Major. M.P.Vora, M.B.B.S., D.V.D., I.M.S. (Rtd.)
Indian Medical Record
A monthly journal of Public Health, Tropical Medicine and Surgery etc .
Volume LXXXVII, Number-11of November 1966
This article was solely contributed to Indian Medical Record
The epididymis, testis, tunica vaginalis and vas are so intimately associated both in their function and anatomically that any disease of any one of these organs will invariably affect the others to a greater or lesser extent. Hence the term epididymitis would be improper.
Acute epididymo-orchitis develops secondary to genital gonorrhoea either acute or chronic and most frequently follows from 15 to 21 days. The infection spreads by a direct extension of the gonococcus from the posterior urethra to the ejaculatory duct and thence by the vas deference to the epididymis. Much more rarely it is due to lymphatic or haematogenic spread from the urethral tract. Occasionally reverse peristalsis set in action may be responsible for the spread of the infection. The acute attack may pass on into a chronic condition. This complication is more frequent in young men though no age is exempt. Suppuration is seldom observed. Amelioration of acute symptoms and reduction of the urethral discharge almost invariably coincide with the onset of epididymal involvement.
Etiology and Pathology
About ten percent cases of gonorrhoea do suffer from epididymo-orchitis in the course of illness. It is either due to direct extension or lymphogenous or haematogenous transference of the gonococcus from the posterior urethra. At times, reverse peristalsis may spread the infection to the epididymis. The condition is predisposed by an injury to the epididymis, trauma of the urethra, heavy work, weight-lifting, cycling, horse-riding, alcoholic or sexual excesses, and holding of urine for a long time during an acute attack of gonorrhoea or an acute exacerbation on the top of chronic gonorrhoea. The attack of epididymo-orchitis comes on within 24 hours of the definite event. For this very reason, instrumentation of the urethra or the prostatic massage is prohibited during the acute stage of infection. It invariably leads to spread of infection. The involvement of epididymis is accompanied by discomfort, dragging sensation in the scrotum, moderate fever, vomiting and intense pain. The earliest sign of infection is nearly always noticed in the globus minor at the lower pole of the testis.
Gonococci reach epididymis either by back pressure or by continuity of the surface infection or by lymphatics, penetrate spaces between the cells and produce peritubular infiltrations, swelling and small abscesses in the tissues. It is often the lower lobe of the epididymis that is first involved. Fibrosis with obliteration of the tubules is a common result, thus causing obstruction to the passage of semen produced. When both sides are involved, complete aspermia and sterility may be brought about. Presence of a small hydrocele is not uncommon. If the infection is severe, local suppuration in the epididymis is observed. Abscess usually points posteriorly through the skin.
Symptoms and signs
The individual symptoms caused are varied and depend to some extend on the locations in the body of the offending foci of infection. Epididymis is frequently involved during the second or third week following the acute attack of gonorrhoea. The attack comes on within a day of the definite event such as heavy work, trauma or injury. The globus minor is ushered in by a pain in the groin, pain radiating along the line of the spermatic cord or upward into iliac fossa. In some cases, the pain radiates down into the scrotum and gives rise to the feeling of weight. At the time of attack, the urethral signs and symptoms are appreciably lessened. The rise in temperature to 102°F to 104°F, increase in the pulse rate, urgency and frequency of micturation and acute tenderness of the scrotum are present. The vas deferens feels swollen, thickened and tender. The epididymis is tense and tender along the posterior border of the testicle. The skin over the part is red, hot and oedematous. There may be a small hydrocele. The condition is usually confined to one side but may occur on both sides. At times an abscess may develop when suppuration supervenes; the lower part of the scrotum then shows marked changes, the epididymis becomes fixed to the skin in the situation, the swelling shows fluctuation and the pus generally points behind through the skin, but seldom bursts into the tunica vaginalis. Sometimes an abscess along the spermatic cord is noticed. The acute attack subsides in about six to seven days and a subacute or chronic condition supervenes gradually. Sterility due to obliteration of the epididymal tubes or the spermatic cord is common. On an inquiry, the history of the recent attack of acute urethritis is available. If care is taken to examine the urethra, before the urine is passed, one may find a small amount of pus in the urethra or the urine passed will show turbidity or threads due to the presence of pus in the urine.
