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ACUTE EPIDIDYMITIS: A WORK-RELATED INJURY? Eugene K. Sawyer, MD, and John R. Anderson, DO Livonia, Michigan Occupational medicine physicians frequently are presented with requests by employers to determine the work-relatedness of medical illnesses or injuries. Occasionally, this involves a sudden onset of acute epididymitis in the male employee after strenuous activity in the workplace. Because the vast majority of acute epididymitis cases have an underlying sexually transmitted disease component, this poses a real dilemma for the consulting physician. This article discusses the etiology and pathogenesis of acute epididymitis along with its epidemiologic significance and reviews workers' compensation and its possible legal interpretation when acute epididymitis occurs at the worksite. (J Nati Med Assoc. 1996;88:385-387.) Key words * epididymitis * work-related injuries occupational medicine Determination of the work-relatedness of illnesses or injuries is one of the many duties performed by the occupational medicine physician. Periodically, acute epididymitis is one such condition, especially if occurring at the workplace. Because it involves a certain level of morbidity and occasionally considerable time lost from work, the element of compensation becomes significant. ETIOLOGY AND PATHOGENESIS Epididymitis is the clinical syndrome resulting from inflammation of the epididymis, part of the genital tract in males. The epididymis is a cone-shaped structure located on the posterior aspect of the testis. Sperm passFrom the Concentra Occupational Health Centers, Livonia, Michigan. Requests for reprints should be addressed to Eugene K. Sawyer, MD, Concentra Occupational Health Centers, 34095 Plymouth Rd, PO Box 2869, Livonia, Ml 48151-0869. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 88, NO. 6 es through the epididymis and then to the vas deferens and finally empties into the posterior urethra. During this passage, the sperm achieves motility and the potential to fertilize an ovum. Inflammation of the epididymis (epididymitis) causes pain and swelling that is generally unilateral and usually relatively acute in onset. Epididymitis affects mainly adults. Until recently, the general opinion was that epididymitis could be classified as specific, nonspecific, and traumatic. Specific epididymitis was presumed to be caused by identifiable organisms, such as gonorrhea, syphilis, and tuberculosis. Nonspecific epididymitis was secondary to an unidentifiable etiologic agent or event. Traumatic epididymitis was due to a reflux of sterile urine down the vas, leading to a chemical inflammation.' However, over the past 20 years, with the improvement in microbiologic culture technology, especially for Chlamydia trachomatis, data now indicate that the vast majority of acute epididymitis have an underlying bacteriological pathogenesis. Berger et a12 reported 85%, 88%, and 85% evidence, respectively, of C trachomatis in men <35 years old with acute epididymitis. These studies also revealed that in men >35 year old, the predominant organisms were not sexually transmitted, but coliform bacteria. Recently, there have been a few reports of incidences of acute epididymitis in some men taking the antiarrthymic drug, amiodarone.3 Most of these cases were bilateral, and these men had no evidence of genital urinary tract infection. Despite these isolated cases, one can conclude that the vast majority of cases of acute epididymitis have an underlying microbiological precursor (either sexually transmitted organisms or coliform bacteria). Also debatable until recently was the route of spread of the infection to the epididymis. It is now generally accepted that the infecting organisms reach the epididymitis by retrograde spread from the prostate, urethra, or seminal vesicle.45 385 ACUTE EPIDIDYMITIS TABLE. PATIENT PROFILE: ACUTE EPIDIDYMITIS Occupational Nonoccupational (n=4) (n=1 1) Profile Symptomatic event 7 Lifting 4 Straining None Patient age 8 <35 years 3 >35 years Presenting symptoms 9 Pain only 2 Pain/swelling Swelling only Physical findings 5 Tenderness only Tenderness/swelling 6 Lymphadenopathy Treatment 5 Anti-inflammatory 1 Antibiotics only 5 Both Disability status 2 Unable to work 7 Restricted work 2 Regular work Duration of disability 4 3to7days 7to 14days 3 >14 days 3 1 Unknown None Genitourinary cultures 2 1 1 3 1 3 1 2 2 1 ? ? ? 1 1 2 4 None EPIDEMIOLOGIC SIGNIFICANCE The prevalence of epididymitis in the general population varies among studies. Berger6 estimated that in 1977, 634,000 patients sought treatment in the United States. Drotman7 noted that during the same period (1977-1978), 779,000 ambulatory visits of 4/1000 male-visits were made for acute epididymitis. The US Public Health Service estimates 500,000 cases of acute epididymitis yearly.8 The literature, however, is replete with evidence, both documented and anecdotal, of acute epididymitis following severe physical straining, such as lifting heavy objects.9"0 From 1963 to 1964 in Great Britain, 13,600 claims were made for workmen's compensation for epididymitis." Even in the military, two studies showed that epididymitis accounted for more days lost from service than any other disease in the armed services.'21'4 The question, therefore, is whether the incidental injury (heavy lifting/strain) activates a dormant infec- 386 tion already present, either in the epididymis or in some other previously infected genitourinary structure. Moreover, if the incident occurred in the workplace, the dilemma is determining whether the acute epididymitis would have occurred (as