Epididymitis, orchitis, orchiepididymitis

Epididymitis (inflammation of the epididymis) is manifested by pain and swelling, almost always one-sided, developing acutely. Often, the testes are involved in the inflammatory process (orcoepididymitis). On the other hand, inflammation from the testicle (especially viral orchitis) often extends to the appendage. Orchitis and epididymitis, depending on the rate of development and clinical course, are classified as acute and chronic.

ICD-10 codes

• N45.0. Orchitis, epididymitis and epididymoorkhitis with an abscess.
• N51.1. Lesions of the testis and its appendages in diseases classified elsewhere.

Epidemiology

Most often epididymitis develops as a result of infection into the appendage by hematogenous way as a complication of infectious diseases ( influenza, tonsillitis, pneumonia, etc.).

[1], [2], [3], [4], [5], [6], [7], [8], [9]

Causes

With epididymitis caused by sexually transmitted pathogens, the infection spreads from the urethra and the bladder.

It is suggested that with nonspecific granulomatous orchitis, chronic inflammation is caused by autoimmune reactions. Orchitis in children and mumps orchitis have a hematogenous origin. Orhoepididymitis is also observed in certain systemic infections, such as tuberculosis, syphilis, brucellosis and cryptococcosis.

Often, the infection falls into the epididymis on the vas deferens due to its anti-peristaltic contractions, in the inflammatory process in the urethra, as well as when bougying the latter or damaging it during instrumental examination. The same conditions are created during prolonged stay in the urethra of the catheter.

The testicle is compacted, enlarged, larger than the testicle due to inflammatory infiltration and swelling from the compression of the blood and lymph vessels, on a section of a dark red color with mucous or mucopurulent exudate. The tubules of the appendage are dilated, they contain mucopurulent contents. The vas deferens are thickened, infiltrated (deferent), the lumen is narrowed and contains the same inflammatory exudate as in the tubules of the epididymis. Often, the shells of the spermatic cord (funiculitis) are also involved in the inflammatory process. Establish the etiology of epididymitis is not easy. 15% of patients with acute epididymitis develop chronic inflammation with densification. If the testicle is damaged, chronic inflammation can lead to its atrophy and impairment of spermatogenesis. New data on the incidence and prevalence of epididymitis are absent. Acute epididymitis in young men is associated with sexual activity and infection in the partner.

The most common type of orchitis, mumps orchitis, develops in 20-30% of patients in the post-pubertal period who have suffered an epidemic parotitis. In 10% of cases, the inflammation of the epididymis is facilitated by trauma.

[10], [11], [12]

Symptoms of epididymitis, orchitis, orchoepidymitis

In acute epididymitis, inflammation and edema start from the tail of the epididymis and can spread to the remaining parts of the epididymis and testicular tissue. The spermatic cord is edematous and painful. In all men with epididymitis caused by sexually transmitted pathogens, there is a history of sexual contact that could have occurred several months before the onset of symptoms of the disease. When examining a patient immediately after obtaining a urine sample for analysis, you can not see signs of urethritis or discharge from the urethra, because leukocytes and bacteria are washed out of the urethra during urination.

Acute epididymitis begins suddenly with a rapidly increasing epididymis, sharp pains in it, an increase in body temperature to 38-40 ° C and chills. Inflammation and edema spread to the testicles and scrotum, as a result of which the skin of the scrotum is stretched, losing clutches, becomes hyperemic, there may appear reactive edema of the testicles. The pains irradiate into the inguinal, sometimes in the lumbar region and the sacrum, sharply increase during movement, forcing patients to be in bed.

Nonspecific epilidymitis in the clinical picture of the disease and objective research data can sometimes be difficult to distinguish from tuberculosis of the epididymis. The enlargement of the organ, focal seals, its tuberosity can be observed with both types of epididymitis. Precise changes in the vas deferens the appearance of purulent fistula of the scrotum with the simultaneous presence of another tuberculous focus in the body, the detection of mycobacterium tuberculosis in the urine or purulent discharge from the fistula of the scrotum with a persistent acid reaction of urine testify to the tubercular nature of the lesion. Of decisive importance for differential diagnosis is the detection of mycobacteria tuberculosis in the punctate appendage or biopsy data.

With minor pulling pains and low-grade fever, there is condensation in the restricted area of the appendage, more often in the tail area. Then procecc extends to the entire appendage. When the inflammation of the epididymis is often affected and vas deferens. When palpating a smooth dense duct is defined, which extends to the outer opening of the inguinal canal. Sometimes it can be palpated by rectal examination near the prostate. With inflammation of the ductus can develop funikulit.

The acute period of the disease lasts 5-7 days, after which the pain decreases, the body temperature decreases, the swelling of the scrotum and inflammatory infiltrate decreases. However, the appendage remains enlarged, dense and painful on palpation for a few more weeks.

Diagnostics

Bacterial etiology of epididymitis is diagnosed by microscopy of Gram stained smears from the urethra. The presence in the smear of gram-negative diplococci, located intracellularly, is characteristic of infection caused by N. Gonorrhoeae. Detection in the smear of only leukocytes indicates non-gonococcal urethritis. If a mumps tumor is suspected, the diagnosis is confirmed by epidemic parotitis in the anamnesis and the detection of specific IgM in the serum.

[13], [14], [15], [16]

Differential diagnostics

The disease must be differentiated with orchitis, epididymitis, festering cyst of spermatic cord, infringed inguinal hernia. It is mandatory to conduct differential diagnosis between epididymitis and torsion of the spermatic cord using all available information, including patient's age, history of urethritis, clinical evaluation and Doppler testicular testicular findings. The elevated position of the scrotum during the twisting of the spermatic cord does not reduce pain, as with epididymitis, but on the contrary, strengthens (Pren's symptom).

Isolated enlargement of the testicle occurs with tumors, as well as with brucellosis, in which the accompanying edema of the testicle shells is often noted.

Sometimes differential diagnosis with a tumor is possible only during surgery using the method of urgent biopsy and histological examination.

[17], [18], [19], [20], [21], [22], [23]

Treatment of epididymitis, orchitis, orchoepidymitis

A few studies have been carried out to study the degree of penetration of antimicrobial agents into the tissue of the testicles and the epididymis in humans. Of all the drugs studied, the most suitable properties were found in fluoroquinolones, macrolides and cephalosporins.

Antibiotic should be chosen based on the empirical idea of that. That in young sexually active men the cause of the disease is usually C. Trachomatis. And in older men with prostate adenoma or other micturition disorders, most commonly traditional uropathogens. Studies comparing the results of a microbiological evaluation of a material obtained by puncturing the appendage of swabs from the urethra and urine showed very good correlation. Thus, before the start of antibiotic therapy, you should take a smear from the urethra or obtain a spermogram for culture.

Non-drug treatment

Supportive therapy includes bed rest, raised testicles and anti-inflammatory drugs. If the pathogen is uropathogenic, then to prevent the recurrence of the infection, a thorough examination should be carried out in order to detect micturition disorders. After the ablation of the inflammatory process, heat is prescribed as a warming compress on the scrotum, diathermy, or UHF to resolve the inflammatory infiltrate.

Medication

Drugs of choice - fluoroquinolones, due to their wide spectrum of activity and good penetration into the tissues of the genitourinary system. Macrolides may be used as alternative drugs.

Forecast

With nonspecific epididymitis, it is favorable. With the recurrence of the disease, obstruction of the appendage and the vas deferens can develop, and in case of bilateral damage, infertility may develop.

[24], [25]