Epididymitis

Epidemiology

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Microbiology

Organisms Which Predominate in Young Males

  • Chlamydia Trachomatis (see Chlamydia Trachomatis, [[Chlamydia Trachomatis]]): most common etiology of bacterial epididymitis in males <35 y/o
  • Neisseria Gonorrhoeae (see Neisseria Gonorrhoeae, [[Neisseria Gonorrhoeae]]): may also be etiologic in cases in young males

Organisms Which Predominate in Older Males and Those who Engage in Anal Insertive Intercourse

Less Common Organisms

Organisms Specifically Associated with HIV Infection


Physiology

  • Epididymis is a Coiled Tubular Structure on the Posterior Aspect of the Testes: running from superior to inferior pole of testes
    • Sperm travel from tubules of rete testis -> epididmyis -> vas deferens
    • Function of Epididmymis: functions in sperm maturaton and provision of immune surveillance of sperm

Diagnosis

Nucleic Acid Amplification Test (NAAT)

  • Indications: second generation tests are indicated to detect both Neisseria Gonorrhoeae and Chlamydia Trachomatis in males/females with or without symptoms
  • Availability: commercially available from multiple manufacturers (Roche, etc)
  • Technique: PCR amplification, strand displacement amplification (SDA), or transcription-mediated amplification (TMA) of organism DNA/RNA in sample
    • Technique can theoretically detect as little as one organism per samples (the detection threshold of culture is approximately 1000 organisms per sample)
    • Sensitivity of various amplification methods varies
  • Optimal Specimen Type
    • Male: first void urine sample
      • Perform as well or better than urethral swabs
    • Female: vaginal swab
      • Vaginal swabs perform as well as cervical swabs (although cervical swabs may be substituted in cases when pelvic exam is performed)
      • Self-collected vaginal swabs are equivalent in sensitivity/specificity to clinician-collected vaginal swabs
      • Female urine specimens are 10% less effective than vaginal swabs for detection of Neisseria Gonorrhoeae (possibly related to the presence of urine inhibitory substances which may interfere with NAAT)
      • Female “clean catch” urine (if being performed at the same time) requires external cleansing of the urethra, which will impede optimal NAAT testing of urine -> therefore, NAAT of female urine should be performed using first void urine without external cleansing prior to collection
  • Cost-Effectiveness: cost effective in preventing sequelae of Neisseria Gonorrhoeae and Chlamydia Trachomatis infections
  • Cross-Reactivity with Non-Gonococcal Neisseria Species: none
  • Advantages of NAAT Over Urethral Swab Culture
    • Higher Sensitivity (100%) and Equal Specificity (99%) Than Urethral Swab Culture
    • Non-Invasive Collection Method: requires only urine to perform, rather than a urethral swab
    • Single Test Can Be Employed for Both Organisms
    • Faster Test Turnaround Time Than Urethral Swab Culture
  • Advantages of NAAT Over Other Molecular Testing Methods
    • NAAT’s are preferred over direct fluorescence antibody testing, ELISA’s, nucleic acid hybridization tests due to their superior sensitivity/specificity
  • Disadvantages of NAAT
    • NAAT does not enable determination of antibiotic sensitivities: therefore, cultures are still required in cases where antibiotic resistance is suspected
    • NAAT does not provide results at the point of care (specimens must be processed in the lab)
    • NAAT is expensive
  • Use of NAAT with Non-Genital Body Specimens
    • NAAT have higher sensitivity than culture to detect Chlamydia Trachomatis in oropharyngeal or rectal samples in males with have intercourse with other males: however, this use is not FDA-approved and needs to be validated in terms of performance at the local lab/clinical site

Urinalysis with Urine Culture

  • Specimen: first void urine specimen is required
    • Urination within 2 hrs of exam should be avoided, as it may impair the ability to detect organisms
  • Criteria: >10 WBC per hpf on first void urine is consistent with urethritis
  • Criteria: positive leukocyte esterase (on dipstick) on first void urine is consistent with urethritis

Urethral Swab with Culture

  • Used historically to diagnose Neisseria Gonorrhoeae and Chlamydia Trachomatis infections: however, NAAT above is now the preferred diagnostic method to detect these organisms
  • Culture is currently the only means of detecting Mycoplasma Genitalium and Ureaplasma Urealyticum infections
    • DNA-based testing methods (with 97% sensitivity) for these organisms have been developed, but are not commercially available yet
  • Criteria: >5 neutrophils per hpf indicates presence of urethritis
  • Disadvantages
    • Urethral swab procedure is uncomfortable

Other Testing

  • Herpes Simplex Virus (HSV) Culture and PCR: indicated in patients who have genital ulcer(s)
  • Affirm PCR Assay: indicated only in female cases to detect the 3 major causes of bacterial vaginosis (Candida, Gardnerella, and Trichomonas)
    • Utilizes vaginal/cervical swab
  • HIV Test: usually indicated in cases of suspected sexually-transmitted infection, due to possibility of co-infection with HIV
  • RPR: usually indicated in cases of suspected sexually-transmitted infection or genital ulcer(s), due to possibility of co-infection with syphilis

Clinical Presentations

Acute Bacterial Epididymitis

Epidemiology

  • Uncommon
  • May Be Seen in Conjunction with Acute Prostatitis (see Prostatitis, [[Prostatitis]]), particularly in older males with underlying prostatic obstruction or prior instrumentation

Diagnosis

  • Urinalysis: may be consistent with urinary tract infection

Clinical

  • Fever (see Fever, [[Fever]])
  • Irritative Urinary Voiding Symptoms: due to associated urinary tract infection
    • Dysuria (see Dysuria, [[Dysuria]])
    • Urinary Frequency
    • Urinary Urgency
  • Rigors (see Rigors, [[Rigors]])
  • Reactive Hydrocele: may be seen in advanced cases with epididymo-orchitis
  • Scrotal Wall Erythema: may be seen in advanced cases with epididymo-orchitis
  • Sepsis (see Sepsis, [[Sepsis]])
  • Severe Swelling/Pain of Affected Testicle (see Testicular Pain, [[Testicular Pain]])

Subacute Bacterial Epididymitis

Epidemiology

  • More Common Presentation
  • May Be Seen in an Otherwise Healthy Male

Risk Factors in Post-Pubertal Males/Men

  • Bicycle Riding
  • Heavy Physical Exertion
  • Motorcycle Riding
  • Sexual Activity

Diagnosis

  • Urinalysis: usually negative

Clinical

  • Scrotal Pain (see Testicular Pain, [[Testicular Pain]]): with more subtle epididymal induration and tenderness (with with without swelling)
    • May detect an inflammatory focal nodule within a normal, non-tender epididymis
  • Absence of Irritative Urinary Voiding Symptoms: due to lack of associated urinary tract infection

Chronic Epididymitis

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Treatment

Acute Bacterial Epididymitis

  • Hospitalization: may be required, if sepsis is present
  • Antibiotics: indicated
    • In Males <35 y/o (in Absence of Culture Data): use agents which cover Neisseria Gonorrhoeae/Chlamydia Trachomatis
    • In Males >35 y/o or in Those who Engage in Anal Insertive Intercourse (in Absence of Culture Data): use agents which cover Neisseria Gonorrhoeae/Chlamydia Trachomatis and coliforms (for example: using a fluoroquinolone)
  • Ice/Scrotal Elevation: may be used
  • Analgesics: may be required

Subacute Bacterial Epididymitis

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Chronic Epididymitis

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References

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