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Epididymitis (Lecture)

PANCE Blueprint Genitourinary (5%)

Patient will present as → a 25-year-old male with a dull, achy scrotal pain that has been gradually increasing over the last several days. He also reports pain with urination. Physical exam reveals a swollen right testicle with substantial induration. Urinalysis reveals positive leukocyte esterase and 20 WBC/HPF. Raising the testicle makes the pain less intense. (+ Prehn's sign = relief with elevation is a classic sign - compare this to testicular torsion)

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Epididymitis is characterized by dysuria, unilateral scrotal pain, and swelling

The pathogen is based on the patient's age and risk factors

  • men < 35 chlamydia and gonorrhea
  • men > 35 E.coli

+ Prehn's sign = relief with elevation is a classic sign

Testicular torsion should be ruled out in all cases of new-onset testicular pain.

  • With epididymitis, the pain is gradual in onset, and the tenderness is mostly posterior to the testis.
  • With testicular torsion, the symptoms are quite rapid in onset, the testis will be higher in the scrotum and may have a transverse lie, and the cremasteric reflex will be absent. The absence of leukocytes on urine analysis and decreased blood flow on scrotal ultrasound with Doppler will suggest torsion.

Urinalysis and culture, along with studies for GC and Chlamydia - will reveal pyuria and bacteriuria

  • Ultrasound with Doppler studies if concern for torsion

< 35 years, or suspected STD etiology

  • Ceftriaxone (500 mg intramuscular injection in one dose, or 1 g if patient weighs 150 kg or greater) plus doxycycline (100 mg orally twice a day for 10 days)
  • Refer sexual partner(s) for evaluation and treatment if contact within 60 days of the onset of symptoms.

≥ 35 years, with suspected enteric organism

  • Levofloxacin (Levaquin) 500 mg/day PO for 10 days OR
  • Trimethoprim-sulfamethoxazole (one double-strength tablet twice a day for 10 days) is a good alternative

Patients of any age who practice insertive anal intercourse – coverage for N. gonorrhoeae, C. trachomatis, and enteric pathogen infections

    • Ceftriaxone (500 mg intramuscular injection in one dose, or 1 g if patient weighs 150 kg or greater) PLUS a fluoroquinolone (levofloxacin 500 mg orally once daily for 10 days)

Question 1
Which of the following is the most common cause of acute epididymitis in men under the age of 35?
A
Chlamydia trachomatis
B
Ureaplasma urealyticum
Hint:
See A for explanation.
C
Pseudomonas aeruginosa
Hint:
See A for explanation.
D
Escherichia coli
Hint:
See A for explanation.
Question 1 Explanation: 
In men under the age of 35, acute epididymitis is typically caused by Chlamydia trachomatis and Neisseria gonorrhoeae.
Question 2
A 22 year-old male presents to the clinic complaining of scrotal pain that radiates into the groin. Patient admits to being a weightlifter and was lifting 24 hours prior to this pain developing into the scrotum. The patient admits to being sexually active with only his male partner. Examination reveals a reddened scrotum and it is difficult to distinguish the epididymis from the testes on the right side. Elevation of the right testicle brings relief of the pain. This is known as a positive
A
Prehn's sign
B
Cullen's sign
Hint:
Cullen's sign is a bluish discoloration of the umbilicus resulting from hemoperitoneum.
C
Rovsing's sign
Hint:
Rovsing's sign is seen in appendicitis when pressure on the left quadrant produces pain in the right lower quadrant.
D
Murphy's sign
Hint:
Murphy's sign is seen in acute cholecystitis with a sharp increase in tenderness when the gall bladder touches the examining hand causing a stop of the inspiratory effort.
Question 2 Explanation: 
Prehn's sign is seen in epididymitis when elevation of the scrotum with the affected epididymis to the level of the symphysis pubis brings relief from the pain.
Question 3
A 19 year-old man comes to the office because he has had a fever, frequent urination, urgency, dysuria and scrotal pain for the past 2 days. On physical examination, he has a temperature of 101 degrees F, scrotal swelling, and purulent urethral discharge is visible on penile examination. Gram stain of the discharge shows gram negative intracellular diplococci. Which of the following is the most appropriate antibiotic therapy?
A
Ampicillin (Principen)
Hint:
Ampicillin can be prescribed in conjunction with gentamicin to treat acute pyelonephritis.
B
Ciprofloxacin (Cipro)
Hint:
Ciprofloxacin can be prescribed to treat acute cystitis or chronic bacterial prostatitis.
C
Ceftriaxone (Rocephin)
D
Nitrofurantoin (Macrobid)
Hint:
Nitrofurantoin can be prescribed to treat acute cystitis.
Question 3 Explanation: 
Ceftriaxone is an effective treatment for acute epididymitis caused by Neisseria gonorrhoeae.
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References: Merck Manual · UpToDate

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