7.07 Epididymitis

agk’s Library of Common Simple Emergencies

Presentation

An adult male complains of dull to severe scrotal pain developing over a period of hours to a day, and radiating to the ipsilateral lower abdomen or flank. There may be a history of recent urethritis, prostatitis or prostatectomy (allowing ingress to bacteria), straining with lifting a heavy obiect, or sexual activity with a full bladder (allowing reflux of urine). There may be fever, nausea, or urinary urgency or frequency. The epididymis, is tender, swollen, warm, and difficult to separate from the firm, nontender testicle. Increasing inflammation can extend up the spermatic cord and fill the entire scrotum, making examinations more difficult, as well as produce frank prostatitis or cystitis. The rectal exam therefore may reveal a very tender, boggy prostate.

What to do:

• Ascertain that the testicle is normal in position and perfusion. Doppler ultrasound may help pick up a drop-off in arterial flow from spermatic cord to testicle in testicular torsion.
• Palpate and ausculate, the scrotum to rule out a hernia. Gently palpate the prostate once. Culture urine and/or any urethral discharge to identify a bacterial organism.
• On rare occasions, for severe pain, you may infiltrate the spermatic cord above the inflammation with local anesthetic for better palpation and diagnosis (e.g., 1% lidocaine without epinephrine). Lesser pain may respond to antiinflammatory analgesics (e.g., Motrin, aspirin with codeine).
• Prescribe antibiotics for likely organisms. In men under 35, ceftriaxone 250 mg im in the ED and a prescription for doxycycline 100mg bid for 10 days should eradicate N. gonorrhea and C. trachomatis. An alternative treatment is ofloxacin (Floxin) 300mg bid x 10d. In men over 35, ciprofloxacin 500mg bid for 10-14 days may be better for gram negative bacteria.
• Arrange for 2-3 days of strict bedrest, with the scrotum elevated, and urologic followup.

What not to do:

• Do not miss testicular torsion. It is far better to have the urologist explore the scrotum and find epididymitis than to delay and lose a testicle to ischemia (which can happen in only 4 hours).

Discussion

Testicular torsion is more likely in children and adolescents, and has a more sudden onset, although it can be recurrent and is often related to exertion or direct trauma. If the spermatic cord is twisted, the testicle may be high, the epididymis may be in other than its normal posterior position, and there will most likely be no cremasteric reflex. A testicular scan can help differentiate torsion from the sometimes similar presentation of acute epididymitis. When torsion is highly suspected you may try a therapeutic detorsion by externally rotating the testicle 180 degrees with the patient standing.

References:

• Caldamone AA, Valvo JR, Altebarmakian VK et al: Acute scrotal swelling in children. J Ped Surg 1984;19:581-584.
• Knight PJ, Vassy LE: The diagnosis and treatment of the acute scrotum in children and adolescents. Ann Surg 1984;200:664-673.

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