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Abstract
Epididymitis is a common presentation of acute testicular pain seen in the emergency department, the differential diagnosis being testicular torsion. The vast majority of young men with epididymitis have an infective aetiology and this settles with antibiotic treatment. The clinical course of a patient who presented with testicular pain is described. At ultrasonography, the patient was found to have the uncommon condition of testicular microlithiasis, a condition that has been linked to malignant disease. Emergency doctors should be aware of the potential consequences of returning scrotal pain consistent with epididymitis to the community on antibiotic treatment alone. All patients with probable epididymitis should have either a scrotal ultrasound or specialist follow up.
- microlithiasis
- epididymitis
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A 22 year old white man presented to the emergency department of the Leicester Royal Infirmary complaining of an increasingly painful left testicle, after mild blunt scrotal trauma sustained five days previously. The pain had not been alleviated by over the counter non-steroidal analgesia. He described no urinary symptoms and had not had intercourse for some months. He gave a history of chronic bilateral testicular tenderness and had been treated for epididymitis in the past.
On examination, he was afebrile. Scrotal examination revealed a very tender left epididymis and a mildly tender right epididymis, clinically inconsistent with torsion. Urine analysis was negative. An ultrasound scan of the scrotum was arranged from the emergency department, which was reported as a bilateral epididymitis and bilateral testicular microlithiasis with no haematoma or infarct seen (fig 1). The patient was discharged with antibiotic treatment and urology outpatient follow up.
Scrotal ultrasound shows the testis (upper left quadrant) with microliths (small white dots). There is also evidence of epididymitis present, depicted by a thickened oedematous epididymis (lower left quadrant).
DISCUSSION
Epididymitis itself is not an uncommon emergency department presentation. However, because of a lack of epidemiological data the actual incidence is unknown. Symptoms are usually unilateral and patients generally present with testicular pain accompanied by a tender swollen epididymis. They may present with dysuria, fever, scrotal erythema, and orchitis. Epididymitis is mostly infective in aetiology, with Chlamydia trachomatis and Neisseria gonorrhoeae being the two most common sexually transmitted organisms.1 From an emergency department perspective; the important diagnosis to exclude is testicular torsion. Simultaneous bilateral epididymitis as in this case is rare. In a review of 610 cases, bilateral epididymitis was noted in only 9% and in a proportion of these the initial presentation was unilateral and thereafter developed bilaterally.2
First documented in the 1960s as microcalcification within the lumina of seminiferous tubules, testicular microlithiasis is a rare diagnostic entity.3 As an essentially asymptomatic pathology, the prevalence in the male population remains unknown. Radiological studies assessing the incidence on ultrasonography have quoted figures ranging from 0.16% to.4%.4 Specific postmortem investigation to assess the incidence suggests a figure of 4% for adult men.5 Electron microscopy in the 1980s confirmed these deposits as consisting of a central calcified core surrounded by cellular debris, glycoprotein, and collagen.6 On ultrasound the deposits are less than 2 mm in diameter, hyperechoic, and tend not to cast an acoustic shadow. Reported associations include crypto-orchidism, Kleinfelter's syndrome, infertility, testicular pain, and testicular neoplasm.4,7 It has therefore been suggested that testicular microlithiasis should be considered a premalignant condition, and patients should have clinical and ultrasonographic follow up.8
As far as we are aware, there is no previous published case of bilateral epididymitis and bilateral microlithiasis occurring simultaneously in the same patient. This case reports standard emergency department management of acute testicular pain, following a pathway geared to excluding a diagnosis of testicular torsion. Once excluded, many patients are discharged from the emergency department with antibiotic treatment and often no specialist follow up.
This case highlights the importance of vigilance among emergency clinicians with regard to the painful scrotum in the absence of testicular torsion. Indeed, the take home message for us to learn here is that a clinical diagnosis of epididymitis without a scrotal ultrasound and or urology follow up is potentially hazardous.
Contributors
Shakthi Venketraman and Jim Gray realised this case merited reporting and conducted a literature search. Philip Evans edited the paper, stands guarantor, and oversaw the project. All authors contributed to writing the case report.