Epididymitis in Older Boys: Dysfunctional Voiding as an Etiology

Pediatric epididymitis: A 20-year single-center experience of 61 cases

BACKGROUND

The etiology of acute epididymitis (AE) in children remains poorly understood. This study was performed to analyze the clinical and imaging findings in children with AE.

METHODS

We retrospectively reviewed children with AE treated at our institute from 2003 to 2023. The patients' medical charts were reviewed to record their clinical features and radiological and laboratory data. Multiple acute episodes occurring in individual patients were also recorded.

RESULTS

In total, 61 patients with AE were identified. Their median age at first presentation was 8 years (range, 0-22 years). The duration of pain ranged from 0 to 10 days. Accompanying genitourinary anomalies (GUA) were observed in 11 (18%) patients: hypospadias in 2, anorectal malformation in 9, neurogenic bladder in 3, undescended testis in 1, and surgery for contralateral testicular torsion in 1. One patient was diagnosed with Henoch-Schönlein purpura. Urine culture results were available in 41 patients and positive in 5 (11%). Eight patients had pre-existing infection (upper respiratory infection in four, enteritis in three, and posthitis in one). Eight (13%) patients experienced more than a second episode of epididymitis, and five (62%) of these eight patients had GUA. Testicular atrophy was present in five patients, detected 2-6 months after epididymitis.

CONCLUSION

Most cases of AE occurred in the prepubertal period, and most urine tests were negative. Recurrent epididymitis was associated with GUA. Because some patients showed signs of testicular atrophy, careful follow-up is necessary.

Outcome of acute epididymo-orchitis: risk factors for testicular loss

PURPOSE

Acute epididymo-orchitis (AEO) is a common urological condition characterised by pain and swelling of the epididymis which can affect men of any age. The aetiology and to some extent the management of the patient differ between paediatric and young and older adult groups.

METHODS

A retrospective analysis was performed at the University Hospital Limerick from 2012 to 2016. Hospital In-Patient Enquiry (HIPE) data were obtained for all patients diagnosed with orchitis, epididymitis, epididymo-orchitis or testicular abscess over this 5-year period.

RESULTS

140 patients were identified, the age range was 0-89, median age 35.6. These were then split into 3 clinical groups, pre-pubertal (Group 1, 0-15-year-olds), sexually active young men (Group 2a, 16-35-year-olds) and men over 35 (Group 2b). Nine patients had an abscess on ultrasound investigation. There was a significant correlation between the presence of an abscess and the need for an orchidectomy (2 patients, P = 0.035). Two patients were reported as having an atrophic testis following AEO and both were in Group 2b.

CONCLUSION

Overall, 7/131 (5%) patients had loss or atrophy of a testicle following an episode of AEO. Nineteen patients had further readmissions with AEO (14%).

Perspective in Pediatric Pathology, Chapter 24. Testicular Inflammatory Processes in Pediatric Patients

Acute scrotal pain in children represents a major diagnostic and therapeutic challenge. An important initial differentiation should be made between epididymitis and other processes that cause acute scrotal pain, such as testicular torsion and tumor. Infectious agents disseminating through the blood flow can damage the testis by causing orchitis. On the other hand, infections ascending via spermatic pathways typically lead to epididymitis [ 1 ].

Recurring priapism may be a symptom of voiding dysfunction – case report and literature review

Recurring priapism is rare in pre-pubertal children and may be attributed to multiple causes. We propose that voiding dysfunction (VD) may also justify this symptom and detail a clinical case of recurring stuttering priapism associated to overactive bladder that completely resolved after usage of anticholinergics and urotherapy. Sacral parasympathetic activity is responsible for detrusor contraction and for spontaneous erections and a relationship between erections and bladder status has been proved in healthy subjects (morning erections) and models of medullar trauma. High bladder pressures and/or volumes, voiding incoordination and posterior urethritis can potentially trigger reflex erections.

The aetiology and current management of prepubertal epididymitis

INTRODUCTION

The aim of this study was to review the published evidence on the pathogenesis and management of acute epididymitis (AE) in prepubertal boys after the authors encountered an unexpectedly large number of such cases in their institution.

