Epididymitis is an inflammatory reaction of the epididymis to one of several infectious agents or to local trauma. Acute epididymitis may present at any age, with a sudden onset of pain and swelling of the epididymis in the scrotum. Epididymitis can present in a sexually transmitted form or one associated with urinary tract infections and prostatitis. Thus, eliciting a specific history of sexual exposure or of prior genitourinary tract disease is crucial for diagnosis and appropriate treatment. Much less frequently, epididymitis may also be caused by a reflux of sterile urine into the epididymis, causing a local sterile chemical inflammation.

The patient's age suggests the most likely etiology of epididymitis. Within each age group, the cause appears to be the same as the most common cause of genitourinary infection in that group. In heterosexual men younger than 35, urethritis caused by Neisseria gonorrhoeae or Chlamydia trachomatis is more common than bacteriuria. Thus, in this patient population, epididy-mitis is most commonly caused by these same organ

12.6. Ultrasound showing heterogenous echotexture of a testis cancer isms, with C. trachomatis causing about two-thirds of the cases of noncoliform, nongonococcal epididymitis in these patients. By contrast, in men older than 35, sexually transmitted urethritis is uncommon; thus, a non-sexually transmitted form of epididymitis is more likely, most commonly caused by Enterobacteriaceae or Pseudomonas. Epididymitis that develops in children, which is rare, is most commonly caused by the coliform organisms that cause bacteriuria. It is important, however, to rule out anatomic abnormalities in children with epididymitis. In infants, epididymitis is more likely to result from genitourinary abnormalities. In im-munosuppressed males, a very small percentage may have epididymitis resulting from systemic disease such as tuberculosis, cryptococcus, or brucella.

While some men may have only a nonspecific finding of fever or other signs of infection, patients with acute epididymitis usually complain of sudden-onset, severely painful swelling of the scrotum. Pain may radiate along the spermatic cord and reach the abdomen, or possibly even the flank. The onset may be acute over 1 or 2 days, or sometimes more gradual; it is often accompanied by dysuria or irritative lower urinary tract symptoms. Erythema of the scrotum may develop, and the epididymis may double in size in as little as 3 - 4 h. Many patients also have urethral discharge. In acute epididymitis, inflammation and swelling usually begin in the tail of the epididymis and may spread to involve the rest of the epididymis and testicle. The spermatic cord is usually tender and swollen. Epididymitis is frequently accompanied by erythema, which is generally unilateral and primarily in the posterior aspect of the scrotum. If the patient is examined early in the course of the disease, the swelling maybe localized to one portion of the epididymis. Later, the ipsilateral testis is often involved, producing epididymo-orchitis and making it difficult to distinguish the testicle from the epi-didymis within the inflammatory mass. Scrotal examination often reveals the presence of a hydrocele, caused by the secretion of inflammatory fluid between the layers of the tunica vaginalis testis. Urinalysis usually shows leukocytes and often bacteria. Usually, the mi-crobial etiology of epididymitis can be determined by examining a Gram-stained urethral smear and Gram stain of a midstream urine specimen for Gram-negative bacteriuria. The presence of intracellular Gram-negative diplococci on the smear correlates with the presence of N. gonorrhoeae, whereas the presence of only white blood cells on the urethral smear indicates the presence of nongonococcal urethritis. C. trachomatis will be isolated in approximately two-thirds of these patients. In older men, the presence of coliform bacteria often leads to diagnosis. Treatment for patients with bacterial epididymitis depends on the age and history of the patient, and underlying co-morbidities. Infirm individuals with a fever and in severe cases, leukocyto-sis, should be admitted for intravenous antibiotics. In young, sexually active men, suspected sexually transmitted epididymitis should be treated with a single dose of ceftriaxone (250 mg i.m.) followed by tetracycline (500 mg p.o. q.i.d.) or doxycycline (100 mg p.o. b.i.d.) for 21 days. This regimen covers both C. trachomatis and N. gonorrhoeae. In older patients, empiric treatment with agents appropriate for both Gram-negative rods and Gram-positive cocci shouldbe initiated, pending urine culture and sensitivity results. Usually, treatment with a fluoroquinolone (levofloxacin 500 mg/d p.o. or ciprofloxacin 500 mg p.o. bid for at least 3 weeks) and an anti-inflammatory medication should be started. Bed rest, scrotal elevation, analgesics, and local ice packs are exceedingly helpful. Surgery may be necessary to manage complications of acute epididymal infections such as a testicular abscess. Making the differential diagnosis between epididymitis and testicular torsion at the beginning of the patient encounter is imperative, particularly in men younger than 35. Delayed diagnosis of torsion can result in testicular infarction and loss of a testicle. Generally, Prehn's sign, which is elevation of the scrotum upward toward the abdomen, manifests as relief of testicular discomfort in the patient with epididymitis, and worsening discomfort in the patient with torsion. While Prehn's sign is useful, it is not always accurate. If the clinician is trying to differentiate between torsion and epididymitis ultrasonography of the scrotum, preferably with color flow Doppler imaging, should be performed to evaluate blood flow to the testicle, in which epididymitis has increased blood flow to the testicle (Fig. 12.8). Finally, tuberculous epididy-mitis must be considered. Although this condition is more likely to be confused with a malignancy than a cause of an acute scrotal mass, it can be an important cause of epididymitis in patients from areas where tuberculosis is endemic. Testicular malignancy must also be suspected, since as many as 10 % of patients with testicular cancer may present with epididymitis.

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