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Epididymitis
Swollen, sore and infected
Definitions
• Epididymitis – inflammation of the epididymis usually as a result of
bacterial or viral infection, rarely as a result of trauma or urinary
reflux from the urethra[1]
• Epididymo-orchitis – inflammation of both the testis and epididymis[1]
• Orchitis – inflammation of testis due to trauma, ischaemia,
metastasis, mumps or infection elsewhere in the body[1]
Anatomy Review
Epididymitis
• Acute – pain and swelling < 6 weeks
• Subacute – pain and swelling 6 weeks – 3 months
• Chronic – pain > 3 months can be subdivided – inflammatory,
obstructive and epididmyalgia[2]
Incidence
• 13 cases per 10,000 Australian male patient encounters at the GP[3]
• 31 per 10,000 in age cohort 25 – 29 years[3]
• Similar in the UK[4]
• 24 per 10,000 for all ages
• 27 per 10,000 for the 25 – 34 year old cohort
Aetiology
• No exact causes identified
• Urinary reflux (congenital, mechanical)
• Presence of infectious agent
• STI vs Urologic Pathogen[5]
Bugs Bugs Bugs
• Bacteria[5]
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•
•
•
•
Enteric bacteria (Pseudomonas and E Coli)
Tuberculosis
Syphilis
Gonorrhoea
Chlamydia
• Viruses
•
•
•
•
Coxsackie A6 virus (hand, foot and mouth disease)[6]
Enterovirus and adenovirus [5]
Hepatitis B [7]
Mumps [8]
Other Aetiologies
• Trauma
• Obstruction secondary to vasectomy
• Fungal infections such as candida and histoplasmosis
• Rheumatic conditions
• Parasitic infection such as trichomoniasis and schistosomiasis [5]
• Can be amiodarone induced [9]
• Posterior urethral valves in children [10]
• Xanthogranulomatous inflammation [11, 12]
Pathophysiology
• Infection limited by segmental nature of epididymis[13]
• Unilateral in acute setting with bilateral impact on
spermatogenesis[14]
• Bilateral in chronic setting
• Abscess
• Segmental infarction[15]
• Fertility impact
• 6 – 7% azoospermia, 22 – 37% oligospermia[14]
Diagnostic Criteria – Physical Signs[5]
• Pain – location of pain
• Swelling – induration of scrotal sac
• Surgical history
• Sexual history
Diagnostic Criteria – Biochemical
• Urinalysis
• Urine culture / gram staining of urethral discharge
• Haematology – WCC and CRP
• No specific serum inflammatory marker has yet been discovered for
epididymitis though work continues[16]
• Semen culture no longer necessary
Ultrasound of Epididymitis - Acute
• Increased PSV of testicular artery on affected side versus normal
side[17]
• Epididymis / testis is thickened / enlarged
• Echotexture may be heterogeneous and hypoechoic
• Increased vascularity compared to surroundings under Doppler
interrogation
• Reactive hydrocele[17]
Acute
Features
Heterogeneous
Echotexture
Reactive Hydrocoele
Increased
Vascularity
Ultrasound of Epididymitis – Chronic
• Thickened epididymis / testis / tunica vaginalis
• Induration of scrotal wall
• Heterogeneous echotexture
• Coarse calcifications
• Testicular infarct – wedge shaped hypoechoic area [15]
Utility of Ultrasound
• Exclusion of testicular torsion / mass
• Visualise extent of disease progress – abscess formation / secondary
infarction
• Follow up of epididymitis – success of treatment
References
1.
Taber's Cyclopedic Medical Dictionary. 22nd ed. Cyclopedic Medical Dictionary, ed. D. Venes. 2013, Philadelphia: F.A. Davis Co.
2.
Shoskes, D.A., Urological Men’s Health : A Guide for Urologists and Primary Care Physicians. Current Clinical Urology, ed. E.A. Klein. 2012, Totowa, NJ: Springer: Humana Press.
3.
Chen, M.Y., et al., Trends in clinical encounters for pelvic inflammatory disease and epididymitis in a national sample of Australian general practices. International Journal of STD &
AIDS, 2006. 17(6): p. 384-386.
4.
Nicholson, A., et al., Management of epididymo-orchitis in primary care: results from a large UK primary care database. The British Journal of General Practice, 2010. 60(579): p. e407e422.
5.
Michel, V., et al., Epididymitis: revelations at the convergence of clinical and basic sciences. Asian Journal of Andrology, 2015. 17(5): p. 756 - 763.
6.
Vuorinen, T., et al., Epididymitis Caused by Coxsackievirus A6 in Association with Hand, Foot, and Mouth Disease. Journal of Clinical Microbiology, 2014. 52(12): p. 4412-4413.
7.
Aydin, Ö.A., et al., An Unusual Extrahepatic Manifestation of Acute Hepatitis B Infection: Epididymitis. Viral Hepatit Dergisis, 2014. 20(2).
8.
Doyle, J.S., E.K. Paige, and D.W. Spelman, Mumps presenting as epididymo-orchitis among young travellers: under-recognition, missed diagnoses and transmission risks. The Medical
journal of Australia, 2011. 194(6): p. 317.
9.
Nikolaou, M., et al., Amiodarone-induced epididymitis: A case report and review of the literature. International Journal of Cardiology, 2007. 121(1): p. e15-e16.
10.
Kwong, J., et al., Bilateral Epididymitis in a Child With Undiagnosed Posterior Urethral Valves. Urology, 2013. 82(1): p. 225-227.
11.
Ezer, S.S., et al., Xanthogranulomatous Orchiepididymitis: A Very Uncommon Cause of Scrotal Mass in Childhood. Urology, 2013. 82(1): p. 228-230.
12.
Repetto, P., et al., Bilateral xanthogranulomatous funiculitis and orchiepididymitis in a 13-year-old adolescent boy. Journal of Pediatric Surgery, 2012. 47(10): p. e33-e35.
13.
Stammler, A., et al., Epididymitis: ascending infection restricted by segmental boundaries. Human Reproduction, 2015. 30(7): p. 1557-1565.
14.
Rusz, A., et al., Influence of urogenital infections and inflammation on semen quality and male fertility. World Journal of Urology, 2012. 30(1): p. 23-30.
15.
Pearl, M.S. and M.C. Hill, Ultrasound of the Scrotum. Seminars in Ultrasound, CT and MRI, 2007. 28(4): p. 225-248.
16.
Pilatz, A., et al., Clinical evaluation of human epididymis protein 4 as a biomarker for epididymitis. Biomarkers in Medicine, 2012. 6(3): p. 311-7.
17.
Pilatz, A., et al., Acute epididymitis in ultrasound: Results of a prospective study with baseline and follow-up investigations in 134 patients. European Journal of Radiology, 2013. 82(12):
p. e762-e768.
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