310

Practical Urology: EssEntial PrinciPlEs and PracticE

Diagnostic Evaluation

severe bacterial orchitis should be admitted

and treated with intravenous antibiotics

A thorough history and physical examination

(aminoglycosides, cephalosporins, or combi-

are the most valuable aspects of the diagnostic

nations of both) until culture results are avail-

evaluation of men with acute scrotal pain and

able and sensitivity-specific adjustments can

swelling. In patients with clinical orchitis, scro-

be made.1

tal ultrasound should be obtained as testicular

malignancy has been reported to masquerade

Treatment of Noninfectious

as orchitis.13 At least 10% of men with testicular

malignancy will initially be incorrectly diag-

Epididymorchitis

nosed as an acute inflammatory processes or

Nonspecific therapy for patients with noninfec-

spermatic cord torsion.14 High-frequency trans-

ducer sonography (7.5–10 MHz) is considered

tious epididymorchitis includes nerve blocks,

the best modality for evaluation of scrotal

analgesics, scrotal elevation, bed rest, and non-

pathology including orchitis.5 Heterogeneous

steroidal anti-inflammatory drugs.18

echotexture and enlargement of the testicle are

typical ultrasound findings in orchitis.15 Color

Epididymitis

Doppler ultrasound will show increased blood

flow to the epididymis in epididymorchitis16

Definition and Etiology

(Fig. 23.1). Scrotal wall thickening, hydrocele, or

pyocele may also be seen in association with this

inflammatory process on sonographic exams.17

Epididymitis is defined as inflammation of the

epididymis.1 Epididymitis is the fifth most com-

Treatment of Infectious Orchitis

mon urologic diagnosis made in men between the

ages of 18 and 59.19 In the US military, epididymi-

Doxycycline is effective in treating orchitis due

tis is responsible for more man hours lost to ill-

ness than any other urologic diagnosis.20

to C. trachomatis or N. gonorrhea. Third-

There are a number of causes of this inflam-

generation cephalosporins, such as ceftriax-

matory process including bacterial, viral, and

one, are also effective antimicrobial agents for

fungal infections; autoimmune disease; trauma;

epididymorchitis. C. trachomatis is also effec-

vasculitis; and idiopathic inflammatory causes.

tively treated with quinolones and macrolides,

Although it is known that a great number of

and treatment is usually maintained for

patients with epididymitis do not have an

3 weeks. Evaluation and treatment of sexual

infectious source, there is a paucity of evidence

partners is recommended as well. Patients with

explaining the mechanism of this disease

process.18,21

Although the pathophysiology of acute

epididymitis is not well understood, it is theo-

rized to be secondary to retrograde flow of

infected urine into the ejaculatory duct. This

theory is supported by the fact that 56% of men

diagnosed with acute bacterial epididymitis

have concomitant benign prostatic hyperplasia

with bladder outlet obstruction, urethral stric-

ture disease, or prostate cancer. Other mecha-

nisms must also be responsible for acute

epididymitis as men who have undergone

vasectomy develop symptoms of clinical

epididymitis.18,21

E. coli is the most common infectious patho-

gen in men older than 35 years of age with infec-

tious epididymitis. Other bacterial pathogens

Figure 23.1. Ultrasound image of acute epididymorchitis.

less commonly seen include U. urealyticum,

Corynebacteria species, Mycoplasma species,

Clinical Signs and Symptoms

and M. polymorpha.22 C. trachomatis is thought

to be the primary source of infectious epididym-

The mean age of patients presenting with

itis in men 35 years of age or younger. Men

epididymitis is 41. 43% of patients with

infected with C. trachomatis have a 4.28% inci-

epididymitis are between the ages of 20 and

dence of developing acute epididymitis.23

39 years. Another 29% are between the ages of

Chronic epididymitis has become the termi-

40 and 59 years.36

nology of choice for urologists defining a clini-

Acute epididymitis typically develops over a

cal picture of chronic epididymal pain which

course of several days and may present with

may or may not be associated with clinical signs.

