Epididymitis
Author
Kai Zhang (Department of Urology, Peking University First Hospital, Beijing, China)
Executive Summary
Epidemiology and pathogenesis
1. Epididymitis is inflammation of the epididymis, causes pain and swelling. Acute epididymitis represents sudden occurrence of pain and swelling of the epididymis associated with acute inflammation of the epididymis. Chronic epididymitis represents 3-month or longer history of symptoms of discomfort and/or pain in the scrotum, testicle or epididymis that is localized to one or both epididymis.
2. 1% patients in the urologic clinic were identified with the diagnosis of epididymitis. Most patients (80%) could be classified as chronic epididymitis (LE: 3).
3. In sexually active men, epididymitis is commonly the result of a sexually transmitted infection; the most common organisms causing epididymitis are N.gonorrhoeae, and C. trachomatis (LE: 3). Men who have anal intercourse are at higher risk of epididymitis caused by Enterobacteriaceae.
4. In elderly men, BPH and associated stasis, UTI, and catheterization are the most common causes of epididymitis; the most common causative microorganisms in the pediatric and elderly age groups are the coliform organisms that cause bacteriuria (LE: 3).
Diagnosis
1. Culture of a mid-stream urine (MSU) specimen should be performed. Sexually transmitted infection with C. trachomatis or N. gonorrhoeae should be detected by NAAT on first voided urine. A urethral swab or smear should be performed for Gram staining and culture if N. gonorrhoeae is likely. Detection of these pathogens should be reported according to local procedures (GR:C).
2. In boys and young men, acute epididymitis and spermatic cord torsion should always be differentiated as soon as possible (GR: B).
Treatment
1. In acute epididymitis, antimicrobials should be selected on the empirical basis.
2. For acute epididymitis most likely caused by N.gonorrhoeae, and C. trachomatis, the regimen is ceftriaxone 1000 mg intramuscularly in a single dose, plus doxycycline 100 mg orally twice a day for 10 days (GR: C).
3. For acute epididymitis most likely caused by enteric organisms, fluoroquinolones are recommended as first line agents: ofloxacin 300 mg twice a day for 10 days or levofloxacin 500 mg once a day for 10days (GR: C).
4 Supportive therapy includes bed rest, up positioning of the testes (GR: C).
5. In chronic epididymitis, a 4 to 6-week trial of antibiotics that would potentially be effective against possible bacterial pathogens and C. trachomatis (GR: C).
Introduction
The purpose of this guideline is to identify accepted criteria for definition, classification, diagnosis, and therapy of epididymitis based on the literature search. It will help Asian urologists and GPs on diagnosis and treatment of epididymitis, and may be necessary to the collaborative studies on this field in the future. The text focuses on an infectious or inflammatory disease of the human epididymis, while the conditions such as chronic epididymalgia, epididymo-orchitis or orchitis are not included.
Definitions
Epididymitis is inflammation of the epididymis, causes pain and swelling which is almost always unilateral and relatively acute in onset. In some cases, the testes are involved in the inflammatory process (epididymo-orchitis). On the other hand, inflammatory processes of the testicle, especially virally induced orchitis, often involve the epididymis[1].
Epididymitis are classified as acute or chronic processes according to the onset and clinical course. Acute epididymitis represents sudden occurrence of pain and swelling of the epididymis associated with acute inflammation of the epididymis. Chronic epididymitis represents 3-month or greater history of symptoms of discomfort and/or pain in the scrotum, testicle or epididymis that is localized to one or both epididymis on clinical examination[2].
1% patients in the urologic clinic were identified with the diagnosis of epididymitis. Most patients (80%) could be classified as chronic epididymitis (defined as duration of symptoms for 3 or more months) (LE: 3)[3]. Less than 1% patients undergoing TURP or other transurethral procedure (LE:3), such as holmium laser enucleation of the prostate (LE: 3), TRUS-guided biopsy of prostate (LE:2), prostate brachytherapy (LE: 2) occur epididymitis[4][5][6][7]. Urethral catheterization is one of the risk factors of epididymitis (LE: 3)[8][9].
