Epididymitis, orchitis, orchoepididymitis.

Epididymitis (inflammation of the epididymis) is manifested by pain and swelling, almost always one-sided, developing acutely. Often the testicles are involved in the inflammatory process (orchiepididymitis). On the other hand, inflammation from the testicle (especially viral orchitis) often spreads to the epididymis. 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 epididymo-orchitis with abscess.
• N51.1. Disorders of testicle and epididymis in diseases classified elsewhere.

Epidemiology

Most often, epididymitis develops as a result of infection entering the appendage through the hematogenous route as a complication of infectious diseases ( flu, tonsillitis, pneumonia, etc.).

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Reasons

In epididymitis caused by sexually transmitted infections, the infection spreads from the urethra and bladder.

In non-specific granulomatous orchitis, chronic inflammation is thought to be caused by autoimmune reactions. Orchitis in children and mumps orchitis are of hematogenous origin. Orchiepididymitis is also observed in some systemic infections, such as tuberculosis, syphilis, brucellosis, and cryptococcosis.

Often, the infection gets into the epididymis through the vas deferens due to its antiperistaltic contractions, during an inflammatory process in the urethra, as well as during the latter's bougienage or damage during an instrumental examination. The same conditions are created during a long stay of a catheter in the urethra.

The epididymis is compacted, enlarged, and larger than the testicle due to inflammatory infiltration and edema from compression of the blood and lymphatic vessels. It is dark red in cross-section with mucous or mucopurulent exudate. The epididymis tubules are dilated and contain mucopurulent contents. The vas deferens is thickened, infiltrated (deferentitis), its lumen is narrowed and contains the same inflammatory exudate as in the epididymis tubules. The membranes of the spermatic cord are often involved in the inflammatory process (funiculitis). It is difficult to establish the etiology of epididymitis. Chronic inflammation with compaction develops in 15% of patients with acute epididymitis. If the testicle is affected, chronic inflammation can lead to its atrophy and impaired spermatogenesis. There are no new data on the incidence and prevalence of epididymitis. Acute epididymitis in young men is associated with sexual activity and infection in the female partner.

The most common type of orchitis, mumps orchitis, develops in 20-30% of postpubertal patients who have had epidemic mumps. In 10% of cases, inflammation of the epididymis is caused by trauma to the epididymis.

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Symptoms of Epididymitis, Orchitis, Orchiepididymitis

In acute epididymitis, inflammation and swelling begin at the tail of the epididymis and may extend to the rest of the epididymis and testicular tissue. The spermatic cord is swollen and tender. All men with epididymitis caused by sexually transmitted pathogens have a history of sexual intercourse, which may have occurred several months before symptoms appeared. When a patient is examined immediately after obtaining a urine sample for testing, signs of urethritis or urethral discharge may not be seen because white blood cells and bacteria are washed out of the urethra during urination.

Acute epididymitis begins suddenly with a rapidly increasing enlargement of the epididymis, sharp pains in it, an increase in body temperature to 38-40 °C and chills. Inflammation and swelling spread to the membranes of the testicle and scrotum, as a result of which the skin of the scrotum stretches, losing its layers, becomes hyperemic, and reactive hydrocele of the membranes of the testicle may appear. The pain radiates to the inguinal, sometimes to the lumbar region and sacrum, sharply intensifies with movement, forcing patients to stay in bed.

Non-specific epilidymitis is sometimes difficult to differentiate from epididymal tuberculosis based on the clinical picture of the disease and objective examination data. Enlargement of the organ, focal compactions, and its tuberosity can be observed in both types of epididymitis. Clear-cut changes in the vas deferens, the occurrence of purulent scrotal fistulas with the simultaneous presence of another tuberculous lesion in the body, the detection of Mycobacterium tuberculosis in urine or purulent discharge from scrotal fistulas with persistent acidic urine testify to the tuberculous nature of the lesion. The detection of Mycobacterium tuberculosis in the epididymal puncture or biopsy data is of decisive importance for differential diagnostics.

With minor nagging pain and subfebrile temperature, a seal appears on a limited area of the appendage, most often in the tail area. Then the process spreads to the entire appendage. With inflammation of the appendage, the vas deferens is often affected. Palpation reveals a smooth, dense duct that extends to the external opening of the inguinal canal. Sometimes it can be felt during a rectal examination near the prostate. Funiculitis may develop with inflammation of the vas deferens.

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 upon palpation for several more weeks.

Diagnostics

Bacterial etiology of epididymitis is diagnosed by microscopy of Gram-stained smears from the urethra. The presence of intracellular gram-negative diplococci in the smear is characteristic of infection caused by N. gonorrhoeae. Detection of only leukocytes in the smear indicates non-gonococcal urethritis. If mumps orchitis is suspected, the diagnosis will be confirmed by a history of mumps and detection of specific IgM in the blood serum.

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Differential diagnostics

The disease must be differentiated from orchitis, epididymitis, suppurating cyst of the spermatic cord, strangulated inguinal hernia. It is necessary to conduct differential diagnostics between epididymitis and torsion of the spermatic cord using all available information, including the patient's age, history of urethritis, clinical assessment data and Doppler examination of the testicular vessels. Elevated position of the scrotum in torsion of the spermatic cord does not reduce pain, as in epididymitis, but on the contrary, increases it (Prehn's symptom).

Isolated enlargement of the testicle occurs with tumors, as well as with brucellosis, in which concomitant hydrocele of the testicular membranes is very often noted.

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

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Treatment of epididymitis, orchitis, orchiepididymitis

Only a few studies have been conducted to investigate the penetration of antimicrobials into human testicular and epididymal tissue. Of the drugs studied, the most favorable properties were found in fluoroquinolones, macrolides, and cephalosporins.

The choice of antibiotic should be based on the empirical understanding that in young sexually active men the cause of the disease is usually C. trachomatis, and in older men with prostate adenoma or other urination disorders, traditional uropathogens are most often the cause. Studies comparing the results of microbiological evaluation of material obtained by puncture of the epididymis, smears from the urethra and urine have shown a very good correlation. Therefore, before starting antibiotic therapy, a smear from the urethra should be taken or a spermogram should be obtained for cultural examination.

Non-drug treatment

Supportive therapy includes bed rest, elevated testicles, and anti-inflammatory drugs. If the pathogen is uropathogenic, then to prevent relapses of the infection, a thorough examination should be conducted to identify urination disorders. After the inflammatory process subsides, heat is prescribed in the form of a warming compress on the scrotum, diathermy, or UHF to resolve the inflammatory infiltrate.

Drug treatment

The drugs of choice are fluoroquinolones, due to their broad spectrum of activity and good penetration into the tissues of the genitourinary system. Macrolides can be used as alternative drugs.

Forecast

In non-specific epididymitis, the prognosis is favorable. In case of recurrence of the disease, obstruction of the appendage and vas deferens may develop, and in case of bilateral lesions, infertility.

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