One hundred twenty-eight consecutive cases of acute scrotal inflammation were evaluated. Thirty-six (28%) were diagnosed with acute epididymitis. The mean age was 12 years and all had descended testes. The 36 patients fell into two groups: 5 infants (10 weeks to 9 months), and 31 boys 7 years and older (7 to 20 years). In older boys, the enlarged, tender epididymitis was usually palpable separate from the testis, but this was not possible in infants who were found to have a single indurated mass. Ten of 36 patients had fever (28%), four patients had urethral discharge (11%), and four had leukocytosis (11%). The urinalysis was normal in 28 of 36 (78%). Of the 8 abnormal urinalyses (pyuria), 7 were in sexually active boys and 1 had a neurogenic bladder. Radionuclide scans were diagnostic in 31 of 33 (94%), while scans in infants were difficult to interpret due to scrotal size. Physical exam alone was felt to be diagnostic in only 6 of 36 (17%). All 5 infants and 3 older boys underwent scrotal exploration to rule out torsion. After initial treatment, all infants underwent ultrasound and voiding cystourethrogram (VCUG) while 29 of 31 older boys underwent ultrasound and 10 had VCUGs. These studies, performed to rule out upper urinary tract anomalies were all normal except for 1 in a boy with myelodysplasia who was found to have reflux into a dysplastic kidney. All were treated with antibiotics and followed until the scrotum returned to normal (6 weeks to 6 months). No complications, sequelae, or testicular atrophy occurred.
Nine of the 36 boys (25%) were circumcised. None of the infants were circumcised. This finding was compared to three other groups of patients who were matched for age and race. Twenty-six percent (11) of another group of 43 boys diagnosed elsewhere with acute epididymitis were circumcised. The overall circumcision rates of two other separate groups, one, a statewide circumcision rate and the other, 200 consecutive ED visits by males without a urological diagnosis, were 70% and 65% respectively. The statistical difference in the circumcision status between the two epididymitis groups and the two control groups was highly significant (p=0.0004).
This study is the first to analyze the relationship of circumcision and acute epididymitis. The authors have shown the unreliability of physical findings in diagnosing epididymitis and document the accuracy of radionuclide scrotal scans in older boys and its limitations in infants. While the number of patients in the study was small, the finding of normal ultrasounds and VCUGs in all but one case supports the conclusion that most boys with epididymitis do not have significant urinary anomalies. The authors’ recommendations that a urinary tract sonographic study be performed in all patients with acute epididymitis, while reserving a VCUG for those patients with an abnormal ultrasound, seems reasonable.
The most important finding of the study is the correlation of an intact foreskin...