What is the proper procedure for a physical exam to diagnose epididymitis?

Physical Examination for Epididymitis

The physical exam for epididymitis should focus on identifying a swollen, tender epididymis with the testis in normal anatomic position and an intact cremasteric reflex, while ruling out testicular torsion as the primary differential diagnosis. 1, 2

Key Physical Examination Findings

Primary Findings to Identify

• Palpate for unilateral testicular pain and tenderness with swelling of the epididymis - this is the hallmark presentation 1
• Confirm the testis is in anatomically normal position - this helps differentiate from testicular torsion where the testis may be elevated or horizontally oriented 2, 3
• Assess the cremasteric reflex - an intact ipsilateral cremasteric reflex strongly suggests epididymitis rather than torsion 3
• Examine for epididymal swelling and tenderness - the epididymis will be enlarged and exquisitely tender to palpation 2, 3

Additional Physical Findings

• Check for scrotal erythema - may be present but is less common in chlamydial epididymitis compared to other etiologies 4
• Assess for fever - present in approximately 58% of cases and suggests more severe infection 5
• Look for urethral discharge - more common in sexually transmitted epididymitis (58.3% in chlamydial cases) 4

Critical Differential: Ruling Out Testicular Torsion

• Testicular torsion must be ruled out in all cases of acute testicular pain, especially in adolescents 1
• Emergency evaluation is indicated when pain onset is sudden and severe rather than gradual 1
• Testicular torsion requires immediate specialist consultation as testicular viability may be compromised 1
• Epididymitis typically presents with gradual onset of posterior scrotal pain, whereas torsion presents with sudden onset 2, 3

Diagnostic Workup Following Physical Exam

Urethral Assessment

• Perform Gram-stained smear of urethral exudate looking for ≥5 polymorphonuclear leukocytes per oil immersion field to diagnose urethritis 1, 6
• Obtain intraurethral swab or first-void urine for culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 1, 6

Urine Studies

• Examine first-void urine for leukocytes if urethral Gram stain is negative 1, 6
• Urine culture should be obtained, particularly in men over 35 years where enteric organisms are more common 2

Additional Testing

• Obtain syphilis serology and offer HIV counseling/testing in sexually active patients 1, 6

Common Pitfalls to Avoid

• Do not dismiss the possibility of torsion based on age alone - while more common in adolescents, it can occur at any age and requires immediate surgical consultation if suspected 1
• Do not assume urethritis symptoms will always be present - chlamydial epididymitis is not always preceded by urethritis symptoms 4
• Do not rely solely on leukocyte count in urethral discharge - no exact correlation exists between C. trachomatis presence and leukocyte reaction intensity 4
• Reevaluate if no improvement occurs within 3 days of treatment initiation - persistent symptoms require comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 1, 6