Editing Epididymitis

{{Short description|Inflammation of the epididymis, part of the testicle}}
{{Infobox medical condition (new)
| name            = Epididymitis
| synonyms        = Inflammation of the epididymis<ref name=AFP2016/>
| image           = Acute epididymitis, low mag.jpg
| caption         = Acute epididymitis with abundant fibrinopurulent exudate in the tubules.
| field           = [[Urology]], [[Infectious disease (medical specialty)|infectious disease]]
| pronounce       = {{IPAc-en|audio=Epidimitis.ogg|ˌ|ɛ|p|ɪ|ˌ|d|ɪ|d|ɪ|ˈ|m|aɪ|t|ɪ|s}} {{Respell|EP|ih|DID|im|EYE|tis}}
| symptoms        = Pain in the back of the [[testicle]], swelling of the testicle, [[dysuria|burning with urination]], frequent urination<ref name=AFP2016/>
| complications   = [[Infertility]], [[chronic pain]]<ref name=AFP2016/>
| onset           = Over a day or two<ref name=AFP2016/>
| duration        =
| types           = Acute (< 6 weeks), chronic (>12 weeks)<ref name=AFP2016/>
| causes          = [[Gonorrhea]], [[chlamydia]], [[enteric bacteria]], reflux of urine<ref name=AFP2016/>
| risks           =
| diagnosis       = Based on symptoms, [[ultrasound]]<ref name=AFP2016/>
| differential    = [[Testicular torsion]], [[inguinal hernia]], [[testicular cancer]], [[orchitis]]<ref name=AFP2016/><ref name=AFP2009/>
| prevention      =
| treatment       = [[Pain medications]], [[antibiotics]], elevation<ref name=AFP2016/>
| medication      = [[NSAIDs]], [[ceftriaxone]] and [[doxycycline]], [[ofloxacin]]<ref name=AFP2016/>
| prognosis       =
| frequency       = 600,000 per year (age 15-35, US)<ref name=AFP2009/>
| deaths          =
}}

'''Epididymitis''' is a medical condition characterized by [[inflammation]] of the [[epididymis]], a curved structure at the back of the [[testicle]].<ref name=AFP2016>{{cite journal|last1=McConaghy|first1=JR|last2=Panchal|first2=B|title=Epididymitis: An Overview.|journal=American Family Physician|date=1 November 2016|volume=94|issue=9|pages=723–726|pmid=27929243}}</ref> Onset of pain is typically over a day or two.<ref name=AFP2016/> The pain may improve with raising the testicle.<ref name=AFP2016/> Other symptoms may include swelling of the testicle, [[dysuria|burning with urination]], or frequent urination.<ref name=AFP2016/> [[Orchitis|Inflammation of the testicle]] is commonly also present.<ref name=AFP2016/>

In those who are young and sexually active, [[gonorrhea]] and [[chlamydia]] are frequently the underlying cause.<ref name=AFP2016/> In older males and men who practice insertive [[anal sex]], [[enteric bacteria]] are a common cause.<ref name=AFP2016/> Diagnosis is typically based on symptoms.<ref name=AFP2016/> Conditions that may result in similar symptoms include [[testicular torsion]], [[inguinal hernia]], and [[testicular cancer]].<ref name=AFP2016/> [[Doppler ultrasound|Ultrasound]] can be useful if the diagnosis is unclear.<ref name=AFP2016/>

Treatment may include [[pain medications]], [[NSAIDs]], and elevation.<ref name=AFP2016/> Recommended [[antibiotics]] in those who are young and sexually active are [[ceftriaxone]] and [[doxycycline]].<ref name=AFP2016/> Among those who are older, [[ofloxacin]] may be used.<ref name=AFP2016/> Complications include [[infertility]] and [[chronic pain]].<ref name=AFP2016/> People aged 15 to 35 are most commonly affected, with about 600,000 people within this age group affected per year in the United States.<ref name=AFP2009>{{cite journal|last1=Trojian|first1=TH|last2=Lishnak|first2=TS|last3=Heiman|first3=D|title=Epididymitis and orchitis: an overview.|journal=American Family Physician|date=1 April 2009|volume=79|issue=7|pages=583–7|pmid=19378875}}</ref>

