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Infectious Disease And Microbiology – Epididymitis
Epididymitis is an inflammatory condition of the epididymis, most commonly caused by infection but also occasionally due to noninfectious causes such as trauma, drugs, or systemic diseases. It can be classified as acute or chronic, with chronic epididymitis defined by symptoms lasting more than three months.
Epididymitis is a common urologic condition, particularly in men aged 18–50 years, and is one of the leading causes of scrotal pain in this age group. It shows a bimodal age distribution, affecting younger sexually active men (16–30 years) and older men (51–70 years). It is also more common in men who engage in unprotected anal intercourse. Additional risk factors include bacteriuria, recent urinary tract instrumentation or surgery, prolonged sitting, strenuous physical activity, and conditions such as prostatic obstruction in older men or congenital urinary abnormalities in children.
Prevention focuses mainly on reducing sexually transmitted infections (STIs). This includes abstinence, mutual monogamy with an uninfected partner, and consistent and correct use of latex condoms. These measures significantly reduce the risk of infection-related epididymitis.
The pathophysiology typically involves retrograde ascent of pathogens from the urethra or bladder into the epididymis. Increased voiding pressures and urinary reflux into the vas deferens may contribute, especially in patients with underlying voiding dysfunction such as urethral strictures or bladder outlet obstruction.
The causes of epididymitis vary by age and risk factors. In younger men, the most common causes are sexually transmitted pathogens, particularly Neisseria gonorrhoeae and Chlamydia trachomatis. In older men or those with urinary tract abnormalities, enteric organisms such as Escherichia coli, Klebsiella, Proteus, and Pseudomonas are more common. Less frequently, infections may be caused by organisms such as Mycobacterium tuberculosis, Brucella, fungi, or parasites. Noninfectious causes include vasculitic diseases, medications like amiodarone, trauma, or idiopathic mechanisms. Epididymitis is often associated with orchitis (inflammation of the testis).
Clinically, patients typically present with gradual onset of unilateral scrotal pain and swelling over several days. Pain is usually localized to the posterior aspect of the testis and may radiate to the lower abdomen. Urinary symptoms such as dysuria, frequency, urgency, or hematuria may be present, along with fever and chills. A preceding urethral discharge suggests a sexually transmitted cause. Chronic epididymitis presents with persistent or intermittent discomfort lasting more than six weeks.
On physical examination, there is localized tenderness of the epididymis that may progress to testicular swelling. Urethral discharge may be visible. The cremasteric reflex is usually preserved, which helps distinguish epididymitis from testicular torsion. Pain may improve with elevation of the testis (Prehn’s sign). In advanced cases, reactive hydrocele or scrotal erythema may develop.
Diagnosis involves laboratory and imaging studies. Urethral swabs and urine samples are used to detect infection, including Gram stain, culture, and PCR testing for Chlamydia and Gonorrhea. Urinalysis may show leukocytes or leukocyte esterase. Blood cultures may be useful in severe cases. Inflammatory markers such as CRP and ESR may help differentiate epididymitis from testicular torsion. Color Doppler ultrasonography is the imaging modality of choice and typically shows increased blood flow in the epididymis, helping to exclude torsion, which shows reduced flow.
The main differential diagnosis is testicular torsion, which is a surgical emergency and must always be excluded. Other less common considerations include testicular tumors.
Treatment is primarily medical. Empiric antibiotic therapy should be started promptly based on the most likely pathogens. In sexually transmitted cases, treatment includes a single intramuscular dose of ceftriaxone followed by oral doxycycline for 10 days, or azithromycin as an alternative. In cases due to enteric organisms, fluoroquinolones such as levofloxacin or ofloxacin are commonly used. Supportive measures include bed rest, scrotal elevation, analgesics, and nonsteroidal anti-inflammatory drugs. Patients with HIV are treated similarly, although atypical pathogens may be more common.
Surgical intervention is reserved for complications such as abscess formation, testicular infarction, or pyocele. Hospital admission is required for severe cases with systemic symptoms or suspected bacteremia.
Patient education is essential. Patients with sexually transmitted epididymitis should ensure that their sexual partners are evaluated and treated if exposure occurred within the preceding 60 days. Sexual activity should be avoided until treatment is completed and symptoms have resolved.
Complications include bacteremia, testicular infarction, scrotal abscess, chronic epididymitis, infertility, and formation of a draining sinus. In children, distinguishing epididymitis from testicular torsion is especially important, as torsion is more common and requires urgent surgical management.
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