Epididymitis

Epididymitis is a medical condition characterised by inflammation of the epididymis, a curved structure at the back of the testicle. It often presents with pain, swelling, and urinary symptoms, and can lead to serious complications if untreated.

Signs and Symptoms

Epididymitis typically affects males aged 15 to 35, presenting acutely over several days. Symptoms include pain and swelling in one testicle, which may hang lower than usual in the scrotum. Additional symptoms often include dysuria, urethral discharge, and fever. Chronic epididymitis, which persists for more than three months, may present with point tenderness and an indurated epididymis. Scrotal ultrasound is often used to confirm the diagnosis, especially in chronic cases where symptoms have persisted for over five years.

Complications

Untreated acute epididymitis can lead to abscess formation and testicular infarction. Chronic epididymitis can cause permanent damage to the epididymis and testicle, potentially resulting in infertility and chronic pain. The infection may also spread to other organs or systems.

Causes

Bacterial infection is the most common cause of acute epididymitis, often originating from urinary tract infections that backtrack to the epididymis. In sexually active men, Chlamydia trachomatis and Neisseria gonorrhoeae are frequent culprits, while E. coli is more common in older men and those practising insertive anal sex. Non-infectious causes include sterile urine reflux, genito-urinary surgery, and certain medications. Rare causes include viral infections and systemic conditions like sarcoidosis and Behçet's disease.

Diagnosis

Diagnosis is typically based on symptoms, with ultrasound imaging used to confirm the condition when necessary. Doppler ultrasound helps distinguish epididymitis from other conditions like testicular torsion, inguinal hernia, and testicular cancer. Additional tests may be needed to identify underlying causes, especially in younger children and sexually active men.

Classification

Epididymitis can be classified as acute, subacute, or chronic based on symptom duration. Chronic epididymitis is characterised by persistent inflammation without infection, requiring differentiation from other causes of scrotal pain such as testicular cancer, varicocele, and cysts.

Treatment

Treatment typically involves antibiotics, pain management, and supportive care. For sexually transmitted infections, azithromycin and cefixime are commonly used, with doxycycline as an alternative. For cases caused by enteric bacteria, ofloxacin or levofloxacin is recommended. In children, co-trimoxazole or cephalexin are preferred.

Supportive measures include scrotal elevation, cold compresses, and NSAIDs for pain relief. Severe cases may require hospitalisation and surgical intervention, such as epididymotomy or epididymectomy, though these are rare. Chronic epididymitis might eventually resolve on its own, but medications like doxazosin can be effective.

Epidemiology

Epididymitis accounts for 0.69 percent of medical visits in men aged 18 to 50, with 600,000 cases annually in the United States. It mainly affects males aged 16 to 30 and 51 to 70. The incidence has been rising, possibly due to increased cases of chlamydia and gonorrhoea.

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Self-assessment MCQs (single best answer)

What is the primary structure affected in epididymitis?

Which age group is most commonly affected by epididymitis?

What are common symptoms of acute epididymitis?

What is a potential complication of untreated acute epididymitis?

Which bacteria are commonly associated with epididymitis in sexually active men?

What diagnostic tool is often used to confirm epididymitis?

Which medication is commonly used to treat sexually transmitted epididymitis?

What supportive measure can help alleviate pain in epididymitis?

Which condition must be differentiated from epididymitis using Doppler ultrasound?

What is the incidence of epididymitis in men aged 18 to 50 annually in the United States?