What are the diagnostic criteria for epididymitis in a male patient in his late 50s presenting with painful testes?

Diagnostic Criteria for Epididymitis

In a male patient in his late 50s with painful testes, diagnose epididymitis based on unilateral testicular pain and tenderness with palpable epididymal swelling, supported by urinalysis showing pyuria and urine culture for enteric organisms, after excluding testicular torsion. 1

Clinical Presentation

Key symptoms and signs to identify:

• Gradual onset of posterior scrotal pain over hours to days, distinguishing it from the sudden onset of testicular torsion 1, 2
• Unilateral testicular pain and tenderness localized to the epididymis, typically beginning at the lower pole and progressing upward 1, 2
• Palpable epididymal swelling with the testis in anatomically normal position 3, 4
• Positive Prehn sign: pain relief when elevating the scrotum over the symphysis pubis (helps differentiate from torsion where this maneuver does not relieve pain) 1, 2
• Urinary symptoms including dysuria, frequency, urgency, or weak stream are common in older men 5, 2
• Reactive hydrocele may develop as inflammation progresses 5, 2
• Fever may be present in severe cases 2

Age-Specific Diagnostic Approach

For men over 35 years (like this patient):

The etiology differs dramatically by age, which determines the diagnostic workup:

• Gram-negative enteric bacteria, particularly E. coli, are the predominant pathogens in men over 35 5, 6
• Associated with urinary tract infections, recent urinary instrumentation, surgery, or anatomical abnormalities 1, 5
• Urinalysis and urine culture are the essential diagnostic tests, not urethral swabs 5, 2

For younger men (14-35 years):

• Chlamydia trachomatis and Neisseria gonorrhoeae are primary pathogens 1, 3
• Urethral swab testing with nucleic acid amplification test (NAAT) is required rather than relying solely on urinalysis 2

Required Diagnostic Evaluation

For this patient in his late 50s, perform:

• Urinalysis examining first-void uncentrifuged urine for leukocytes (pyuria) 1
• Urine culture and Gram stain for Gram-negative bacteria 1, 5
• Doppler ultrasound if diagnosis is uncertain or to rule out testicular torsion, abscess, or other complications 1, 5

Additional testing if sexually active or younger:

• Gram-stained smear of urethral exudate for urethritis (>5 polymorphonuclear leukocytes per oil immersion field) 1
• Culture or NAAT of intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 1
• Syphilis serology and HIV counseling 1

Critical Differential Diagnosis

Testicular torsion must be excluded immediately as it is a surgical emergency:

• More frequent in adolescents but can occur at any age 1
• Sudden onset of severe pain (versus gradual onset in epididymitis) 1, 2
• Negative Prehn sign (no pain relief with scrotal elevation) 1, 2
• Emergency surgical consultation required if diagnosis questionable, as testicular viability is compromised within 6-8 hours 1

Other conditions to consider if symptoms persist:

• Tumor, abscess, testicular cancer, tuberculosis, or fungal epididymitis if no improvement after 3 days of appropriate treatment 1

Common Pitfalls

Critical errors to avoid:

• In men over 35, do not rely solely on urethral testing—urine culture is the key diagnostic test for enteric organisms 5, 2
• In sexually active men under 35, do not rely solely on urinalysis—urethral swab NAAT is essential as STI-related epididymitis frequently presents without significant pyuria 2
• Failure to exclude testicular torsion can result in testicular loss; maintain high suspicion with sudden onset or severe pain 1
• Inadequate follow-up: if no improvement within 3 days of treatment, re-evaluate both diagnosis and therapy 1, 5
• Persistent symptoms after completing antibiotics warrant comprehensive evaluation for chronic conditions, abscess, or malignancy 1, 5