Epididymal Conditions: Features, Treatment, and Risks
Epididymitis
For sexually transmitted epididymitis in men under 35 years, treat with ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days; for men over 35 years with enteric organism infection, use levofloxacin 500 mg once daily or ofloxacin 300 mg twice daily for 10 days. 1
Clinical Presentation and Diagnosis
Men present with unilateral testicular pain and tenderness with swelling of the epididymis, typically with gradual onset of posterior scrotal pain that may be accompanied by dysuria and urinary frequency 1, 2
Diagnostic workup must include:
- Gram-stained smear of urethral exudate (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 1
- Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 1
- First-void urine examination for leukocytes if urethral Gram stain is negative 1
- Syphilis serology and HIV counseling/testing 1
Pyuria is commonly present in both age groups: in younger men (14-35 years) as part of sexually transmitted infection, and in men over 35 years due to enteric organisms from urinary tract infections 1
Age-Based Treatment Algorithms
For men under 35 years (sexually transmitted etiology):
- Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 3
- This regimen covers both N. gonorrhoeae and C. trachomatis 1, 2
For men who practice insertive anal intercourse:
- Ceftriaxone 250 mg IM single dose PLUS levofloxacin 500 mg once daily OR ofloxacin 300 mg twice daily for 10 days 1
- This covers enteric organisms in addition to sexually transmitted pathogens 1
For men over 35 years (enteric organism etiology):
- Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1
- These infections are typically caused by enteric bacteria secondary to bladder outlet obstruction from benign prostatic hyperplasia or urethral stricture 2, 4
Supportive Care and Follow-Up
Adjunctive measures: Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 1
Critical follow-up timing: Reevaluate within 3 days if no improvement occurs 1
Persistent symptoms after completing antimicrobials require comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 1
Critical Pitfall: Testicular Torsion
- Testicular torsion must be ruled out in all cases of acute testicular pain, especially in adolescents and when pain onset is sudden and severe 1
- This requires immediate specialist consultation as testicular viability may be compromised 1
- Emergency testing is indicated when pain onset is sudden rather than gradual 1
Complications and Risks
Untreated acute epididymitis can lead to infertility and chronic scrotal pain, making recognition and therapy vital to reduce morbidity 2
In immunosuppressed patients, fungi and mycobacteria are more likely causative organisms 1
Sexual Partner Management
- Partners of patients with suspected or confirmed STI-related epididymitis should be referred for evaluation and treatment 1
- Contact tracing should include partners from the 60 days preceding symptom onset 1
- Patients should avoid sexual intercourse until they and their partners complete treatment and are symptom-free 1
Epididymal Cysts and Spermatoceles
For symptomatic epididymal cysts or spermatoceles larger than 5 cm causing pain or bothersome enlargement, sclerotherapy is the primary treatment approach with cure rates of 64-87%, while surgical excision under microscopy is reserved for failed sclerotherapy or when fertility preservation is critical. 5, 6
Clinical Features and Natural History
Epididymal cysts are benign masses that occur most commonly in men aged 20-40 years 6, 7
Men typically tolerate these lesions for an average of 48 months before seeking treatment 7
At the time patients seek excision, spermatoceles have grown to an average of 4.2 cm in greatest diameter, roughly the size of a normal testicle 7
Most patients (58%) seek surgery due to a combination of pain and sensation of mass, while those with isolated pain symptoms are approximately 10 years younger 7
Conservative Management
Conservative management is the treatment of choice in the majority of cases, particularly in prepubertal children where epididymal cysts are considered self-limiting 8
Treatment criteria: Symptomatic cysts larger than 5 cm in diameter with pain, discomfort, or bothersome enlargement 5
Sclerotherapy (First-Line Intervention)
Sclerotherapy outcomes:
- Hydroceles: 67% cure rate after single treatment, 87% overall cure rate 5
- Epididymal cysts: 46% cure rate after single treatment, 64% overall cure rate, improving to 84% with repeat treatment 5
Sclerosing agent options:
- Polidocanol (3%) is preferred for its local anesthetic properties, making it suitable for delicate scrotal structures 5
- Tetracycline is an alternative with reported long-term cure rates 5
- Sodium tetradecyl sulphate (STD) has high initial success rates and patient satisfaction 5
Follow-up protocol:
- Assessments at 3,6, and 12 months post-sclerotherapy 5
- Repeat sclerotherapy offered if symptoms persist or cyst remains larger than 5 cm 5
Surgical Excision
Microscopic cystectomy is recommended when:
Advantages of microscopic technique:
- Significantly reduced bleeding (2-3 mL) with no wound drainage required 6
- Lower incidence of postoperative scrotal hematoma, edema, and long-term pain 6
- Better preservation of epididymal patency through refined treatment 6
Optimal surgical timing:
- Surgery should be performed before the cyst reaches 0.8 cm in diameter 6
- Cysts larger than 0.9 cm can cause complete destruction of all tubules of the ipsilateral epididymis and damage to the testicular output network 6
Risks of Non-Microscopic Surgery
- Traditional nonmicroscopic epididymal cyst resection carries risks of postoperative edema, hematoma, sustained pain, and seminal tract obstruction 6
- These complications have led to concerns about fertility outcomes in patients undergoing conventional surgery 6
Differential Diagnosis
- Epididymal cysts and spermatoceles are distinct entities: epididymal cysts are benign masses that can occur at any age, while spermatoceles specifically contain sperm and typically occur post-puberty 8
- Ultrasound imaging easily characterizes and differentiates between these conditions 8
- Critical distinction from acute epididymitis: cysts/hydroceles require mechanical drainage or sclerotherapy, not antibiotics 5