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Updated: Feb 12 2018


  • Snapshot
    • A 20-year-old man presents with left-sided testicular pain and swelling. He has a past medical history of multiple sexually transmitted infections. On physical exam, his left scrotum and testicle are erythematous, indurated, and tender to palpation. An ultrasound reveals a thickened epididymis. He is sent to the lab for testing for sexually transmitted diseases.
  • Introduction
    • Clinical definition
      • inflammation of epididymis with symptoms of < 6 weeks
    • Epidemiology
      • incidence
        • 25 per 100,000 persons
      • demographics
        • men 18-35 years old
      • risk factors
        • sexual activity
        • bladder outlet obstruction
    • Etiology
      • pathogens from sexually transmitted infections in men less than 35 years of age
        • Neisseria gonorrhoeae
        • Chlamydia trachomatis
      • urinary tract pathogens in men greater than 35 years of age
        • Escherichia coli
    • Pathogenesis
      • consequence of sexually transmitted disease or urinary tract infection
        • retrograde ascent of pathogen
      • bladder outlet obstruction
        • bacteriuria and subsequent retrograde ascent of pathogen
    • Prognosis
      • resolves with antibiotics
  • Presentation
    • Symptoms
      • testicular pain and often unilateral
      • lower abdominal pain
      • urinary frequency or urgency
      • urinary dysuria
    • Physical exam
      • fever
      • testicular erythema, tenderness, and induration
      • cremasteric reflex intact
      • Prehn's sign
        • decrease in pain with scrotal elevation
  • Imaging
    • Ultrasound
      • indications
        • to rule out testicular torsion
      • findings
        • enlarged and thick epididymis
        • increased blood flow
        • may also find reactive hydrocele
  • Studies
    • Urine
      • positive leukocyte esterase
      • 10 or more wbc/hpf
      • nucleic amplification testing for Chlamydia and Neisseria
  • Differential
    • Testicular torsion
      • absent cremasteric reflex
  • Treatment
    • Medical
      • antibiotics guided by sexual and urologic history
        • ceftriaxone and doxycycline
          • for sexually transmitted diseases
        • fluoroquinolone
          • for enteric pathogens
  • Complications
    • Sepsis
    • Testicular atrophy
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