METHODS

Using MEDLINE(®), a literature search was performed for articles in English with the words "pre-pubertal" OR "boys" OR "p(a)ediatric" OR "children" AND "epididymitis" OR "epididymo-orchitis".

RESULTS

The literature suggests that it is rare to find a bacterial infection or anatomical anomaly as a cause for AE in this population. A postviral infectious phenomenon is the most likely explanation. The management should be supportive and antibiotics reserved for those with pyuria or positive cultures. Urodynamic studies and renal tract ultrasonography have been advocated for those with recurrent epididymitis.

CONCLUSIONS

AE in prepubertal boys is more common than believed previously. A careful history for recent viral illnesses should be included. Antibiotics, urinary tract imaging and functional studies should be used in selected cases.

Management of recurrent epididymitis in children: application of neurovascular sparing vas clipping in refractory cases

PURPOSE

To investigate the efficacy of therapeutic methods for recurrent epididymitis and neurovascular sparing vas clipping in refractory cases.

MATERIALS AND METHODS

Fifteen boys with recurrent epididymitis were enrolled: the first group (9) with primary structural anomalies and the second group (6) with voiding dysfunction without structural anomalies. Median age was 4 (29 months to 7 years) and 4.5 (6 months to 11 years) years, respectively. Mean follow up was 7.5 (2-11) and 5.2 (3.5-8) years, respectively.

RESULTS

Urethrovasal reflux was detected in all patients of the first group except one. Endoscopic injection of bulking agent was successfully applied in three patients with no recurrent epididymitis. No further episodes of epididymitis were reported after valve ablation or clean intermittent catheterization. In four non-responders, vas clipping was successfully undertaken. Voiding dysfunction was the possible etiology of epididymitis but with no obvious urethrovasal reflux in the second group. No further episodes of epididymitis occurred using bladder retraining and medications for detrusor and sphincter relaxation.

CONCLUSIONS

The results suggest that neurovascular sparing vas clipping can be used effectively in children with structural anomalies and urethrovasal reflux who have developed intractable epididymitis.

Are antibiotics necessary for pediatric epididymitis?

OBJECTIVES

To determine the percentage of cases of epididymitis in pediatric patients that is of bacterial cause and to identify factors that predict a positive urine culture.

METHODS

We conducted a retrospective chart review of patients diagnosed with acute epididymitis or epididymo-orchitis in 1 pediatric emergency department for 11 years. Charts were reviewed for historical, physical, laboratory, and radiologic data. A positive urine culture was used to identify patients with a bacterial cause of epididymitis.

RESULTS

A total of 160 patient records were initially identified as having a diagnosis of epididymitis; of these, 20 met exclusion criteria or did not have records available for review and 140 cases of epididymitis were reviewed. Patients' age ranged from 2 months to 17 years, with a median age of 11 years. Of these patients, 91% received empiric antibiotic therapy. Also, of these patients, 97 (69%) had a urine culture sent, of whom 4 (4.1%; 95% confidence interval, 1.1%-10.2%) were positive. Of the 4 positive urine cultures, 3 had organisms not sensitive to usual empiric therapy for urinary tract infections. The boys with positive urine cultures were not significantly different from the other patients in age, maximum temperature, or number of white blood cells on urinalysis.

CONCLUSIONS

Given the low incidence of urinary tract infections in boys with epididymitis, in prepubertal patients, antibiotic therapy can be reserved for young infants and those with pyuria or positive urine cultures. Because it is difficult to predict which patients will have a positive urine culture, urine cultures should be sent on all pediatric patients with epididymitis.

Ultrasonography and clinical findings in children with epididymitis, with and without associated lower urinary tract abnormalities

BACKGROUND

Epididymitis is most commonly idiopathic but can also be associated with urinary tract abnormalities (UTAs). The distinctive clinical and imaging findings of children with epididymitis and underlying UTAs are not known.

