Epididymitis in Children

Get CMEEpididymitis in ChildrenOne of the great aspects of working in my ED is being surrounded by a multitude of amazing and brilliant teammates. One, Dr. Christyn Magill, recently provoked this Morsel of knowledge: just because it ends in “-itis” does not mean it needs antibiotics! Excellent point! We have covered this previously with Sinusitis, but another excellent example of this notion is Epididymitis!! Let us take a moment to review how Epididymitis in Children:

 

Acute Scrotal Pain

 

Acute Epididymitis in Children

  • Epididymitis is not rare in children.
    • Older literature described it as a rare condition, but newer research shows greater frequency of disease than previously known. [Nistal, 2016; Redshaw, 2014]
    • Majority of cases occur in prepubertal / early adolescent boys (11-14 years). [Redshaw, 2014; Santillanes, 2011]
    • Comprises up to 35-65% of all acute scrotal pain cases. [Nistal, 2016]
  • Epididymitis is often considered to be due to an infection.
    • Older males often have reflux of urine due to prostatic hypertrophy.
    • Young males (<35 years) often have an associated sexually transmitted disease.
    • What about the children who are not sexually active?
  • In young children, the INCIDENCE of infection is LOW. [Nistal, 2016; Santillanes, 2011]
    • Of ~1,500 patients with acute epididymitis, only ~15% had positive urine cultures. [Cristoforo, 2016]
    • Unfortunately, >85% still received antibiotics. [Cristoforo, 2016; Santillanes, 2011]
    • In the end, the majority are classified as idiopathic. [Redshaw, 2014; Min Joo, 2013]
      • True etiology is still not fully understood.
      • May be due to:
        • Inflammation from adjacent torsion of appendix of testis
        • Reflux of sterile urine
        • Viral illness (ex, Mumps, Coxsackie B, influenza, EBV)
        • Anatomic abnormalities (likely in younger patients)
        • Trauma
  • Epididymitis is usually a unilateral process. [Nistal, 2016]
    • The right side is affected more often.
    • Hydrocele is usually observed along with local symptoms of inflammation.

 

Epididymitis: Evaluation/Management

  • 1st, don’t overlook the potential for torsion as the etiology!
    • Distinguishing epididymitis from testicular torsion clinically can be difficult. [Redshaw, 2014]
    • Have low threshold for obtaining Ultrasound.
  • If history, exam, and U/S are consistent with epididymitis, consider the age:
    • Young boys who are not sexually active
      • Low risk for infectious etiology. [Cristoforo, 2016; Santillanes, 2011]
        • May wish to treat based on abnormal urinalysis.
        • Could also wait until Urine Culture results, as rates of true infections are slow low. [Cristoforo, 2016; Santillanes, 2011]
      • Treat with NSAIDs, scrotal support, and rest
    • Sexually active boys
      • At risk for STDs!
      • Consider testing and starting empiric therapy.
      • Also can use NSAIDs, scrotal support, and rest (and AVOIDING SEX!).

 

Moral of the Morsel

  • Don’t overlook torsion! Think of epididymitis as the potential cause of acute scrotal pain in young boys, but check that ultrasound!
  • Just because it has “-itis” at the end of the word, does not mean it is an antibiotic deficiency!
    • There is an abundance of antibiotics given to boys with epididymitis who have a low risk for infection. Don’t add to the problem. (see C. Difficile)
    • Check a Urine Culture (maybe even resist the urge to react to a urinalysis) and educate the family.

 

References

Cristoforo TA1. Evaluating the Necessity of Antibiotics in the Treatment of Acute Epididymitis in Pediatric Patients: A Literature Review of Retrospective Studies and Data Analysis. Pediatr Emerg Care. 2017 Jan 17. PMID: 28099292. [PubMed] [Read by QxMD]

Nistal M1, Paniagua R2, González-Peramato P1, Reyes-Múgica M3. Perspective in Pediatric Pathology, Chapter 24. Testicular Inflammatory Processes in Pediatric Patients. Pediatr Dev Pathol. 2016 Nov/Dec;19(6):460-470. PMID: 27575254. [PubMed] [Read by QxMD]

Redshaw JD1, Tran TL2, Wallis MC3, deVries CR4. Epididymitis: a 21-year retrospective review of presentations to an outpatient urology clinic. J Urol. 2014 Oct;192(4):1203-7. PMID: 24735936. [PubMed] [Read by QxMD]

Joo JM1, Yang SH, Kang TW, Jung JH, Kim SJ, Kim KJ. Acute epididymitis in children: the role of the urine test. Korean J Urol. 2013 Feb;54(2):135-8. PMID: 23550228. [PubMed] [Read by QxMD]

Santillanes G1, Gausche-Hill M, Lewis RJ. Are antibiotics necessary for pediatric epididymitis? Pediatr Emerg Care. 2011 Mar;27(3):174-8. PMID: 21346680. [PubMed] [Read by QxMD]

Sakellaris GS1, Charissis GC. Acute epididymitis in Greek children: a 3-year retrospective study. Eur J Pediatr. 2008 Jul;167(7):765-9. PMID: 17786475. [PubMed] [Read by QxMD]

Somekh E1, Gorenstein A, Serour F. Acute epididymitis in boys: evidence of a post-infectious etiology. J Urol. 2004 Jan;171(1):391-4; discussion 394. PMID: 14665940. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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