pain and swelling, often unilateral. Fevers, ery-

The discomfort may vary in degree and is asso-

thema of the scrotum, hydrocele formation, ure-

ciated with scrotal, epididymal, or testicular

thritis, involvement of the testis, leukocytosis,

pain lasting for at least 3 months.24 Chronic

and positive urine cultures may also be seen in

epididymitis is thought to account for up to 80%

the presentation of acute epididymitis.18 Patients

of visits to the urologist for scrotal pain.25

who undergo urinary tract instrumentation or

Other less common causes of infectious

even clean intermittent catheterization are at

orchitis and epididymitis include B. melitensis,

higher risk of developing infectious epididymi-

M. tuberculosis, C. neoformans, and the mumps

tis, especially if they have infected urine during

virus.5 Chronic infectious epididymitis is most

the time of instrumentation.36-38

commonly due to M. tuberculosis, which is

Patients with chronic epididymitis can have

thought to be secondary to hematogenous

painful point tenderness in the epididymis with

spread.26 Tenpercentof patientswithBrucellosis

or without a palpable abnormality on physical

develop epididymitis due to this gram negative

examination. Scrotal ultrasound may demon-

coccobacillus.27

strate an epididymal abnormality in these men.

Other noninfectious sources of chronic

It is also common that the clinical and ultra-

epididymitis include sarcoidosis and Behcet’s

sound evaluation in men with chronic epididym-

disease. Sarcoidosis is more commonly seen in

itis is completely normal.39 The majority of

black patients, and this chronic granulomatous

patients with chronic epididymitis have had

process can affect the genitourinary tract in up

these symptoms for 5 years, and the average age

to 5% of patients.28,29 Behcet’s disease is a mul-

at the time of presentation is 49 years.24 These

tiorgan vasculitic disease of an idiopathic

men may complain of erectile dysfunction, neu-

nature.30

rological diseases, and musculoskeletal com-

Clinicians must also be aware of iatrogenic

plaints.18 When compared to controls, men with

sources of epididymitis. Clinical noninfectious

chronic epididymitis have a greater number of

epididymitis can be a complication of the use of

sexual partners, a more frequent history of sex-

the drug amiodarone for arrhythmias.14 This is

ually transmitted disease, and have used sexu-

due to anti-amiodarone HCL antibodies which

ally transmitted disease protection less often.24

attack the epididymal lining. Clinical epididym-

Patients with male factor infertility may reveal

itis is seen in 11% of patients on high-dose ami-

a history of chronic epididymitis which has been

odarone.31 Prostate biopsy is another iatrogenic

associated with oligoasthenospermia and alter-

source of epididymitis. There is a 0.2% rate of

ations in spermatozoa DNA integrity.40

epididymitis after transrectal ultrasound and

Patients with sarcoid epididymitis have pro-

biopsy of the prostate.32

gressive enlargement of the epididymis, which

Epididymitis in children is often secondary to

can be bilateral in up to 30% of these men.