a complication of a preexisting or underlying infection) without superimposed trauma or injury.' CLINICAL REVIEW A recent review of our records at Concentra Occupational Health Centers (Table) indicated that 15 patients were diagnosed with acute epididymitis during a 9-month period. Four of the cases were deemed to be nonoccupational by the examining physician because there was no verifiable work-related activity prior to the onset of symptoms. However, all four patients did report a history of heavy lifting or straining at home. The remaining 11 patients all reported an immediate, preceding event of heavy lifting or severe straining (pulling) at work. All patients denied previous or concurrent additional genitourinary symptoms, such as dysuria, urethral discharge, or urinary hesitancy, frequency, or urgency. The physical findings for both the occupational and nonoccupational patients were either tenderness alone or tenderness and swelling of the epididymis. The treatment protocol consisted basically of anti-inflammatory medications alone or a combination of antibiotics and anti-inflammatory medications. One patient received only antibiotics. There was no observable evidence that one regimen was more effective than the other in terms of morbidity and length of disability. Seven patients were placed on restricted disability status. Two patients were returned to regular duty, and one was judged significantly disabled to be placed on unable-to-work status. The duration of the disabilities ranged from 3 days to <14 days. Unfortunately, due to the limitation of workers' compensation rules/regulations, no urethral cultures were performed to confirm or exclude an underlying urogenital disease. This limitation notwithstanding, the basic criteria for the determination of compensability were the location (site) and the type of activity immediately preceding the onset of symptoms. This determination was made irregardless of any preexisting genitourinary disorder. DISCUSSION The rationale for this determination is based on the directives from the National Institute for Occupational Safety and Health (NIOSH) in regard to the aggravation JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 88, NO. 6 ACUTE EPIDIDYMITIS of preexisting conditions, published in the Guide to the Work-Relatedness of Disease. It states that in the current system of workers' compensation, an aggravation of a preexisting disease or physical impairment can be defined as any occupational occurrence, act, or exposure that will make worse, intensify, or increase the severity of any physical or mental problem that existed before the occupational exposure. Some of the examples cited were: the effects on an employee with known allergies exposed to allergens in the workplace resulting in frequent asthmatic attacks or a recovered alcoholic with mild liver disease being exposed to carbon tetrachloride at work, resulting in greater liver damage. It concludes that if there is any occupational contribution to an existing disease, the disease can become compensable.'5 Using this interpretation, it is certainly reasonable to qualify certain incidences of acute epididymitis as compensable. This becomes particularly relevant if an identifiable work-related laborious task immediately preceded the onset of symptoms. SUMMARY Acute epididymitis is a disease that is not uncommon and generally is caused by sexually transmitted organisms. It primarily affects young men who constitute a high percentage of the workforce. Because it involves a certain degree of morbidity and occasionally considerable time lost from work, the element of compensation becomes significant both to the worker and the company. In the event the symptoms occurred at work with associated strenuous activities, we have deemed it as work-related and compensable. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 88, NO. 6 Literature Cited 1. Nickel WR, Plumb RT. In: Harrison JH, et al, eds. Campbell's Urology. 4th ed. Philadelphia, Pa: WB Saunders Co; 1978:684. 2. Berger RE. Acute epididymitis: etiology and therapy. Semin Urol. 1991;9:29. 3. Gasparich JP, et al. Amiodarone-associated epididymitis in the absence of infection. J Urol. 1985;133:971-972. 4. Melekos MD, Asbach HW. Epididymitis: aspects concerning etiology and treatment. J Urol. 1987;1 38:83-86. 5. Berger RE. Epididymitis. Sex Transm Dis. 1984;57:650662. 6. Berger RE, Alexander ER, Harnish JR Etiology, manifestations and therapy of acute epididymitis: prospective study of 50 cases. J Urol. 1979;121:750-754. 7. Drotman DP. Epidemiology and treatment of epididymitis. Infectious Dis. 1 982;4(suppl 4):5788. 8. US Public Health Service. Sexually Transmitted Diseases 1980 Status Report; NIAID Study Group. Washington, DC: Government Printing Office; 1981. NIH publication 81-221. 9. Tanagho EA. Nonspecific infections of the urinary. In: Smith DR, ed. General Urology. 1 0th ed. Los Altos, Calif: Lange Medical Publications; 1981:182. 10. Cathcart CW. Epididymitis from muscular strain followed by tuberculosis of epididymitis. Edinburgh Med J. 1921;26:152-153. 11. Hanley HG. Non-specific epididymitis. Br J Surg. 1 966;53:873. 12. Bormel P Current concepts of the etiology and treatment of epididymitis. Med Bull US Army. 1963;20: 332-334. 13. Wolin LH. On the etiology of epididymitis. J Urol. 1971;105:531. 14. Vordemark JS. Acute epididymitis: experience with 123 cases. Mil Med. 1985;1 50:27-30. 15. Kusnetz S, Hutchison MK, eds. A Guide to the WorkRelatedness of Disease. Washington, DC: US Dept of Health, Education, and Welfare; 1979. National Institute for Occupational Safety and Health publication 79-116. 387