Epididymitis

Acute epididymitis is a clinical syndrome causing pain, swelling, and inflammation of the epididymis and lasting <6 weeks (1191). Sometimes a testicle is also involved, a condition referred to as epididymo-orchitis. A high index of suspicion for spermatic cord (testicular) torsion should be maintained among men who have a sudden onset of symptoms associated with epididymitis because this condition is a surgical emergency.

Acute epididymitis can be caused by STIs (e.g., C. trachomatis, N. gonorrhoeae, or M. genitalium) or enteric organisms (i.e., Escherichia coli) (1192). Acute epididymitis caused by an STI is usually accompanied by urethritis, which is frequently asymptomatic. Acute epididymitis caused by sexually transmitted enteric organisms might also occur among men who are the insertive partner during anal sex. Nonsexually transmitted acute epididymitis caused by genitourinary pathogens typically occurs with bacteriuria secondary to bladder outlet obstruction (e.g., benign prostatic hyperplasia) (1193). Among older men, nonsexually transmitted acute epididymitis is also associated with prostate biopsy, urinary tract instrumentation or surgery, systemic disease, or immunosuppression. Uncommon infectious causes of nonsexually transmitted acute epididymitis (e.g., Fournier’s gangrene) should be managed in consultation with a urologist.

Chronic epididymitis is characterized by a ≥6-week history of symptoms of discomfort or pain in the scrotum, testicle, or epididymis. Chronic infectious epididymitis is most frequently observed with conditions associated with a granulomatous reaction. Mycobacterium tuberculosis (TB) is the most common granulomatous disease affecting the epididymis and should be suspected, especially among men with a known history of or recent exposure to TB. The differential diagnosis of chronic noninfectious epididymitis, sometimes termed orchialgia or epididymalgia, is broad (e.g., trauma, cancer, autoimmune conditions, or idiopathic conditions). Men with this diagnosis should be referred to a urologist for clinical management (1191,1192).

Diagnostic Considerations

Men who have acute epididymitis typically have unilateral testicular pain and tenderness, hydrocele, and palpable swelling of the epididymis. Although inflammation and swelling usually begin in the tail of the epididymis, it can spread to the rest of the epididymis and testicle. The spermatic cord is usually tender and swollen. Spermatic cord (testicular) torsion, a surgical emergency, should be considered in all cases; however, it occurs more frequently among adolescents and men without evidence of inflammation or infection. For men with severe unilateral pain with sudden onset, those whose test results do not support a diagnosis of urethritis or urinary tract infection, or for whom diagnosis of acute epididymitis is questionable, immediate referral to a urologist for evaluation for testicular torsion is vital because testicular viability might be compromised.

Bilateral symptoms should increase suspicion of other causes of testicular pain. Radionuclide scanning of the scrotum is the most accurate method for diagnosing epididymitis but it is not routinely available. Ultrasound should be used primarily for ruling out torsion of the spermatic cord in cases of acute, unilateral, painful scrotal swelling. However, because partial spermatic cord torsion can mimic epididymitis on scrotal ultrasound, differentiation between spermatic cord torsion and epididymitis when torsion is not ruled out by ultrasound should be made on the basis of clinical evaluation. Although ultrasound can demonstrate epididymal hyperemia and swelling associated with epididymitis, it provides minimal diagnostic usefulness for men with a clinical presentation consistent with epididymitis. A negative ultrasound does not rule out epididymitis and thus does not alter clinical management. Ultrasound should be reserved for men if torsion of the spermatic cord is suspected or for those with scrotal pain who cannot receive an accurate diagnosis by history, physical examination, and objective laboratory findings.

All suspected cases of acute epididymitis should be evaluated for objective evidence of inflammation by one of the following POC tests:

• Gram, MB, or GV stain of urethral secretions demonstrating ≥2 WBCs per oil immersion field (737) (see Urethritis). These stains are preferred POC diagnostic tests for evaluating urethritis because they are highly sensitive and specific for documenting both urethral inflammation and presence or absence of gonococcal infection. Gonococcal infection is established by documenting the presence of WBC-containing intracellular gram-negative or purple diplococci on urethral Gram, MB, or GV stain, respectively.
• Positive leukocyte esterase test on first-void urine.
• Microscopic examination of sediment from a spun first-void urine demonstrating ≥10 WBCs/HPF.

