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Epididymitis

What is Epididymis?

The epididymis is a coiled tube behind each testicle. Each epididymis continues upwards as the vas deferens. The sperm cells produced by the testicles are stored in the epididymis and they mature as they travel through it. This vas deferens runs in the pelvis and behind the bladder where it joins with the seminal vesicle and forms the ejaculatory duct. At ejaculation, the fluid that comes out at the end of the penis is made up of sperm cells, secretions from the seminal vesicles and the prostate.

What is Epididymitis?

Epididymitis refers to inflammation of the epididymis. It is a significant cause of morbidity and is the fifth most common urologic diagnosis in men aged 18-50 years.  It can be acute (sudden) or chronic (long-term) and is typically from a bacterial infection. In children, there may be an underlying congenital anomaly of the urogenital tract

Acute epididymitis is felt quickly with swelling and pain, and it usually goes away with treatment. Chronic epididymitis typically is a duller pain, develops slowly and is a longer-term problem. Symptoms of chronic epididymitis can get better, but may not go away fully with treatment and may come and go. Most cases of epididymitis are seen in adults.

When the swelling involves the testicle it is called Epididymo-orchitis. Isolated swelling of the testicle without the epididymis is called Orchitis; a condition quite uncommon.

Signs and Symptoms of Epididymitis

Acute epididymitis

  • Scrotal pain and swelling of gradual onset (Scrotal pain of sudden onset may point to another condition called Testicular Torsion which is a urological emergency).

  • Usually one-sided

  • Dysuria, frequency, or urgency

  • Fever and chills (25% of adults, up to 71% of children).

  • Usually, no nausea or vomiting (in contrast to testicular torsion)

  • Urethral discharge preceding the onset of acute epididymitis (in some cases)

Chronic epididymitis

  • Long-standing history of pain (usually greater than 6 weeks)

  • Scrotum is not usually swollen but may be indurated in long-standing cases

  • Parotid gland swelling 3 to 5 days prior to the onset of scrotal swelling may point to Mumps orchitis.

 

Causes of Epididymitis

Acute epididymitis is most often caused by an infection from bacteria and the most implicated organism is E. coli

  • In children it is often caused by urinary tract infection.

  • In men, in addition to urinary tract infection, a sexually transmitted disease is one of the causes (commoner in men <39 years of age). Mostly from chlamydia, mycoplasma or rarely gonorrhea. In this case, testicular swelling may be preceded by urethral discharge

  • Bladder outlet obstruction from enlarged prostate

  • Bacterial prostatitis

  • Partly blocked urethra

  • Recent catheter use

  • Drug use (e.g. Amiodarone)

  • Tuberculosis

Diagnosis

Urine Culture - Your doctor will take a history of your symptoms and examine you. He/she may request for a culture of your urine sample for evidence of infection.

Urethral swab culture - If your doctor thinks you may have developed acute epididymitis from a sexually transmitted disease, he/she may test a swab of fluid from your urethra.

Scrotal Ultrasound - Scrotal ultrasound may be requested to assess the structure of the scrotal content. It can measure the blood flow in the epididymis, examine the inside of the testis and see other changes in the scrotum.

Other supportive investigations which may be carried out include;

  • Complete blood count for evidence of leukocytosis

  • Erythrocyte Sedimentation Rate (ESR)

  • Retrograde and Antegrade Urethrography

  • Abdominopelvic Ultrasound

  • Cystoscopy

  • Chest X-ray for suspected cases of tuberculous epididymitis

Treatment

Treatment often starts with a 2-3 week course of antibiotics. Most cases can be treated on outpatient basis with pills. Broad spectrum antibiotics may be started based on local sensitivity pattern and then specific antibiotics chosen based on culture result. Hospital stay may be required for bad cases of infection.

In addition to antibiotics the mainstays of supportive therapy for acute epididymitis include:

  • Reduction in physical activity

  • Scrotal support and elevation

  • Ice packs

  • Anti-inflammatory agents

  • Analgesics

  • Avoidance of urethral instrumentation

Surgical options include the following:

  • Epididymotomy: Infrequently performed in patients with acute suppurative epididymitis

  • Epididymectomy: Typically reserved for refractory cases

  • Orchiectomy: Indicated only for patients with unrelenting epididymal pain

  • Skeletonization of the spermatic cord via subinguinal varicocelectomy: Performed in rare cases of refractory pain due to chronic epididymitis and ochialgia.

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