Introduction
Background
The epididymis is a coiled tubular structure located along the posterior aspect of the testis. It allows for the storage, maturation, and transport of sperm, connecting the efferent ducts of the testis to the vas deferens. Inflammation of the epididymis can be acute (<6 wk) or chronic and is most commonly caused by infection.
Under Investigation
A retrospective chart review identified 36 patients with a chief complaint of acute scrotal pain who were evaluated by an emergency physician (EP) with the aid of bedside ultrasonography. The EP’s ultrasound examinations agreed with the results of confirmatory studies (radiology or surgery) for 35 of 36 patients, giving a sensitivity of 95% (95% confidence interval [CI], 0.78–0.99) and a specificity of 94% (95% CI, 0.72-0.99).1
The use of bedside ultrasonography by EPs to accurately diagnose patients with acute scrotal pain is promising; however, the skill level of EPs at using ultrasonography varies, and larger randomized, prospective blinded studies need to be done to further evaluate the accuracy of these results.
A second area of investigation is the use of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to help differentiate epididymitis from testicular torsion. A prospective study evaluated 120 patients with the diagnosis of an acute scrotum; serum CRP and ESR were drawn at the time of admission. Of the 46 patients diagnosed with epididymitis, 44 (95.6%) had elevation of CRP level; of the 23 with torsion, 1 (4%) had elevation of CRP level; and, of the 51 other patients with other noninflammatory causes of acute scrotum, none had significant elevation of CRP level. The authors proposed cutoff values of distinguishing epididymitis from noninflammatory causes of acute scrotum of 24 mg/L for CRP level and 15.5 mm/h for ESR.2 The use of ESR and CRP is also promising, but again further investigations are necessary.
Pathophysiology
Epididymitis most often is due to the retrograde extension of organisms from the vas deferens and is rarely the result of hematogenous spread. Bacterial infection results in the infiltration of white blood cells into the epididymal connective tissue, with resultant congestion and edema. This inflammation can rapidly spread to the tubules, with the risk of abscess formation and necrosis of the epididymis.3,4 The causative organism is identified in 80% of patients and varies according to the age of the patient.
In prepubertal males, the predominating sources are pathogens that cause bacteriuria (ie, coliform bacteria [Escherichia coli]). Workup should include a urologic evaluation for a genitourinary anomaly, which is present in as many as 50% of these patients.5,6 Epididymitis in this age group may also be secondary to a postinfectious inflammatory reaction to certain pathogens. Research has shown that boys with epididymitis had significantly elevated titers for Mycoplasma pneumoniae, enteroviruses, and adenoviruses when compared with control groups.7
In sexually active men (age 35 years has frequently been used as a parameter in research studies), the predominating sources are Chlamydia trachomatis and Neisseria gonorrhoeae, with C trachomatis being responsible for nearly two thirds of all cases. In homosexual men younger than 35 years, coliform bacteria are highly represented.
A retrospective cohort study of 17,764 male Air Force members evaluated the incidence of reproductive health outcomes in those with and without a history of C trachomatis. A cumulative incidence of orchitis/epididymitis of 4.28%, yielding a Hazard ratio of 1.38 (95% CI, 1.13-1.70).7
Epididymitis can result from nonbacterial causes. Chemical epididymitis is due to the reflux of sterile urine causing an inflammatory response. Tuberculosis, brucellosis, schistosomiasis, Ureaplasma, prostate brachytherapy, and amiodarone have all been implicated in causing epididymitis.
Frequency
United States
Epididymitis is the most common cause of intrascrotal inflammation. Incidence is less than 1 case in 1,000 males per year.
Mortality/Morbidity
Infection of the epididymis can lead to the formation of an epididymal abscess. In addition, progression of the infection can lead to involvement of the testicle, causing epididymo-orchitis or a testicular abscess. Sepsis is a potential consequence of severe infection. Bilateral epididymitis may result in sterility due to occlusion of the ductules from peritubular fibrosis.
- Patients with epididymitis secondary to a sexually transmitted disease have 2-5 times the risk of acquiring and transmitting the human immunodeficiency virus.8
- All sexual partners of patients with epididymitis secondary to a sexually transmitted disease need referral to ensure that they receive adequate testing and treatment.
Age
Epididymitis is primarily a disease of adults, most commonly affecting males aged 19-40 years.
Clinical
History
The progression of epididymitis usually is gradual in nature, with symptoms often peaking within 24 hours of onset. Initially, the patient may note abdominal or flank pain because cellular inflammation typically begins in the vas deferens. As the inflammation descends to the lower segment of the epididymis, the patient notes discomfort localized to the scrotum. Younger patients or any patient with a sexually transmitted epididymitis may note symptoms related to urethritis. A recent history of endourethral instrumentation or urinary tract infection is more common in older patients. Symptoms include the following:
- Scrotal pain and edema
- Urinary frequency, urgency, or dysuria
- Urinary retention from bladder outlet obstruction in older patients
- Nausea
- Fever and chills
- Abdominal or flank pain
- Bilateral epididymal involvement (10%)
- Urethral discharge
Physical
- Edematous tender epididymis: Early on, in cases without significant testicular involvement, tenderness may be clearly localized to the epididymis.
- Erythematous edematous scrotum
- Scrotal abscess
- Scrotal fluctuance
- Scrotal fixation to underlying epididymis
- Reactive hydrocele
- Prehn sign has been used to distinguish epididymitis from testicular torsion. Classically, scrotal elevation decreases pain in epididymitis and not in torsion. However, the Prehn sign is not reliable for distinguishing epididymitis from testicular torsion.
- Urethral discharge (10%)
- Fever or other constitutional symptoms with progression of disease
Causes
- Epididymitis most often is due to the retrograde extension of bacterial organisms from the vas deferens.
- Prepubertal males - Coliform bacteria (E coli)
- Sexually active males -C trachomatis is the most common organism followed by N gonorrhoeae
- Older males - Coliform bacteria most common, sexually transmitted diseases (STDs) less common
- Less common causes of epididymitis include the following:
- Chemical epididymitis due to the reflux of sterile urine
- Boys with epididymitis due to a postinfectious inflammatory reaction to pathogens, such as Mycoplasma pneumoniae, enteroviruses, and adenoviruses
- Candidal epididymitis in immunocompromised patients (AIDS)
- Epididymitis as an extrapulmonary manifestation of tuberculosis
- Epididymitis secondary to exposure to amiodarone therapy or prostate brachytherapy
More on Epididymitis |
 Overview: Epididymitis |
| Differential Diagnoses & Workup: Epididymitis |
| Treatment & Medication: Epididymitis |
| Follow-up: Epididymitis |
| References |
| Next Page » |
References
Blaivas M, Sierzenski P, Lambert M. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Acad Emerg Med. Jan 2001;8(1):90-3. [Medline].
Asgari SA, Mokhtari G, Falahatkar S, Mansour-Ghanaei M, Roshani A, Zare A. Diagnostic accuracy of C-reactive protein and erythrocyte sedimentation rate in patients with acute scrotum. Urol J. 2006;3(2):103-7. [Medline].
Harwood-Nuss AL, Etheredge W, McKenna I. Urologic Emergencies. Emergency Medicine Concepts and Clinical Practice. 1998;Vol 3:2241-2243.
Schneider RE. Male genital problems. In: Tintinalli JE, et al, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. McGraw Hill Text; 1996:536-537.
Cappèle O, Liard A, Barret E, Bachy B, Mitrofanoff P. Epididymitis in children: is further investigation necessary after the first episode?. Eur Urol. Nov 2000;38(5):627-30. [Medline].
Knowles DR. Epididymitis. Last updated August 26, 2006. Available from: MedlinePlus. Available at www.nlm.nih.gov/medlineplus/ency/article/001279.htm.
Trei JS, Canas LC, Gould PL. Reproductive tract complications associated with Chlamydia trachomatis infection in US Air Force males within 4 years of testing. Sex Transm Dis. Sep 2008;35(9):827-33. [Medline].
Nusbaum MR, Wallace RR, Slatt LM, Kondrad EC. Sexually transmitted infections and increased risk of co-infection with human immunodeficiency virus. J Am Osteopath Assoc. Dec 2004;104(12):527-35. [Medline].
Centers for Disease Control and Prevention. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. Apr 13 2007;56(14):332-6. [Medline]. [Full Text].
Burgher SW. Acute scrotal pain. Emerg Med Clin North Am. Nov 1998;16(4):781-809, vi. [Medline].
Drury NE, Dyer JP, Breitenfeldt N, Adamson AS, Harrison GS. Management of acute epididymitis: are European guidelines being followed?. Eur Urol. Oct 2004;46(4):522-4; discussion 524-5. [Medline].
Galejs LE. Diagnosis and treatment of the acute scrotum. Am Fam Physician. Feb 15 1999;59(4):817-24. [Medline].
Haidl G, Allam JP, Schuppe HC. Chronic epididymitis: impact on semen parameters and therapeutic options. Andrologia. Apr 2008;40(2):92-6. [Medline].
Joly-Guillou ML, Lasry S. Practical recommendations for the drug treatment of bacterial infections of the male genital tract including urethritis, epididymitis and prostatitis. Drugs. May 1999;57(5):743-50. [Medline].
Merlini E, Rotundi F, Seymandi PL, Canning DA. Acute epididymitis and urinary tract anomalies in children. Scand J Urol Nephrol. Jul 1998;32(4):273-5. [Medline].
National Guideline Clearinghouse. Epididymitis. Sexually transmitted diseases guidelines 2006. 2006. Center for Disease Control and Prevention; August 4, 2006. [Full Text].
Novella G, Porcaro AB, Righetti R, Cavalleri S, Beltrami P, Ficarra V. Primary lymphoma of the epididymis: case report and review of the literature. Urol Int. 2001;67(1):97-9. [Medline].
Peterson NE. Common urologic emergencies: a logical and practical approach to rapid diagnosis and treatment. Emerg Med Rep. 1994;15:16.
Rosenstein D, McAninch JW. Urologic emergencies. Med Clin North Am. Mar 2004;88(2):495-518. [Medline].
Schwab R. Acute scrotal pain requires quick thinking and plan of action. Emerg Med Rep. 1992;13:2.
Somekh E, Gorenstein A, Serour F. Acute epididymitis in boys: evidence of a post-infectious etiology. J Urol. Jan 2004;171(1):391-4; discussion 394. [Medline].
Swartz D. Acute scrotal mass. In: Harwood-Nuss A, Linden CH, eds. The Clinical Practice of Emergency Medicine. 2nd ed. Lippincott Williams & Wilkins Publishers; 1996:270-272.
Further Reading
Keywords
epididymitis, epididymo-orchitis, intrascrotal inflammation, Escherichia coli, Chlamydia trachomatis, Neisseria gonorrhoeae, chemical epididymitis, epididymal abscess, testicular abscess, sterility, peritubular fibrosis, sexually transmitted epididymitis, urethritis, scrotal pain, scrotal edema, urinary frequency, urinary urgency, dysuria, urinary retention, urethral discharge, scrotal abscess, Prehn sign, candidal epididymitis
