Are antibiotics necessary for pediatric epididymitis?

Pediatric Non-Testicular Torsion Acute Scrotum - Is the use of prophylactic antibiotics in patients with normal urine analysis justified?

OBJECTIVES

To determine if empirical antibiotic treatment for non-testicular torsion (NNT) acute scrotum is necessary in the setting of a normal urine analysis (UA).

METHODS

Retrospective chart review revealed 314 pediatric patients with clinically diagnosed NTT acute scrotum with negative UA between 2004-2019. Exclusion criteria included previous urological history and immunocompromised state. Patients were divided into those with antibiotics treatment versus those without. The independent t-test was used to compare numerical variables while the chi-squared test was used to compare categorical variables.

RESULTS

Of the 314 patients identified, 141 (44.9%) received empiric antibiotics despite negative UA. Clinical findings and demographic characteristics between groups were not found to be significant. Patients clinically diagnosed with epididymo-orchitis were more likely to be prescribed antibiotics (48.2 vs 30.6%, p=0.02). Trimethoprim-sulfamethoxazole accounted for 83% of the antibiotics that were prescribed in our study. There was no significant difference in symptom resolution between patients prescribed antibiotics and those not prescribed antibiotics (5.1 days vs 4.6 days, p=0.71). Additionally, no patient in either group returned with complications such as worsening symptoms or urinary tract infection between presentation and their scheduled follow up visit.

CONCLUSION

Based on our analysis, antibiotics in NTT acute scrotum appear to have no benefit in symptom resolution or complication reduction in patients without any predisposing urological risk factors and negative UA at presentation. Given the risk and rise of antibiotic resistance providers need to be careful to select treatments based on available evidence.

How useful is a complete urinary tract ultrasound in orchiepididymitis?

Orchiepididymitis (OE) is a frequent cause of pediatric emergency department attendance in boys presenting with acute scrotum. The etiology of most episodes of OE remains unclear and there is no consensus regarding the correlation between OE and underlying genitourinary malformations. Whether imaging evaluation should comprise complete urinary tract ultrasonography (US) or voiding cystography is a subject of debate. The aim of this retrospective, single-center study was to analyze i) the number/type of urinary tract malformations detected by US following a first episode of OE in boys with no previously known malformation and ii) the frequency of associated urinary tract infection (UTI). We reviewed the records of 495 boys <16 years presenting to our pediatric emergency department with acute scrotum between January 2012 and December 2017. Patients with incomplete radiological data were excluded. Of 119 boys with a radiologically-confirmed first episode of OE, 99 had a complete urinary tract US and were included in the study. No genitourinary malformation was detected (0%). Urinary cultures showed UTI in 3/98 (3.1%) patients. Mean age at presentation was 9.7 years (standard deviation, 3.9) with a three-peak incidence of OE at 10–13 years, 4–5 years, and during infancy. Conclusion: Complete urinary tract US does not appear to be useful during a first episode of OE in countries with an antenatal US screening rate similar to Switzerland. The very low UTI rate suggests that a urinalysis is sufficient to investigate a first episode of OE and antibiotics should be reserved for positive urinalysis only.

[CLINICAL AND IMAGING FINDINGS OF ACUTE EPIDIDYMITIS IN CHILDREN]

(Objective) The etiology of acute epididymitis in children remains poorly understood. Several studies have demonstrated that urine tests are negative in the majority of children with acute epididymitis, and the condition is self-limiting. The need for radiological evaluation of the urinary tract in children with acute epididymitis is still debatable. The aim of this study was to describe clinical and imaging findings in children with acute epididymitis. (Methods) We identified 47 children with acute epididymitis at our institute between 2017 and 2021.We retrospectively reviewed their clinical features and radiological and laboratory data. All children underwent ultrasonography of the kidney and urinary tract. (Results) Median patient age was 9 years (range, 6 months-16 years) and 60% of the cases occurred between the ages of 7 and 12 years. Thirteen children (28%) had a past history of genitourinary malformations. The common malformations were hypospadias in eight children and bladder dysfunction in three. Ultrasound revealed no new urinary tract abnormalities in the remaining 34 children. Urinalysis were performed in 27 children, nine of whom (33%) had pyuria. Urine culture was positive in two children. Of the nine children with genitourinary malformations, eight had pyuria. All 18 children without genitourinary malformations had a negative urinalysis except for one patient (p< 0.0001). (Conclusions) Acute epididymitis is a common cause of acute scrotum in pediatric patients. In this study, one-third of acute epididymitis cases presented pyuria, and about 30% had a past history of genitourinary malformations. The presence of pyuria was associated with a past history of genitourinary malformations. For children with no previous genitourinary malformations, routine use of ultrasound for the detection of urinary tract abnormalities is questionable due to the low yield.

Evaluating the Necessity of Antibiotics in the Treatment of Acute Epididymitis in Pediatric Patients: A Literature Review of Retrospective Studies and Data Analysis

OBJECTIVES

This literature review and data analysis aims to evaluate the percentage of pediatric patients with acute epididymitis found to have bacterial etiology and the percentage of patients in these studies that were treated with antibiotic therapy versus conservative therapy.

METHODS

A search of EBSCO through January 13, 2016, using the key words epididymitis or epididymo-orchitis and child, children, or pediatric, identified 542 potential studies.Twenty-seven retrospective studies met the inclusion criteria, containing patients aged 21 years or younger with acute epididymitis or epididymoorchitis. The number and age of patients, urine cultures and urinalysis results, number of patients treated with antibiotics, and incidence were extracted.

RESULTS

A total of 1496 patients with acute epididymitis were identified. A urinalysis was obtained for 1124 patients, and 190 (16.9%) were positive. Aurine culturewas obtained for 670 patients, and 100 (14.9%) were positive. Fourteen studies addressed antibiotic administration wherein 652 patients were with acute epididymitis and 554 (85%) received antibiotics.Of 502 patients with urinalysis results, urine culture results, and antibiotic treatment rates, 54 (10.8%) were positive for a bacterial source. Antibiotics were administered to 410 (81.7%) of these 502 patients.

CONCLUSIONS

Practitioners should consider only prescribing antibiotics to patients with acute epididymitis if there is an abnormal urinalysis or urine culture.

Epididymitis and its aetiologies in a central London sexual health clinic

Epididymitis is a common cause of scrotal pain presentation in sexual health clinics; however, it is unclear what fraction is attributable to transmissible infections. We, therefore, reviewed the aetiologies causing epididymitis. A retrospective data analysis of all cases of epididymitis diagnosed from January 2018 to December 2018 in three sexual health clinics was conducted, collecting demographics, results, management and symptom resolution at two weeks follow up. A total of 127 cases of epididymitis (mean age 32 years, heterosexual 97, MSM 30) were included. Among them 14 cases (11%) were caused by sexual transmitted infections (<35 years n = 9; >35 years n = 5): seven cases of chlamydia, six gonorrhoea, one syphilis and one trichomonas vaginalis. There were three cases of urinary tract infection diagnosed. All cases were treated with antibiotics recommended by the British Association for Sexual Health and HIV (BASHH). At two weeks follow up post-treatment 10 (7%) were symptomatic; 91% did not attend for follow up. Sexually transmitted infections were associated with acute epididymitis in 11% of this study cohort.

Assessing the Utility of Ultrasound and Urinalysis for Patients with Possible Epididymo-Orchitis - A Retrospective Study

Purpose

Many experts recommend ordering an ultrasound and a urinalysis on all patients with scrotal pain. While the ultrasound may help diagnose a number of potential causes of scrotal pain, the urinalysis primarily has value in assessing for epididymo-orchitis. This study sought to evaluate the utility of these diagnostic tests for patients who presented to the emergency department (ED) with acute scrotal pain and possible epididymo-orchitis.

Patients and Methods

This was a single-center chart review of patients presenting to the ED with scrotal pain. Trained research assistants reviewed charts to obtain urinalysis and ultrasound results as well as diagnoses and treatments provided. Using the final diagnosis as a gold standard, the sensitivity and specificity of ultrasound and urinalysis were calculated for the diagnosis of epididymo-orchitis. Also, through a prespecified definition of “changed management,” we estimated the percentage of cases in which a urinalysis changed management of patients with acute scrotal pain.

Results

We identified 663 adult and pediatric patients who presented with scrotal pain during 2016. All patients had an ultrasound performed, and 458 (69.1%) had a urinalysis done. The sensitivity of urinalysis for epididymo-orchitis was 58.2% (95% CI 48.9% to 67.1%), and the specificity was 85.1% (95% CI 80.8% to 88.7%). For ultrasound, the sensitivity was 78.8% (95% CI 71.4% to 85.0%) and the specificity was 98.1% (95% CI 96.4% to 99.1%). In 24 of 458 cases (5.2% [95% CI 3.4% to 7.7%]) where a urinalysis was obtained, its results may have changed management of the patient.

Conclusion

The diagnosis of patients who present to the ED with scrotal pain is primarily driven by the ultrasound results. While the urinalysis may occasionally provide some benefit in the evaluation of patients with suspected epididymo-orchitis, the reflexive ordering of a urinalysis in patients with scrotal pain may be unnecessary.

Testicular necrosis due to complicated epididymitis and ruptured sperm granuloma in a 13-year-old boy

Sperm cell granuloma, also termed epididymitis nodosa, is a form of chronic epididymitis that occurs secondary to inflammation, trauma, and/or a vasectomy. We present a rare such case that to our knowledge is unique in pediatric literature: a 13-year-old boy presented with clinical and sonographic findings of epididymo-orchitis. At first, the boy was admitted for a short course of conservative treatment and was discharged. Symptoms deteriorated, he was readmitted and surgery revealed a non-twisted testis, with normal vas and vessels that ended in a necrotic testicular parenchyma. Histology showed a case of epididymitis nodosa and ruptured sperm granuloma that caused vascular compression, thrombosis and testicular necrosis. Epididymitis nodosa should be considered in cases of testicular swelling when clinical course is unusual and conservative treatment fails.

Different managements for prepubertal epididymitis based on a preexisting genitourinary anomaly diagnosis

There is no clear consensus regarding investigating for accompanying genitourinary anomalies (GUAs) in patients with prepubertal acute epididymitis (AE). Moreover, risk factors for the recurrence and the need for a surgical intervention have never been discussed. The purpose of this study was to evaluate the different clinical courses of prepubertal AE based on knowledge of preexisting GUAs. Between January 2005 and December 2014, AE was diagnosed in 189 pediatric patients <10 years old. Clinical characteristics and treatments were retrospectively analyzed. The median age at first AE was 64.3 months. A GUA was detected prior to the development of AE in 49 patients (known GUA group) including 34 with hypospadias. Among the other 140 patients (unknown GUA status group), six patients were diagnosed with a GUA after the first AE episode. In the known GUA group, 35 patients (71.4%) experienced recurrence and the only risk factor associated with recurrence was the presence of cystic dilated prostatic utricle (p = 0.013). In the unknown GUA status group, the risk factors for an existing GUA were being <1-year-old (p<0.001) and positive urine culture (p = 0.015). Only nine patients (6.4%) in this group experienced recurrence. Vasectomy was recommended for patients with recurrent AE with an accompanying GUA and performed in 19 patients (10.1%). Most GUAs are diagnosed prior to AE development. Clinicians should consider different treatment approaches based on whether the AE patient has been diagnosed with a GUA previously, because the clinical characteristics and the recurrence rate are significantly different.

Prospective Validation of Clinical Score for Males Presenting With an Acute Scrotum

OBJECTIVE

The objective was to validate the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score among pediatric emergency medicine providers for the evaluation of pediatric males presenting with testicular pain and swelling (acute scrotum).

METHODS

We conducted a prospective cohort study of males 3 months to 18 years old presenting with an acute scrotum. History and physical examination findings, including components of the TWIST score (hard testicle, absent cremasteric reflex, nausea/vomiting, and high riding testicle) as well as diagnostic results (ultrasound, urine, sexually transmitted infection testing) were recorded. Testicular torsion was confirmed by surgical exploration. Frequencies of patient characteristics, TWIST components, and tests were calculated. We performed the kappa statistic for inter-rater reliability and calculated the test characteristics and receiver operator characteristics curves for the TWIST score (range = 0-7).

RESULTS

During the study period 258 males were enrolled in the study; 19 (7.4%) had testicular torsion. The mean (±SD) age was 9.8 (±0.3) years. The high-risk TWIST score of 7 had 100% specificity (95% confidence interval [CI] = 98%-100%) with 100% positive predictive value (95% CI = 40%-100%) for testicular torsion. The area under the curve was 0.82. The kappa statistic for the overall TWIST score was fair at 0.39.

CONCLUSIONS

In this prospective validation of the TWIST score among pediatric emergency providers, the high-risk score demonstrated strong test characteristics for testicular torsion. The TWIST score could be used as part of a standardized approach for evaluation of the pediatric acute scrotum to provide more efficient and effective care.

Variation in the evaluation of testicular conditions across United States pediatric emergency departments

OBJECTIVES

To explore the variation in diagnostic testing and management for males diagnosed with three testicular conditions (testicular torsion, appendix testis torsion, epididymitis/orchitis) using a large pediatric health care database. Diagnostic testing is frequently used in evaluation of the acute scrotum; however, there is likely variability in the use of these tests in the emergency department setting.

METHODS

We conducted a cross-sectional study of males with the diagnoses of testicular torsion, appendix testis torsion, and epididymitis/orchitis. We identified emergency department patients in the Pediatric Health Information Systems (PHIS) database from 2010 to 2015 using diagnostic and procedure codes from the International Classification of Diseases Codes 9 and 10. Frequencies of diagnoses by demographic characteristics and of procedures and diagnostic testing (ultrasound, urinalysis, urine culture and sexually transmitted infection testing) by age group were calculated. We analyzed testing trends over time.

RESULTS

We identified 17,000 males with the diagnoses of testicular torsion (21.7%), appendix testis torsion (17.9%), and epididymitis/orchitis (60.3%) from 2010 to 2015. There was substantial variation among hospitals in all categories of testing for each of the diagnoses. Overall, ultrasound utilization ranged from 33.1-100% and urinalysis testing ranged from 17.0-84.9% for all conditions. Only urine culture testing decreased over time for all three diagnoses (40.6% in 2010 to 31.5 in 2015).

CONCLUSIONS

There was wide variation in the use of diagnostic testing across pediatric hospitals for males with common testicular conditions. Development of evaluation guidelines for the acute scrotum could decrease variation in testing.

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 ].

Scrotal pain: evaluation and management

Scrotal pain is a common complaint in a urological practice. Its diagnosis can prove challenging in both acute and chronic forms and requires a thorough and complete history and physical examination. This article discusses the evaluation and management of several entities of scrotal pain, including testicular torsion, epididymitis, postvasectomy pain, varicocele, and chronic orchialgia.

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.

Acute epididymitis in children: the role of the urine test

PURPOSE

Acute epididymitis is considered to have an important role in children with scrotal pain. Recent reports have shown that urinalysis is not helpful for the diagnosis and treatment of acute epididymitis owing to negative microbiological findings. Therefore, we analyzed clinical and laboratory characteristics to examine the diagnostic yield of urinalysis in children.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 139 patients who were diagnosed with acute epididymitis from 2005 to 2011. Diagnosis was based on symptoms, physical findings, and color Doppler ultrasonography (DUS). To investigate the characteristics of epididymitis in children, the patients were divided into 3 groups: group A (aged less than 18 years, 76 patients), group B (18 to 35 years old, 19 patients), and group C (older than 35 years, 44 patients).

RESULTS

There were statistically significant differences in age, symptom duration, hospital stays, and lesion location in each group. White blood cell count and serum C-reactive protein levels, pyuria, and positive urine culture results were statistically higher in the older age group. The most common cause of acute epididymitis in children was idiopathic (96.1%).

CONCLUSIONS

In our group of children with epididymitis, 73 cases out of 76 (96.1%) resulted in negative pyuria in urinalysis. In addition, the most common cause of epididymitis was idiopathic. Because most urinalyses do not show pyuria, we believe that routine antibiotics may be not required in pediatric patients with epididymitis. If urinalysis shows pyuria with or without positive urine culture, antibiotics should be considered.

Segmental haemorrhagic infarction of the testis in a paediatric patient: a rare aftermath of epididymitis

Testicular infarction is an uncommon finding in paediatric age and is usually due to testicular torsion or trauma causing venous rupture with thrombosis and/or arteriolar obstruction. Other causes of segmental infarction of the testes are represented by polyarteritis nodosa, thromboangioiitis obliterans and hypersensitivity angiitis. A few cases of testicular infarction due to epididymitis have been described in the literature related mainly to adult patients. Epididymitis is usually treated in the outpatient setting with close follow-up, but according to our present experience, and reviewing the literature, there may be some cases in which, surgical exploration is mandatory in order to avoid testicular damage.