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Updated: Dec 22 2021

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
  • 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
    • Ultrasound
      • 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
          • ceftriaxone + fluroquinolones
            • for penetrative anal intercourse
  • Complications
    • Sepsis
    • Testicular atrophy
  • Prognosis
    • Resolves with antibiotics
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