==Signs and symptoms==
[[Image:Epididymis-KDS.jpg|thumb|Adult human testicle with epididymis: A. Head of epididymis, B. Body of epididymis, C. Tail of epididymis, and D. Vas deferens]]
Those aged 15 to 35 are most commonly affected.<ref name=AFP2009/> The acute form usually develops over several days, with pain and swelling frequently in only one testis, which will hang low in the scrotum.<ref name=brown/>  There will often be a recent history of [[dysuria]] or [[urethra|urethral discharge]].<ref name=brown/>  Fever is also a common symptom.  In the chronic version, the patient may have painful point tenderness but may or may not have an irregular epididymis upon [[palpation]], though palpation may reveal an indurated epididymis.  A scrotal ultrasound may reveal problems with the epididymis, but such an ultrasound may also show nothing unusual.  The majority of patients who present with chronic epididymitis have had symptoms for over five years.<ref name=kav/>{{rp|p.311}}

===Complications===
Untreated, acute epididymitis's major complications are [[abscess]] formation and testicular [[infarction]].  Chronic epididymitis can lead to permanent damage or even destruction of the epididymis and testicle (resulting in infertility and/or [[hypogonadism]]), and infection may spread to any other [[organ (anatomy)|organ]] or system of the body. Chronic pain is also an associated complication for untreated chronic epididymitis.<ref name=nickel/>

== Causes ==
Though urinary tract infections in men are rare, bacterial infection is the most common cause of acute epididymitis.<ref name=AMP09/> The [[bacteria]] in the [[urethra]] back-track through the [[urinary tract|urinary]] and [[human reproductive system|reproductive structures]] to the epididymis. In rare circumstances, the infection reaches the epididymis via the bloodstream.<ref>{{cite web |url=https://www.lecturio.com/concepts/epididymitis-and-orchitis/| title=Epididymitis and Orchitis
|website=The Lecturio Medical Concept Library |access-date= 19 July 2021}}</ref>

In sexually active men, ''[[Chlamydia trachomatis]]'' is responsible for two-thirds of acute cases, followed by ''[[Neisseria gonorrhoeae]]'' and ''[[E. coli]]'' (or other bacteria that cause [[urinary tract infection]]). Particularly among men over age 35 in whom the cause is ''E. coli'', epididymitis is commonly due to urinary tract obstruction.<ref name=brown>{{Cite book|title=Oxford American Handbook of Emergency Medicine|last=Brown|first=Jeremy|year=2008|page=992|publisher=Oxford University|place=New York|url=https://books.google.com/books?id=csdGgwKCIQUC&pg=PT841|isbn=978-0-19-518924-7}}</ref><ref name="Smith"/> Less common microbes include ''[[Ureaplasma]]'', [[Mycobacterium]], and ''[[cytomegalovirus]]'', or ''[[Cryptococcus (fungus)|Cryptococcus]]'' in patients with [[HIV infection]]. ''E. coli'' is more common in boys before [[puberty]], the [[elderly]], and [[homosexual men|men who have sex with men]].  In the majority of cases in which bacteria are the cause, only one side of the scrotum or the other is the locus of pain.<ref>{{Cite book|title=Sexually Transmitted Diseases: A Physician Tells You What You Need to Know|last=Marr|first=Lisa|edition=Second|year=2007|publisher=Johns Hopkins University |url=https://books.google.com/books?id=aywGiP9w-u8C&pg=PT36|isbn=9780801886591}}</ref>

Non-infectious causes are also possible. Reflux of sterile urine (urine without bacteria) through the [[ejaculatory duct]]s may cause inflammation with obstruction. In children, it may be a response following infection with [[enterovirus]], [[adenovirus]], or ''[[Mycoplasma pneumoniae]]''.  Rare non-infectious causes of chronic epididymitis include [[sarcoidosis]] (more prevalent in black men) and [[Behçet's disease]].<ref name=kav/>{{rp|p.311}}

