eMedicine Specialties > Urology > Common Problems of the Testicle

Epididymitis: Differential Diagnoses & Workup

Author: Edmund S Sabanegh Jr, MD, Director, Center for Male Fertility, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation
Coauthor(s): Christina B Ching, MD, Resident, Department of Urology, Cleveland Clinic Foundation; Badrinath R Konety, MD, Associate Professor, Department of Urology, University of California at San Francisco
Contributor Information and Disclosures

Updated: Nov 10, 2009

Differential Diagnoses

Hydrocele
Testicular Trauma
Inguinal hernia
Testicular Tumors: Nonseminomatous
Scrotal Trauma
Testicular Seminoma
Testicular Torsion

Other Problems to Be Considered

Scrotal hernia
Idiopathic scrotal edema
Reactive hydrocele
Pyocele
Henoch-Schönlein purpura
Behçet disease
Polyarteritis nodosa
Vasculitis

Workup

Laboratory Studies

  • Acute epididymitis and nonviral orchitis
    • The WBC count may be elevated with a left shift (10,000-30,000 cells/μL).
    • A midstream urine culture and Gram stain are useful in guiding therapy. Urinalysis findings are positive for pyuria in only 25% of patients and are sterile in 40%-90% of patients.
    • Obtain a urethral swab culture (before void, after prostate massage) for gonorrheal and chlamydial infections if the patient is in the at-risk age group or if the patient is older than 40 years and not monogamous. Gonorrheal infections often demonstrate gram-negative diplococci on smear, while chlamydial infections can be established in two thirds of cases when only WBCs are seen on smear. Chlamydia polymerase chain reaction (PCR) is highly specific and sensitive for chlamydial infection.
    • Perform blood cultures if the patient is systemically ill.
    • It is recommended that pediatric patients be evaluated for underlying congenital anomalies via abdominopelvic ultrasonography, voiding cystourethrography, and, in some cases, cystoscopy, especially when the urine culture result is positive. Debate is ongoing as to whether further work-up is necessary only in those with recurrent episodes or also after a first episode of epididymitis or epididymo-orchitis.
  • Mumps orchitis
    • Use immunofluorescent antibody testing to confirm the diagnosis upon clinical doubt.
    • Urinalysis and culture findings are negative.
  • Amiodarone plasma levels or antibodies are not helpful in the diagnosis of amiodarone-induced epididymitis.

Imaging Studies

Use imaging studies to help distinguish acute epididymitis from the more ominous testicular torsion. Do not allow studies to delay intervention or exploration if testicular torsion is suspected because testicular viability drops significantly with delay. In addition, the clinical evaluation is paramount and imaging studies should be used if the examination findings are indeterminate. Confirmatory imaging is unnecessary in a patient with a clear history consistent with epididymitis; ultrasonographic results are positive in only 69% of patients with clinical epididymitis.

  • Color Doppler ultrasonography
    • This test is the most widely available; however, it is examiner-dependent. The effectiveness of the examination can be limited by pain and patient size (eg, infants). It should also be reserved for patients with indeterminate examination, history, or laboratory workup findings.
    • Increased blood flow occurs with epididymitis; no flow occurs with torsion. Testicular tumors can also appear hyperemic.
    • The examination may reveal epididymal enlargement or a reactive hydrocele of mixed echogenicity (inhomogeneous echogenicity).
    • Use ultrasonography to help detect a scrotal abscess, as well as complications of epididymitis and bacterial or pyogenic orchitis.
    • Chronic epididymitis is characterized by an enlarged testis and epididymitis, as well as thickened tunica vaginalis with a heterogeneous echo pattern and the presence of course calcifications. The testicle may be atrophic and hypoechoic or heterogeneous from testicular infarction secondary to compromise of the testicular blood flow due to intratesticular edema.
    • The sensitivity for torsion is 82%-100%, and the specificity is 100%.

      Color Doppler sonogram of the left epididymis in ...

      Color Doppler sonogram of the left epididymis in a patient with acute epididymitis. The image demonstrates increased blood flow in the epididymis resulting from the active inflammation.

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      Color Doppler sonogram of the left epididymis in ...