systemic viral infection, most commonly sec-

Extragonadal sarcoidosis frequently precedes

ondary to M. pneumoniae, enteroviruses, and

the diagnosis of sarcoid epididymitis.29 Patients

adenoviruses. Mumps epididymitis is rarely

with epididymitis associated with Behcet’s dis-

seen in the USA since an effective vaccine was

ease may have tender genital ulcers, aphthous

introduced in 1985.33,34 A vasculitic epididymi-

ulcers, and uveitis.30

tis may also develop in children with Henoch-

Children with epididymitis present with an

Schonlein Purpura due to immunoglobulin

acute scrotum, sonographic hyperemia on

A complex deposition, causing small vessel

Doppler, and any two of the following: leukocy-

vasculitis.35

tosis, fever with a temperature greater than

Children with acute epididymitis and a posi-

injection therapy.24Despite evidence that up to

tive urine culture should undergo renal ultra-

75% of patients do not have an identifiable bac-

sound and VCUG. Ultrasound examination of

terial urinary tract infection concomitantly with

the kidneys and urinary bladder without VCUG

their clinical epididymitis, antibiotics are rou-

is adequate for children with acute epididymitis

tinely given. Empirical antibiotic administration

and a negative urine culture.41

in the absence of positive urine cultures has

been steadily increasing, from 75% to 95%

Treatment of Acute Epididymitis

between the years of 1965 and 2005. Antibiotic

administration does not decrease the length of

The evaluation and treatment of epididymitis

symptoms or the return to full activity in men

without an identifiable bacterial pathogen.36,53

traditionally includes use of empiric antibiotics

when infection is suspected and supportive

management such as bed rest, scrotal elevation,

Surgical Treatment of Chronic

analgesics, and nonsteroidal anti-inflammatory

Epididymitis

drugs. In patients at risk for a sexually transmit-

ted disease, treatment should consist of one dose

Surgical treatment for chronic epididymitis is

of Ceftriaxone 250 mg intramuscularly and

poorly studied in clinical trials with no level-

Doxycycline 100 mg by mouth twice a day for

one evidence to support the use of a specific sur-

10 days. Patients older than 35 years of age with

gical procedure. Fewer than 250 patients with

a suspected bacterial pathogen should be treated

chronic scrotal pain have been treated with dif-

empirically with Levofloxacin 500 mg by mouth

fering surgical therapies in the available litera-

daily for 10 days or Ofloxacin 300 mg by mouth

ture

despite the common

nature of

chronic

twice a day for 10 days.42

scrotal pain. The authors

do

not

advocate

In patients diagnosed with C. trachomatis,

orchiectomy for chronic orchitis/epididymitis,

sexual partners should be treated as well to pre-

but if orchiectomy is recommended, the patient

vent pelvic inflammatory disease, infertility, and

should previously have failed conservative ther-

chronic pelvic pain in the female partner.

apy and must be apprised of the risks, benefits,

Without treatment of the partner, the couple

and options of orchiectomy. As many patients

will be at risk of transmitting the pathogen back

will continue to have pain or have pain recur

and forth to one another and causing recurrent

after orchiectomy, the surgeon should be aware

infections.51

of the medical legal aspects of this action.

