Rosen & Barkin's 5-Minute Emergency Medicine Consult (244 page)

DIAGNOSIS

• Gradual onset of mild to moderate testicular or scrotal pain, usually unilateral
  
• Progressive scrotal swelling
  
• Dysuria (30%):
  
  • Recent UTI
    
  • History of abnormal bladder function
    
• Urethral discharge:
  
  • Of patients with gonococcal epididymitis, 21–30% did not complain of urethral discharge.
    
  • No demonstrable urethral discharge in 50%
    
• Fever (14–28%)
  
• Recent urethral instrumentation or catheterization
  

• Tenderness in groin, lower abdomen, or scrotum
  
• Scrotal skin commonly erythematous and warm
  
• Early:
  
  • May feel swollen, indurated epididymis
    
• Later:
  
  • May not be able to distinguish epididymis from testis
    
  • Spermatic cord may be edematous.
    
• Intact cremasteric reflex
  
• Prehn sign:
  
  • Pain relief with testicular elevation
    
  • Commonly observed but not specific
    
• Coexistent prostatitis is rare (8%).
  
• Pyogenic bacterial orchitis:
  
  • Patients usually are acutely ill.
    
  • Fever
    
  • Intense discomfort, swelling of testicle
    
  • Often reactive hydrocele
    

• Must differentiate from testicular torsion
  
• Early consultation with urologist if strong suspicion of testicular torsion
  

• CBC:
  
  • Often leukocytosis in the range of 10,000–30,000/mm
    ³
    
• Urinalysis and culture:
  
  • Positive leukocyte esterase on first-void urine or >10 WBC per high-power field on first-void urine sediment
    
  • 15–50% of patients with epididymo-orchitis have pyuria.
    
  • 24% of patients have positive urine bacterial cultures.
    
• Urethral swab (50–73% have demonstrable urethritis despite minority of symptoms)
  
  • Gram stain and culture or DNA amplification for
    C. trachomatis/N. gonorrhea
    
  • Avoid bladder emptying within 2 hr of tests (lowers sensitivity).
    
  • Especially for postpubertal and sexually active
    
• Blood culture if systemically ill
  

• US: Color Doppler imaging:
  
  • 82–100% sensitivity, 100% specificity in detecting testicular torsion or decreased blood flow
    
  • Epididymo-orchitis:
    
    • Hyperemia
      
    • Increased vascularity and blood flow
      
  • Advantages:
    
    • Can evaluate for epididymitis or other causes of scrotal pain
      
    • 70% sensitivity, 88% specificity for epididymitis
      
  • Disadvantages:
    
    • Highly examiner dependent
      
    • Difficult in infants or children
      
• Testicular scintigraphy:
  
  • Radionuclide study to assess perfusion
    
  • 90–100% sensitivity, 89–97% specificity in detecting testicular torsion
    
  • Inflammatory processes have increased flow and uptake.
    
  • Not routinely available at many institutions
    

Surgical exploration indications:

• Scrotal abscess
  
• If torsion cannot be excluded
  
• Suspected or proved ischemia caused by severe epididymitis
  
• Patient with solitary testicle
  
• Scrotal fixation: Indicates severe inflammation and potential suppuration
  

• Testicular torsion
  
• Testicular tumor
  
• Torsion of testicular appendages
  
• Trauma to scrotum
  
• Acute hernia
  
• Acute hydrocele
  

TREATMENT

• IV access
  
• IV fluids, especially if systemically ill
  

• IV access
  
• IV fluids, especially if systemically ill
  

• Antibiotics:
  
  • Cover for chlamydial and gonococcal etiologies if adult or presumed sexually transmitted
    
  • Cover for coliform etiology:
    
    • Child, or adult >35 yr of age
      
    • Insertive partner in anal intercourse
      
    • Presumed nonsexually transmitted
      
• Bed rest, scrotal support, ice packs
  
• Analgesics and anti-inflammatories
  

• Age <35 yr or sexually active postpubertal males:
  
  • Ceftriaxone 250 mg IM once + doxycycline 100 mg PO BID for 10 days:
    
    • May substitute azithromycin 1 g PO once for doxycycline if tetracycline allergy
      
    • Quinolones no longer recommended if suspect
      N. gonorrhea
      
• Age >35 yr or insertive partners in anal intercourse or negative culture/DNA amplification for
  C. trachomatis/N. gonorrhea
  or allergy to cephalosporins/tetracyclines:
  
  • Ofloxacin 300 mg PO BID
    or
    levofloxacin 500 mg/d PO for 10 days
    

• Bacterial epididymitis is uncommon in prepubertal boys and antibiotic regimens are not well established.
  
• If concurrent UTI:
  
  • TMP–SMX: 4 mg/kg TMP and 20 mg/kg SMX BID for 10 days
    
• Avoid quinolones and tetracyclines in children
  

FOLLOW-UP

• Surgical indications present
  
• Older age group if it is the only way to ensure appropriate workup:
  
  • Many will have underlying urologic pathology.
    
• Systemically ill, fever, nausea, vomiting
  
• Scrotal abscess
  
• Intractable pain
  

• Fails to meet admission criteria
  
• Patient with good follow-up
  
• Able to take oral antibiotics
  

• Children need workup for urologic abnormalities:
  
  • Voiding cystourethrography, renal US
    
• If bacteriuria present, exam of lower tract with cystoscopy after treatment completed
  

• Failure to improve within 3 days of commencing antibiotics warrants urologic evaluation.
  
• Persistence of symptoms after full antibiotic course warrants search for other causes of epididymitis:
  
  • TB or fungal epididymitis, scrotal abscess, tumor, infarction.
    
• Sexual partners of patients with suspected or confirmed
  C. trachomatis/N. gonorrhea
  should be tested/treated.
  
• Children need urology consult for evaluation of structural urogenital abnormalities.
  

• Testicular torsion should be ruled out in all cases of new-onset testicular pain.
  
• Epididymitis usually due to STD in sexually active men <35 yr
  
• Epididymitis usually due to coliform bacteria in men >35 yr
  
• Antibiotic treatment is started immediately and empirically based on clinical picture.
  

• Brenner JS, Ojo A. Causes of scrotal pain in children and adolescents. UpToDate. Available at
  www.uptodate.com
  . Accessed on January 30, 2013.
  
• Ching CB, Sabanegh ES. Epididymitis. eMedicine. Available at
  emedicine.medscape.com/article/436154-overview
  . Accessed on January 30, 2013.
  
• Tekgül S, RiedmillerH, Gerharz E, et al. European Societyfor Paediatric Urology and European Association of Urology. Guidelines on paediatric urology. Available at
  http://www.uroweb.org/gls/pdf/19_Paediatric_Urology.pdf
  .
  
• Tracy CR, Steers WD, Costabile R. Diagnosis and management of epididymitis.
  Urol Clin North Am
  . 2008;35(1):101–108.
  
• Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010.
  MMWR Recomm Rep
  . 2010;59(RR-12):1–110.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Gonococcal Disease
  
• Prostatitis
  
• Testicular Torsion
  
• Urethritis
  

CODES