![]() Kembara Xtra - Medicine - Epididymitis Introduction Scrotal discomfort and swelling caused by inflammation (infectious or non-infectious) of the epididymis, induration of the posterior epididymis, eventual scrotal wall edema, involvement of the nearby testicle, and creation of a hydrocele. Acute epididymitis is characterized by scrotal pain for less than six weeks. Chronic epididymitis is characterized by scrotal pain for more than six weeks. Epididymo-orchitis is the medical term for epididymitis that involves the testis. Classification: infectious (bacterial, viral, fungal, and parasitic); noninfectious (chemical, traumatic, autoimmune, idiopathic, industrial, and noninfectious); chronic versus acute. Affected System(s): the Reproductive System Epidemiology (Prevalence and Incidence) The predominant age group is younger men who are sexually active or older men who suffer from urinary tract infections; in older men, the condition is typically caused by a blockage in the bladder outlet (also known as benign prostatic hyperplasia, or BPH). Men only make up the majority of the population. Considerations Relating to Children Epididymitis is reported to be the most common cause of acute scrotum in boys who have not yet reached puberty; it is even more common than testicular torsion. Incidence Common (600,000 cases each year in the United States); 1 in 1,000 male adults each year; 1.2 in 1,000 male children aged 2 to 13 each year; Prevalence Common; Causes and effects: etiology and pathophysiology Retrograde transmission of urine bacteria from the prostate or urethra to the epididymis via the ejaculatory ducts and the vas deferens is the cause of infectious epididymitis. Rarely, hematogenous dissemination of the infection can also occur. – The causal organism is found in eighty percent of patients, however it varies according on the age of the patient. Noninfectious epididymitis – Often no etiology is established, however, it can be triggered by trauma, autoimmune disease, or vasculitis – Likely owing to reflux of sterile urine creating a chemical inflammation rather than an infectious one – Epididymitis that is not contagious – Epididymitis that is contagious can be caused by bacteria, viruses, or fungi. Reflux of urine through orifice of ejaculatory ducts at verumontanum may occur with history of urethritis/prostatitis because inflammation may produce rigidity in musculature surrounding orifice to ejaculatory ducts, holding them open. – Can develop as a sequelae of strenuous exercise with a full bladder when urine is pushed through internal urethral sphincter (located at proximal It may take up to 24 hours for an inflammatory reaction to occur after exposing the epididymis to a foreign fluid. 14 years of age – The cause is mostly unclear, however it is likely due to anatomic anomalies that result in urine reflux, such as vesicoureteral reflux, ectopic ureter, or anorectal malformation (rectourethral fistula) – This condition can occur in children who have not yet reached their full adult height and weight. Henoch-Schonlein purpura may also be a symptom of the postinfectious syndrome caused by Mycoplasma pneumoniae, enterovirus, or adenovirus. This condition might manifest as acute scrotum. Ages 14 to 35 – Typically Chlamydia trachomatis (serous urethral discharge) or Neisseria gonorrhoeae (purulent discharge) in sexually active males; with anal intercourse, probable Escherichia coli or Haemophilus influenzae; Chlamydia trachomatis (serous urethral discharge) or Neisseria gonorrho Patients older than 35 years: Most frequently intestinal bacteria, but on occasion Staphylococcus aureus or Staphylococcus epidermidis - Tuberculosis (TB), if sterile pyuria, nodularity of the vas deferens (hematogenous spread), and recent infection in elderly males who frequently have distal urinary tract obstruction, benign prostatic hyperplasia (BPH), urinary tract infection (UTI), or catheterization. The most frequent granulomatous disease that affects the epididymitis is tuberculosis (TB). – Granulomatous reaction following BCG intravesical therapy for bladder cancer – Reflux of sterile urine after transurethral prostatectomy Syphilis, blastomycosis, coccidioidomycosis, and cryptococcosis are uncommon causes of epididymitis; however, brucellosis can be a prevalent cause in endemic locations. Amiodarone can induce noninfectious epididymitis; the severity of the condition is dose-dependent and often improves with a reduction in drug dosage (below 200 mg per day). Risk Factors Urinary tract infection Prostatitis Indwelling urethral catheter Urethral instrumentation or transurethral surgery Urethral or meatal stricture Transrectal prostate biopsy Prostate brachytherapy (seeds) for prostate cancer Anal intercourse High-risk sexual activity Strenuous physical activity Prolonged sedentary periods Bladder obstruction (B – Laborers; employees in restaurant kitchens – People who have a full bladder while engaging in strenuous physical activity – New recruits to the military, especially those who start off physically unprepared Early treatment of prostatitis and BPH; vasectomy or vasoligation after transurethral