Any form of epididymitis can be caused by genito-urinary [[surgery]], including [[prostatectomy]] and  [[urinary catheterization]]. [[Congestive epididymitis]] is a long-term complication of [[vasectomy]].<ref name="pmid10785217">{{cite journal |vauthors=Schwingl PJ, Guess HA |title=Safety and effectiveness of vasectomy |journal=Fertil. Steril. |volume=73 |issue=5 |pages=923–36 |year=2000 |pmid=10785217|doi=10.1016/S0015-0282(00)00482-9|citeseerx=10.1.1.494.1247 }}</ref><ref name="pmid8237740">{{cite journal |author=Raspa RF |title=Complications of vasectomy |journal=American Family Physician |volume=48 |issue=7 |pages=1264–8 |year=1993 |pmid=8237740 }}</ref> Chemical epididymitis may also result from drugs such as [[amiodarone]].<ref name="amiodarone">{{cite journal |vauthors=Ibsen HH, Frandsen F, Brandrup F, Møller M |title=Epididymitis caused by treatment with amiodarone |journal=Genitourin Med |volume=65 |issue=4 |pages=257–8 |date=August 1989 |pmid=2807285 |pmc=1194364 |doi= 10.1136/sti.65.4.257}}</ref>

==Diagnosis==
[[File:Ultrasonography of epididymitis.jpg|thumb|[[Doppler ultrasound]] of epididymitis, seen as a substantial increase in blood flow in the left epididymis (top image), while it is normal in the right (bottom image). The thickness of the epididymis (between yellow crosses) is only slightly increased.]]

Diagnosis is typically based on symptoms.<ref name=AFP2016/> Conditions that may result in similar symptoms include [[testicular torsion]], [[inguinal hernia]], and [[testicular cancer]].<ref name=AFP2016/> [[Doppler ultrasound|Ultrasound]] can be useful if the diagnosis is unclear.<ref name=AFP2016/>

Epididymitis usually has a gradual onset. Typical findings are redness, warmth, and swelling of the scrotum, with tenderness behind the testicle, away from the middle (this is the normal position of the epididymis relative to the testicle). The [[cremasteric reflex]] (elevation of the testicle in response to stroking the upper inner thigh) remains normal.<ref name=AFP2016/> This is a useful sign to distinguish it from testicular torsion. If there is pain relieved by elevation of the testicle, this is called [[Prehn's sign]], which is, however, non-specific and is not useful for diagnosis.<ref>{{Cite web |url=http://www.aafp.org/afp/990215ap/817.html |title=Diagnosis and Treatment of the Acute Scrotum - February 15, 1999 - American Academy of Family Physicians |access-date=May 19, 2008 |archive-date=June 6, 2011 |archive-url=https://web.archive.org/web/20110606042106/http://www.aafp.org/afp/990215ap/817.html |url-status=dead }}</ref>
Before the advent of sophisticated [[medical imaging]] techniques, surgical exploration was the standard of care. Today, [[Doppler ultrasound]] is a common test: it can demonstrate areas of blood flow and can distinguish clearly between epididymitis and torsion. However, as torsion and other sources of testicular pain can often be determined by palpation alone, some studies have suggested that the only real benefit of an ultrasound is to assure the person that they do not have testicular cancer.<ref name=baran>{{Cite book|title=Urogenital pain in clinical practice|last=Granitisioti|first=P.|editor1-last=Baranowski|editor1-first=Andrew Paul |editor2-last=Abrams|editor2-first=Paul|editor3-last=Fall|editor3-first=Magnus|chapter=Scrotal pain conditions|year=2008|publisher=Informa Healthcare USA|place=New York|chapter-url=https://books.google.com/books?id=ZGA5vzK3V4cC&pg=PA238|isbn=978-0849399329}}</ref>{{rp|p.237}} [[Nuclear medicine|Nuclear]] testicular blood flow testing is rarely used.{{citation needed|date=May 2021}}

Additional tests may be necessary to identify underlying causes. In younger children, a urinary tract anomaly is frequently found. In sexually active men, tests for [[sexually transmitted infection]]s may be done. These may include [[microscopy]] and [[Microbiological culture|culture]] of a first void urine sample, [[Gram stain]] and culture of fluid or a swab from the [[urethra]], [[nucleic acid amplification test]]s (to amplify and detect microbial [[DNA]] or other [[nucleic acid]]s) or tests for [[syphilis]] and [[HIV]].

