Acute Epididymitis (irrirative voiding symptoms, accompanied by enlarged painful epididymus)

What Is Acute Epididymitis?

Acute epididymitis is an inflammation of the epididymis—the coiled tube at the back of the testicle that stores and carries sperm. It is often infectious, either sexually transmitted or urinary in origin, depending on the patient’s age and risk factors.

🧠 Etiology: Age-Based Clues

Age Group

Likely Cause

Common Pathogens

<35 years

Sexually transmitted infection (STI)

Chlamydia trachomatis, Neisseria gonorrhoeae

>35 years

Urinary tract pathogen

E. coli, Pseudomonas

Children

Often viral or anatomic abnormality (e.g., reflux)

E. coli or viral

💡 Also consider:

  • Anal intercourse → Enteric organisms (E. coli)

  • Recent urologic procedures → Instrumentation-related infection

  • Amiodarone → Can cause non-infectious epididymitis

🩺 Clinical Presentation

  • Gradual onset of unilateral scrotal pain and swelling

  • Scrotal erythema, warmth, and tenderness

  • Pain relief with scrotal elevation (🌟 Prehn’s sign – positive)

  • Dysuria, urinary frequency (if UTI-related)

  • Fever or chills (in some cases)

  • Urethral discharge (if STI-related)

  • Normal cremasteric reflex (unlike testicular torsion)

🔬 Diagnosis: Workup for NP Practice

Test

Purpose

Urinalysis + Urine Culture

Look for pyuria/bacteriuria (esp. in older men)

NAAT (PCR) for GC/Chlamydia

Standard for sexually active men <35

Scrotal ultrasound with Doppler

If testicular torsion cannot be ruled out; shows increased blood flow to epididymis

STI screen

If indicated, also screen for HIV, syphilis, etc.

⚠ Testicular torsion is a surgical emergency — rule this out urgently in sudden, severe pain (esp. if <25 years old).

💊 Treatment Based on Cause

👨‍⚕ <35 years old or STI risk

  • Ceftriaxone 500 mg IM (1 dose) + Doxycycline 100 mg BID x 10 days

👴 >35 years old or low STI risk

  • Levofloxacin 500 mg PO daily x 10 days
    or

  • Ofloxacin 300 mg PO BID x 10 days

📌 If anal intercourse:
Use Ceftriaxone + Levofloxacin to cover both GC and enteric organisms.

🧑‍⚕ NP Management Tips

  • Scrotal support, NSAIDs, rest

  • Educate on safe sex practices

  • Abstain from sexual activity during treatment + 7 days after partner(s) treated

  • Treat sexual partners if STI is confirmed

  • If no improvement in 48–72 hours → reconsider diagnosis or refer to urology

🔁 Follow-Up

  • Reassess symptoms in 1–2 weeks

  • Test of cure not usually required unless:

    • Symptoms persist

    • Noncompliance suspected

    • Resistant organism suspected

🚩 Red Flags – When to Refer

  • Suspicion of testicular torsion

  • Severe or worsening symptoms

  • Recurrent episodes

  • Suspected abscess or testicular involvement (orchitis)

  • Fertility concerns

🧠 Clinical Pearl Recap

Sign

Description

Prehn’s Sign

Relief of pain when scrotum elevated (often positive in epididymitis)

Cremasteric Reflex

Intact in epididymitis, absent in testicular torsion

Ultrasound

Shows increased blood flow (vs. decreased in torsion)