All suspected cases of acute epididymitis should be tested for C. trachomatis and N. gonorrhoeae by NAAT. Urine is the preferred specimen for NAAT for men (553). Urine cultures for chlamydial and gonococcal epididymitis are insensitive and are not recommended. Urine bacterial cultures should also be performed for all men to evaluate for the presence of genitourinary organisms and to determine antibiotic susceptibility.

Treatment

To prevent complications and transmission of STIs, presumptive therapy for all sexually active men is indicated at the time of the visit before all laboratory test results are available. Selection of presumptive therapy is based on risk for chlamydial and gonococcal infections or enteric organisms. Treatment goals for acute epididymitis are 1) microbiologic infection cure, 2) improvement of signs and symptoms, 3) prevention of transmission of chlamydia and gonorrhea to others, and 4) decreased potential for chlamydial or gonococcal epididymitis complications (e.g., infertility or chronic pain). Although the majority of men with acute epididymitis can be treated on an outpatient basis, referral to a specialist and hospitalization should be considered when severe pain or fever indicates other diagnoses (e.g., torsion, testicular infarction, abscess, or necrotizing fasciitis) or when men are unable to comply with an antimicrobial regimen. Age, history of diabetes, fever, and elevated C-reactive protein can indicate more severe disease requiring hospitalization (1193).

Levofloxacin monotherapy should be considered if the infection is most likely caused by enteric organisms only, and gonorrhea has been ruled out by Gram, MB, or GV stain. This includes men who have undergone prostate biopsy, vasectomy, and other urinary tract instrumentation procedures. Treatment should be guided by bacterial cultures and antimicrobial susceptibilities. As an adjunct to therapy, bed rest, scrotal elevation, and nonsteroidal anti-inflammatory drugs are recommended until fever and local inflammation have subsided. Complete resolution of discomfort might not occur for a few weeks after completion of the antibiotic regimen.

Other Management Considerations

Men who have acute epididymitis confirmed or suspected to be caused by N. gonorrhoeae or C. trachomatis should be advised to abstain from sexual intercourse until they and their partners have been treated and symptoms have resolved. All men with acute epididymitis should be tested for HIV and syphilis.

Follow-Up

Men should be instructed to return to their health care providers if their symptoms do not improve <72 hours after treatment. Signs and symptoms of epididymitis that do not subside in <3 days require reevaluation of the diagnosis and therapy. Men who experience swelling and tenderness that persist after completion of antimicrobial therapy should be evaluated for alternative diagnoses, including tumor, abscess, infarction, testicular cancer, TB, and fungal epididymitis.

Management of Sex Partners

Men who have acute sexually transmitted epididymitis confirmed or suspected to be caused by N. gonorrhoeae or C. trachomatis should be instructed to refer all sex partners during the previous 60 days before symptom onset for evaluation, testing, and presumptive treatment (see Chlamydial Infections; Gonococcal Infections). If the last sexual intercourse was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be evaluated and treated. Arrangements should be made to link sex partners to care. EPT is an effective strategy for treating sex partners of men who have or are suspected of having chlamydia or gonorrhea for whom linkage to care is anticipated to be delayed (125,126) (see Partner Services). Partners should be instructed to abstain from sexual intercourse until they and their sex partners are treated and symptoms have resolved.

Special Considerations

Drug Allergy, Intolerance, and Adverse Reactions

The risk for penicillin cross-reactivity is negligible between all third-generation cephalosporins (e.g., ceftriaxone) (658,681) (see Management of Persons Who Have a History of Penicillin Allergy). Alternative regimens have not been studied; therefore, clinicians should consult an infectious disease specialist if such regimens are required.

HIV Infection

Men with HIV infection who have uncomplicated acute epididymitis should receive the same treatment regimen as those who do not have HIV. Other etiologic agents have been implicated in acute epididymitis among men with HIV, including CMV, salmonella, toxoplasmosis, U. urealyticum, Corynebacterium species, Mycoplasma species, and Mima polymorpha (1192).

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