| Clinical Findings Clinical manifestations, laboratory results, and imaging findings may differ, depending on the etiology of the acute scrotum syndrome. In epididymitis, clinical findings are influenced by whether the etiology is infectious versus noninfectious, and in the case of the former, by whether the presentation is local versus systemic. Symptoms and Signs Patients with epididymitis characteristically complain of testicular or scrotal pain and may also complain of inguinal pain. In severe cases, acute swelling of the spermatic cord may result in flank pain from obstruction of the ureter as it crosses over the spermatic cord. More than two thirds of patients with epididymitis describe a gradual onset of pain. Symptoms typical of the underlying cause, such as urethral discharge associated with sexually transmitted epididymitis or symptoms of urinary urgency and frequency associated with urinary tract infection, are discussed in detail below. Rarely, epididymitis may present with nonspecific symptoms such as fever or malaise, especially in patients with epididymitis associated with chronic catheterization or neurogenic bladder associated with a spinal cord injury. On examination, the scrotum on the involved side may be red and edematous. The testicle tends to lie in the normal position in the scrotum. Shortly after the onset of inflammation, the tail of the epididymis, which connects with the vas deferens near the lower pole of the testes, is swollen. Later, swelling spreads to the head of the epididymis, near the upper pole of the testes. The groove between the epididymis and the testicle should be examined, as this will help to demonstrate whether the maximum swelling is in the testicle or in the epididymis. The spermatic cord may be swollen and tender (a condition termed funiculitis). A hydrocele may be present; characteristically this results from secretion of fluid by the inflamed tunica vaginalis. Signs and symptoms more specific for a particular etiology of epididymitis are discussed below. Findings Associated with Urethritis Men with epididymitis secondary to sexually transmitted pathogens often have a history of dysuria or urethral itching or discharge. Usually, they have a history of recent sexual exposure. If the patient has not voided recently, spontaneous urethral discharge may be apparent on examination. It is important to recognize that asymptomatic urethral infection without discharge may occur. Such asymptomatic urethral infections have been estimated for up to 50% of gonococcal infections and over 75% of chlamydial infections. If no spontaneous discharge is noted, then the urethra should be stripped from the base of the penis to the urethral meatus ("milked") and examined again. In some patients, digital rectal examination may reveal abnormalities suggestive of bacterial prostatitis. The degree of scrotal erythema and epididymal edema may be less in patients with chlamydial epididymitis compared with those in whom epididymitis is a result of other etiologies. However, massive erythema and edema may also occur with untreated C trachomatis epididymitis. Findings Associated with Bacteriuria In patients with coliform or pseudomonal epididymitis, a history of bacteriuria or symptoms suggesting urinary tract infection may or may not be present. Symptoms include urinary frequency, urgency, or dysuria. Patients may have a history of symptoms suggestive of urinary tract obstruction (eg, hesitancy or slow urinary stream), indicating conditions that predispose them to urinary tract infection (eg, urethral stricture and benign prostatic hypertrophy). Others may have a history of conditions predisposing them to bacteriuria, including prostatic calculi, recent genitourinary or prostate instrumentation, neurogenic bladder, an indwelling catheter, or chronic bacterial prostatitis. Findings Associated with Systemic Infectious or Inflammatory Diseases Bilateral epididymal involvement is more common in epididymitis caused by systemic diseases; in contrast, epididymitis associated with urethritis or bacteriuria is nearly always unilateral. Symptoms or signs relating to systemic infection or inflammation may be present. For example, in tuberculous epididymitis, patients can present with clinical disease involving the kidneys, adrenal glands, lymphatics (retroperitoneal, abdominal, or mediastinal), or all of these structures. Patients with tuberculous epididymitis often have a prior history of pulmonary tuberculosis or a history of exposure to tuberculosis. Another example is epididymitis occurring with Behçet syndrome, in which patients may have oral or genital ulcers, other cutaneous lesions, eye involvement (eg, iritis, uveitis, etc), arthritis, and central nervous system involvement. Genitourinary examination findings in systemic infectious or inflammatory disorders otherwise tend to resemble the findings in epididymitis associated with urethritis or bacteriuria. One exception is that in tuberculous epididymitis, a "string of beads" may be noted on palpation of the vas deferens due to presence of granulomas. An additional, less specific, finding is prostatic calculi that may be detected on digital rectal examination. Findings Associated with Amiodarone Sterile epididymitis has been recognized as a complication of amiodarone therapy, especially at high dosages. Although amiodarone-associated epididymitis is usually bilateral, it may be unilateral. |
