Epididymitis is an inflammatory process in the appendage of the testicle. This urological pathology is rarely found in isolation and is usually combined with orchitis, urethritis. The main symptoms include pain in the groin area, swelling, temperature reaction. Dysuric disorders and discharge from the urethra in some cases precede the appearance of acute epididymitis. Diagnosis is based on physical examination, palpation, ultrasound, PCR tests to detect STIs. Treatment involves antibacterial therapy, taking into account the pathogen, the appointment of NSAIDs, physiotherapy. With purulent complications, an operation is performed.
ICD 10
N45 Orchitis and epididymitis
Meaning
According to research in the field of clinical urology, every fifth man aged 18-50 faces epididymitis, this pathology is less common in children. The main role of the structures of the appendage of the testicle (head, body and tail) is to provide conditions for the maturation, accumulation and transportation of sperm. Advanced bilateral epididymitis due to adhesive processes and obliteration of ducts leads to an obstructive form of male infertility (bilateral lesion of appendages is detected in 10%). About 600 thousand new cases of inflammation of the epididymis are registered per year. At risk are men who practice promiscuous sexual relations, age-related patients after surgical interventions on the organs of the genitourinary sphere.
Epididymitis causes
The main reason is the penetration of specific or non–specific pathogens into the appendage of the testicle with the development of inflammation. The main predisposing factor is considered to be a decrease in the reactivity of the immune system against the background of generalized infection, during chemotherapy and radiation therapy, hormone intake, hypothermia, chronic alcoholism and drug use. Conditions that often cause epididymitis:
- Chronic urological diseases. Persistent inflammation in the prostate, bladder, vesicles is the leading cause of involvement in the process of the epididymis. More often, the causative agent of a nonspecific infection is E. coli. In addition, epididymitis can cause a violation of the outflow of urine due to prostate hyperplasia, urethral stricture, uronephrolithiasis. In children under one year of age, pathology is initiated by congenital anomalies of the structure of the organs of the genitourinary sphere.
- Specific infections. This group includes sexually transmitted diseases (gonorrhea, chlamydia, trichomoniasis), which are most common in sexually active men. In adolescents, epididymitis can develop as a complication of viral mumps, chickenpox. A specific lesion of the epididymis occurs when infected with Koch’s bacillus and is one of the manifestations of genitourinary tuberculosis.
- Urological interventions and injuries. Epididymitis can provoke operations for varicocele, inguinal hernia, obstruction of the ejaculatory ducts. Favorable conditions for the reproduction of microflora are created by catheterization, augmentation, and a functioning cystostomy. Epididymitis may occur after urethrocystoscopy, cystolithotripsy or ureteral stenting.
- Other states. Other infections, for example, brucellosis, CMV, blastomycosis lead to damage to the epididymis in individuals with immunosuppression. Congenital or acquired vesical reflux predisposes to inflammation. Acute epididymitis is diagnosed in patients with Behcet syndrome and Schenlein-Genoch purpura as part of a systemic inflammatory process. Epididymitis on the background of taking amiodarone occurs in 3-11% of patients.
Pathogenesis
Ways of infection with epididymitis: ascending (with the initial development of acute urethritis), hematogenic and lymphogenic (from foci of inflammation in neighboring organs or from distant structures – tonsils, carious teeth, etc.), secretory (with primary viral orchitis) and canalicular.
Initially, there is infiltration of the interstitial tissue of the epididymis, swelling and thickening of its shell, which is due to increased exudation. Violation of blood circulation and lymph outflow leads to the spread of inflammation to the testicle. Further progression is expressed in the formation of micro- or macro-processes in the appendage or testicle. On the background of antibacterial therapy, the reverse development occurs, but the processes of sclerosis, especially with bilateral lesions, lead to obliteration of the seminal ducts and infertility.
Epididymitis symptoms
Clinical manifestations correlate with the severity of the inflammatory process and include intense pain in the corresponding inguinal region, swelling, redness of the skin. With a bilateral lesion of the appendages, pain occurs on both sides. Acute epididymitis is characterized by the development of the disease within 2-3 days with a gradual increase in pain syndrome. An increase in temperature with chills in an acute process occurs in every fifth man. In childhood, hyperthermia accompanies epididymitis in 70% of cases.
With viral mumps, the appearance of urological symptoms for 3-5 days is preceded by an increase in the salivary glands, difficulty swallowing, soreness in the parotid region. If epididymitis is a complication of venereal urethritis, urination disorders initially appear (frequent urge, pain during urination and after, urinary incontinence) and purulent discharge from the urethra. With primary prostatitis, pain in the perineum, episodes of dyspareunia are typical. 20% of patients have enlarged regional lymph nodes.
