Pediatrics

Epididymitis

OVERVIEW: What every practitioner needs to know

Are you sure your patient has epididymitis? What are the typical findings for this disease?

Acute epididymitis is an inflammation of the epididymis lasting less than 6 weeks that is caused by infection or trauma. In the pediatric, adolescent, and young adult population younger than age 35 years, it is primarily a problem of sexually active adolescents and young adults and is usually caused by Chlamydia trachomatis or Neisseria gonorrhoeae. Epididymitis caused by Escherichia coli or other bowel flora can be secondary to unprotected insertive anal intercourse.

Uncommonly, epididymitis can be caused by urinary pathogens in male patients with or without genitourinary abnormalities. Nonsexually transmitted epididymitis in the pediatric population may be caused by instrumentation, surgery, or catheterization or can be secondary to anatomic abnormalities. Epididymitis often presents with involvement of the testis and presents as epididymoorchitis.

The most common symptoms of epidiymitis are subacute onset of pain within the hemiscrotum, involving the scrotum, testicle, or epididymis, associated with epididymal swelling and tenderness.

Also common are the symptoms of inguinal, flank, or abdominal pain, a reactive hydrocele, urethral discharge, dysuria, and sometimes fever.

Most patients with epididymitis from sexually transmitted infection have accompanying dysuria or urethral discharge, or both.

What other disease/condition shares some of these symptoms?

In a sexually active individual who presents with acute or subacute scrotal pain, testicular torsion must be ruled out. An urgent consultation with a urologist is called for as the likelihood of torsion increases. If the teen has any risk factors suggesting torsion (i.e., prepubertal teen, non–sexually active teen, elevated or rotated testes, history of previous pain episodes, or acute onset with rapid progression), an immediate consultation with a urologist should be obtained and a nuclear scan or color flow Doppler ultrasonography should be considered.

Orchitis can cause similar symptoms, but it usually occurs without dysuria or urethral discharge. Mumps infection is the most common cause. Mumps orchitis is usually unilateral and occasionally occurs without a history of parotitis. Other viruses (e.g., adenovirus, coxsackievirus, echovirus, Epstein-Barr virus) may also cause orchitis, but with less frequency.

Table I helps differentiate epididymitis from testicular torsion.

Table I.

Differentiating Acute Epididymitis from Testicular Torsion
Symptoms and Findings Epididymitis Torsion
Pain Description Severe Severe
Onset of pain Hours to days Sudden/abrupt
Previous Episodes Usually not 50% of cases
Nausea or vomiting Usually not Frequent
Time to Presentation 24 hours or more Minutes to hours; <24 hours
Cremasteric reflex? Usually present Usually absent
Epididymis on examination Palpable, tender, inflamed Obscured or anterior
Prehn sign Present: pain is relieved with elevation of the scrotum Absent: no pain relief or increased pain with elevation of the scrotum
Urethral symptoms May have dysuria or discharge Absent
Urethral Gram stain May show white blood cells or gram-negative intracellular diplococci Negative
Urinalysis First-catch urine may show white blood cells or leukocyte esterase Usually negative

What caused this disease to develop at this time?

Epididymitis is primarily a problem of sexually active adolescents and young adults. It may be more common among those with a previous history of sexually transmitted infection but is not usually a recurrent condition. A typical history may include recent onset of sexual activity with a new partner, with increasing symptoms of genital discomfort.

In the absence of sexual activity, a history of genitourinary abnormalities, invasive genitourinary surgery, or recent invasive procedures including urinary catheterization are important elements to obtain in the patient history. Epididymitis is uncommon in prepubertal males and uncommon in non–sexually active males without a history of genitourinary tract anomalies. A thorough history and physical examination will usually allow the diagnosis to be made.

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

Epididymitis is a clinical syndrome that usually occurs in the presence of urethritis, which may be asymptomatic. Therefore, in the context of unilateral testicular pain and tenderness, a reactive hydrocele, and palpable swelling of the epididymis, laboratory test results confirming urethritis help to solidify the diagnosis.

A urine sample should be sent for a nucleic acid amplification test for C. trachomatis and N.gonorrhoeae, which are the most common causative organisms.

