The epididymis is a long and twisted tube, located above and behind each testicle. It collects and stores sperm before ejaculation made by the testicles. Inflammation and infection of the epididymis is called epididymitis.
Although trauma may cause occasionally epididymal inflammation, most cases can be divided into two groups:
- A sexual transmitted form associated with urethritis and commonly caused by Chalmydia trachomatis and Neisseria gonorrhoea
- A primary non-sexually transmitted form, associated with urinary tract infections and prostatitis, and caused mainly by Enterobacteriaceae or Pseudomonas.
In its early stages epididymitis is a cellular inflammation, in the acute stage, the epididymis is swollen and indurated. The infection spreads from the lower to the upper pole. On section, small abscesses may be seen. The tunica vaginalis often secrets serous fluid (inflammatory hydrocele), which in rare cases may become purulent. The spermatic cord becomes thickened. The testis become swollen secondarily from passive congestion, but rarely becomes involved in the infectious process. Histologically, changes range from edema and infiltration with neutrophils, plasmocytes and lymphocytes, to actual abscess formation. Bilateral epididymitis may result in sterility or low levels of fertility.
The patient may have experienced symptoms of urethritis of prostatitis (urethral discharge, burning sensation when urinating, fever). At times, bacteria from the urethra pr prostate are transmitted to the epididymis as a consequence of urethral instrumentation or prostatic surgery.
Pain that is usually quite severe develops suddenly in the scrotum and may radiate along the spermatic cord and even reach the flank. the epididymis is very sensitive. Swelling is rapid and may cause the organs to double their normal size in the course of 3-4 hours. Body temperature may reach 40 degrees Celsius.
There may be tenderness over the groin (spermatic cord), the scrotum is usually enlarged, and the overlying skin may be red. If an abscess is present, the overlying skin may appear dry, flaky, and thinned; the abscess may rupture spontaneously. Early in the course of acute epididymitis, the enlarged, indurated, tender epididymis may be distinguished from the testis, but after a few hours, the testis and epididymis typically become one mass. The spermatic cord is thickened by edema; a reactive hydrocele secondary to the inflammation may develop within a few days.
The hemogram typically shows marked elvation of the leucocytes. The cause of epididymitis can be differetiated by examination of Gram-stained smears or cultures of a mildstream urine specimen and a urethral specimen. If coliform bacteria, Pseudomonas, N gonorrhoea or Trachomatis are found, a presumptive diagnosis of epididymitis is established.
Differential Diagnosis: tuberculous epididymitis, testicular tumors, torsion of the spermatic cord, torsion of the appendages of the testis or epididymis, testicular trauma, mumps orchitis.
Epididymitis may lead to epdidymal abscesses that may extend and destroy the testis (epididymo-orchitis), but this is very rare. Chronic epidymitis may develop however.
Specific Measures. Sexually transmitted acute epididymitis occurs mainly in young adults in association with urethritis, without underlying genitourinary disease or abnormalities. For treatment, doxycycline is recommended. Alternative treatment for gonococcal urethritis and epididymitis is ciprofloxacin or a third generation cephalosporin (antibiotics). Non-sexually transmitted acute epididymitis can be treated with trimethoprim- sulfomethoxazole. The patients should be evaluated for underlying genitourinary tract disease.
General Measures. Bed rest is recommended when the disease is in the acute phase. Support for testicle that is enlarged partially relieves the discomfort. Local injection of anesthetics like xiline in the spermatic cord may produce relief of pain and discomfort. Oral analgesics and antipyretic (fever drugs) are recommended. An ice pack used in the early stages helps prevent excessive swelling. Sexual activity or physical strain may exacerbate the infection , and worsen the symptoms, therefore they should be avoided.
If epididymitis is diagnosed promptly and the treatment is appropriate, it usually resolves slowly without complications. Complete resolution of pain and all symptoms often takes up to 3 weeks, for the epididymis to return to its normal size and consistency it may take up to 5 weeks.