Mortality is on the order of 20% to 30%. There is debate about whether diabetes increases the mortality rate (Chawla et al. 2003, Nisbet and Thompson 2002).
This is an inflammatory condition of the epididymis, often involving the testis, and caused by bacterial infection. It presents with pain, swelling, and tenderness of the epididymis. It should be distinguished from chronic epididymitis where there is longstanding pain in the epididymis, but usually no swelling.
Infection ascends from the urethra or bladder. In men aged <35 years, the infective organism is usually Neisseria gonorrhoeae, Chlamydia trachomatis, or coliform bacteria (causing a urethritis that then ascends to infect the epididymis). In children and older men, the infective organisms are usually coliforms.
52 H. HASHIM AND J.REYNARD
A rare, noninfective cause of epididymitis is the antiarrhyth-mic drug amiodarone, which accumulates in high concentrations within the epididymis, causing inflammation (Gasparich 1984). It can be unilateral or bilateral and resolves on discontinuation of the drug.
Torsion of the testicle is the main differential diagnosis. A preceding history of symptoms suggestive of urethritis or urinary infection (burning when passing urine, frequency, urgency, and suprapubic pain) suggests that epididymitis is the cause of the scrotal pain, but these symptoms may not always be present in epididymitis. In epididymitis, pain, tenderness, and swelling may be confined to the epididymis, whereas in torsion the pain and swelling are localised to the testis. However, there may be overlap in these physical signs.
Where doubt exists—where you are unsure whether you are dealing with a torsion or epididymitis—exploration is the safest option. Though radionuclide scanning can differentiate between a torsion and epididymitis, this is not available in many hospitals. Colour Doppler ultrasonography, which provides a visual image of blood flow, can differentiate between a torsion and epi-didymitis, but its sensitivity for diagnosing torsion is only 80%, i.e., it misses the diagnosis of torsion in as many as 20% of cases (these 20% of cases have torsion, but normal findings on Doppler ultrasonography of the testis). Its sensitivity for diagnosing epi-didymitis is about 70%. Again, if in doubt, explore.