Gram staining of a specimen from an endourethral swab will make the diagnosis of urethritis when there are five or more white blood cells per oil immersion field and will assist with a presumptive diagnosis of gonococcal infection if gram-negative intracellular diplococci are present. Gram staining is a rapid diagnostic test that is both highly sensitive and specific for urethritis and the presence or absence of gonococcal infection.

In evaluation of epididymitis, a rapid diagnostic test is recommended, and if Gram stain is not immediately available, an alternative test can be examination of a first-voided urine, in which a positive leukocyte esterase test result or microscopic examination demonstrating 10 or more white blood cells per high-power field is also diagnostic of urethritis.

A culture of intraurethral exudate is an alternative to nucleic acid amplification tests.

Would imaging studies be helpful? If so, which ones?

Clinical evaluation is the hallmark of making the diagnosis of epididymitis, and further imaging studies are not usually helpful when the clinical presentation is straightforward and have only limited utility overall in making this diagnosis.

If testicular torsion is being considered as a possible diagnosis in the context of a painful scrotum, first consult a urologist before ordering any radiologic tests that may delay diagnosis and surgical therapy.

When the diagnosis is unclear or only a limited examination is possible because of pain, reactive hydrocele, or inexperience of the provider and testicular torsion is not felt to be a likely diagnosis or when radiologic decisions are made in concert with a urologist, an ultrasonogram of the scrotum is a noninvasive test that will help define the anatomy. Ultrasonography is reserved for patients with scrotal pain with an equivocal or nondiagnostic history, physical examination, or objective laboratory findings. On ultrasonography, epididymitis may show epididymal swelling and hyperemia. However, a negative ulatrasound should not alter clinical management of epididymitis.

The most accurate radiologic method of diagnosis is radionuclide scanning of the scrotum, but this imaging method is not routinely available and is rarely needed to make the clinical diagnosis in the presence of a complete history, physical examination, and laboratory evaluation.

If you are able to confirm that the patient has epididymitis, what treatment should be initiated?

Empirical treatment for acute epididymitis should be instituted immediately before confirmatory laboratory results are available. The goals of therapy are to ensure treatment of the infection, improve clinical signs and symptoms, prevent transmission to others, and decrease the chance of potential complications.

Epididymitis is usually caused by C. trachomatis or N. gonorrhoeae. Therefore, recommended first-line therapy is ceftriaxone (250 mg) intramuscularly in a single dose plus doxycycline 100 mg orally twice a day for 10 days. For acute epididymitis most likely caused by enteric organisms, levofloxacin 500 mg orally once daily for 10 days or ofloxacin 300 mg orally twice a day for 10 days is recommended. For men who are at risk for both sexually transmitted and enteric organisms, such as men who have sex with men and report insertive anal intercourse, ceftriaxone and a fluoroquinolone are recommended.

Most patients can be treated on an outpatient basis with close follow-up. Patients should return to their health care provider if signs and symptoms do not improve within 48 hours of initiation of therapy, and if they do not subside within 3 days, the diagnosis and therapy should be reevaluated. In the case of high fever, severe pain, or low likelihood of patient compliance with the antibiotic regimen, hospital admission should be considered.

Persistent epididymal swelling and tenderness that persist despite completion of antimicrobial therapy must be evaluated for possible testicular tumor, abcess, infarction, tuberculosis, or fungal epididymitis.

Adjunctive therapy for epididymitis includes scrotal support, ice, bed rest, and analgesic agents.

Patients should be counseled to notify sexual partners within the past 60 days and to refer those sex partners for evaluation and treatment.

What are the adverse effects associated with each treatment option?

Antimicrobial and adjunctive therapies are usually well tolerated with little risk compared with the benefit of eradicating the causative infection.

What are the possible outcomes of epididymitis?

The prognosis is excellent for full recovery in most cases of acute epididymitis. Infertility and chronic pain are the most worrisome complications of acute epididymitis.

Short-course antimicrobial therapy is usually well tolerated with little risk.

What causes this disease and how frequent is it?