Typically, in epididymitis due to common bacteria and sexually transmitted organisms, the infection is spread from the urethra or bladder. In sexually active men younger than 35 years of age, epididymitis is commonly the result of a sexually transmitted infection (LE: 3). In elderly men, BPH and associated stasis, UTI, and catheterization are the most common causes of epididymitis[10][11]. Bacterial prostatitis and/or seminal vesiculitis are associated with epididymal infection in postpubertal males of all ages (LE: 3)[12]. In infants and boys, epididymitis is often related to a UTI and/or an underlying genitourinary congenital anomaly (LE: 3) or even to the presence of a foreskin (LE: 3)[13][14]. In the boys with genitourinary congenital anomaly, recurrent epididymitis is common [15]. In men younger than the age of 35 who are sexually active with women, the most common organisms causing epididymitis are N. gonorrhoeae and C. trachomatis (LE: 3)[10][16]. Men who have anal intercourse and those with abnormalities of the urinary tract resulting in bacteriuria are at higher risk of epididymitis caused by Enterobacteriaceae [1]. The most common causative microorganisms in the pediatric and elderly age groups are the coliform organisms that cause bacteriuria (LE: 3)[17]. Tuberculosis, mycobacteria, viral, fungal, mycoplasmal and parasitic microorganisms can be associated with epididymitis. Rarely, epididymitis could be a complication of brucellosis[18][19].
Chronic epididymitis may result from other disease such as Behçet disease (LE: 3) or treatment with amiodarone (LE: 4)[20][21].
Clinical Evaluation
Men with epididymitis that is caused by sexually transmitted organisms may have a history of sexual exposure. A negative sexual risk history does not exclude STIs in sexually active men. Lower urinary tract surgery or catheterization may cause epididymitis.
In acute epididymitis, the inflammation and swelling usually begin in the tail of the epididymis, and may quickly spread to involve the rest of the epididymis. Physical examination localizes the tenderness to the epididymis. If it continues to the testis then the swollen epididymis becomes indistinguishable from the testis. The spermatic cord is usually tender and swollen. In chronic epididymitis, may result from inadequately treated acute epididymitis, the inflammation and pain in the epididymis is usually without swelling[2].
Culture of a mid-stream urine (MSU) specimen should be performed. Sexually transmitted infection with C. trachomatis or N. gonorrhoeae should be detected by NAAT on first voided urine. A urethral swab or smear should be performed for Gram staining and culture if N. gonorrhoeae is likely. Detection of these pathogens should be reported according to local procedures [1].
In boys and young men, acute epididymitis and spermatic cord torsion should always be differentiated as soon as possible using all available information, including the age of the patient, history of urethritis, clinical evaluation and Doppler (duplex) scanning of testicular blood flow. High-resolution ultrasonography is reliable for the differentiation between epididymitis and spermatic cord torsion (GR: B)[22][23][24]. Chronic epididymitis can sometimes be the first clinical manifestation of urogenital tuberculosis.
Treatment
In acute epididymitis, antimicrobials should be selected on the empirical basis. (1) For sexually active men, who are at risk of infection with C. trachomatis or N. gonorrhoeae, a therapeutic regimen that covers both these pathogens is mandatory. As antibiotic resistance in N. gonorrhoeae increased dramatically over the last years, fluoroquinolones should not be the drugs of first choice. The proper regimen is ceftriaxone 1000mg intramuscularly in a single dose, plus doxycycline 100 mg orally twice a day for 10 days (GR:C). (2) In older men, with BPH or other micturition disturbances, the most common urinary tract pathogens are involved, fluoroquinolones are recommended as first line agents: ofloxacin 300 mg twice a day for 10 days or levofloxacin 500 mg once a day for 10days (GR: C)[25][26]. In chronic epididymitis, a 4 to 6-week trial of antibiotics that would potentially be effective against possible bacterial pathogens and particularly C. trachomatis may be appropriate (GR: C)[3][27].
Supportive therapy includes bed rest, up positioning of the testes (GR: C). Anti-inflammatory agents, analgesics and nerve blocks have all been recommended as empirical treatment (GR: C). If uropathogens are found as causative agents, a thorough search for micturition disturbances should be carried out to prevent relapse (GR: C). In case of C. trachomatis epididymitis, the sexual partner should also be treated (GR: C)[1][3]. Urethral catheter should be withdrawn or substituted by suprapubic catheterization (GR: B)[28].
In young men, epididymitis can lead to permanent occlusion of the epididymal ducts and thus to infertility, therefore, one should consider antiphlogistic therapy with methylprednisolone, 40mg/day, and reduce the dose by half every second day (GR: C)[1].
Abbreviations
AAUS: Asian Association of UTI and STI, BPH: benign prostatic hyperplasia, CDC: Centers for Disease Control and Prevention, EAU: European Urological Association, GPs: general practitioners, ICUD: International Consultation on Urological Diseases, MSU: mid-stream urine, STD: sexually transmitted diseases, TRUS: transrectal ultrasonography, TURP: transurethral resection of prostate, UTI: urinary tract infection, WBC: white blood cells
Reference
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