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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
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