1. Epididymitis Swollen, sore and infected

2. Definitions Epididymitis – inflammation of the epididymis usually as a result of bacterial or viral infection, rarely as a result of trauma or urinary reflux from the urethra [1] Epididymo-orchitis – inflammation of both the testis and epididymis [1] Orchitis – inflammation of testis due to trauma, ischaemia, metastasis, mumps or infection elsewhere in the body [1]

3. Anatomy Review

4. Epididymitis Acute – pain and swelling < 6 weeks Subacute – pain and swelling 6 weeks – 3 months Chronic – pain > 3 months can be subdivided – inflammatory, obstructive and epididmyalgia [2]

5. Incidence 13 cases per 10,000 Australian male patient encounters at the GP [3] 31 per 10,000 in age cohort 25 – 29 years [3] Similar in the UK [4] 24 per 10,000 for all ages 27 per 10,000 for the 25 – 34 year old cohort

6. Aetiology No exact causes identified Urinary reflux (congenital, mechanical) Presence of infectious agent STI vs Urologic Pathogen [5]

7. Bugs Bugs Bugs Bacteria [5] Enteric bacteria (Pseudomonas and E Coli) Tuberculosis Syphilis Gonorrhoea Chlamydia Viruses Coxsackie A6 virus (hand, foot and mouth disease) [6] Enterovirus and adenovirus [5] Hepatitis B [7] Mumps [8]

8. Other Aetiologies Trauma Obstruction secondary to vasectomy Fungal infections such as candida and histoplasmosis Rheumatic conditions Parasitic infection such as trichomoniasis and schistosomiasis [5] Can be amiodarone induced [9] Posterior urethral valves in children [10] Xanthogranulomatous inflammation [11, 12]

10. Pathophysiology Infection limited by segmental nature of epididymis [13] Unilateral in acute setting with bilateral impact on spermatogenesis [14] Bilateral in chronic setting Abscess Segmental infarction [15] Fertility impact 6 – 7% azoospermia, 22 – 37% oligospermia [14]

11. Diagnostic Criteria – Physical Signs [5] Pain – location of pain Swelling – induration of scrotal sac Surgical history Sexual history

12. Diagnostic Criteria – Biochemical Urinalysis Urine culture / gram staining of urethral discharge Haematology – WCC and CRP No specific serum inflammatory marker has yet been discovered for epididymitis though work continues [16] Semen culture no longer necessary

14. Ultrasound of Epididymitis - Acute Increased PSV of testicular artery on affected side versus normal side [17] Epididymis / testis is thickened / enlarged Echotexture may be heterogeneous and hypoechoic Increased vascularity compared to surroundings under Doppler interrogation Reactive hydrocele [17]

15. Acute Features Reactive Hydrocoele Heterogeneous Echotexture Increased Vascularity

16. Ultrasound of Epididymitis – Chronic Thickened epididymis / testis / tunica vaginalis Induration of scrotal wall Heterogeneous echotexture Coarse calcifications Testicular infarct – wedge shaped hypoechoic area [15]

17. Utility of Ultrasound Exclusion of testicular torsion / mass Visualise extent of disease progress – abscess formation / secondary infarction Follow up of epididymitis – success of treatment

18. References 1.Taber's Cyclopedic Medical Dictionary. 22nd ed. Cyclopedic Medical Dictionary, ed. D. Venes. 2013, Philadelphia: F.A. Davis Co. 2.Shoskes, D.A., Urological Men’s Health : A Guide for Urologists and Primary Care Physicians. Current Clinical Urology, ed. E.A. Klein. 2012, Totowa, NJ: Springer: Humana Press. 3.Chen, M.Y., et al., Trends in clinical encounters for pelvic inflammatory disease and epididymitis in a national sample of Australian general practices. International Journal of STD & AIDS, 2006. 17(6): p. 384-386. 4.Nicholson, A., et al., Management of epididymo-orchitis in primary care: results from a large UK primary care database. The British Journal of General Practice, 2010. 60(579): p. e407- e422. 5.Michel, V., et al., Epididymitis: revelations at the convergence of clinical and basic sciences. Asian Journal of Andrology, 2015. 17(5): p. 756 - 763. 6.Vuorinen, T., et al., Epididymitis Caused by Coxsackievirus A6 in Association with Hand, Foot, and Mouth Disease. Journal of Clinical Microbiology, 2014. 52(12): p. 4412-4413. 7.Aydin, Ö.A., et al., An Unusual Extrahepatic Manifestation of Acute Hepatitis B Infection: Epididymitis. Viral Hepatit Dergisis, 2014. 20(2). 8.Doyle, J.S., E.K. Paige, and D.W. Spelman, Mumps presenting as epididymo-orchitis among young travellers: under-recognition, missed diagnoses and transmission risks. The Medical journal of Australia, 2011. 194(6): p. 317. 9.Nikolaou, M., et al., Amiodarone-induced epididymitis: A case report and review of the literature. International Journal of Cardiology, 2007. 121(1): p. e15-e16. 10.Kwong, J., et al., Bilateral Epididymitis in a Child With Undiagnosed Posterior Urethral Valves. Urology, 2013. 82(1): p. 225-227. 11.Ezer, S.S., et al., Xanthogranulomatous Orchiepididymitis: A Very Uncommon Cause of Scrotal Mass in Childhood. Urology, 2013. 82(1): p. 228-230. 12.Repetto, P., et al., Bilateral xanthogranulomatous funiculitis and orchiepididymitis in a 13-year-old adolescent boy. Journal of Pediatric Surgery, 2012. 47(10): p. e33-e35. 13.Stammler, A., et al., Epididymitis: ascending infection restricted by segmental boundaries. Human Reproduction, 2015. 30(7): p. 1557-1565. 14.Rusz, A., et al., Influence of urogenital infections and inflammation on semen quality and male fertility. World Journal of Urology, 2012. 30(1): p. 23-30. 15.Pearl, M.S. and M.C. Hill, Ultrasound of the Scrotum. Seminars in Ultrasound, CT and MRI, 2007. 28(4): p. 225-248. 16.Pilatz, A., et al., Clinical evaluation of human epididymis protein 4 as a biomarker for epididymitis. Biomarkers in Medicine, 2012. 6(3): p. 311-7. 17.Pilatz, A., et al., Acute epididymitis in ultrasound: Results of a prospective study with baseline and follow-up investigations in 134 patients. European Journal of Radiology, 2013. 82(12): p. e762-e768.

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