It is a quiet morning in the ED. I know it’s difficult to believe. The triage nurse rolls in a young patient who is screaming in pain. “Doc, doc, my n@&* are killing me!” You can’t help but start thinking about a differential diagnosis on your way to interview your new patient.
He is a 20-year-old male with no past medical history who is complaining of right testicular pain that started two days ago. He reports that he was lying down when the pain started suddenly. It is increasing in intensity, excruciating in nature, and not improved by anything. The pain is associated with abdominal discomfort, nausea, and a few episodes of non-bloody emesis. He denies fever, chills, dysuria, polyuria, hesitancy, penile discharge, and trauma. He is sexually active with only women and occasionally uses condoms.
You put your gloves on, ready to narrow down your differential diagnosis and do an exam:
The left hemiscrotum/testicle appears normal. The right hemiscrotum is edematous, the testicle is diffusely firm with severe tenderness. It is lying in normal position. Cremasteric reflex is present bilaterally. There is no urethral discharge
What is your differential diagnosis?
- Testicular torsion
- Epididymitis
- Orchitis
- Appendix torsion
- Hernia
- Testicular tumor
- Idiopathic scrotal edema
What is your initial workup?
Labs (not very useful):
UA and urine culture – A UA negative or positive for pyuria does not exclude epididymitis. Patients with a positive urine culture tended to be sexually active and younger.
CBC, BMP, coags, type and screen – pre-operative tests, but likely unnecessary
Imaging:
Scrotal ultrasonography – primarily to evaluate for testicular torsion, however ultrasound can also help diagnose epididymitis, hernias, tumors and other pathology (see below)
Consults:
Urology – If worried about torsion, get your consultants on board immediately!
Given your history and exam, you suspect this is likely epididymitis. So what is epididymitis anyway?
First, let’s refresh your anatomy:
Source: Anatomy of scrotum and testicle. 2017. Human body anatomy.
The epididymis is a single, tubular structure approximately 4-5 m long (1) compressed into an area of about 5 cm that serves to promote sperm maturation and motility (2). Epididymitis refers to inflammation of this structure. The etiology of epididymitis varies depending on age and may include bacterial or fungal infection, however it can also be non-infectious or idiopathic.
Children and men older than 35 years are more likely to have infection by urinary coliforms such as E. coli, Pseudomonas, Proteus, and Klebsiella due comorbidities like prostatic hypertrophy and reflux of urine. Sexually active men under 35 are presumed to have gonorrhea or chlamydia trachomatis due to increased sexual activity, no use of barrier protection and no comorbidities (3).
How do you identify epididymitis on sonography?
The epididymis, located at the superior pole of the testicle, will be enlarged, hypoechoic, and hyperemic. The testicle itself should have normal blood flow and may be hyperemic. It is important to recall that detection of intratesticular blood flow cannot exclude testicular torsion (4).
What are some possible complications of epididymitis?
- Scrotal abscess and pyocele
- Testicular infarction
- Fertility problems
- Testicular atrophy
- Cutaneous fistulization from rupture of an abscess through the tunica vaginalis (seen especially in tuberculosis)
- Recurrence, chronic epididymitis, and orchialgia
How do you treat epididymitis?
It depends on suspected etiology!
Age < 35 years old: Treat for gonorrhea and chlamydia with ceftriaxone 250 mg IM single dose + doxycycline 100 mg PO BID for 10 days.
Age > 35 years old and no STI risk factors: Treat for gram-negative bacilli with ofloxacin, 300 mg PO BID for 10 days or levofloxacin 500 mg PO daily for 10 days.
Age > 35 year old WITH risk factors for STI: Ofloxacin or levofloxacin + ceftriaxone IM.
Let’s go back to our patient, whose ultrasonography results are back…
Source: Anthony, Joe. Pyocele with orchitis. 2015. Ultrasound-images.
This ultrasound shows a pyocele (red arrow) – a purulent collection within the potential space between the visceral and parietal tunica vaginalis surrounding the testicle. Fournier’s gangrene is the most concerning complication of a scrotal pyocele. Classically, pyocele is treated with antibiotics alone and surgical drainage, if necessary. This is where your urology consultants can help with recommendations. If a conservative approach is attempted, then serial US examinations should be performed to ensure that the abscess does not progress. If you suspect Fournier’s gangrene, the patient will need admission for urgent IV antibiotics, possible confirmatory CT, and surgical drainage (5).
This post was written by Dr. Carolina Camacho, PGY-3 resident Kings County/SUNY Downstate Emergency Medicine
References
(2) Davis, J. (2016). Male Genital Problems. In J. Tintinalli, Emergency Medicine A comprehensive Study Guide (pp. 601-608). NC.
Charles Murchison
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2 Comments
Jan · January 13, 2020 at 2:16 am
Thank you for this blog! Epididymitis Causes
Jane Guadalupe · January 13, 2020 at 2:16 am
Thank you for this blog! Epididymitis Causes