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Snapshot
  • A 60-year-old man with a history of benign prostatic hyperplasia presents with one-sided testicular pain and urinary frequency. He also reports pain with urination. Physical exam reveals a swollen right testicle with substantial induration. Urinalysis reveals positive leukocyte esterase and 20 wbc/hpf. He is prescribed antibiotics for epididymitis.
Introduction
  • Clinical definition
    • inflammation of epididymis with symptoms of < 6 weeks
  • Epidemiology
    • incidence
      • 25 per 100,000 persons
    • demographics
      • men 18-35 years old
    • risk factors
      • sexual activity
      • bladder outlet obstruction
  • Etiology
    • pathogens from sexually transmitted infections in men less than 35 years of age
      • Neisseria gonorrhoeae
      • Chlamydia trachomatis
    • urinary tract pathogens in men greater than 35 years of age 
      • Escherichia coli
      • Pseudomonas aeruginosa
  • Pathogenesis
    • consequence of sexually transmitted disease or urinary tract infection
      • retrograde ascent of pathogen
    • bladder outlet obstruction
      • bacteriuria and subsequent retrograde ascent of pathogen
  • Prognosis
    • resolves with antibiotics
Presentation
  • Symptoms
    • testicular pain and often unilateral
    • lower abdominal pain
    • urinary frequency or urgency
    • urinary dysuria
  • Physical exam
    • fever
    • testicular erythema, tenderness, and induration
    • cremasteric reflex intact
    • Prehn's sign
      • decrease in pain with scrotal elevation
Imaging
  • epididymitisUltrasound
    • indications
      • to rule out testicular torsion
    • findings
      • enlarged and thick epididymis
      • increased blood flow
      • may also find reactive hydrocele
Studies
  • Labs
    • urethral swab
      • Gram stain or methylene blue stain showing white blood cells
    • urine
      • positive leukocyte esterase
      • 10 or more wbc/hpf
      • nucleic amplification testing for Chlamydia and Neisseria
Differential
  • Testicular torsion
    • absent cremasteric reflex
Treatment
  • Medical
    • antibiotics guided by sexual and urologic history
      • drugs
        • ceftriaxone and doxycycline
          • for sexually transmitted diseases
        • fluroquinolones
          • for enteric pathogen
Complications
  • Sepsis
  • Testicular atrophy
 

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