Clinical presentation of pain, swelling and inflammation of the testes and epididymis. It may be associated with systemic infective symptoms, overlying skin inflammation and urinary symptoms.
Aetiology / Epidemiology
- Ascending infection from the urethra, often from a urinary tract infection or sexually transmitted infection.
- Common across wide variety of age groups.
- Inflammation often starts at the tail of epididymis, progressing to head and testis.
- Consider torsion (and Fournier’s) as a differential diagnosis.
Causative organism
- In younger sexually active men – sexually transmitted organisms (chlamydia trachomatis, Neisseria gonorrhoea and mycoplasma genitalium) are more common.
- In older men typical urinary organisms (E.coli, pseudomonas, enterococcus, klebsiella) are more likely.
- Consider tuberculosis in the appropriate population.
- The traditional cut off of 35 years old was based on small older studies.
- High risk groups including those with IDCs or those who practice CISC.
- Other less common organisms are viruses – mumps, cox-sackie (hand-foot-mouth) etc.
- Other rare causes – amiodarone, vasculitis, Henoch-Schonlein purpura
Clinical presentation
- Progressive pain and swelling to unilateral scrotum – usually over days, sometimes acutely
- 96 % unilateral
- Dysuria, penile discharge
- 1 in 4 are febrile, 6 % have abscess
- O/E – Erythema of skin, oedema, warmth, epididymal tenderness, fevers
Work-up
History:
- Duration of symptoms
- Systemic symptoms (fevers, torsion as differential)
- Urinary symptoms
- Medical history including immunosuppression, amiodarone, medications
- Sexual history and risk of STIs
- Risk factors for UTIs – instrumentation, incomplete emptying
Examination:
- Scrotal examination – warmth, tenderness, oedema
- Obs (fevers, haemodynamics)
- Look for urethral discharge (gonorrhoea)
- Prostate exam – consider concurrent prostatitis
- Abdominal examination – full bladder, hernia
- Other stigmata of mumps (parotid swelling), TB (scrotal sinus), viral illness (rash)
Investigations:
- First pass urine for NAAT chlamydia/gonorrhoea
- Mid stream urine for culture
- Bloods – inflammatory markers, renal function
- Ultrasound – exclude alternate diagnoses, abscesses, tumours
- Post void scan
- TB testing if appropriate
Treatment
- Ensure not torsion.
- Treat for both STI and UTI until cultures return.
- 1 g IV/IM ceftriaxone + 1 g azithromycin + 14 days ciprofloxacin or norfloxacin.
- If febrile consider hospitalisation and intravenous antibiotics (piperacillin/tazobactam).
- NSAIDs. Icepacks. Scrotal support. Follow up to ensure resolution (swelling may take weeks – consider abscess if no significant improvement).
- Abstain from sex until STI cultures returned, contract tracing if confirmed.
Chronic epididymitis
- Should probably be lumped in with chronic scrotal content pain or orchalgia
- Defined as pain localised to the epididymis for > 3 months
- Consider 3 separate groups
- Inflammatory – post epididymitis, tuberculosis, amiodarone
- Postobstructive – post vasectomy, iatrogenic
- Idiopathic