Emergent Management of Acute Epididymitis 

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. An example of active inflammation of the epididymis is seen in the image below.

Go to Epididymitis for complete information on this topic.

Acute scrotal pain is a common complaint in the emergency room. One must have a high index of suspicion for testicular torsion, a true scrotal emergency, when evaluating patients with acute testicular or scrotal pain.^[1]

The most common misdiagnosis for testicular torsion is epididymitis. Often, this results from reliance on imperfect diagnostic tests over clinical judgment. Surgical exploration to definitively exclude torsion is not a high-risk procedure. Insist on rapid, in person, consultation by the urologist in suspect cases.

Ultrasonography

Ultrasonography is noninvasive and can help to differentiate epididymitis from testicular torsion.^[2] (The ultrasonogram below demonstrates the presence of epididymitis.) One area under investigation is the ability of emergency physicians to use bedside ultrasonography to accurately diagnose patients with acute scrotal pain.

In a retrospective chart review of 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 ultrasonographic findings agreed with the results of confirmatory studies (radiology or surgery) in 35 of 36 patients. Beside ultrasonography therefore had a sensitivity of 95% and a specificity of 94%.^[3]

However, although the use of bedside ultrasonography to accurately diagnose patients with acute scrotal pain is promising, the skill level of EPs at using ultrasonography varies, and larger randomized, prospective, blinded studies must be performed to further evaluate the accuracy of these results.

CRP and ESR

A study by Asgari et al suggested that C-reactive protein (CRP) levels and the erythrocyte sedimentation rate (ESR) may be useful in differentiating epididymitis from testicular torsion. In the prospective study, the investigators 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 the CRP level, while of the 23 with torsion, 1 (4%) had elevation of the CRP level. Of the 51 other patients with other noninflammatory causes of acute scrotum, none had significant elevation of the CRP level. In addition, the ESR was highest in the epididymitis group. The authors proposed cutoff values for distinguishing epididymitis from noninflammatory causes of acute scrotum of 24 mg/L for the CRP level and 15.5 mm/h for the ESR.^[4]

As with beside ultrasonography, the use of ESR and CRP is promising, but further investigations are necessary.

Patients with testicular or scrotal pain require immediate evaluation in order to identify and quickly treat potential cases of testicular torsion. Although most cases of torsion occur in patients aged 12-18 years, testicular torsion should be considered in any patient aged 12-30 years who presents with a scrotal complaint. Obtain immediate urologic consultation if unable to clearly differentiate testicular torsion from epididymitis or other scrotal pathology.

Acute epididymitis is treated with antibiotic therapy, analgesics for pain control, and supportive care, which includes scrotal elevation and support, application of an ice pack, and, in some cases, spermatic cord block.

Consult a urologist immediately if torsion is a possibility. Testicular torsion is a clinical diagnosis, and consultation should not be delayed for the performance of additional ancillary studies. Otherwise, most cases of epididymitis can be managed on an outpatient basis with follow-up with a urologist scheduled within 3-7 days.

All pediatric cases of epididymitis require immediate consultation because of the high incidence of associated genitourinary anomalies.

Most cases of epididymitis can be managed on an outpatient basis. However, admit the patient for parenteral therapy if any of the following are present:

• Intractable pain
• Nausea or vomiting that interferes with oral therapy
• Clinical evidence of an abscess (or inability to rule out an abscess)
• Signs of toxicity or possible sepsis
• Failure to improve during initial 72 hours of outpatient management
• Immunocompromised patient with significant signs or symptoms

Initiate treatment as discussed above.

The patient must be evaluated by a urologist within 3-7 days of presentation. This follow-up is mandatory, as a testicular tumor occasionally is the true cause of the symptoms.

The patient must receive detailed instructions for treatment, including reasons for immediate return.

Patients with epididymitis secondary to a potential sexually transmitted disease and all of their sexual contacts need referrals in order to screen and diagnose all comorbid sexually transmitted diseases, including human immunodeficiency virus (HIV) infection.

In pediatric patients with no prior urologic history and in the absence of bacteriuria, one retrospective study suggested that investigation for underlying urinary tract pathology should be carried out after the second episode.^[8]