Epididymoorchitis
Chronic epididymitis evaluation scale, from Nickel 2003
Evaluation/Workup
Acute epididymoorchitis
- Non-infectious causes: tumors, Behcet disease (oral/genital ulcers, uveitis, skin lesions), amiodarone epididymitis, anti-sperm antibodies, trauma, torsion
- Infectious causes: E. coli, gonorrhea, chlamydia, mumps, coxsackie virus, Tb, fungus, ureaplasma, Trichomonas
- Potential symptoms: pain, swelling, urethritis/discharge, fever, hydrocele, erythema/edema on exam
- Workup: diagnosis and underlying cause made with history/physical, scrotal US can be beneficial but not required if diagnosis clear
- Infectious treatment: ceftriaxone 250mg IM x1 + doxycycline 100mg BID x10 days (if STI suspected), levofloxacin 500mg daily x10 days (if UTI suspected), ceftriaxone 250mg IM x1 + levofloxacin 500mg daily x10 days (if cause unclear)
- Further management: admit for IV antibiotics if fevers or leukocytosis, consider repeating imaging if no improvement within 72hrs, induration/swelling can takes weeks/months to resolve
Chronic epididymoorchitis
- Definition: pain lasting for > 6 weeks
- Causes: post-surgical, pelvic floor dysfunction, post-infectious, granulomatous, amiodarone, tumor, varicocele, referred pain (stone, hernia, herniated disc, aortic aneurysm), may be idiopathic (18-25%)
- Post-vasectomy: 30% report short-term pain, chronic pain in 0.1-15%
- Granulomatous: can be infectious (TB, brucellosis, syphilis, leprosy), post-BCG, sarcoidosis, or idiopathic, may require orchiectomy to differentiate from malignancy
- Workup: culture urethral discharge (if present), scrotal US (assess for testicular abnormalities), can consider CT imaging to assess for causes of referred pain
- Conservative management: scrotal support, NSAIDs, avoid exacerbating activities, heat/ice packs
- BCG orchitis: isoniazid 300mg QD and rifampin 600mg QD x3-6mo, check LFTs and give Vitamin B6 50mg QD while taking isoniazid, do not need to treat if asymptomatic
Algorithm for management of chronic scrotal pain, from Campbell's
Treatments
Minimally invasive therapies
- Pelvic floor physical therapy: consider if abnormal pelvic floor tone is noted on DRE and patient has other associated symptoms
- Cord block: inject 20mL 0.25% bupivicaine (without epinephrine) into spermatic cord, can also combine with methylprednisolone, resolution of pain indicates non-referred pain and cord denervation may be beneficial, testicular atrophy is rare but possible side effect
- Botox: inject 100U distal to external ring, wears off by 6mo
Surgical options
- Targeted excision: if pain is clearly due to hydrocele, spermatocele, torsion, patients report good improvement with repair
- Varicocelectomy: microsurgical (up to 85% pain resolution), nonmicrosurgical (up to 72%)
- Post-vasectomy pain: pain may be due to sperm granuloma, consider vasectomy reversal, may take 3mo to improve pain
- Cord denervation: transect nerves found in cremasteric muscle fibers, perivasal sheath, and posterior lipomatous tissue (trifecta nerve complex), cure rates 50-70%
- Neuromodulation: minimal data, only effective with case reports
- Epididymectomy: complete improvement in 50-75%, progression to orchiectomy in 22-100%
- Orchiectomy: relief in 0-75%, better improvement with inguinal approach
- Post-orchiectomy phantom pain: identify genital branch of genitofemoral nerve, resect neuroma, place proximal end into pelvis