Epididymitis

Question 1

What is epididymitis?

Answer 1

• Inflammation of epididymis
• Testes inflam = orchitis
• Most common 15-30 and >60
• Two conditions can occur together - epididymo-orchitis
• But most are solely epididymitis, sole orchitis is rare and mostly viral

Question 2

Pathophys of epididymo-orchitis

Answer 2

• Local extension of infection from lower urinary tract (bladder and urethra)
• Either via enteric (classic UTI) or non-enteric (sexually transmitted organisms)

Question 3

Most common organisms for epididymo-orchitis based on age

Answer 3

• Males <35 - sexually transmitted so neisseria gonorrhoea and chlamydia trachomatis
• Males >35 - enteric organism from UTI so E-coli, klebsiella pneumoniae, pseudomonas aeruginosa

Males >35 often secondary to outflow obstruction eg BPH

Question 4

What is mumps orchitis?

Answer 4

• Complication of mumps viral infection
• Unilateral or bilateral orchitis + fever
• 4-8 days onset after mumps parotitis
• Usually self resolves within 1 week with supportive management

Question 5

Complications of mumps orchitis

Answer 5

• Testicular atrophy
• Infertility

Question 6

Investigations of suspect mumps orchitis

Answer 6

• Mumps IgM/IgG serology
• Notifiable disease - local health protection team must be notified

Question 7

RF for epididymo-orchitis

Answer 7

Non-enteric:
* Men who have sex with men
* Multiple sexual partners
* Known contact of gonorrhoea

Enteric:
* Recent cathterisation or instrumentation
* Bladder outlet obstruction eg BPH, urethral stricture
* Immunocompromised

Question 8

Symptoms of epididymitis

Answer 8

• Unilateral scrotal pain
• Associated swelling
• Fever and rigors
• Associated symptoms of underlying disease - dysuria, storage LUTS, urethral discharge - CLARIFY SEXUAL HISTORY

Question 9

Examination findings for epididymitis

Answer 9

• Affected side is red and swollen - bilateral is rare
• Tender on palpation - epididymis +/- testes
• Associated hydrocele

Question 10

Specific examination tests for epididymitis

Answer 10

• Cremasteric reflex - should be intact
• Prehns sign - positive suggests epididymitis

Question 11

What is Prehns sign?

Answer 11

• Patient supine
• Scrotum elevated by examiner
• If pain relieved by elevation = positive
• BUT unreliable test

Question 12

Bedside and bloods for epididymitis

Answer 12

• Urine dipstick - check for infection, low threshold to send MC&S
• Non-enteric - first void volume sent for NAAT - chlamydia, gonorrhoea, mycoplasma genitalium
• Bloods - FBC, CRP, blood cultures if septic

Nucleic acid amplification test

Question 13

Imaging for epididymitis

Answer 13

• Usually clinical diagnosis
• US testes using US doppler can be used to confirm and rule out abscess
• Colour doppler will be able to show increased vascularity, also assess testicular blood flow

Question 14

Management epididymitis

Answer 14

• Abx
• Analgesia
• Usually outpatient unless systemic infection or uncontrolled pain

Question 15

Suggested first line for enteric vs STI epididymitis

Answer 15

• Enteric - Ofloxacin or Levofloxacin
• STI - Ceftriaxone IM and Doxycycline oral (+ single dose azithromycin if gonorrhoea likely)

Question 16

Prostatitis sexual activity info

Answer 16

• Abstain from sexual activity until abx course complete and symptoms resolve
• Barrier contraception counselling to reduce risk of STIs

Question 17

Chronic epididymitis that fails to respond to therapy and causes persistent pain - management

Answer 17

May warrant orchiectomy in rare cases

Question 18

Complications epididymitis

Answer 18

• Reactive hydrocele
• Abscess formation
• Testicular infarction

Symptoms usually improve within 48hrs of starting abx though :)