Can epididymitis cause hematuria?

Epididymitis and Hematuria: Clinical Relationship

Epididymitis does not typically cause hematuria, as these are distinct clinical entities affecting different parts of the genitourinary system. 1 While both conditions may coexist in some patients, epididymitis itself does not directly cause blood in the urine.

Understanding Epididymitis

Epididymitis is inflammation of the epididymis, presenting with:

• Unilateral testicular pain and tenderness
• Gradual onset of symptoms (unlike testicular torsion)
• Swelling of the epididymis
• Hydrocele may be present
• Normal anatomical position of the testis

Etiology by Age Group

1. Men <35 years old:

   • Most commonly caused by sexually transmitted infections (STIs):
     • Chlamydia trachomatis
     • Neisseria gonorrhoeae
   • Enteric organisms in men who practice insertive anal intercourse 1

2. Men >35 years old:

   • Usually caused by gram-negative enteric organisms
   • Associated with urinary tract infections, instrumentation, or anatomical abnormalities 1, 2

3. Children:

   • Predominantly idiopathic (96.1% of cases)
   • Rarely associated with urinary tract infections 3, 4

Diagnostic Evaluation

The CDC guidelines recommend the following diagnostic procedures for epididymitis 1:

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 specimen
5. Syphilis serology and HIV counseling/testing

Important Note on Hematuria

While the diagnostic workup includes urine examination, this is primarily to identify leukocytes and bacteria, not to detect hematuria. Neither the CDC guidelines nor other authoritative sources mention hematuria as a typical finding or symptom of uncomplicated epididymitis 1.

Differential Diagnosis

When evaluating scrotal pain with hematuria, consider:

1. Urinary tract infection - May cause both hematuria and referred pain to the scrotum
2. Kidney stones - Can present with hematuria and referred scrotal pain
3. Testicular torsion - Surgical emergency requiring immediate intervention
4. Tuberculous epididymitis - Rare cause that may present with hematuria in disseminated disease 5
5. Trauma - Can affect both the urinary tract and scrotal contents

Treatment Approach

Treatment depends on the likely causative organism:

1. For STI-related epididymitis (men <35 years):

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

2. For enteric organisms (men >35 years or insertive anal intercourse):

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

3. For children with idiopathic epididymitis:

   • Supportive therapy may be sufficient if urinalysis is normal
   • Antibiotics only if pyuria or positive urine culture 3, 4

Clinical Pearls and Pitfalls

1. Key pitfall: Confusing epididymitis with testicular torsion, which is a surgical emergency requiring immediate intervention.

2. Distinguishing features:

   • Epididymitis: Gradual onset, positive Prehn sign (pain relief with elevation)
   • Testicular torsion: Sudden onset, high-riding testis, absent cremasteric reflex 6

3. Follow-up:

   • Improvement should be seen within 3 days of treatment
   • Persistent symptoms require reevaluation of diagnosis and therapy
   • Consider other diagnoses if swelling and tenderness persist after treatment 1

4. Complications:

   • Infertility
   • Chronic scrotal pain
   • Abscess formation
   • Testicular atrophy (rare)

Remember that while epididymitis and hematuria may occasionally coexist, the presence of hematuria should prompt investigation for other urological conditions rather than being attributed to epididymitis alone.