These are the images, diagnosis and treatment of cases the disease caused by Epididymitis . This is a Epididymitis Disease
Acute epididymitis results from ascending lower genital tract infection, analogous to the pathogenesis
of pelvic inflammatory disease in women. Chlamydia trachomatis and Neisseria gonorrhoeae cause most cases in men under 35 years old. Coliform bacteria or other traditional uropathogens are common causes in men older than 35 years, the insertive partners in anal intercourse, and in men with anatomic anomalies or recent urethral instrumentation. Tuberculosis and fungal infections such as coccidioidomycosis or cryptococcosis are occasionally implicated; tuberculosis in particular should be considered in patients with or at risk of HIV. Noninfective epididymitis can be caused by vasculitis and, rarely, certain drugs such as the anti-arrhythmic drug amiodarone. All teens and young adults with acute testicular pain should be evaluated for testicular torsion, a surgical emergency. Epididymitis is usually unilateral and rarely explains vague or bilateral testicular pain without tenderness, induration, or swelling; men with such complaints often have chronic pelvic pain syndrome or prostatitis.
EPIDEMIOLOGY
Incidence and Prevalence
• Medical claims data suggest that 0.3–0.5% of males age 14-35 are diagnosed with epididymitis per
year
• No accurate statistics available; epididymitis probably complicates ≤1% of urethral gonococcal and
chlamydial infections
• In heterosexual men <35 years old, 50–70% due to C. trachomatis and 5–40% due to N. gonorrhoeae, depending on local incidences of chlamydial infection and gonorrhea
• In men >35 years old, most cases are due to coliforms or Pseudomonas and are associated with bacterial UTI
Transmission
• As for C. trachomatis and N. gonorrhoeae
• Coliform urethritis and epididymitis can be sexually acquired by anal intercourse
Age
• Most sexually acquired cases age 15–35 years
Sexual Orientation
• Men who participate in insertive anal intercourse may be at elevated risk
Other Risk Factors
• Urinary tract instrumentation
• Anatomic abnormalities of lower urinary tract
• Bacterial prostatitis
• Tuberculosis in HIV-infected persons
• Amiodarone therapy
• Contrary to past beliefs, valsalva maneuver (“strain”) with reflux of urine into epididymis does not
cause epididymitis
HISTORY
Incubation Period
• Not well studied; onset often follows urethral chlamydial, gonococcal, or coliform infection by several days to a few weeks
Symptoms
• Testicular pain and swelling, usually unilateral, ranging in severity from mild to severe
• Sometimes inguinal pain
• Symptoms usually develop over 1–2 days, but onset may be perceived as sudden
• Fever may occur but is uncommon
• Urethritis reflects underlying etiology, i.e., usually mild or absent in chlamydial infection, prominent in gonorrhea
• Urinary urgency or frequency, without discharge, suggest bacterial UTI
• Bilateral testicular pain, without urethritis, UTI, tenderness, or other examination findings are rarely due to epididymitis; consider chronic pelvic pain syndrome or prostatitis
Epidemiologic History
• Often high-risk sexual exposure, as for chlamydia or gonorrhea
PHYSICAL EXAMINATION
• Symptoms and examination abnormalities usually are unilateral
• Epididymal and testicular enlargement
• Tenderness, often severe, often localized to epididymis but may involve entire testicle as well as epididymis (epididymo-orchitis)
• Scrotal erythema in severe cases
• Signs of urethritis often present, e.g., purulent or mucopurulent urethral discharge
LABORATORY TESTS
Evaluation for Lower Genital Tract Infection
• Evaluate as described for NGU, chlamydial infection, and gonorrhea
• In coliform epididymitis, midstream urine may show pyuria by microscopy or leukocyte esterase test
Microbiologic Tests
• NAATs for C. trachomatis and N. gonorrhoeae
• Urine culture for uropathogens
Other Tests
• Immediate assessment of blood flow (e.g., Doppler study or radionuclide scan) in patients at risk for
testicular torsion:
° Age <25 years, especially teens
° Sudden onset
° Absence of urethritis or pyuria
° Testicle elevated in scrotal sac
• Blood culture if febrile
DIAGNOSIS
• Epididymal or testicular tenderness and swelling plus evidence of urethritis or bacterial urinary tract
infection establishes the diagnosis with high reliability
• Differential diagnosis includes the “four Ts”
° Torsion: Common in teens, many of whom also are at risk for STD
° Tumor, i.e. testicular cancer
° Trauma, sometimes without history of injury
° Tuberculosis
• Other uncommon causes include cryptococcosis and other systemic fungal infections, vasculitis syndromes, amiodarone toxicity
TREATMENT
Suspected Sexually Acquired Epididymitis
• Ceftriaxone 250 mg IM plus doxycycline,∗ 100 mg PO bid for 10 days
Nonsexually Acquired Infective Epididymitis
• Ofloxacin† 300 mg PO bid for 10 days
• Levofloxacin† 500 mg PO once daily for 10 days
PARTNER MANAGEMENT AND PREVENTION
• As for chlamydial infection and gonorrhea
16–1. Acute epididymitis of right testicle; mucopurulent urethral discharge is present.
CASE 1
Patient Profile Age 28, married electrical engineer
History Mild left testicular pain for 2 days, becoming severe with swelling for 6 hours; denied urethral discharge and dysuria; sexual exposure 1 month earlier with new female partner
Examination Scrotum warm, skin erythematous; testicle indurated, enlarged to twice normal size; marked tenderness, maximal posteriorly, extending into spermatic cord; mucopurulent (white) urethral discharge
Differential Diagnosis Acute epididymitis; possible trauma, torsion, cancer, tuberculosis, or other
granulomatous inflammation
Laboratory Gram-stained urethral smear showed >15 PMNs per 1000× (oil immersion) microscopic field, without GND; leukocyte esterase test on midstream urine (negative); urethral cultures sent for C. trachomatis (positive) and N. gonorrhoeae (negative); midstream urine culture (no growth)
Diagnosis Chlamydial epididymitis
Treatment Ceftriaxone 250 mg IM (single dose) plus doxycycline 100 mg PO bid for 10 days
Partner Management Advised to refer wife and his new partner for treatment for presumptive chlamydia infection
16–2. Acute epididymitis due to amiodarone; the epididymis is enlarged and erythematous;
surgery was performed because tumor was suspected. Infectious epididymitis has a similar
appearance.
surgery was performed because tumor was suspected. Infectious epididymitis has a similar
appearance.
REFERENCES
H. Hunter Handsfield, MD, Color Atlas & Synopsis of Sexually Transmitted Diseases, Third Edition.
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