Epididymitis

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Definition, Classification and Etiology of Epididymitis

Acute or chronic inflammation of the epididymis of various etiologies:

• Bacterial epididymitis
  • Epididymitis secondary to urinary tract infection: E. coli, Proteus, Klebsiella, Pseudomonas, Staphylococci
  • Epididymitis secondary to sexually transmitted diseases: Chlamydia, Neisseria
  • Tuberculosis: rare cause (hematogenous manifestation)
• Nonbacterial infectious epididymitis: viral, fungal or parasitic etiology
• Noninfectious epididymitis: traumatic etiology, autoimmune, amiodarone-induced or idiopathic
• Chronic epididymitis: duration longer than six weeks
• Chronic epididymyalgia

Epididymitis: Signs and Symptoms

• Testicular pain: tenderness of the epididymis
• Tender and swollen spermatic cord
• Swollen Scrotum, reddening and fever with advanced inflammation
• Intact cremasteric reflex, Prehn's sign is not reliable, should be positive (lifting of the testis alleviates the pain).

Diagnosis of Epididymitis

Urine analysis:

• Urine sediment: leukocyturia.
• Urine culture: can identify the pathogen, but is negative at 40–90% of patients.

Ultrasound imaging

Ultrasound imaging is mandatory for differential diagnosis to testicular torsion. In epididymitis, ultrasound imaging shows an enlarged epididymis, often together with a hydrozele [ultrasound imaging: epididymitis]. It is important to rule out abscess formation, involvement of the testicular parenchyma and rule out testicular torsion with Doppler ultrasound (see below).

Ultrasound imaging of epididymitis: typical signs are an enlarged epididymis with a hydrocele. By courtesy, N. Günther, Augsburg.

Doppler ultrasound:

Typical findings for an epididymitis are increased testicular perfusion and an enlarged epididymis. Doppler ultrasound is important for the exclusion of a testicular torsion; however, a false-positive detection of testicular blood flow is possible. An arterial Doppler signal in the testicle should disappear by the compression of the spermatic cord at the external inguinal ring. If the signal is not affected with compression of the spermatic cord, a scrotal vessel is transmitting the Doppler signal.

Surgical Exploration of the Scrotum

In the slightest doubt about the diagnosis of epididymitis, a surgical exploration of the scrotum must be done to exclude testicular torsion. When a testicular tumor might be possible, an inguinal approach to the testis is necessary.

Diagnosing voiding dysfunction

Uroflowmetry, exclusion of residual urine in the bladder, retrograde urethrography and/or cystogram should be performed after healed epididymitis, if a voiding dysfunction is suspected. Voiding dysfunctions are most likely in children and in elderly patients with epididymitis.

Treatment of Epididymitis

Symptomatic Treatment

• Bed rest
• Elevation and cooling of the testes
• Anti-inflammatory drugs such as Dicloenac 75 mg 1-0-1
• For the sudden relieve of strong pain: nerve block of the spermatic cord at the external inguinal ring with a long-acting local anesthetic such as bupivacaine

Antibiotic Treatment of Epididymitis

After obtaining a urine culture a calculated antibiotic treatment is initiated: