Updated: 12/15/2019

Epididymitis

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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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Questions (1)

(M2.RL.15.61) A 31-year-old man with no significant past medical history presents to his primary care provider complaining of right scrotal pain. He states that the pain began 2 days ago and has gradually worsened. He denies burning on urination. On further questioning, he reports two new sexual partners in the past 6 months. Vital signs T 99.8 F, HR 75 bpm, BP 125/80 mmHg, RR 12 rpm. Exam demonstrates a swollen right scrotum that is painful to the touch. Doppler ultrasonography of his right testicle is shown in Figure A. Urinalysis is positive for white blood cells. Of the following choices, which is the next best step? Tested Concept

QID: 106402
FIGURES:
1

Ceftriaxone and doxycycline

64%

(25/39)

2

Levofloxacin

5%

(2/39)

3

Supportive care and MMR vaccine

10%

(4/39)

4

Referral to urologist

13%

(5/39)

5

CT abdomen and pelvis

3%

(1/39)

M 7 E

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Evidence (2)
Topic COMMENTS (5)
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