OBJECTIVE

To describe clinical and imaging findings in children with epididymitis and the association with UTAs.

MATERIAL AND METHODS

The study group included all children evaluated for epididymitis confirmed by scrotal US in a 6-year period. The clinical and imaging findings and disease recurrence were compared between children with and without UTAs.

RESULTS

A total of 47 boys (mean/SD 9.61/4.40 years, range 0.1 to 17.1 years) met the entry criteria, of whom 17 had UTAs. The most common UTAs were hypospadias, neurogenic bladder, and functional bladder abnormality (six each). Age at presentation and likelihood of testicular swelling or hydrocele was not different between children with and without UTAs. Marked epididymal swelling was more common in children with UTAs (9/17, 53%) than in those without UTAs (5/30, 17%; P=0.02), as was recurrent epididymitis (with UTAs, 9/17, 53%; without UTAs, 5/30, 17%; P=0.02). Chronic epididymitis (five children), presentation with scrotal mass (four), and epididymal abscess (two) occurred only in children with UTAs.

CONCLUSION

Children with epididymitis who have UTAs are more likely to present with marked epididymal swelling, develop recurrent disease, and have a more protracted course.

Acute epididymitis in Greek children: a 3-year retrospective study

The aim of the study was to compare historical features, physical examination findings, and testicular color Doppler ultrasound in pediatric patients with epididymitis compared to testicular torsion and torsion of the appendix testes. A retrospective review of the medical records of 66 boys presenting with clinical aspects of acute scrotum over a 3-year period was performed. Sixty-six patients were included in the study (29 with epididymitis, 8 with testicular torsion and 12 with torsion of the appendix testis, 4 with scrotal abscesses, 5 with scrotal swelling, and 1 with inflamed epididymal cyst). The duration of symptoms ranged from 6 h to 4 days with a peak on the second day. Urine cultures and viral testes were negative in all patients. Color Doppler ultrasound was diagnostic for epididymitis in 28 patients (96.6%). Systemic intravenous antibiotics were given in all 29 patients with epididymitis. No patient showed signs of testicular atrophy in the follow-up. The increasing incidence of epididymitis should question the policy of routine exploration of the acute scrotum in children. The history and physical examination cannot reliably identify those boys who can be managed conservatively. Color Doppler ultrasound is a useful adjunct in the evaluation of the acute scrotum when physical findings are equivocal but it can also be misleading.

Inflamation of the testis and epidididymis in an otherwise healthy child: is it a true bacterial urinary tract infection?

PURPOSE

The exact etiology of acute gonadal inflamation (EO) in children is unknown. Bacterial infection and underlying urological abnormalities are thought to be the main causes, and hence antibiotic treatment and further invasive urinary tract imaging studies are usually recommended. The purpose of this study was to assess the role of bacterial infection in pediatric acute EO.

MATERIALS AND METHODS

We retrospectively searched our electronic medical archive for children under the age of 18 years with the diagnosis of acute EO between 1997 and 2002. Patients' charts were retrieved and reviewed for clinical and laboratory data.

RESULTS

During 1997-2002, 193 patients with acute EO were treated. There were two subgroups according to the results of urinary cultures: 182 children (94.3%) had negative urine cultures and 11 (5.7%) had positive cultures. In the negative culture group the mean age was 9.8+/-3.2 years (0.5-17). Medical history for urological disease was negative in all patients. Presenting symptom was scrotal pain in 165 (90.7%), and only three patients (1.6%) had accompanying urinary symptoms. Physical examination was normal besides tender gonad. Urinalysis was completely normal in 169 (92.9%) patients. Scrotal Doppler ultrasound (US) demonstrated non-specific inflammatory process in 146 patients (80%), in nine (5%) torsion of the appendix testis was documented and in 27 (14.8%) scrotal US was normal. Follow up was available in 40% all of whom had an uneventful recovery with normal physical examination. In the positive culture group of 11 patients, the mean age was 11+/-6.7 years (3 months to 16 years), and eight patients (73%) had a known congenital urological abnormality. Presenting symptom was pain in five (45.4%) and pain with swelling in six (55.6%). Accompanying dysuria, frequency and urgency occurred in eight (72.7%) patients. Urinalysis was abnormal in 10 (90.9%). US demonstrated increased blood flow to the gonad in 10 (90.9%).

