Епідидиміт

Scrotal pain occurs in both bacterial and nonbacterial epididymitis. Pain can be severe and is sometimes referred to the abdomen. In bacterial epididymitis, patients may also have fever, nausea, or urinary symptoms. Urethral discharge may be present if the cause is urethritis.

Physical examination reveals swelling, induration, marked tenderness, and sometimes erythema of a portion of or all of the affected epididymis and, sometimes, the adjacent testis. Sepsis is suggested by fever, tachycardia, hypotension, and a toxic appearance.

• Clinical evaluation

• Sometimes urethral swab and urine culture

Diagnosis of epididymitis is confirmed by finding swelling and tenderness of the epididymis. However, unless findings are clearly isolated to the epididymis, testicular torsion must also be considered, particularly in patients < 30 years; immediate color Doppler ultrasonography is indicated. A genitourinary consultation is indicated if the cause is unclear or the disorder is recurrent.

Urethritis suggests that the cause of epididymitis is a sexually transmitted pathogen, and a urethral swab is sent for gonococcus and chlamydia nucleic acid amplification testing (NAAT) or culture. Otherwise, the infecting organism usually can be identified by urine culture. Urinalysis and culture are normal in nonbacterial causes.

• Antibiotics

• Supportive measures

Epididymitis treatment consists of scrotal elevation (eg, with a jockstrap when upright) to decrease repetitive, minor bumps, scrotal ice packs, anti-inflammatory analgesics, and a broad-spectrum antibiotic such as levofloxacin 500 mg orally once a day for 10 days. Alternatively, doxycycline 100 mg orally twice a day or sulfamethoxazole/trimethoprim double-strength (160/800 mg) orally twice a day may be used. Levofloxacin with a single dose of ceftriaxone 500 mg IM (1 g in patients > 150 kg) is preferred for patients who practice anal intercourse or if epididymitis is likely caused by enteric organisms. Doxycycline is preferred for patients with suspected gonorrhea or chlamydial acute epididymitis. A single dose of ceftriaxone 500 mg IM (1 g in patients ≥ 150 kg) should be added to oral antibiotics in men who practice insertive anal intercourse or if chlamydia or gonorrhea is suspected (1). Ceftriaxone treatment also covers gram-negative bacteria (eg, E. coli).

If sepsis is suspected, an aminoglycoside such as tobramycin or a 3rd-generation cephalosporin such as ceftriaxone may be useful until the infecting organism and its sensitivities are known.

Abscess and pyocele usually require surgical drainage.

Recurrent bacterial epididymitis secondary to incurable chronic urethritis or prostatitis occasionally can be prevented by vasectomy. An epididymectomy, occasionally done for chronic epididymitis, may not relieve symptoms.

Patients who must continuously wear an indwelling urethral catheter are prone to develop recurrent epididymitis and epididymo-orchitis. In such cases, placement of a suprapubic cystostomy or institution of a self-catheterization regimen may be useful.

Treatment of nonbacterial epididymitis includes the above general measures, but antimicrobial therapy is not warranted. Nerve block of the spermatic cord with local anesthesia can relieve symptoms in severe, persistent cases.