Acute Epididymitis

Background

• Acute epididymitis refers to inflammation of the epididymis of < 6 weeks duration.
• Epididymo-orchitis refers to concurrent inflammation of the testes, present in > 50% of cases.
• The disease often arises due to the retrograde ascent of a sexually transmitted or a urinary tract pathogen.
• Cause varies with age and risk factors for sexually transmitted infections.
  • Sexually transmitted infections (STIs) are the cause in men < 35 years old.
  • Urinary tract pathogens are the cause in men > 35 years old.
  • In prepubertal males, the etiology is often unclear, but may be associated with urogenital anomaly in about 25% and illness is usually self-limited.
• Men who practice insertive anal intercourse are at risk for infection with both sexually transmitted and enteric pathogens.
• Typical symptoms include acute, unilateral testicular pain and swelling which may be accompanied by symptoms associated with cystitis, urethritis, or prostatitis, such as urinary frequency and dysuria.

Evaluation

• Diagnosis is made clinically based on compatible physical exam findings including:
  • tender, swollen or indurated epididymis (found at posterior aspect of the testicle)
  • erythematous scrotum and/or tender, swollen testicle, typically in normal position
• Evaluate all suspected cases for evidence of lower urinary tract inflammation, which can be determined by any of the following:
  • Gram stain or methylene blue stain of urethral swab showing ≥ 2 white blood cells (WBC)/oil immersion field
  • positive leukocyte esterase on urinalysis
  • urine microscopy with ≥ 10 WBC/high power field
• To determine cause:
  • test patients at high risk for STI for Chlamydia trachomatis and Neisseria gonorrhoeae by nucleic acid amplification testing (urine is preferred specimen).
  • culture urine in all children and adults with a positive urinalysis or potential STI.
  • culture urine in patients with infections likely due to enteric pathogens.
• Test all patients with relevant sexual histories for other sexually transmitted infections including HIV.
• Consider scrotal ultrasound for patients when diagnosis is unclear clinically and to help rule out testicular torsion, which is a surgical emergency. If testicular torsion is suspected, consider doppler ultrasound if it will not delay surgery.
• Consider pelvic ultrasound in infants, young children, and older adults to rule out congenital or anatomical issues.

Management

• Centers for Disease Control and Prevention (CDC) recommendations for empiric therapy for adults include:
  • if acute epididymitis is most likely caused by sexually transmitted chlamydia or gonorrhea (typically men < 35 years old), both:
    • ceftriaxone 500 mg intramuscularly in single dose (1 g for persons weighing ≥ 150 kg) and
    • doxycycline 100 mg orally twice daily for 10 days
  • if acute epididymitis is most likely caused by enteric organism only (typically men > 35 years old), levofloxacin 500 mg orally once daily for 10 days
  • if acute epididymitis likely caused by sexually transmitted chlamydia, gonorrhea, or enteric organisms (such as in men who practice insertive anal sex), both:
    • ceftriaxone 500 mg intramuscularly in single dose (1 g for persons weighing ≥ 150 kg) and
    • levofloxacin 500 mg orally once daily for 10 days
• Definitive therapy may need adjustment based on the susceptibility of the detected organism.
• British Association for Sexual Health and HIV (BASHH) 2010 recommendations largely agree with recommendations from the CDC.
• Acetaminophen or nonsteroidal anti-inflammatory drugs, scrotal elevation, and ice packs may be appropriate for pain relief.
• Sex partners of patients diagnosed with a STI should be referred for evaluation and treatment.
• Patients should be counseled to abstain from sexual activity until patient and partner(s) have completed antibiotic treatment and symptoms have resolved.
• Follow-up is advised in 2-7 days to assess for response to treatment, which typically begins within 72 hours. Alternate diagnoses should be considered in unresponsive cases.
• In prepubertal boys, epididymitis is generally self-limiting and heals without complications with analgesics and rest if it is not associated with either a urinary tract infection or congenital abnormality of the lower urinary tract.