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Epididymitis - Causes, Symptoms, Diagnosis, and Treatment

What is epididymitis?

Epididymitis is an inflammation of the coiled tube (epididymis) at the back of the testicle that stores and carries sperm. Although males of any age can develop epididymitis, it occurs most frequently between ages of 20 to 39. When it develops in children, it is usually due to inflammation caused by trauma. However, some children develop it because of bacterial infections, some of which may be due to sexual abuse.


What are epididymitis causes?

The cause of epididymitis is usually a bacterial infection. The bacteria usually get to the epididymis by moving back through (retrograde) the urethra, prostate, vas deferens into the epididymis. The responsible bacteria are usually identified in about 80% of cases.


Two main groups of organisms cause most cases of epididymitis: sexually transmitted organisms and coliforms (organisms that commonly live in the intestines).

- In men younger than about 39 years of age, the causes are usually the same organisms that cause the sexually transmitted diseases of chlamydia (responsible for nearly 50%-60% of cases) and gonorrhea. The bacterial species are Chlamydia trachomatis and Neisseria gonorrhea, respectively.

- In those older than 39 years of age, the causes are usually coliforms, which are bacteria (such as Escherichia coli) that live in the intestines. These organisms also frequently cause bladder infections. Any age of men who participate in anal intercourse are more likely to get infected with E. coli or other fecal bacteria. Epididymitis is rarely caused by fungi or Mycobacterium spp.

- Chemical epididymitis (rare) is inflammation caused by the retrograde (backward) flow of urine when exercising or having sex with a full bladder.

- Amiodarone (Nexterone), a frequently used heart medication, occasionally causes inflammation of the epididymis.

- Viral infections (including mumps), mainly in the pediatric population.

What are epididymitis symptoms?

Epididymitis symptoms depend on the cause. They can include:

- A tender, swollen, red or warm scrotum
- Testicle pain and tenderness, usually on one side — the pain may get worse when you have a bowel movement
- Painful urination or an urgent or frequent need to urinate
- Painful intercourse or ejaculation
- Chills and a fever
- A lump on the testicle
- Enlarged lymph nodes in the groin (inguinal nodes)
- Pain or discomfort in the lower abdomen or pelvic area
- Discharge from the penis
- Blood in the semen

Chronic epididymitis

Signs and symptoms of epididymitis usually develop over a day or two and get better with treatment. In some cases, epididymitis may not clear up completely or may recur. This is known as chronic epididymitis. Symptoms of chronic epididymitis may come on gradually. Sometimes the cause of chronic epididymitis is not identified.


How is epididymitis diagnosed?

Your doctor will do a physical exam, which may reveal enlarged lymph nodes in your groin and an enlarged testicle on the affected side. Your doctor also may do a rectal examination to check for prostate enlargement or tenderness and order blood and urine tests to check for infection and other abnormalities.

Other tests your doctor might order include:

Sexually transmitted infection (STI) screening. This involves obtaining a sample of discharge from your urethra. Your doctor may insert a narrow swab into the end of your penis to obtain the sample, which is then tested for the presence of bacteria or other infectious organisms. The results can be used to select the most effective antibiotic for treatment.

Ultrasound imaging. This noninvasive test uses high-frequency sound waves to create images of structures inside your body and is used to rule out conditions, such as twisting of the spermatic cord (testicular torsion) or a testicular tumor. Your doctor may use this test if your symptoms began with sudden, severe pain and other tests have not been definitive.

Nuclear scan of the testicles. Also used to rule out testicular torsion, this test involves injecting trace amounts of radioactive material into your bloodstream. Special cameras then can detect areas in your testicles that receive less blood flow, indicating torsion, or more blood flow, supporting the diagnosis of epididymitis.

How is epidiymitis treated?

The health care practitioner likely will treat the individual with antibiotics through an IV, a shot, or pills orally (to be taken for 10 days or longer). Often the treatment depends on the identity of the infecting bacteria; many physicians elect to treat with at least two different antibiotics because individuals are occasionally infected with more than one organism.

For men younger than 39 years of age, Ceftriaxone, Azithromycin, and Doxycycline are often prescribed. For men older than 39 years od age or those who participate in anal intercourse, Ciprofloxacin, Ofloxacin, Sulfamethoxazole and trimethoprim are often prescribed.

The CDC guidelines recommend that for acute epididymitis most likely caused by enteric organisms or with negative gonococcal culture or PCR nucleic acid amplification test the following:
Ofloxacin (Floxin) 300 mg orally twice a day for 10 days or levofloxacin 500 mg orally once daily for 10 days.

Guidelines change frequently; most health care practitioners who treat epididymitis are aware of these guidelines, and depending on local resistance patterns of pathogens, may change the type and duration of antibiotics to best fit the patient's condition. Pediatric treatments are best administered by pediatricians and are usually based on the weight of the patient and the infecting organism's antibiotic susceptibility. If the infection is not treated early, complications may develop that require surgery.

For patients with non-infectious causes of epididymitis (for example, chemical, inflammation) anti-inflammatory medication is often prescribed; occasionally, consultation with a urologist is recommended for additional treatments.

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