surgery; avoiding vigorous rectal exam with acute prostatitis. Prevention. Safer sexual behaviors. Mumps immunization. Antibiotic prophylaxis for urethral manipulation. Avoid vigorous rectal exam with acute prostatitis. Prior to engaging in regular strenuous physical activity, it is important to: Treat constipation Physically prepare the body Empty the bladder before engaging in physical activity. associated conditions include prostatitis, urethritis, and orchitis; hematospermia; constipation; and urinary tract infection (UTI). History of Present Illness Gradual onset of scrotal pain, occasionally radiating to the groin region over the course of one to two days Urethral discharge or signs of UTI, such as frequent urination, dysuria, cloudy urine, or hematuria Over the course of one to two days, the pain may have gradually increased in intensity. • Comprehensive sexual history, with particular emphasis on recent exposures • Fever in only 11–19% of cases The entire hemiscrotum may become enlarged and reddened; the testis may become indistinguishable from the epididymis; the scrotal wall may become thick and indurated; and a reactive hydrocele may occur. Noninfectious epididymitis – Unilateral scrotal pain or swelling that is preceded by prolonged intensive physical exercise with a full bladder – Absence of signs and symptoms of infection Considerations Relating to Children Bacteremia caused by an infection with H. influenzae has the potential to cause acute epididymitis. It is imperative to rule out the possibility of testicular torsion in male adolescents, especially those older than 13 years old, using scrotal ultrasonography. a patient's medical history is not useful in making the distinction between epididymitis and testicular torsion. Considerations Regarding the Aged Despite having a serious infection or abscess, diabetics who suffer from sensory neuropathy may not feel any pain. The Patient's Clinical Examination The epididymis is extremely sensitive to palpation, and its tail is significantly larger in contrast to the contralateral side. The Prehn sign indicates that the discomfort can be alleviated by elevating the testicles or epididymis. The lack of a cremasteric reflex ought to pique one's interest in the possibility of testicular torsion. Testicular or testicular appendage torsion; urethritis or orchitis; testicular trauma; epididymal congestion following vasectomy; testicular cancer; epididymal cyst; inguinal hernia; spermatocele; hydrocele; hematocele; varicocele; epididymal adenomatoid tumor; epididymal rhabdomyosarcoma; epididymal Results From the Laboratory Initial Examinations (lab, imaging) It is recommended that any and all possible cases be investigated for objective evidence of inflammation using at least one of the following methods: – Urinalysis and urine culture, preferably performed on first-void pee, in order to test for the presence of positive leukocyte esterase and bacteriuria. - Culture of urine and Gram stain of urethral discharge; less than two white blood cells per oil immersion field; evaluation for gonococcal infection. – A microscopic inspection of sediment from a spun first-void pee with less than ten white blood cells visible in each high-power field. – Chlamydia and gonorrhea testing of urine for all suspected cases. Having a CRP level that is greater than 24 mg/L is indicative of epididymitis. Having a normal urinalysis and a negative culture are both indicative of noninfectious epididymitis. ● Doppler ultrasound is the preferred diagnostic tool to use when a testicular torsion or tumor cannot be ruled out, particularly in youngsters. In the evaluation of acute scrotum in adult males, ultrasound has a sensitivity and specificity of 100%, in contrast to the sensitivity range of 63.6–100% and the specificity range of 97–100% seen in pediatric patients. Considerations Relating to Children In youngsters, further radiographic imaging should be performed in order to rule out the presence of anatomic anomalies. Diagnostic Methods and Other Procedures This is a diagnosis made in the clinic. Management includes bed rest or a restriction on exercise; elevating the scrotum with an athletic scrotal supporter; using an ice pack wrapped in a towel; and avoiding constipation. Spermatic cord block with local anaesthetic in extreme cases. If noninfectious epididymitis: – No strenuous physical activity and avoidance of any Valsalva maneuvers for several weeks. – Empty bladder before to strenuous workouts. In severe cases, spermatic cord block with local anesthesia. The First Line Of Defense Is Medication Sexually active adults under the age of 35 should take doxycycline 100 mg PO BID for ten days to treat Chlamydia trachomatis in addition to ceftriaxone 250 mg IM 1 to treat Neisseria gonorrhoeae. In the past sixty days, you have had sexual contact with all of your partners. 