CONCLUSIONS

Negative history for urological disease, absence of urinary symptoms and normal urinalysis make the diagnosis of bacterial EO unlikely. In this setting, once testicular torsion was excluded, there is no justification for antimicrobial treatment or further imaging of the urinary tract.

Urinary tract infections in children: treatment

Urinary tract infection is a frequent diagnosis in children who are referred to the urologist. Infections vary in scope and severity, warranting thoughtful consideration of appropriate therapy. Infections of the genitourinary system may include bacterial,viral, fungal, or parasitic microorganisms. Adequate therapy requires rapid detection and control of these conditions to prevent pyelonephritic renal scarring and its sequelae.

Acute epididymitis in boys: evidence of a post-infectious etiology

PURPOSE

We studied the etiology and management of pediatric epididymitis.

MATERIAL AND METHODS

We performed 1-year prospective study in children with epididymitis. All patients underwent an immediate sonographic study of the scrotum. Microbiological studies included throat and urine cultures as well as viral cultures of nasopharyngeal and stool specimens. Serological tests for group A streptococcus and Mycoplasma pneumoniae as well as for enteroviruses, adenoviruses, influenza and parainfluenza viruses in the appropriate seasons were performed in patients and controls.

RESULTS

A total of 44 patients 2 to 14 years old (mean age 9.8 +/- 3.2) were studied. Hospital admissions peaked during the summer and winter. The incidence of epididymitis was around 1.2/1,000 boys yearly. One patient had familial Mediterranean fever and another had Henoch-Schonlein purpura. Microbiological studies of the urine, throat, nasopharynx and stool yielded bacterial/viral growth in 9 patients (20.4%). Serological studies revealed significantly elevated titers to certain pathogens in patients with epididymitis compared with controls, including M. pneumoniae (53% vs 20%), enteroviruses (62.5% vs 10%) and adenoviruses (20% vs 0%). Most patients were treated with analgesics and 3 patients received antibiotics intravenously. Systemic and local signs and symptoms resolved gradually in 1 to 7 days.

CONCLUSIONS

Our results suggest that epididymitis in boys is not rare and it is mostly an inflammatory phenomenon (presumably post-infectious) with a benign course. The treatment of these patients is basically with analgesics with a little role for antibiotics.

Genitourinary imaging in children

Genitourinary imaging in children has gone through a metamorphosis in the past 30 years, paralleling technical advances in sonography, CT scanning, and MR imaging. The imaging sequences for hydronephrosis and UTI are still controversial and require outcomes analysis to determine which studies are most beneficial and efficacious.

The nontraumatic, acute scrotum

Regardless of age, any presentation of an acute scrotum requires prompt triage and immediate evaluation. The potential for significant reduction in morbidity and mortality exists if timely diagnosis and treatment are provided. Often overlooked, an early scrotal examination in the emergency department may produce the most accurate information into the underlying pathologic process, be it systemic or localized to the scrotum. Although the immediately lethal conditions presenting as acute scrotal pain should be considered, the combined incidence and morbidity associated with testicular torsion make its exclusion paramount in acute scrotal presentations. Similarly, a painless scrotal mass must be assumed to be a testicular neoplasm until proven otherwise, with appropriate work-up and rapid urologic follow-up assured.

[Acute scrotum in the child]

Torsion of the spermatic cord is the most common etiology of acute scrotum in children. Children with torsion usually present with acute scrotal pain, nausea and vomiting, and only early surgical treatment, within 6 hours of the onset of symptoms, may ensure the preservation of the testis. For that reason any acute scrotal pain with edema requires urgent specialized evaluation. Other etiologies include less severe diseases as torsion of an appendage, epididimytis, trauma, and other rare conditions such as acute idiopathic scrotal edema.