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Epididymitis, Orchitis, and Prostatitis
Epididymitis
Epididymitis, an inflammatory reaction of the epididymis to infectious or noninfectious stimuli, occurs across a wide age range in pediatric patients and may present in combination with testicular inflammation (epididymo-orchitis). Predisposing factors, clinical presentation, and etiologies differ by age and exposure history, and careful physical examination, laboratory testing, and imaging studies may be required to differentiate epididymitis or epididymo-orchitis from testicular torsion.
Epidemiology
The reported incidence of acute epididymitis, as a cause of acute scrotal pain in children, ranges from 4% to 60.3%. In one large cross-sectional study of 17,000 children presenting to emergency departments with acute scrotum, the rate of epididymitis with or without orchitis was higher than that of either testicular torsion or appendix testis torsion (60.3%, 21.7%, and 17.9% respectively).
There are varying reports on the peak age of presentation of epididymitis. A 21-year retrospective study from an outpatient pediatric urology clinic reported a mean age at first presentation of approximately 11 years, with the majority of cases occurring during the pubertal period (10–14 years). Only 1.5%–4% of patients with epididymitis are <2 years at the time of diagnosis. , Approximately 25% of children with epididymitis experience a second episode within 5 years, with most cases occurring <7 months from the initial episode. Acute epididymitis is common in sexually active adolescents and young men as it is frequently related to sexually transmitted infections.
Predisposing Factors and Microbial Etiologies
Epididymitis can occur as the result of a direct infectious etiology, an inflammatory post-infectious reaction, or, occasionally, secondary to trauma, systemic disease (e.g., Henoch-Schönlein purpura), or medications (e.g., amiodarone, anti-PD1). , The microbial causes and associated predisposing factors of acute bacterial epididymitis in children and adolescents vary with age.
In both young boys and adolescents, retrograde ascent of gram-negative bacteria (e.g., Escherichia coli, Pseudomonas aeruginosa ) from the urethra to the epididymis is one mechanism of infection. When these organisms are identified in urine culture from a patient with acute epididymitis, an evaluation for underlying genitourinary tract abnormalities should be considered, especially in prepubertal children with recurrent epididymitis. , , , In sexually active adolescents, epididymitis can occur as a complication of urethral infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae . , In the prepubertal population, a post-infectious inflammatory reaction to several pathogens can lead to epididymitis (e.g., enterovirus, adenovirus, Mycoplasma pneumoniae ). , Rarely, hematogenous spread of pathogens to the epididymis from a primary focus of infection may occur (e.g., Haemophilus influenzae, Brucella, Salmonella, Mycobacterium tuberculosis , as well as fungal pathogens including Histoplasma capsulatum ). , Such cases frequently present as acute epididymo-orchitis. Determination of the specific bacterial etiology of epididymitis is less frequent in children than in adults. , ,
Clinical Manifestations
Patients with epididymitis usually present with a history of gradual onset of unilateral scrotal pain and swelling that increases over 1–2 days. Associated symptoms may include lower urinary tract symptoms (frequency, urgency, dysuria) as well as constitutional symptoms such as fever. ,
Physical examination findings include swelling and tenderness of the epididymis that may extend to the adjacent testis. Alleviation of pain with testicular elevation (Prehn sign) is consistent with the diagnosis but not pathognomonic. The cremasteric reflex is usually present in epididymitis in contrast to its absence in testicular torsion. Torsion of the appendix testis, which should also be considered in the differential diagnosis of acute scrotum, may present with a bluish discoloration in the upper pole of the scrotal area, referred to as the “blue dot sign.” When epididymitis is associated with urethritis in sexually active pubertal boys, urethral discharge often also is present.
Diagnostic Testing
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