8.2.2 Epididymitis

Inflammation of the epididymis causes pain and swelling, which is almost unilateral and relatively acute in onset. In many cases, the testicle is involved in the inflammatory process known as epididymo-orchitis. Among sexually active men younger than 35 years, epididymitis is most often caused by С trachomatis or N. gonorrhoeae (Table 13) [8,9]. Sexually transmitted epididymitis is usually accompanied by urethritis. Non-sexually transmitted epididymitis is associated with UTI. This type occurs more frequently among men aged over 35 years, those who have recently undergone urinary tract instrumentation or surgery and those who have anatomical abnormalities [9].

Diagnosis

In acute epididymitis, inflammation and swelling usually begin in the tail of the epididymis, and may spread to

involve the rest of the epididymis and testicular tissue [4].

Although men with epididymitis due to sexually transmitted microorganisms always have a history of sexual

activity, exposure can have been months prior to onset. The microbial aetiology of epididymitis is usually easy

to determine by gram-stained examination of both a urethral smear for urethritis and of a midstream urine

specimen for gram-negative bacteriuria [8,9]. Intracellular gram-negative diplococci on the smear correlate with

the presence of N. gonorrhoeae. Only white blood cells on urethral smear are indicative of non-gonorrhoeal

urethritis; С trachomatis will be isolated in approximately two thirds of these patients [10].

Ejaculate analysis

Ejaculate analysis according to WHO criteria, including leukocyte analysis, may indicate persistent inflammatory activity. In many cases, transiently decreased sperm counts and forward motility are observed [3,5,8]. Ipsilateral low-grade orchitis [11,12] has been discussed as the cause of this slight impairment in sperm quality (Table 17) [13].

Development of stenosis in the epididymal duct, reduction of sperm count and azoospermia are moreimportant in the follow-up of bilateral epididymitis (see above Obstructive azoospermia). The real figure of azoospermia after epididymitis remains unclear.

Table 17. Acute epididymitis and impact on sperm parameters

Author	Negative Influence on			Comment
	Density	Motility	Morphology
Ludwig & Haselberger [14]	+	+	+	Pyospermia in 19 of 22 cases
Berger et al. [8]		+
Weidner et al. [5]	+	+	+	Azoospermia in 3 of 70 men
Haidl [15]		+		Chronic infections; macrophages elevated
Cooper et al. [16]		Decrease in epididymal markers: alpha-glucosidase, L-carnitine

Treatment Antibiotic therapy is indicated before culture results are available (Table 1).

Treatment of epididymitis will result in:

• Microbiological cure of infection

• Improvement of signs and symptoms

• Prevention of transmission to others

• Decrease in potential complications, e.g. infertility or chronic pain

Patients who have epididymitis known or suspected to be caused byN. gonorrhoeae or C. trachomatis should be instructed to refer sex partners for evaluation and treatment [17].