If the patient appears toxic, has systemic

In

one

study, 10

patients

with

chronic

symptoms (fevers or leukocytosis, necrotizing

epididymitis (defined as epididymal pain last-

fasciitis or testicular infarction), or has signifi-

ing greater than 3 months),underwent epididy-

cant comorbidities (e.g. immunosuppression or

mectomy for intractable symptoms. Only one of

uncontrolled diabetes mellitus), then hospital-

these patients had significant improvement in

ization is warranted where close observation,

pain.54 Other authors have reported much higher

supportive care, parenteral antibiotics, and

success rates, such as six out of seven patients

fluid resuscitation should be administered as

(86%) having significant improvement in pain

needed.18

55

after epididymectomy. Chronic or recurrent

epididymitis and persistent epididymalgia with

Treatment of Chronic Epididymitis

point tenderness to the epididymis may be rea-

sonable indications for epididymectomy.56

Although there is no level-one evidence for the

Surgical treatment for chronic epididymitis

optimal treatment of chronic epididymitis, local

should be considered only after failure of exten-

supportive therapy including heat, nerve blocks,

sive conservative therapy and after appropriate

analgesics, tricyclic antidepressants, anticonvul-

counseling, with the understanding that the

sants such as gabapentin,and anti-inflammatory

symptoms may not improve after surgery, or

drugs are common practice and may offer some

may indeed worsen.A retrospective review of 32

relief.52 Other treatment options implemented

men who underwent epididymectomy for

for chronic epididymitis include phytotherapy,

chronic epididymitis showed that outcomes

anxiolytics, narcotics, acupuncture, and steroid

were

best

when the

patient had a

palpable

314

Practical Urology: EssEntial PrinciPlEs and PracticE

epididymal abnormality on physical examina-

with doxycycline 100 mg by mouth twice a day

tion.Men in this study without a palpable abnor-

for 6 weeks and either streptomycin 1 g intra-

mality, but with sonographic changes had

muscularly daily for 14 days or rifampin 600–

slightly worse outcomes, and those without

900 mg daily by mouth for 6 weeks.62

either a palpable abnormality or a demonstrable

Epididymitis in children is often secondary to

ultrasound abnormality did not improve with

viral infections and should be treated conserva-

epididymectomy.39

tively with ice packs and analgesics.34 Epidi-

Some surgeons have attempted microsurgical

dymitis associated with Henoch-Schonlein

denervation of the spermatic cord for symp-

Purpura is a self-limited disease and may improve

tomatic relief of chronic scrotal pain. Micro-

with the administration of corticosteroids.35

surgical denervation of the spermatic cord was

performed in 79 men on 95 testicular units for

Testicular Torsion and Torsion

chronic orchalgia over a mean duration of

62 months. There was complete relief of pain in

of the Testicular and Epididymal

71% of the patients, partial relief in 17%, and

Appendages

there was no change from the preoperative sta-

tus in 12%, with no patients experiencing wors-

ened postoperative pain. The mean follow-up

Clinical Signs, Symptoms,

was 20.3 months.57

and Differential Diagnosis of

Treatment of Purulent and Atypical

the Acute Scrotum

The acute scrotum includes the diagnoses of

Epididymitis

testicular torsion, acute epididymorchitis, and

The diagnosis of purulent epididymitis is made

torsion of a testicular appendage. A thorough

with the combination of physical examination,

history and physical examination is the key to

ultrasound evaluation, and occasionally needle

making an accurate diagnosis. Leukocytosis is

aspiration of the epididymis. Epididymectomy

frequently not found to be a distinguishing

is performed when possible and orchiectomy is

parameter for these diagnoses.Pyuria was found

performed when an abscess or necrosis of tes-

in 26% of patients with epididymorchitis. Color

ticular tissue is present. Common causative

Doppler ultrasound has the highest sensitivity

organisms include N. gonorrhea, C. trachomatis,

(87.9%) and specificity (93.3%) of differentiat-

and E. coli.58

ing testicular torsion from the other diagnoses

Corticosteroids should be utilized as first-line

of the acute scrotum.63

treatment for pain and swelling in sarcoid

Testicular torsion can be seen in patients of

epididymitis. In the rare case where surgical

any age, but most commonly occurs in males

exploration is undertaken, a frozen section

between the ages of 12 and 18. Testicular torsion

should be obtained to prevent an unnecessary

occurs in one out of every 4,000 men below the

epididymectomy or orchiectomy.29 If a patient

age of 25.64 The risk of having spermatic cord

with sarcoid epididymitis is found to be oli-

torsion or torsion of an appendage of the testicle

gospermic, he should consider sperm storage.59

or epididymis is one in 160 by the age of 25.65

Treatment of Behcet’s disease is targeted at

The incidence of bilateral testicular torsion

symptomatic relief, mainly with corticosteroids.30

(synchronous or metachronous) is 2%.66

Treatment of epididymal tuberculosis should

The most consistent presentation of testicular

consist of a 6 month course using a three drug

torsion is the acute onset of severe testicular

regimen including isoniazid,rifampin,and pyrazi-

pain. Pain may be followed by nausea, vomiting,

namide. Ethambutol should be added to the regi-

and even a low-grade fever. The hemiscrotum of

men if the patient is from a highly drug-resistant

the affected side is typically swollen, tender, and

region, until sensitivities are available.60,61 Men

inflamed on physical examination.Another typi-

with Bacille Calmette-Guerin epididymitis are

cal physical sign is the absence of the cremasteric

treated with isoniazid and rifampin.

reflex.67 Pain is not relieved by elevation of

Patients with epididymitis due to Brucellosis,

the scrotum.11 Patients may present with a “bell

(infection with B. melitensis), should be treated

clapper” deformity, when the tunica vaginalis