Epididymitis

Epididymitis must also be considered in boys presenting with acute scrotal pain. However, it is usually of a more insidious onset and may be accompanied with urinary symptoms and progressive scrotal swelling. Physical examination demonstrates a swollen ery-thematous hemiscrotum associated with epididymal engorgement and tenderness (Fig. 8.44). In contrast to torsion, the cremasteric reflex is usually intact and elevation of the testis improves pain (Prehn's sign) (Ka-dish and Bolte 1998). Doppler US should be performed; it typically reveals an enlarged hyperemic epididymis, a thickened scrotal wall and normal or increased blood flow to the testis (Munden and Trautwein 2000). Although a bacterial etiology must be considered, the majority of episodes of epididymitis in prepubertal children is secondary to a postinfectious viral etiology (Somekh et al. 2004). Symptoms usually resolve within

Fig. 8.44. Left epididimo-orchitis in a 5-year-old boy. The left hemiscrotum is red, indurated, and edematous; the underlying left epididymis and testis were diffusely tender

Fig. 8.43. Intraoperative photograph demonstrating testicular and epididymal ischemia secondary to spermatic cord torsion

Fig. 8.44. Left epididimo-orchitis in a 5-year-old boy. The left hemiscrotum is red, indurated, and edematous; the underlying left epididymis and testis were diffusely tender

1-3 days following a course of reassurance, scrotal elevation, and nonsteroidal anti-inflammatories. There is usually no role for antibiotics; however, if the urine is positive for bacteruria, an appropriate course of antimicrobial therapy is obviously warranted. The most common underlying bacterium in prepubertal children is Escherichia coli; however, Chlamydia trachomatis must also be considered in sexually active postpu-bertal boys.

In the past, any boy presenting with epididymitis underwent a complete evaluation of the upper urinary tract in order to rule out potentially contributing urinary tract pathology such as an ectopic ureter or PUV. However, as most cases of epididymitis are postinfec-tious and nonbacterial in origin, renal US has been shown to be unnecessary in the majority. In general, only boys under the age of 4, those with documented bacterial infection, evidence of sepsis, and those with urinary tract symptoms are more likely to harbor some underlying urogenital anomaly, and would thus benefit from antibiotic therapy and radiologic evaluation.

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