Epididymitis: An Overview

 

Am Fam Physician. 2016 Nov 1;94(9):723-726.

  Patient information: See related handout on epididymitis, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Inflammation of the epididymis, or epididymitis, is commonly seen in the outpatient setting. Etiology and treatment are based on patient age and the likely causative organisms. Epididymitis presents as the gradual onset of posterior scrotal pain that may be accompanied by urinary symptoms such as dysuria and urinary frequency. Physical findings include a swollen and tender epididymis with the testis in an anatomically normal position. Although the etiology is largely unknown, reflux of urine into the ejaculatory ducts is considered the most common cause of epididymitis in children younger than 14 years. Neisseria gonorrhoeae and Chlamydia trachomatis are the most common pathogens in sexually active males 14 to 35 years of age, and a single intramuscular dose of ceftriaxone with 10 days of oral doxycycline is the treatment of choice in this age group. In men who practice insertive anal intercourse, an enteric organism is also likely, and ceftriaxone with 10 days of oral levofloxacin or ofloxacin is the recommended treatment regimen. In men older than 35 years, epididymitis is usually caused by enteric bacteria transported by reflux of urine into the ejaculatory ducts secondary to bladder outlet obstruction; levofloxacin or ofloxacin alone is sufficient to treat these infections. Because untreated acute epididymitis can lead to infertility and chronic scrotal pain, recognition and therapy are vital to reduce patient morbidity.

Epididymitis (inflammation of the epididymis) can affect children and adults and is commonly seen in the outpatient setting. Epididymitis often occurs with orchitis (inflammation of the testis); this is referred to as epididymo-orchitis.1 Figure 1 illustrates normal scrotal anatomy.2 In acute epididymitis, pain and scrotal swelling are present for less than six weeks. Chronic epididymitis lasts longer than three months and is usually characterized by pain in the absence of scrotal swelling.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

If acute epididymitis is thought to be due to gonorrhea or chlamydia, intramuscular ceftriaxone (single 250-mg dose) plus oral doxycycline (100 mg twice daily for 10 days) is the recommended treatment regimen.

C

1

In men with epididymitis who practice insertive anal intercourse, an enteric organism is likely in addition to gonorrhea or chlamydia; intramuscular ceftriaxone (single 250-mg dose) plus either oral levofloxacin (Levaquin; 500 mg once daily for 10 days) or ofloxacin (300 mg twice daily for 10 days) is the recommended treatment regimen.

C

1

In men older than 35 years with epididymitis, sexually transmitted infections are less likely, and monotherapy with levofloxacin or ofloxacin is the empiric regimen of choice.

C

1


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

If acute epididymitis is thought to be due to gonorrhea or chlamydia, intramuscular ceftriaxone (single 250-mg dose) plus oral doxycycline (100 mg twice daily for 10 days) is the recommended treatment regimen.

C

1

In men with epididymitis who practice insertive anal intercourse, an enteric organism is likely in addition to gonorrhea or chlamydia; intramuscular ceftriaxone (single 250-mg dose) plus either oral levofloxacin (Levaquin; 500 mg once daily for 10 days) or ofloxacin (300 mg twice daily for 10 days) is the recommended treatment regimen.

C

1

In men older than 35 years with epididymitis, sexually transmitted infections are less likely, and monotherapy with levofloxacin or ofloxacin is the empiric regimen of choice.

C

1


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

View/Print Figure

Figure 1.

Anatomy of the scrotum.

Reprinted with permission from Tiemstra JD, Kapoor S. Evaluation of scrotal masses. Am Fam Physician. 2008;78(10):1167.


Figure 1.

Anatomy of the scrotum.

Reprinted with permission from Tiemstra JD, Kapoor S. Evaluation of scrotal masses. Am Fam Physician. 2008;78(10):1167.

Epidemiology

The annual incidence of acute epididymitis is approximately 1.2 per 1,000 boys two to 13 years of age (mean age = 11 years)4,5; about one-fourth of this group has recurrence within five years.5 Among adult men, 43% of epididymitis cases occur between 20 and 30 years of age.4,6 In one series, epididymitis occurred with orchitis in

The Authors

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JOHN R. McCONAGHY, MD, is associate director of the Family Medicine Residency and a professor in the Department of Family Medicine at The Ohio State University Wexner Medical Center in Columbus....

BETHANY PANCHAL, MD, is an assistant professor in the Department of Family Medicine at The Ohio State University Wexner Medical Center.

Address correspondence to John R. McConaghy, MD, The Ohio State University, Dept. of Family Medicine, 2231 North High St., Columbus, OH 43201 (e-mail: john.mcconaghy@osumc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Center for Disease Control and Prevention. 2015 sexually transmitted diseases treatment guidelines. Epididymitis. http://www.cdc.gov/std/tg2015/epididymitis.htm. Accessed October 20, 2015....

2. Tiemstra JD, Kapoor S. Evaluation of scrotal masses. Am Fam Physician. 2008;78(10):1165–1170.

3. Trojian TH, Lishnak TS, Heiman D. Epididymitis and orchitis: an overview. Am Fam Physician. 2009;79(7):583–587.

4. Somekh E, Gorenstein A, Serour F. Acute epididymitis in boys: evidence of a post-infectious etiology. J Urol. 2004;171(1):391–394.

5. Redshaw JD, Tran TL, Wallis MC, deVries CR. Epididymitis: a 21-year retrospective review of presentations to an outpatient urology clinic. J Urol. 2014;192(4):1203–1207.

6. Tracy CR, Steers WD, Costabile R. Diagnosis and management of epididymitis. Urol Clin North Am. 2008;35(1):101–108.

7. Kaver I, Matzkin H, Braf ZF. Epididymo-orchitis: a retrospective study of 121 patients. J Fam Pract. 1990;30(5):548–552.

8. Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics. 1998;102(1 pt 1):73–76.

9. Nikolaou M, Ikonomidis I, Lekakis I, Tsiodras S, Kremastinos D. Amiodarone-induced epididymitis: a case report and review of the literature. Int J Cardiol. 2007;121(1):e15–e16.

10. Gatti JM, Patrick Murphy J. Current management of the acute scrotum. Semin Pediatr Surg. 2007;16(1):58–63.

11. Ciftci AO, Senocak ME, Tanyel FC, Büyükpamukçu N. Clinical predictors for differential diagnosis of acute scrotum. Eur J Pediatr Surg. 2004;14(5):333–338.

12. Karmazyn B, Steinberg R, Kornreich L, et al. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys. Pediatr Radiol. 2005;35(3):302–310.

13. Crawford P, Crop JA. Evaluation of scrotal masses. Am Fam Physician. 2014;89(9):723–727.

14. Davis JE, Silverman M. Scrotal emergencies. Emerg Med Clin North Am. 2011;29(3):469–484.

15. Yang DM, Lim JW, Kim JE, Kim JH, Cho H. Torsed appendix testis: gray scale and color Doppler sonographic findings compared with normal appendix testis. J Ultrasound Med. 2005;24(1):87–91.

16. Santillanes G, Gausche-Hill M, Lewis RJ. Are antibiotics necessary for pediatric epididymitis?. Pediatr Emerg Care. 2011;27(3):174–178.

17. Haecker FM, Hauri-Hohl A, von Schweinitz D. Acute epididymitis in children: a 4-year retrospective study. Eur J Pediatr Surg. 2005;15(3):180–186.


 

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