Anatomy review

A: 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 the

epididymis
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 catheter
Causes 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 men

ages 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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infections


Epididymitis ? signs/symptoms

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? Heavy sensation in the

testicle 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 during

urination 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 secretions

demonstrating 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 Torsion

Acute 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 days

For 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 of

blood (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.