The authors from Edith Wolfson Medical Center, Holon, Israel, performed a prospective controlled study of 44 children (2 to 14 years of age) with acute epididymitis diagnosed by ultrasound. Control patients were males of similar age presenting for routine surgery. All patients with epididymitis underwent immediate scrotal ultrasonography as well as throat and urine cultures, viral cultures of the nasopharynx, and stool cultures. Serological tests for group A streptococcus and Mycoplasma pneumoniae were obtained in all cases and controls. Serological tests for enteroviruses, adenovirus, influenza, and parainfluenza virus were obtained in cases and controls when seasonally appropriate. One patient had epididymitis attributed to Henoch-Schönlein purpura and another had familial Mediterranean fever as a cause of epididymitis. Viral and/or bacterial growth was identified in 9 (20%) out of the 44 patients. Serological studies revealed significantly elevated titers of pathogens among patients with epididymitis compared to controls: M pneumoniae (53% versus 20%), enterovirus (62.5% versus 10%), and adenovirus (20% versus 0%). Urinary symptoms such as dysuria or increased micturition frequency were reported in 1% of cases. The authors conclude that epididymitis in the pediatric population is not rare and often post-infectious in etiology.
The evaluation of pediatric patients presenting with an acute scrotal pain is a complex endeavor. In postpubertal patients, epididymitis is often infectious in nature and sexually transmitted diseases should be ruled out. In a minority of prepubertal cases, urinary tract infection is present; but in most, the urine is sterile and the urinalysis is normal.1 The authors of the current study shed new light on the longstanding controversy surrounding the cause of epididymitis in prepubertal children. The hypothesis has been that sterile urine refluxes into the vas and epididymis and results in a chemically induced inflammatory response. The authors of the current study found that many of their patients had elevated titers for M pneumoniae, enterovirus, or adenovirus. The authors noted that 50% of their patients had experienced an upper respiratory infection during the month that preceded the epididymitis as compared to 22% of controls (P<.0001).
Serology in the clinical evaluation of the prepubertal child with epididymitis is not recommended, as the results will not affect treatment. Surprisingly, there is little agreement regarding the incidence of acute epididymitis in boys presenting with acute scrotal pain. Some authors claim that it is “rare” (and that torsion of the appendix testis is common); while in another series, the diagnosis of epididymitis was made in up to 71% of boys presenting with acute scrotal pain.2 In the current series, only 11% of the patients were diagnosed with torsion of the appendix testis. I have occasionally seen patients with apparent recurrent “torsion” of the appendix testis and it is possible that torsion of the appendix testis begins as an inflammatory, post-infectious condition as well.
Although the authors try to convince us that epididymitis might...