Epididymitis

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DESCRIPTION

Epididymitis is an acute inflammation of the epididymis that can cause severe scrotal pain. It is important to differentiate epididymitis from testicular torsion (TT) or testicular appendage torsion.

EPIDEMIOLOGY

  • Epididymitis is the most common cause of acute scrotum, approximately 37–65% of cases. The incidence ranges between 0.8 and 1.2 cases per 1,000 persons per year.
  • There is a bimodal distribution with a peak in incidence in infants <1 year of age and peripubertal boys.

RISK FACTORS

  • Urologic manipulation (cystoscopy, intermittent self-catheterization, surgery of the urethra)
  • Viral illness
  • Sexually transmitted infections
  • Anatomic congenital and acquired urologic abnormalities (e.g., ectopic ureter; posterior urethral valves, urethral abnormalities)

PATHOPHYSIOLOGY

  • The majority of cases of epididymitis are idiopathic (73%).
  • Viral epididymitis: second most common cause
    • Urinalysis and culture are negative.
    • Often elevated titers of enterovirus, Mycoplasma pneumoniae, and adenoviruses
    • Some cases of epididymitis may be due to postinfectious inflammation as 50% of patients had respiratory symptoms within 1 month of presentation, and presentations appear to peak in concert with rotavirus and enterovirus.
  • Bacterial epididymitis: 2–6% of cases and is related to age
    • Due to ascending infection from the urethra or bladder, reflux of infected urine into the vas deferens, or hematogenous dissemination
    • Infants aged <1 year:
      • Typically, due to genitourinary anomalies (73% vs. 21% in children aged >1 year)
      • Abnormalities include meatal stenosis, neurogenic voiding dysfunction, urethral stenosis, posterior urethral valves, and ectopic ureter.
      • Typical bacteria include Escherichia coli, Klebsiella, and Enterococcus.
    • Postpubertal sexually active and sexually abused patients may have acquired sexually transmitted infections such as gonorrhea or chlamydia.
  • Chemical epididymitis: due to reflux of sterile urine into the vas deferens or drugs (amiodarone)
  • Posttraumatic
  • Torsion of an epididymal appendage

COMMONLY ASSOCIATED CONDITIONS

  • Systemic serositis (familial Mediterranean fever, sarcoidosis, Kawasaki disease)
  • Systemic vasculitis (Henoch-Schönlein purpura, polyarteritis nodosa)
  • Voiding dysfunction
  • Urethral strictures distal to the external sphincter

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