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Acute epididymitis

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Updated 2024 EAU guidelines for the diagnosis and management of acute epididymitis.

Background

Overview

Definition
Acute epididymitis is the acute inflammation of the epididymis characterized by pain and scrotal swelling present for < 6 weeks.
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Pathophysiology
Acute epididymitis is caused by a bacterial ascent (UTIs or STIs), viral genesis (adenovirus, enterovirus), fungi (C. albicans, Histoplasma capsulatum), parasites (Trichomonas vaginalis, Schistosoma species, Filariasis), drug-induced (amiodaron), rheumatic (Behçet's disease, vasculitis, Henoch-Schönlein purpura), obstruction (vasectomy), genital trauma, and sterile reflux.
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Disease course
The inflammation of the epididymis results in acute epididymis, which causes clinical manifestations of gradual unilateral scrotal pain and epididymal swelling with concurrent symptoms of fever, hematuria, dysuria, and urinary frequency. Disease progression may lead to abscess formation or Fournier gangrene, infertility, and chronic pain.
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Prognosis and risk of recurrence
Acute epididymis is not associated with an increase in mortality.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of acute epididymitis are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2024), the Center for Disease Control (CDC 2021), the International Union Against Sexually Transmitted Infections (IUSTI 2017), and the American Academy of Family Physicians (AAFP 2016). ...
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Screening and diagnosis

Clinical presentation
As per CDC 2021 guidelines:
Recognize that:
acute epididymitis is characterized by pain, swelling, and inflammation of the epididymis lasting < 6 weeks
sometimes a testicle is also involved, a condition referred to as epididymo-orchitis
acute epididymitis can be caused by STIs (such as C. trachomatis, N. gonorrhoeae, or Mycoplasma genitalium) or enteric organisms (such as E. coli)
acute epididymitis caused by STIs is usually accompanied by urethritis, which is frequently asymptomatic
acute epididymitis caused by sexually transmitted enteric organisms might also occur in males who are the insertive partner during anal sex
nonsexually transmitted acute epididymitis caused by genitourinary pathogens typically occurs with bacteriuria secondary to bladder outlet obstruction (such as BPH)
nonsexually transmitted acute epididymitis in older males is also associated with prostate biopsy, urinary tract instrumentation or surgery, systemic disease, or immunosuppression
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Recognize that:
chronic epididymitis is characterized by a ≥ 6-week history of symptoms of discomfort or pain in the scrotum, testicle, or epididymis
chronic infectious epididymitis is most frequently observed with conditions associated with a granulomatous reaction, with Mycobacterium tuberculosis as the most common granulomatous disease affecting the epididymis, especially in patients with a known history of or recent exposure to tuberculosis
the differential diagnosis of chronic noninfectious epididymitis, sometimes termed orchialgia or epididymalgia, is broad (including trauma, cancer, autoimmune conditions, or idiopathic conditions)
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  • Differential diagnosis

Diagnostic investigations

Urine tests: as per EAU 2024 guidelines, obtain a midstream urine and a first-voided urine for pathogen identification by culture and NAAT.
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  • Scrotal ultrasound

  • Screening for other STIs

Medical management

Setting of care
As per CDC 2021 guidelines:
Treat the majority of patients with acute epididymitis on an outpatient basis.
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Refer patients to a specialist and consider admitting to the hospital in case of severe pain or fever indicating other diagnoses (such as torsion, testicular infarction, abscess, or necrotizing fasciitis) or when patients are unable to comply with an antimicrobial treatment.
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  • Antibiotic therapy

  • Management of sexual partners

Nonpharmacologic interventions

Supportive measures: as per CDC 2021 guidelines, offer bed rest, scrotal elevation, and NSAIDs as an adjunct to antibiotic therapy until fever and local inflammation have subsided.
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Patient education

General counseling
As per CDC 2021 guidelines:
Counsel patients with acute epididymitis confirmed or suspected to be caused by N. gonorrhoeae or C. trachomatis to abstain from sexual intercourse until they and their partners have been treated and symptoms have resolved.
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Instruct patients to return to their healthcare providers if their symptoms do not improve < 72 hours after treatment.
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Follow-up and surveillance

Follow-up
As per CDC 2021 guidelines:
Reevaluate the diagnosis and therapy if signs and symptoms of epididymitis do not subside in < 3 days.
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Evaluate for alternative diagnoses (including tumor, abscess, infarction, testicular cancer, tuberculosis, and fungal epididymitis) in patients experiencing swelling and tenderness persisting after completion of antimicrobial therapy.
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Quality improvement

Reporting: as per EAU 2024 guidelines, follow national policies on reporting and tracing/treatment of contacts for STIs.
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