35 years old, without a preexisting suspicion of an STD with an intestinal origin (i.e., bacteriuria due to bladder outlet obstruction, prostate biopsy, urinary instrumentation, systemic illness, and/or immunosuppression). – Levofloxacin 500 mg orally every day for ten days OR – Ofloxacin 300 mg orally every other day for ten days (2)[C],(4)[A] – Please take note that the FDA issued a black box warning on fluoroquinolones in 2016 due to the possibility for irreversible and debilitating adverse effects. For infections that aren't too severe, trimethoprim-sulfamethoxazole can be an option. For men who engage in insertive anal intercourse: ceftriaxone 250 mg IM 1 in addition to fluoroquinolone as described above; for men who test positive for HIV, there is typically no difference in treatment. Analgesia: nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen or ibuprofen for moderate to severe pain If the patient is unable to take NSAIDs, steroid treatment may be necessary. – Acetaminophen combined with codeine or oxycodone for moderate to severe pain Septic or toxic patient 3rd-generation cephalosporin or aminoglycoside For Behcet, sarcoid, and Henoch-Schonlein purpura Steroids, such as methylprednisolone, 40 mg/day recommended Chronic epididymitis 2-week course of nonsteroidal anti Oral administration of double-strength trimethoprim-sulfamethoxazole (Bactrim, Septra) every 12 hours for 10 to 14 days; the development of bacterial resistance may reduce the drug's efficacy. Depending on the situation, either rifampin (rifampicin) or vancomycin should be added. Considerations Relating to Children It's possible you have a post-infectious inflammatory illness; treat it with pain relievers and anti-inflammatories. The use of antibiotic treatment might be postponed for younger infants until positive urine culture results are obtained. Referral If there is a strong likelihood that the patient has testicular torsion, an immediate ultrasound or a referral to the emergency department for consideration of surgical intervention should be made. Because of the high prevalence of concomitant urogenital anomalies, epididymitis in patients younger than 14 years old warrants a referral to urology. Should be referred to urologist to rule out anatomic anomaly or chemical epididymitis. If HIV positive, CMV, salmonella, toxoplasmosis, Ureaplasma urealyticum, Corynebacterium sp., Mycoplasma sp., and Mima polymorpha must also be considered. If medical care fails, should be referred to urologist. Surgical Procedures Include: a Vasostomy to drain infected material in the event of a severe or refractory disease; a Scrotal Exploration in the event that a clinical diagnosis cannot differentiate between epididymitis and testicular torsion; and Drainage of abscesses, epididymectomy (acute suppurative), or epididymo-orchiectomy in severe cases refractory to antibiotics Surgery to rectify an underlying anatomic defect or obstruction Surgery to remove epididymo-orchiectomy in severe cases refractory to antibiotics The majority of instances are treatable with outpatient care unless one of the following conditions is present: admission; intractable pain; sepsis; abscess; persistent vomiting; scheduled surgery; purulent drainage. Continued Patient Observation and Monitoring We will perform the routine follow-up in one week. In the event that the patient's symptoms do not improve despite receiving treatment, a follow-up appointment should be scheduled within the first three days. Swelling and pain after a course of antibiotics should be assessed for abscess, tumor, infarction, cancer, TB, and fungal epididymitis. In cases of noninfectious epididymitis, a follow-up appointment should be scheduled in four weeks to evaluate the efficacy of NSAIDs and changes in lifestyle. CONSTIPATION If you believe that constipation is causing your pain or chemical epididymitis, then you should think about ways to prevent or treat constipation, such as eating a diet high in fiber. Ensure that the full course of antibiotics is taken, even if there are no symptoms. Prompt diagnosis and treatment of urinary tract infections or prostatitis ● Safer sexual behaviors. Sex should be avoided until the entire antibiotic regimen has been finished and your partner, if they likely have an STD, has been treated. If you have been treated for an STD, your sexual partners should be evaluated for N. gonorrhoeae or C. trachomatis if you had sexual contact with them within the 60 days prior to the beginning of symptoms. If it has been longer than 60 days, your most recent sexual partner should be evaluated. If it turns out to be a non-infectious form of epididymitis, then education on the non-infectious causes of the condition and the appropriate lifestyle adjustments are in order. The prognosis is that the pain will get better within one to three days, but it may take several weeks or months for the induration to go away completely. If both sides of the body are affected, sterility may be the end outcome. Symptoms of epididymitis that is not caused by an infection typically disappear within a week's time. Complications include recurrent epididymitis, infertility, oligospermia, testicular necrosis or atrophy, secondary abscess formation, and fournier gangrene, which is a necrotizing synergistic infection. Other complications include testicular necrosis or atrophy and secondary abscess formation.
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