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Epididymitis

Epididymitis is a topic covered in the 5-Minute Clinical Consult.

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Basics

  • Acute epididymitis: scrotal pain for <6 weeks
  • Chronic epididymitis: scrotal pain for ≥3 months

Description

  • Inflammation (infectious or noninfectious) of epididymis resulting in scrotal pain and swelling, induration of the posterior epididymis, eventual scrotal wall edema, involvement of the adjacent testicle, and hydrocele formation
  • Epididymitis with involvement of testis is named epididymo-orchitis.
  • Classification: infectious (bacterial, viral, fungal, parasitic) versus noninfectious (chemical, traumatic, autoimmune, idiopathic, industrial, noninfectious, vasoepididymal reflux syndrome, vasal reflux syndrome); chronic versus acute
  • System(s) affected: reproductive

Epidemiology

  • Predominant age: usually younger, sexually active men or older men with UTIs; in older men, commonly secondary to bladder outlet obstruction
  • Predominant sex: male only

Pediatric Considerations
In prepubertal boys: Epididymitis is found to be the most common cause of acute scrotum—more common than testicular torsion.

Incidence
  • Common (600,000 cases annually in the United States) (1)
  • 1 in 1,000 adult males per year
  • 1.2 in 1,000 boys age 2 to 13 years per year (2)

Prevalence
Common

Etiology and Pathophysiology

  • Infectious epididymitis
    • Retrograde passage of urine or urinary bacteria from the prostate or urethra to the epididymis via the ejaculatory ducts and the vas deferens, rarely, hematogenous spread
    • Causative organism is identified in 80% of patients and varies according to patient age.
  • Noninfectious epididymitis
    • Often no etiology is found; however, can be instigated by trauma, autoimmune disease, or vasculitis
    • Thought to likely be secondary to reflux of sterile urine causing a chemical inflammation rather than infectious
    • Can develop as a sequelae of strenuous exercise with a full bladder when urine is pushed through internal urethral sphincter (located at proximal end of prostatic urethra) or prolonged periods of sitting
    • Reflux of urine through orifice of ejaculatory ducts at verumontanum may occur with history of urethritis/prostatitis, as inflammation may produce rigidity in musculature surrounding orifice to ejaculatory ducts, holding them open.
    • Exposure of epididymis to foreign fluid may produce inflammatory reaction within 24 hours.
  • <14 years of age
    • Cause largely unknown although likely anatomic abnormalities resulting in urine reflux such as vesicoureteral reflux, ectopic ureter, or anorectal malformation (recto-urethral fistula)
    • May also be part of postinfectious syndrome from Mycoplasma pneumoniae, enterovirus, or adenovirus
    • Henoch-Schönlein purpura may present as acute scrotum.
  • 14 to 35 years of age
    • Usually Chlamydia trachomatis (serous urethral discharge) or Neisseria gonorrhoeae (purulent discharge) in sexually active males
    • With anal intercourse, likely Escherichia coli or Haemophilus influenza
  • >35 years
    • Commonly enteric bacteria but occasionally Staphylococcus aureus or Staphylococcus epidermidis
    • In elderly men, often with distal urinary tract obstruction, benign prostatic hyperplasia (BPH), UTI, or catheterization
    • Tuberculosis (TB), if sterile pyuria, nodularity of vas deferens (hematogenous spread), and recent infection. TB is the most common granulomatous disease affecting the epididymitis (3).
    • Sterile urine reflux after transurethral prostatectomy
    • Granulomatous reaction following BCG intravesical therapy for bladder cancer
  • Amiodarone may cause noninfectious epididymitis; resolves with decreasing drug dosage
  • Syphilis, blastomycosis, coccidioidomycosis, and cryptococcosis are rare causes, but brucellosis can be a common cause in endemic areas.

Risk Factors

  • UTI
  • 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 (BPH, prostate cancer)
  • HIV-immunosuppressed patient
  • Severe Behçet disease
  • Presence of foreskin
  • Constipation
  • Noninfectious epididymitis
    • Increased intra-abdominal pressure (due to frequent physical strain)
      • Military recruits, especially who begin physically unprepared
      • Laborers; restaurant kitchen workers
      • Full bladder during intense physical exertion

General Prevention

  • Safer sexual practices
  • Mumps vaccination
  • Antibiotic prophylaxis for urethral manipulation
  • Early treatment of prostatitis/BPH
  • Vasectomy or vasoligation during transurethral surgery
  • Avoid vigorous rectal exam with acute prostatitis.
  • Emptying the bladder prior to physical exertion
  • Physically conditioning the body prior to engaging in regular intense physical exertion
  • Treat constipation.

Commonly Associated Conditions

  • Prostatitis/urethritis/orchitis
  • Hemospermia
  • Constipation
  • UTI

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Citation

Stephens, Mark B., et al., editors. "Epididymitis." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116211/all/Epididymitis.
Epididymitis. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116211/all/Epididymitis. Accessed April 19, 2019.
Epididymitis. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116211/all/Epididymitis
Epididymitis [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 19]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116211/all/Epididymitis.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Epididymitis ID - 116211 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116211/all/Epididymitis PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -