Epididymitis

EPIDIDYMITIS (epididymitis), inflammation of the epididymis. E. can develop: 1) as a complication of general infection, by hematogenous route (influenza, mumps, furunculosis, typhus, etc.). 2) From trauma, resulting in hemorrhage into the interstitial tissue of the epididymis. Most often, trauma to the testicular epididymis in these cases creates a predisposition for the introduction of infection from the inflamed posterior part of the urethra. 3) As a complication of non-gonorrheal and gonorrheal urethritis. G o n o r r h e a l E. occurs most frequently (in 0.25-12% of all patients with gonorrheal urethritis). Treatment of urethritis by large irrigations according to Jane gives a significantly lower percentage of complications than treatment with an enema. Treatment in conditions of a 'laboratory hospital' gives the smallest percentage (Maryasin-Baevsky). A predisposing factor for the introduction of gonococcal infection into the epididymis is physical trauma to the posterior urethra or testicular epididymis, creating favorable conditions for the development of E. Infection penetrates the epididymis most often due to antiperistaltic movements of the vas deferens or through the lymphatic system, rarely per continuitatem and extremely rarely through blood. The pathological anatomy of gonorrheal E. is characterized mainly by exudative and proliferative processes. The epithelium of the epididymal tubules is more or less desquamated; the interstitial tissue is infiltrated with polymorphonuclear leukocytes, lymphocytes, and plasma cells. In the lumina and in the interstitial tissue, there is seropurulent exudation. In the tail of the epididymis, small abscesses often form both inside and outside the tubules. The corresponding part of the scrotum is often involved in the process; effusion appears in the tunica vaginalis of the testis, and sometimes adhesions form with the skin. Acute E. usually begins suddenly with severe pains radiating along the course of the vas deferens into the inginal region. On examination, enlargement of the corresponding half of the scrotum is striking: the epididymis is enlarged, sharply painful on palpation, and covers the testis in the form of a helmet. The enlargement is particularly pronounced in the tail of the epididymis. The skin of the scrotum is edematous, hyperemic, and hot to the touch. Often the vas deferens, and sometimes the entire spermatic cord, are thickened and painful on palpation. The general condition of the patient is disturbed. Patients complain of chills, general weakness, temperature is elevated, sometimes reaching 39° and higher. Local phenomena in the urethra, on the contrary, improve, and urine often becomes clear. Acute phenomena in the epididymis last 5-7 days, after which reverse development occurs: pains cease, general condition improves. The swelling of the epididymis gradually decreases, resorption occurs slowly - over weeks, and sometimes months. Complete resorption rarely occurs. Usually cicatricial changes remain, palpable as a small or painless nodule, more often in the tail. Inflammation of the epididymis, accompanied by changes in the spermatic cord and vas deferens, resolves much more slowly than without involvement of these structures. After the acute phenomena subside, discharge from the urethra reappears, and urine becomes cloudy. Diagnosis of acute E. presents no difficulties. As for differential diagnosis of gonorrheal E. from E. caused by other etiological factors, it often encounters significant difficulties. Recognition of metastatic and traumatic forms is based primarily on the patient's history. (Non-gonorrheal E. see below.) In doubtful cases, puncture of the epididymis with aspiration of exudate and examination of it for microflora can be a decisive factor. Confusion of acute gonorrheal E. with tuberculous or syphilitic E. or with a tumor of the epididymis is hardly possible due to their sluggish, slow chronic development and slight pain on palpation. The prognosis for E. quo ad valetudinem is doubtful, since the remaining changes of a cicatricial nature after the acute process cause compression or obliteration of the seminiferous tubules, as a result of which the passage of spermatozoa often becomes impossible. With bilateral involvement of the epididymides, azoospermia is observed in 75% of cases (see). Treatment of acute E. consists first of bed rest for the patient and complete rest for the scrotal organs. Locally, heat in the form of a compress, a rubber hot water bottle, or blue light is applied. For severe pains, cold is recommended (Crépe). If there are adhesions with the skin, an erythemal dose from a quartz lamp can be successfully applied. General treatment should be directed toward immunotherapy. For severe phenomena accompanied by sharp pains, autogenous blood therapy is successfully used; after the pains subside, specific treatment with gonovaccine is administered, which gives the best effect in terms of resorption of infiltrates in the acute stage. In prolonged cases with long-lasting infiltrates, diathermy, iontophoresis, or mud therapy are of great benefit. Local treatment of the urethra in the form of large irrigations or instillations should continue throughout the entire period of inflammation. Surgical treatment of E. in the form of epididymectomy can be recommended in cases of recurrent process in the epididymis, formation of large abscesses, or infiltrative and connective tissue changes unresponsive to conservative treatment, in the presence of persistent painful sensations. Tuberculous E. ranks second in frequency after gonorrheal. Tuberculous infection reaches the epididymis either by hematogenous route, which is observed most often, or intracanalicularly from affected higher organs of the urogenital tract, or through lymphatic vessels. Favorable conditions for the development of tuberculous E. are: heredity, the existence in the body of any clinically even dormant focus, trauma, previous gonorrheal or other infectious disease of the epididymis, as well as an intensified sexual life. The latter is confirmed by the fact that 60% of persons who develop tuberculous E. are between 20 and 35 years old, i.e., during the period of most intense sexual life. The process usually appears first in the tail of the epididymis, then spreads to the head and body. Around caseous foci, connective tissue changes often develop. The testis with severe changes in the epididymis is also involved in the process. Tuberculous nodules, and sometimes cavities, can be seen scattered in the area of the body of the epididymis and in the parenchyma of the testis. With further development, the process spreads to the tunics of the testis, causing adhesions with the skin and the formation of fistulas. The vas deferens is often infiltrated and thickened uniformly or in the form of irregular nodules resembling a rosary, painless on pressure. Clinically, tuberculous E. manifests as an acute or chronic process. With acute onset, the epididymis rapidly increases in size, becomes infiltrated, effusion appears in the tunica vaginalis of the testis, the skin reddens, and adheres to the tunics. After 10-12 days, the process subsides. The epididymis decreases in size, becomes painless, but the infiltrate remains, and the process takes a chronic course. More often the process from the very beginning proceeds sluggishly, chronically, with little notice by the patient. The epididymis swells, becomes infiltrated, usually little painful on pressure. The process can drag on for many months and even several years, gradually increasing. Subsequently, the testis, the tunica vaginalis, the vas deferens, and the skin are often involved in the process. The accumulated caseous contents breaks through outward, forming fistulous tracts. Differential diagnosis between tuberculous and gonorrheal E., see gonorrheal E. As for syphilitic involvement, in the latter, besides the history, RW, and the localization of the process - most often in the testis - should be considered. Therapy of tuberculous E. is based primarily on improving the general condition of the patient, locally with X-ray irradiation and quartz lamp. Intramuscular injections of iodine in iodoform emulsion (Hotz) in individual cases bring some improvement. For far-advanced local changes in the epididymides, surgical intervention in the form of epididymectomy, i.e., removal of the entire epididymis or its affected part, or - if the testis is involved - castration is indicated; some authors (Solovov, Pflaumer) recommend ligation of the vas deferens on the other side to prevent the spread of tuberculous infection to the epididymis of the second testis. Even rarer cases are syphilitic E., usually combined with involvement of the testis (orcho-epididymitis). The appearance of such is associated with the presence of the corresponding disease. Its course is subacute or chronic. In treatment, attention must be paid to the primary process. Non-gonorrheal E. results from the introduction of infection (staphylococci, B. coli, diplococci, etc.) into the epididymis, most often through the vas deferens by antiperistalsis, which is caused by mechanical or nervous irritation. On palpation, the epididymis is usually sharply painful, enlarged, especially in the tail, less so in the body and head. Its surface is smooth. The skin of the scrotum is often adherent to the underlying tissues, most frequently in the area of the gubernaculum Hunteri. The course of non-gonorrheal E. is usually acute or subacute. Subsequently, transition to chronic fibrous thickening often occurs, more rarely to abscess.

Differential diagnosis, see Epididymitis, gonorrheal. The distinction from tuberculous Epididymitis is based on repeated microscopic and bacteriological examination of urethral discharge and puncture of the epididymis. In unclear cases, Cappis (Car-pis) recommends performing a biopsy. Treatment consists of rest for the scrotal organs, a warm compress, and protein therapy (see). At the same time, treatment of urethritis is carried out. In the case of an abscess that has developed, epididectomy should be performed. - Traumatic Epididymitis. Trauma affects either directly in connection with tissue damage or indirectly, creating a locus minoris resistentiae for the introduction of bacteria or activating a latent infection in the epididymis. Not only physical traumas but also strong sexual excesses, as a result of delayed blood influx, predispose to such processes. The course of traumatic Epididymitis is characterized by the sudden rapid development of the process following an insult and is accompanied by swelling and pain. The epididymis is enlarged, somewhat hardened, and has a smooth surface. The inflammation sometimes spreads to the spermatic cord. If clinical recovery does not occur within 5-6 days, this usually means a complication of the process with a bacterial infection. Treatment consists of complete rest for the scrotal organs, compresses. After the acute phenomena subside - diathermy. Literature - see literature for the article Testicle.