Less vivid symptoms are observed with chronic epididymitis and inflammation of the epididymis of tuberculous etiology. The patient complains of dull, aching pains that increase after physical exertion. The temperature may periodically rise to subfebrile digits. Of the common manifestations, there is weakness, loss of appetite, sweating. In 20% of cases, disorders of sexual function develop.
Complications
Specific complications of epididymitis are purulent–destructive processes in the appendage and testicle itself: abscesses, fistulas. In severe cases, Fournier gangrene may develop. In 85% of patients after inflammation, spermatogenesis is disrupted to one degree or another: there is a change in the biochemical parameters of the ejaculate, the appearance of pathological forms of spermatozoa, a decrease in their number, which leads to infertility. If you do not start treatment in time, it is possible to attach an immunological factor of infertility. Persistent epididymitis is often complicated by reactive dropsy of the testicle. 20% of men still have chronic pain syndrome associated with damage to nerve structures.
Diagnostics
A preliminary diagnosis is made by a urologist-andrologist based on the assessment of complaints and examination data. On palpation, the affected appendage is felt as a dense painful string, but the reactive dropsy of the large testicle makes it difficult to detail. Diagnostic measures for epididymitis include:
- Laboratory tests. For a blood test, significant leukocytosis with a shift of the formula to the left, acceleration of ESR is typical. In the urine, inflammatory changes appear with concomitant urethritis. Microscopy of the separated urethra and PCR diagnostics are performed if an STD is suspected. A spermogram is recommended to be done three months after the end of therapy.
- Instrumental examination. Scrotal ultrasound and inguinal region shows the state of internal structures, the doppler allows you to assess blood flow: with inflammation it is increased, and with testicular torsion it is slowed down or absent. In children with recurrent epididymitis, an additional examination of the organs of the genitourinary system is performed (intravenous urography, mictional cysturethrography, etc.) ‒ this is necessary to exclude potential developmental abnormalities.
Differential diagnosis is carried out with a twist of the testicular spermatic cord or hydatid. With torsio, the pain develops suddenly, there is no history of previous infection, the temperature is normal. Epididymitis has slightly different manifestations. In case of injury and hematoma, there is a connection with a blow, fall, etc. Inguinal hernia with infringement may have similar symptoms. Ultrasound scanning of the inguinal region and scrotum allows you to establish a diagnosis with high reliability.
Treatment
Therapy depends on the pathogenetic factor, with the empirical appointment of an antibiotic, a drug is chosen taking into account the intended pathogen with the widest possible spectrum of action. In case of venereal infection, both partners should receive specific therapy. The patient is given general recommendations, which include bed rest, wearing a suspension to give an elevated position to the scrotum (prevention of hydrocele, pain reduction with concomitant orchitis), sexual abstinence. Some patients undergo a blockade of the spermatic cord with anesthetics and antibiotics. Treatment of epididymitis includes:
- Drug therapy. First–line drugs are antibiotics, the duration of administration is set individually in each case. NSAIDs enhance the action of antibacterial drugs and have antipyretic and analgesic effects. In case of viral infection, antibiotics are not indicated, immunomodulators and analgesics are used. Tuberculous epididymitis is treated with anti-tuberculosis drugs.
- Local treatment. During the first day, cold is applied to the groin area, and then compresses with anti—inflammatory action (semi-alcoholic, ointment) are applied. Physiotherapy is carried out after the acute inflammation subsides (reduction of edema and normalization of temperature). Magnetic laser and photodynamic effects on the scrotum and groin, electrophoresis are prescribed. 1-1.5 months after the relief of the exacerbation, sanatorium treatment is possible: mud and paraffin applications, therapeutic baths.
- Surgical intervention. The surgical approach is justified for purulent melting of the testicular appendage, frequent recurrence of inflammation (resistance to therapy), chronic pain syndrome, which worsens the quality of life. Organ-bearing surgery (epididymectomy) has an effect on fertility, therefore it is undesirable for young patients.
Prognosis and prevention
The prognosis for early initiation of inflammation therapy is favorable. In children, the outcome of epididymitis against the background of developmental abnormalities depends on the correction of congenital pathology. Bilateral lesion has a greater risk of developing pathozoospermia and infertility.
Prevention includes adherence to monogamous relationships, timely treatment of chronic urological diseases, preventive use of antibiotics and uroseptics during diagnostic procedures and manipulations. Seasonal clothing, avoidance of genital injury, bed rest for viral infections and compliance with all doctor’s recommendations minimize the risk of developing inflammatory processes in the male reproductive sphere.
