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UDC 616.672:616.64
EPIDIDYMITIS: MODERN ASPECTS OF ETIOLOGY, DIAGNOSIS AND
TREATMENT
Rakhimov Farrukh Farkhodovich
assistant, Department of Urology,
Nephrology and Hemodialysis, Bukhara state medical institute,
Bukhara, Republic of Uzbekistan
Email:
https://orcid.org/0009-0003-2962-9785
Resume:
The epididymis is part of the genitourinary tract that includes the testes, the vas
deferens, the prostate, the urethra, and the bladder. Epididymitis is an infection or inflammation
of the epididymis, the tubular structure located on the posterior and superior aspect of the testis
where sperms mature prior to ejaculation. Because of its proximity to the testis, any infectious or
inflammatory process affecting the epididymis may spread to the testis itself, a condition known
as epididymo-orchitis.
Keywords:
epididymitis, testis, fluoroquinolones, treatment, оrchitis.
Introduction.
The majority of cases of epididymitis occur as a result of bacterial infection. The types of
bacterial infection include common urinary pathogens as well as pathogens known to cause
sexually transmitted disease. In most cases of epididymitis, infection occurs either as a result of
the retrograde flow of urine, most commonly seen in elderly males, or as a result of a sexually
transmitted disease, most often encountered in males ages 20 to 40. In males prior to sexual
maturity, the most common cause of epididymitis is inflammation that occurs as a result of
trauma or repetitive activities such as sports. The possibility of a sexually transmitted disease,
however, must be considered even in males prior to sexual maturity due to the possibility of
sexual abuse. Other possible causes of epididymitis include chemical, drug-induced, and viral
infections[4, 2, 5].
Epididymitis can occur in men of any age, though the majority of cases of epididymitis occurs in
males ages 20 to 39 and are most often associated with a sexually transmitted disease. Chlamydia
trachomatis and Neisseria gonorrhea account for approximately 50% of cases of epididymitis
associated with chlamydia and gonorrhea in males less than 39 years of age. After 39 years of
age, the most common etiologic agent responsible for epididymitis is Escherichia coli and other
coliform bacteria found in the gastrointestinal tract. In males prior to sexual maturity,
epididymitis may still be caused by bacterial infections, but it is more common that epididymitis
occurs as a result of an inflammatory process, such as repetitive activities like sports (e.g.,
running, jumping). Though rare, chemical epididymitis may occur as a result of exercising or
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having sexual intercourse with a full bladder, resulting in a retrograde flow of urine. Also,
epididymitis may occur as a result of certain medications, namely amiodarone used in the
treatment of cardiac dysrhythmia. Lastly, viral infections, such as mumps virus, can result in
epididymitis or epididymo-orchitis[1, 3].
Epididymitis is the most common cause of acute scrotal pain in adults. More than 600,000 men
are affected yearly in the United States.
Epididymitis most often occurs as a result of a bacterial infection. In the case of a sexually
transmitted disease, bacteria are introduced during sexual intercourse and migrate through the
genitourinary tract to the epididymis. In cases of infection due to urinary tract infection,
retrograde flow of urine or stagnation of urine along the genitourinary tract results in infection of
the epididymis. When epididymitis is caused by repetitive movements, the mobility of the
scrotum and its contents can result in inflammation of the testes or the epididymis. Certain
viruses, namely mumps virus, have a predisposition to infect the testis[6].
The patient will likely complain of scrotal pain and swelling, quite often gradual in onset rather
than acute. It may begin with flank pain that migrates to the scrotum. The patient may also
complain of urinary symptoms such as dysuria, urinary frequency, urgency, or incontinence of
urine. The patient might also complain of urethral discharge. A careful history should include the
possibility of traumatic injury or injury from repetitive activities such as sports, sexual history
including history of prior sexually transmitted disease exposures, and past medical history
including problems associated with the genitourinary tract such as prior urinary tract infection,
prostatitis, or surgical procedures[7, 13].
A physical exam will likely reveal swelling of the scrotum, and palpation of the scrotum will
likely reveal tenderness of the scrotum, usually unilaterally but in some cases bilaterally.
Tenderness to palpation of the epididymis along the posterior and superior aspect of the testis is
the hallmark of epididymitis. Tenderness upon palpation of the testis itself may indicate the
possibility of epididymo-orchitis or orchitis. The skin overlying the scrotum may appear warm,
erythematous, inflamed, and indurated as a result of infection. Tender inguinal adenopathy may
be present as well. Physical examination of the penis may demonstrate a urethral discharge.
Digital rectal examination may demonstrate tenderness upon palpation of the prostate gland.
These findings, while not necessarily indicative of epididymitis itself, might be present in
infections of the male genitourinary tract[15].
Evaluation of the male patient with scrotal pain should begin with urinalysis. Though nonspecific,
the presence of red blood cells and white blood cells in the urine may indicate an acute infectious
or inflammatory condition. Urine should be cultured to determine the causative agent in cases
associated with urinary tract infection. A urethral swab is indicated in cases where the sexually
transmitted disease is considered likely given the patient's sexual history. The radiographic
evaluation includes ultrasonography with attention not only to the anatomic structure but also to
assess vascular flow to the testis. Ultrasonography can demonstrate inflammation of the
epididymis and testis in cases of epididymitis and epididymo-orchitis. Computerized tomography
also may be of use in cases where the patient has flank pain and urinary symptoms associated
with an acute genitourinary problem such as ureterolithiasis.[6, 7, 8]
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Of utmost importance is ruling out the possibility of testicular torsion as a cause of scrotal pain.
While epididymitis tends to occur rather gradually, the pain associated with testicular torsion
often occurs very abruptly. History alone, however, may not be sufficiently clear to exclude the
possibility of testicular torsion as a result of acute scrotal pain without the aid of emergent
urological consultation and ultrasonography.[9, 14]
Treatment of epididymitis is based upon identification of the causative organism, though
presumptive treatment may be initiated based upon the prevalence of the most typical agents (C.
trachomatis, N. gonorrhea, E. coli). For suspected sexually transmitted cases, ceftriaxone along
with doxycycline is recommended although azithromycin can be used as an alternative.
Fluoroquinolones may be used in older patients where an enteric organism is suspected or likely.
Pain and swelling can be dramatically reduced in many cases by using ice.[10, 11, 12]
Epididymitis caused by repetitive activity is treated symptomatically with rest, anti-inflammatory
medications, scrotal support, and close primary care follow-up.
Conclusions:
Patients with epididymitis caused by the sexually transmitted disease should refrain
from sexual intercourse until asymptomatic, should consider safe sex practices to reduce the
chance of re-infection, and should refer sexual contacts to their primary care provider or to their
local health department for evaluation and treatment. Patients with epididymitis caused by
urinary tract infection should be encouraged to drink plenty of fluids to flush the genitourinary
tract, should be advised to take the entire course of antibiotics as prescribed, and should follow
up with both their primary care provider and with a urologist for further evaluation and
management.
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