Epididymitis

Epididymitis
Classification and external resources
File:Illu testis surface.jpg 1: Epididymis 2: Head of epididymis 3: Lobules of epididymis 4: Body of epididymis 5: Tail of epididymis 6: Duct of epididymis 7: Deferent duct (ductus deferens or vas deferens)
ICD-10	N45.0
ICD-9	604
DiseasesDB	4342
eMedicine	med/704 radio/261 emerg/166
MeSH	D004823

Epididymitis is a medical condition in which there is inflammation of the epididymis (a curved structure at the back of the testicle in which sperm matures and is stored). This condition may be mildly to very painful, and the scrotum (sac containing the testicles) may become red, warm and swollen. It may be acute (of sudden onset) or rarely chronic.

Epididymitis is the most frequent cause of sudden scrotal pain. In contrast with men that have testicular torsion, the cremaster reflex (elevation of the testicle in response to stroking the upper inner thigh) is not altered. If the diagnosis is not entirely clear from the patient's history and physical examination, a Doppler ultrasound scan can confirm increased flow of blood to the affected epididymis.

Infection is the most common cause. In sexually active men, Chlamydia trachomatis is the most frequent causative microbe, followed by E. coli and Neisseria gonorrhoeae. In children, it may follow an infection in another part of the body (for example, a viral illness), or there may be an associated urinary tract anomaly. Another cause is sterile reflux of urine through the ejaculatory ducts. Antibiotics may be needed to control a component of infection. Treatment otherwise comprises of pain killers or anti-inflammatory drugs and bed rest.

Classification

Epididymitis can be classified into acute, subacute, and chronic, depending on the duration of symptoms.

Chronic epididymitis

Chronic epididymitis is epididymitis that ensues for more than six weeks. Chronic epididymitis is characterised by inflammation even when there is no infection present. Tests are needed to distinguish chronic epididymitis from a range of other disorders that can cause constant scrotal pain. These include testicular cancer, enlarged scrotal veins (varicocele), and a cyst within the epididymis. As well, the nerves in the scrotal area are connected to those of the abdomen, sometimes causing pain similar to a hernia (see referred pain). This condition can develop even without the presence of the previously described known causes.

In a typical scenario, a second, longer round of treatment is used. It is believed that the hypersensitivity of certain structures, including nerves and muscles, may cause or contribute to chronic epididymitis. A procedure called a cord block is a last measure. This consists of an injection into the nerve that traces along the epididymis. The injection is a compound of several medications including a steroid, pain killers, and a high dose of an anti-inflammatory. This treatment can quell the pain for 2–3 months in ideal conditions. Some patients may only experience an even shorter duration of 2–3 days, whereas the fortunate ones in rare occasions are never bothered again. This procedure would, of course, have to be repeated when necessary, until the problem goes away completely, or until the routine is simply too bothersome. As a last resort, a patient may then decide to have the epididymis completely removed.

Signs and symptoms

Epididymitis usually presents with gradual onset of pain of testicular pain or pain of the epididymis. The testicle may be warm and/or red.

Causes

A bacterial infection is the most common cause of epididymitis. The bacteria in the urethra back-track through the urinary and reproductive structures to the epididymis. There can be associated urethritis (inflammation of the urethra). In rare circumstances, the infection reaches the epididymis via the bloodstream.

In sexually active men, Chlamydia trachomatis is responsible for two-thirds of cases, followed by Neisseria gonorrhoeae and E. coli (or other bacteria that cause urinary tract infection). Particularly among men over age 35 in whom the cause is E. coli, epididymitis is commonly due to urinary tract obstruction. Less common microbes include Ureaplasma, Mycobacterium, and cytomegalovirus, or Cryptococcus in patients with HIV infection. E. coli is more common in boys before puberty, the elderly and homosexual men.

Non-infectious causes are also possible. Reflux of sterile urine (urine without bacteria) through the ejaculatory ducts may cause inflammation with obstruction. In children, it may be a response following an infection with enterovirus, adenovirus or Mycoplasma pneumoniae.

Epididymitis can also be caused by genito-urinary surgery, including prostatectomy and urinary catheterization. Congestive epididymitis is a long-term complication of vasectomy. Chemical epididymitis may also result from drugs such as amiodarone.

Diagnosis

Epididymitis can be hard to distinguish from testicular torsion. Both can occur at the same time. A urologist may need to be consulted.

Epididymitis usually has a gradual onset. On physical examination, the testicle is usually found to be in its normal vertical position, of equal size compared to its counterpart, and not high-riding. Typical findings are redness, warmth and swelling of the scrotum, with tenderness behind the testicle, away from the middle (this is the normal position of the epididymis relative to the testicle). The cremasteric reflex (if it was normal before) remains normal. This is a useful sign to distinguish it from testicular torsion. If there is pain relieved by elevation of the testicle, this is called Prehn's sign, which is, however, non-specific.

Analysis of the urine may or may not be normal. Before the advent of sophisticated medical imaging techniques, surgical exploration was the standard of care. Nowadays, color Doppler ultrasound is the preferred test. It can demonstrate increased blood flow (also compared to the normal side), as opposed to testicular torsion. Nuclear testicular blood flow testing is rarely used.

Additional tests may be necessary to identify underlying causes. In younger children, a urinary tract anomaly is frequently found. In sexually active men, tests for sexually transmitted diseases may be done. These may include microscopy and culture of a first void urine sample, Gram stain and culture of fluid or a swab from the urethra, nuclear acid amplification tests (to amplify and detect microbial DNA or other nucleic acids) or tests for syphilis and HIV.

Treatment

Antibiotics are used if an infection is suspected. The treatment of choice is azithromycin and cefixime to cover both gonorrhoeae and chlamydia. Fluoroquinolones because of the resistance of gonorrhoeae. Doxycycline maybe used as an alternative to azithromycin.

For cases caused by enteric organisms (such as E. coli), ofloxacin or levofloxacin are recommended.

In children, floroquinolones and doxycycline are best avoided. Since bacteria that cause urinary tract infections are often the cause of epididymitis in children, co-trimoxazole or suited penicillins (for example, cephalexin) can be used. If there is a sexually transmitted disease, the partner should also be treated.

Household remedies such as elevation of the scrotum and cold compresses applied regularly to the scrotum may relieve the pain. Painkillers or anti-inflammatory drugs are often necessary. Hospitalisation is indicated for severe cases, and check-ups can ensure the infection has cleared up. Surgery is rarely necessary, except, for example, in those rare instances where an abscess forms.

Complications

Most cases with adequate treatment develop no complications and do not result in infertility. Untreated, acute epididymitis can lead to a variety of complications. These include chronic epididymitis, abscess, permanent damage, or even destruction of the epididymis and testicle (resulting in infertility and/or hypogonadism), and infection may spread to any other organ or system of the body.

Epidemiology

Epididymitis makes up 1 in 144 outpatient visits (0.69 percent) in men 18 to 50 years old or 600,000 cases in men between 18 to 35 in the United States.

It occurs primarily in those 16 to 30 years of age and 51 to 70 years. There appears to be a recent increase in incidence in the United States that parallels an increase in reported cases of chlamydia and gonorrhea.

Further reading

• Nickel JC (2003). "Chronic epididymitis: a practical approach to understanding and managing a difficult urologic enigma". Rev Urol. 5 (4): 209–15. PMC 1553215 Freely accessible. PMID 16985840. 

External links

• Epididymitis at the Open Directory Project

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