Epididymitis

Epididymitis is an infection of the epididymis.

This organ is a system of small tubules that carries the sperm cells from the testicles to the semen vesicles annexed to the prostate.

Typical symptoms of acute infection are pain, swelling, and increased temperature of the scrotum.

When the infection spreads to the adjacent testicle, it becomes orchitis. The most frequent cause is the migration of pathogens (typically Chlamydia, N gonorrhoeae, and E Coli) from the urethra.

Chronic epididymitis is rare due to tuberculosis infection of the urinary tract. Other symptoms of urinary tuberculosis, as well as scrotal lumps, are frequent. Discharging scrotal fistula is a late sign of untreated disease.

Causes

Epididymitis is a complication of other infections in the urinary tract:

• Sexually transmitted infection of the urethra is 80% of epididymitis (STD or STI);
• Nonsexually transmitted infections (usually in boys and men not sexually active);
• Viral infections (mumps virus);
• Tuberculosis.

Non-infectious causes

• Chemical epididymitis: it occurs when urine flows backward into the epididymis, possibly because of heavy lifting or straining;
• A groin injury;
• Amiodarone: this heart medication can cause inflammation of the epididymis.

The following sexual behaviors (risk factors) can predispose an individual to develop sexually transmitted epididymitis:

• A personal history of STI;
• Sex without a condom;
• Sex with a partner who has STD.

Risk factors for no sexually transmitted epididymitis:

• History of urinary tract infections;
• urinary catheter insertion or endoscopy procedure;
• no circumcision and anatomical abnormality of the urinary tract;
• Prostate enlargement increases the risk of UTI.

 Symptoms

Signs and symptoms are always:

• A red, warm, and swollen scrotum;
• Testicle pain and tenderness;
• A lump on the testicle.

Less commonly:

• Blood in the semen;
• Painful urination and/or urgency and frequency;
• Discharge from the penis;
• Painful intercourse or ejaculation
• Pain or discomfort in the lower abdomen;
• Fever

Diagnosis

Medical history is essential to identify the risk factors and to focus on the correct cause.

We perform the culture of a mid-stream specimen of urine. The urine culture of the first voided urine is an excellent sample to detect sexually transmitted infections.

Men with Enterobacteriaceae may require investigation for lower urinary tract abnormalities.

If tuberculosis is suspected, three sequential early morning urine samples should be cultured. We use microscopy and culture to investigate prostate secretion, ejaculation, and discharge from a draining scrotal fistula, as well as fine-needle aspiration and biopsy.

Treatment

Epididymitis will not go away on its own.

The strong recommendation is antibiotic treatment with ceftriaxone, fluoroquinolones, azithromycin, and doxycycline.

In severe cases, we assess the clinical response after three days after starting the treatment. Moreover, after three days, we are likely to receive the culture results and confirm or change the empiric antibiotic treatment accordingly.

Men with potential or proven STIs should be evaluated at fourteen days to check the cure and ensure tracing and treatment of contacts.

Final recommendations

Do not underestimate acute epididymitis.

Torsion of the spermatic cord (testicular torsion) is the most important differential diagnosis in boys and young men.

There is a strong recommendation to see a doctor if testicular pain, swelling, or lump.

The treatment must be prompt and empiric (without waiting for the lab results), especially in severe cases.

We change the antibiotic after three days in the case of no significant improvement. However, we must reconsider the antibiotic in light of the lab results.

To leave epididymitis untreated, it becomes chronic and may impact your fertility.

External resources

https://www.cdc.gov/std/treatment-guidelines/epididymitis.htm