Acute epididymitis is not a condition that is subject to national surveillance. As a result, US and European data concerning the incidence and prevalence of acute epididymitis are limited. In 1977, an estimated 634,000 patients sought medical treatment for epididymitis in the United States. A study in Canada showed that 0.9% of 8712 men seen at an outpatient practice over a 2.5-year period presented with epididymitis. In Europe, another study estimated the incidence of epididymitis at 1.2/1000 male children.

There has been little change in hospitalization for acute epididymitis since 1996.

The Veterans' Affairs outpatient clinic dataset for 2001 reported a rate of 50 cases of epididymitis/100,000 outpatient visits, with comparable rates in all 10-year age categories from 25-34 years through to 55-64 years (61/100,000-73/100,000). The highest rates were seen among blacks (87/100,000) and people residing in developed countries (57/100,000).

Little is known regarding genetic influences on epididymitis.

How do these pathogens/genes/exposures cause the disease?

One prospective study in prepubertal boys (average age 9 years) studied with ultrasonography acutely in the context of scrotal pain showed hospital admission peaked in the summer and winter, with an incidence of 1.2/100,000 boys. In this study, most cases were felt to occur after infection, with significantly elevated serologic titers to Mycoplasma pneumoniae, enteroviruses, and adenoviruses in cases of epididymitis compared with controls. In this study, all but three boys were treated with analgesic agents and without antibiotics, with gradual resolution of signs and symptoms in 1-7 days. The authors concluded that epididymitis in boys is usually caused by postinfectious inflammation, with little role for antibiotic treatment.

This is in marked contrast to epididymitis in postpubertal, sexually active male patients, in whom most cases are infectious and associated with sexually transmitted pathogens that also cause urethritis in male individuals. Multiple theories exist as to the cause of epididymitis, including retrograde progression of infection, trauma to the urethra or prostate, and hematogenous and lymphatic spread. The primary cause of infectious epididymitis in sexually active male patients remains incompletely understood.

What complications might you expect from the disease or treatment of the disease?

Complications of epididymitis include testicular or scrotal abscess, testicular infarction, chronic epididymitis with chronic pain, and infertility.

How can epididymitis be prevented?

Since most cases of epididymitis are related to sexual activity, safe sexual practices are important in prevention of the disease.

What is the evidence?

Adelman, WP, Joffe, A. "Genitourinary issues in the male college student: a case-based approach". Pediatr Clin North Am. vol. 52. 2005. pp. 199-216.

(A case-based review using typical, atypical, and otherwise instructive clinical cases to review multiple presentations of genitourinary disease in young adult men.)

Adelman, WP, Joffe, A. "The adolescent male genital examination: what's normal and what's not". Contemp Pediatr. vol. 16. 1999. pp. 76-92.

(A basic review of the male genitourinary examination including key discriminators on physical examination to differentiate disease presentations.)

"Sexually transmitted diseases treatment guidelines, 2010". MMWR. vol. 59. 2010. pp. 67-9.

(This update of the 2006 guidelines is the result of consultation with a group of STD experts. Evidence based and expert opinion treatment guidelines.)

Harnisch, JP, Alexander, ER, Berger, RE. "Aetiology of acute epididymitis". Lancet. vol. 309. 1977. pp. 819-21.

(Seminal study showing association with sexually transmitted diseases in young adult males.)

Nickel, JC, Siemens, DR, Nickel, KR. "The patient with chronic epididymitis: characterization of an enigmatic syndrome". J Urol. vol. 167. 2002. pp. 1701-4.

(Review of this uncommon complication of acute epididymitis, especially rare in children and adolescents.)

Somekh, E, Gorenstein, A, Serour, F. "Acute epididymitis in boys: evidence of a post-infectious etiology". J Urol. vol. 171. 2004. pp. 391-4.

(Prospective study showing evidence of a postinfectious cause for epididymal swelling in prepubertal boys.)

Tracy, CR, Steers, WD, Costabile, R. "Diagnosis and management of epididymitis". Urol Clin North Am. vol. 35. 2008. pp. 101-8.

(A good review for the clinician.)

Ongoing controversies regarding etiology, diagnosis, treatment

In HIV/AIDS infection or for other immunocompromised states, therapy is the same as for immunocompetent patients, except that fungal and mycobacterial infections are more common than in immunocompetent patients, so persistent symptoms should prompt further evaluation and treatment looking for these causes.

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