===Classification===
[[File:Suppurative epidydimo orchitis histopathology.jpg|thumbnail|right|Histopathology image of inflamed epididymis and testis]]
Epididymitis can be classified as acute, subacute, and chronic, depending on the duration of symptoms.<ref name=AMP09>{{cite journal |vauthors=Trojian TH, Lishnak TS, Heiman D |title=Epididymitis and orchitis: an overview |journal=Am Fam Physician |volume=79 |issue=7 |pages=583–7 |date=April 2009 |pmid=19378875 }}</ref>

====Chronic epididymitis====
[[File:Epididymal calcifications and cyst.jpg|thumb|[[Scrotal ultrasound]] showing calcifications and cysts in a case of chronic epididymis.]]
Chronic epididymitis is epididymitis that is present for more than 3 months. Chronic epididymitis is characterized by inflammation even when there is no [[infection]] present. Tests are needed to distinguish chronic epididymitis from a range of other disorders that can cause constant scrotal pain including [[testicular cancer]] (though this is often painless), enlarged scrotal veins ([[varicocele]]), calcifications,<ref>{{cite web|url=https://radiopaedia.org/articles/epididymal-calcification|title=Epididymal calcification|author=Matt A. Morgan and Yuranga Weerakkody|website=[[Radiopaedia]]|access-date=2018-05-21}}</ref> and a possible [[cyst]] within the epididymis. Some research has found that as much as 80% of visits to a urologist for scrotal pain are for chronic epididymitis.<ref name=kav>{{Cite book|title=Practical urology: essential principles and practice|last1=Kavoussi|first1=Parviz K.|last2=Costabile|first2=Raymond A.|editor1-last=Chapple|editor1-first=Christopher R.|editor2-last=Steers|editor2-first=William D.|year=2011|chapter=Disorders of scrotal contents: orchitis, epididimytis, testicular torsion, torsion of the appendages, and Fournier's gangrene|publisher=Springer-Verlag|place=London|chapter-url=https://books.google.com/books?id=A9m8TkdCUqEC&pg=PA315|isbn=978-1-84882-033-3}}</ref>{{rp|p.311}} As a further complication, the nerves in the scrotal area are closely connected to those of the abdomen, sometimes causing abdominal pain similar to a hernia (see [[referred pain]]).

Chronic epididymitis is most commonly associated with lower back pain, and the onset of pain often co-occurs with activity that stresses the low back (i.e., heavy lifting, long periods of car driving, poor posture while sitting, or any other activity that interferes with the normal curve of the [[lumbar lordosis]] region).<ref name=baran/>{{rp|p.237}}

==Treatment==
In both the acute and chronic forms, [[antibiotics]] are used if an infection is suspected.  The treatment of choice is often [[azithromycin]] and [[cefixime]] to cover both gonorrhoeae and chlamydia. [[Fluoroquinolone]]s are no longer recommended due to widespread resistance of gonorrhoeae to this class.<ref name="Smith"/>  [[Doxycycline]] may be used as an alternative to azithromycin.  In chronic epididymitis, a four- to six-week course of antibiotics may be prescribed to ensure the complete eradication of any possible bacterial cause, especially the various chlamydiae.

For cases caused by enteric organisms (such as ''E. coli''), [[ofloxacin]] or [[levofloxacin]] are recommended.<ref name="Smith"/>

In children, fluoroquinolones and doxycycline are best avoided. Since bacteria that cause urinary tract infections are often the cause of epididymitis in children, [[co-trimoxazole]] or suited [[penicillin]]s (for example, [[cephalexin]]) can be used.{{citation needed|date=May 2021}}

Household remedies such as elevation of the [[scrotum]] and cold compresses applied regularly to the [[scrotum]] may relieve the pain in acute cases. [[Painkillers]] or [[non-steroidal anti-inflammatory drugs|anti-inflammatory drugs]] are often used for the treatment of both chronic and acute forms. Hospitalisation is indicated for severe cases, and check-ups can ensure the infection has cleared up. Surgical removal of the epididymis is rarely necessary, causes sterility, and only gives relief from pain in approximately 50% of cases.<ref name=nickel/>  However, in acute suppurating epididymitis (acute epididymitis with a discharge of pus), an [[epididymotomy]] may be recommended; in refractory cases, a full [[epididymectomy]] may be required.  In cases with unrelenting testicular pain, removal of the entire testicle—[[orchiectomy]]—may also be warranted.

