User:KDS4444/Epididimytis

Epididymitis (, ěp'ĭ-dĭd'ə-mī'tĭs, ) is a medical condition characterized by inflammation of the epididymis, a curved structure at the back of the testicle in which sperm matures and is stored. This condition comprises gradual onset of testicular pain that can vary from mild to severe, and the scrotum may become red, warm and swollen. It may be acute or chronic, and may occur in one or in both testes.

Epididymitis is the most frequent cause of acute onset scrotal pain in adults. In contrast with men that have testicular torsion, the cremasteric reflex (elevation of the testicle in response to stroking the upper inner thigh) is not altered. If the diagnosis is not entirely clear from the patient's history and physical examination, a Doppler ultrasound scan can confirm increased flow of blood to the affected epididymis (whereas tortion is characterized by ischemia).

In the acute form, bacterial infection is frequently identified as the cause. In sexually active men and men under the age of 40, Chlamydia trachomatis is the most frequent causative microbe; in men over 40, the source is more likely to be E. coli and Neisseria gonorrhoeae. In children, it may follow an infection in another part of the body (for example, a viral illness), or there may be an associated urinary tract anomaly. Another cause is the retrograde flow of infected urine into the ejaculatory ducts.

Classification
Epididymitis can be classified into acute, subacute, and chronic, depending on the duration of symptoms.

Chronic epididymitis
Chronic epididymitis is epididymitis that ensues for more than six weeks. Chronic epididymitis is characterized by inflammation even when there is no infection present. Tests are needed to distinguish chronic epididymitis from a range of other disorders that can cause constant scrotal pain including testicular cancer (though this is often painless), enlarged scrotal veins (varicocele), and a cyst within the epididymis. Some research has found that as much as 80% of visits to a urologist for scrotal pain are for chronic epididymitis. As a further complication, the nerves in the scrotal area are closely connected to those of the abdomen, sometimes causing abdominal pain similar to a hernia (see referred pain).

Signs and symptoms
The mean age of patients who present with epididymis is 41. The acute form develops over the course of several days, with pain and swelling frequently in only one testis, which will hang low in the scrotum. There will often be a history of dysuria or urethral discharge. Fever is also a common symptom. In the chronic version, the patient can have painful point tenderness but may or may not have an irregular epididymis upon palpation, though palpation may reveal an unusually firm epididymis. A scrotal ultrasound may reveal problems with the epididymis, but such an ultrasound may also show nothing unusual. The majority of patients with chronic epididymis have had symptoms for over five years.

Causes
Bacterial infection is the most common cause of epididymitis. The bacteria in the urethra back-track through the urinary and reproductive structures to the epididymis. There can be associated urethritis (inflammation of the urethra). In rare circumstances, the infection reaches the epididymis via the bloodstream.

In sexually active men, Chlamydia trachomatis is responsible for two-thirds of cases, followed by Neisseria gonorrhoeae and E. coli (or other bacteria that cause urinary tract infection). Particularly among men over age 35 in whom the cause is E. coli, epididymitis is commonly due to urinary tract obstruction. Less common microbes include Ureaplasma, Mycobacterium, and cytomegalovirus, or Cryptococcus in patients with HIV infection. E. coli is more common in boys before puberty, the elderly and homosexual men.

Non-infectious causes are also possible. Reflux of sterile urine (urine without bacteria) through the ejaculatory ducts may cause inflammation with obstruction. In children, it may be a response following an infection with enterovirus, adenovirus or Mycoplasma pneumoniae.

Epididymitis can also be caused by genito-urinary surgery, including prostatectomy and urinary catheterization. Congestive epididymitis is a long-term complication of vasectomy. Chemical epididymitis may also result from drugs such as amiodarone.

Diagnosis
Epididymitis can be hard to distinguish from testicular torsion. Both can occur at the same time. A urologist may need to be consulted.

Epididymitis usually has a gradual onset. On physical examination, the testicle is usually found to be in its normal vertical position, of equal size compared to its counterpart, and not high-riding. Typical findings are redness, warmth and swelling of the scrotum, with tenderness behind the testicle, away from the middle (this is the normal position of the epididymis relative to the testicle). The cremasteric reflex (if it was normal before) remains normal. This is a useful sign to distinguish it from testicular torsion. If there is pain relieved by elevation of the testicle, this is called Prehn's sign, which is, however, non-specific.

Analysis of the urine may or may not be normal. Before the advent of sophisticated medical imaging techniques, surgical exploration was the standard of care. Nowadays, Doppler ultrasound is a common test: it can demonstrate areas of blood flow and can distinguish clearly between epididymitis and tortion. However, inasmuch as tortion and other sources of testicular pain can consistently be determined by palpation alone, some studies have suggested that the only real benefit of an ultrasound is to assure the patient that he does not have cancer. Nuclear testicular blood flow testing is rarely used.

Additional tests may be necessary to identify underlying causes. In younger children, a urinary tract anomaly is frequently found. In sexually active men, tests for sexually transmitted diseases may be done. These may include microscopy and culture of a first void urine sample, Gram stain and culture of fluid or a swab from the urethra, nuclear acid amplification tests (to amplify and detect microbial DNA or other nucleic acids) or tests for syphilis and HIV.

Treatment
It is generally believed that most cases of chronic epididymitis will eventually "burn out" of patient's system if left untreated. However, this might take years or even decades. Antibiotics are used if an infection is suspected. The treatment of choice is azithromycin and cefixime to cover both gonorrhoeae and chlamydia. Fluoroquinolones are no longer recommended due to widespread resistance of gonorrhoeae to this class. Doxycycline may be used as an alternative to azithromycin.

For cases caused by enteric organisms (such as E. coli), ofloxacin or levofloxacin are recommended.

In children, fluoroquinolones and doxycycline are best avoided. Since bacteria that cause urinary tract infections are often the cause of epididymitis in children, co-trimoxazole or suited penicillins (for example, cephalexin) can be used. If there is a sexually transmitted disease, the partner should also be treated.

Household remedies such as elevation of the scrotum and cold compresses applied regularly to the scrotum may relieve the pain. Painkillers or anti-inflammatory drugs are often necessary. Hospitalisation is indicated for severe cases, and check-ups can ensure the infection has cleared up. Surgical removal of the epididymis is rarely necessary, causes sterility, and only gives relief from pain in approximately 50% of cases.

Complications
Untreated, acute epididymitis's major complications are abscess formation and testicular infarction. Chronic epididymitis will typically lead to permanent damage or even destruction of the epididymis and testicle (resulting in infertility and/or hypogonadism), and infection may spread to any other organ or system of the body. Chronic pain is also an associated complication for untreated chronic epididymitis.

Epidemiology
Epididymitis makes up 1 in 144 outpatient visits (0.69 percent) in men 18 to 50 years old or 600,000 cases in men between 18 to 35 in the United States.

It occurs primarily in those 16 to 30 years of age and 51 to 70 years. As of 2008 there appears to be an increase in incidences in the United States that parallels an increase in reported cases of chlamydia and gonorrhea.