      Color Doppler sonogram of the left epididymis in a patient with acute epididymitis. The image demonstrates increased blood flow in the epididymis resulting from the active inflammation.


      Scrotal sonogram demonstrating the presence of a ...

      Scrotal sonogram demonstrating the presence of a hydrocele and an enlarged epididymis in a patient with epididymitis. The echogenic white area is the normal testicle surrounded by the hydrocele.

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      Scrotal sonogram demonstrating the presence of a ...

      Scrotal sonogram demonstrating the presence of a hydrocele and an enlarged epididymis in a patient with epididymitis. The echogenic white area is the normal testicle surrounded by the hydrocele.


      Scrotal sonogram showing the testes adjacent to t...

      Scrotal sonogram showing the testes adjacent to the inflamed epididymis with a reactive hydrocele.

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      Scrotal sonogram showing the testes adjacent to t...

      Scrotal sonogram showing the testes adjacent to the inflamed epididymis with a reactive hydrocele.

  • Radionuclide scans
    • Use technetium Tc 99m scanning with imaging every 2 seconds for 2 minutes after injection of the tracer.
    • Acute epididymitis is characterized by increased tracer uptake, while torsion is characterized by defective uptake in the scrotum.
    • Late torsion may result in inflammation that resembles epididymitis.
    • The study’s usefulness is limited by availability, cost, and difficulty with interpretation
    • Sensitivity for torsion is 90%-100%, and specificity is 89%-97%.
    • Hydrocele and abscess cause false-positive results. Spontaneous detorsion and intermittent torsion may cause false-negative results.
  • Radiologic studies are recommended in children who have bacteruria and acute epididymitis in order to evaluate for structural abnormalities (found in >50% of these patients). In infants with bacteruria and epididymitis, in whom anatomical abnormalities are more common than in older children, a vesicoureterogram (VCUG) and abdominal ultrasonography are recommended. Retrograde urethrography is also indicated to evaluate for urethral stricture disease as symptoms dictate.
  • Radiologic studies for mumps orchitis are not indicated, although a reactive hydrocele is common.
  • Patients with tuberculous epididymitis require a full workup for systemic TB. This may include chest radiography, renal function tests, or CT or excretory urography.

Procedures

  • Cystourethroscopy: Along with radiological evaluation, cystourethroscopy may be indicated to evaluate for structural abnormalities in children, as radiographic and clinical suspicion dictates.

More on Epididymitis

Overview: Epididymitis
Differential Diagnoses & Workup: Epididymitis
Treatment & Medication: Epididymitis
Follow-up: Epididymitis
Multimedia: Epididymitis
References
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References

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Further Reading

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Keywords

epididymitis, epididymo-orchitis, orchitis, epididymis, acute epididymitis, chronic epididymitis, tuberculous epididymitis, testicular torsion, bladder outlet obstruction, BOO, urethral stricture, ectopic ureter, ectopic vas deferens, prostatic utricle, urethral duplication, posterior urethral valves, urethrorectal fistula, detrusor sphincter dyssynergia, vesicoureteral reflux, benign prostatic hyperplasia, BPH

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Contributor Information and Disclosures

Author

Edmund S Sabanegh Jr, MD, Director, Center for Male Fertility, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation
Edmund S Sabanegh Jr, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Society for the Study of Male Reproduction, Society of Reproductive Surgeons, and Southwest Oncology Group
Disclosure: Nothing to disclose.

Coauthor(s)

Christina B Ching, MD, Resident, Department of Urology, Cleveland Clinic Foundation
Christina B Ching, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Student Association/Foundation, and American Urological Association
Disclosure: Nothing to disclose.

Badrinath R Konety, MD, Associate Professor, Department of Urology, University of California at San Francisco
Badrinath R Konety, MD is a member of the following medical societies: American College of Surgeons, American Urological Association, and International College of Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Erik T Goluboff, MD, Professor, Department of Urology, College of Physicians and Surgeons, Columbia University; Director of Urology, Allen Pavilion, New York Presbyterian Hospital
Erik T Goluboff, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Urological Association, Medical Society of the State of New York, New York Academy of Medicine, Phi Beta Kappa, and Society for Basic Urologic Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Gyrus-ACMI Honoraria Speaking and teaching

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

 
 
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