It is generally believed that most cases of chronic epididymitis will eventually "burn out" of the patient's system if left untreated, though this might take years or even decades.<ref name=nickel>{{Cite book|title=Diseases of the kidney and urinary tract|last1=Nickel|first1=J. Curtis|last2=Beiko|first2=Darren T.|edition=Eighth|volume=1|year=2007|chapter=Chapter 23:prostatitis, orchitis, and epididymitis|page=645|publisher=Lippincott Williams & Wilkins|place=Philadelphia|chapter-url=https://books.google.com/books?id=hghs1uI2rg8C&pg=PA645|isbn=978-0-7817-9307-0|editor-last=Schrier|editor-first=Robert W.|url=https://archive.org/details/diseasesofkidney0000unse|url-access=registration}}</ref>  However, some [[prostate]]-related medications have proven effective in treating chronic epididymitis, including [[doxazosin]].<ref>{{cite journal | last =Zhou | first =YC | author2 =Xia GS | author3 =Xue YY | author4 =Zhang XD | author5 =Zheng LW | author6 =Jin BF | title =Kidney-tonifying and dampness-expelling Chinese herbal medicine combined with doxazosin for the treatment of chronic epididymitis | journal =Zhonghua Nan Ke Xue | volume =16 | issue =12 | pages =1143–6 | date =2010–2012 | language =zh | url =http://www.druglib.com/abstract/zh/zhou-yc_zhonghua-nan-ke-xue_20101200.html | pmid =21348207 | url-status =live | archive-url =https://web.archive.org/web/20130731160440/http://www.druglib.com/abstract/zh/zhou-yc_zhonghua-nan-ke-xue_20101200.html | archive-date =2013-07-31 }}</ref>

==Epidemiology==
Epididymitis makes up 1 in 144 visits for medical care (0.69 percent) in men 18 to 50 years old or 600,000 cases in males between 18 and 35 in the United States.<ref name=AMP09/>

It occurs primarily in those 16 to 30 years of age and 51 to 70 years.<ref name=AMP09/> As of 2008, there appears to be an increase in incidence in the United States that parallels an increase in reported cases of [[Chlamydia infection|chlamydia]] and [[gonorrhea]].<ref name="Smith">{{cite journal |author=Smith DM|title=A Really Big Pain: Acute Epididymitis |journal=The AIDS Reader |date=September 1, 2008|url=http://www.consultantlive.com/pain/article/1145619/1361797}}</ref>

==References==
{{Reflist}}

==Further reading==
* {{cite journal |author=Galejs LE |title=Diagnosis and treatment of the acute scrotum |journal=Am Fam Physician |volume=59 |issue=4 |pages=817–24 |date=February 1999 |pmid=10068706 |url=http://www.aafp.org/afp/990215ap/817.html |access-date=2008-05-19 |archive-date=2011-06-06 |archive-url=https://web.archive.org/web/20110606042106/http://www.aafp.org/afp/990215ap/817.html |url-status=dead }}
* {{cite journal |author=Nickel JC |title=Chronic epididymitis: a practical approach to understanding and managing a difficult urologic enigma |journal=Rev Urol |volume=5 |issue=4 |pages=209–15 |year=2003 |pmid=16985840 |pmc=1553215 }}

== External links ==

{{Medical resources
|  DiseasesDB     = 4342
|  ICD10          = {{ICD10|N|45|0|n|40}}
|  ICD9           = {{ICD9|604}}
|  ICDO           =
|  OMIM           =
|  MedlinePlus    = 001279
|  eMedicineSubj  = med
|  eMedicineTopic = 704
|  eMedicine_mult = {{eMedicine2|radio|261}} {{eMedicine2|emerg|166}}
|  MeshID         = D004823
}}

{{Male diseases of the pelvis and genitals}}
{{Authority control}}

[[Category:Epididymis disorders]]
[[Category:Inflammations]]
[[Category: Men's health]]
[[Category:Wikipedia emergency medicine articles ready to translate]]
[[Category:Wikipedia medicine articles ready to translate]]