Can epididymitis cause gross hematuria?

Epididymitis and Gross Hematuria

Epididymitis does not typically cause gross hematuria, as there is no direct connection between the epididymis and the urinary collecting system that would allow blood from the inflamed epididymis to enter the urine. 1

Pathophysiology and Clinical Presentation

Epididymitis is characterized by:

• Unilateral testicular pain and tenderness
• Swelling and palpable enlargement of the epididymis
• Possible hydrocele formation
• Elevated temperature of the epididymis
• May involve the testis and scrotal skin 1

The condition is typically caused by:

• In men <35 years: Chlamydia trachomatis or Neisseria gonorrhoeae (sexually transmitted)
• In men >35 years: Gram-negative enteric organisms (often associated with urinary tract infections)
• In men who practice insertive anal intercourse: Enteric bacteria 1, 2

Diagnostic Evaluation

The evaluation of epididymitis should include:

1. Gram-stained smear of urethral exudate for diagnosis of urethritis
2. Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis
3. Examination of first-void urine for leukocytes if urethral Gram stain is negative
4. Culture and Gram-stained smear of urine for Gram-negative bacteria 1

However, urinalysis findings in epididymitis:

• Are often negative, especially in children and adolescents
• Show pyuria in only a small percentage of cases
• Rarely demonstrate bacteriuria 3, 4

Relationship to Hematuria

Importantly, none of the major guidelines on epididymitis management mention gross hematuria as a typical finding or symptom 1. While epididymitis may coexist with conditions that cause hematuria (such as urinary tract infections), the inflammation of the epididymis itself does not directly cause blood to appear in the urine.

If a patient presents with both epididymitis and gross hematuria, clinicians should:

• Consider concurrent urinary tract infection
• Evaluate for urolithiasis
• Rule out urinary tract malignancy, especially in patients >35 years
• Assess for other genitourinary conditions 1

Treatment Approach

Treatment of epididymitis depends on the likely causative organism:

For men <35 years (likely STI-related):

• Ceftriaxone 250 mg IM single dose PLUS
• Doxycycline 100 mg orally twice daily for 10 days 1

For men >35 years (likely enteric organisms):

• Levofloxacin 500 mg orally daily for 10 days OR
• Ofloxacin 300 mg orally twice daily for 10 days 1

Adjunctive measures include:

• Bed rest
• Scrotal elevation
• Analgesics until fever and local inflammation subside 1

Important Considerations

1. If a patient presents with both epididymitis and gross hematuria, the hematuria should be evaluated separately as it likely represents a different pathological process.

2. Testicular torsion must always be ruled out in cases of acute scrotal pain, as it is a surgical emergency that can lead to testicular loss if not treated promptly.

3. In pediatric patients with epididymitis, antibiotic treatment may not be necessary unless urinalysis shows pyuria or positive culture, as most cases are idiopathic 3, 4.