Before prescribing any treatment, it is of prime importance to endeavour to find out the etiologic cause and to establish an accurate diagnosis. Hence no opportunity must be lost to make an adequate inquiry and to examine the urethral smear and the urine in every case of epididymo-orchitis. An acute swelling involving the epididymis and to some extend the spermatic cord, following an attack of acute or chronic urethritis, is often due to gonococcal infection. However, for the accuracy, the demonstration of gonococcus either in the urethral discharge or the urine passed is obligatory. In practically every case, there is a simultaneous infection of the prostate and seminal vesicles. Difficulty in the diagnosis is experienced when the patient had already received some specific treatment or when he is in a chronic stage of infection. In such cases, it is often difficult to find gonococcus and the diagnosis can only be based on the process of exclusion and presumption. Direct examination of the urethral discharge, urine and secretion or exudate from accessory sexual gland is an important diagnostic procedure and must never be omitted before the institution of the specific therapy. For once the therapy is started; the possibility of confirming the etiology becomes remote.
The following conditions need to b considered before arriving at the conclusion.
It is satisfactory in most cases. Occasionally sterility results when both sides are involved.
Prevention of epididymitis is certainly an ideal objective. It can be easily prevented if every case of acute fresh gonorrhoea is properly and adequately treated and a reasonable cure is taken during the course of the illness.
As soon as the acute condition has subsided, the attention must be given to the primary focus of infection i.e. the posterior urethra, the prostate and the vesicle, in every case of acute epididymo-orchitis of gonococcal origin. However, this is often neglected unfortunately to the detriment of the patient’s health and the public health. Rational therapeutics ought to aim to treat the cause and not merely to relieve the symptoms of a disease. To obey the precepts of therapeutic rationality, one must avoid treating symptoms alone, when there is way to attack the cause. Besides, one must not overlook the problem of contact-investigation. Whenever gonococcal etiology is confirmed, the investigation and treatment of the contacts have to be undertaken. Without this, one would be failing in one’s duty.
Rest in bed till acute pain and swelling have subsided. A brisk saline purge, Mist Alkaline with Tr.Belladona one oz three times a day. A suppository containing morphia 1/4 gr. and atropine 1/100 gr. morning and evening daily for a few days, Calcium gluconate 10%, 10 ml I.V. on three consecutive days.
Ice-bag or hot applications to the scrotum. Before resorting to local applications, it is advisable to shave the groin and the scrotum. Hot antiphlogestine, glycerine-belladonna or 20% ichthyol in glycerine should be spread on a piece of lint and applied closely to the scrotum once or twice a day for a week. To keep the dressing in close contact with the scrotum, a triangular or T-shaped bandage is recommended. Support to scrotal contents is of great help in giving relief to the patient. If clear softening or fluctuation is detected at the site, the globus minor should be punctured with a needle and pus aspirated with normal care. If the abscess points out, an open incision on the posterior-lateral aspect into the epididymis is indicated.
Sulphadiazine one gm. four o r five times a day orally for six days or Procain penicillin-G fortified 400,000 units I.M. daily for seven days.
With this line of treatment, most of the cases subside and pain and to some extent local swelling disappear. However, it is necessary to continue efforts to bring about complete resolution. Local applications to the scrotum daily such as hot bath, iodex or 10% Ung.Hydrarg. Ammoniate should be continued for a few weeks, use of well-fitted scrotal support should be advised. It takes about four weeks for the complete resolution to take place. Where diathermy is available, it can be used with profit.
Treatment of the original focus of infection
This is a very tedious and time-consuming process taxing patience both of the doctor and the patient. However, it has to be undertaken. In every case, since the whole urethral tract and pathways from the posterior urethra to the epididymis including one of both seminal vesicles and some areas of the prostate are involved, it is necessary to deal with them in the appropriate way. It has been found that chemotherapy alone, however massive and prolonged it may be, does not prove effective in eradicating the infection, unless local therapeutic measures such as the prostatic massage, urethral dilatation etc. are employed side by side. These measure help to promote drainage, improve local blood supply and permit effective application of the chemotherapy. The amount of chemotherapy required for such cases is about three times that is considered adequate for an acute fresh case of gonorrhoea i.e. three courses of sulphadiazine at week’s interval or 4 to 5 M.U. of penicillin-G. The local measures of therapy i.e. urethral irrigation, weekly prostatic massage and urethral dilatation have to be continued at regular intervals for about 6 to 8 weeks before any assessment can be made. In some cases, a course of treatment may have to be repeated. If the gonococcus is found to be resistant to either sulpha drug or penicillin, one may have to switch over to another antibiotic like oxytetracycline. Average dose is six capsules of 250 mg each daily for seven days by mouth.
Tests of cure
When the full course of treatment is over, it is necessary to follow the patient for a few months and carry out tests of cure of gonorrhoea to confirm bacteriologic and permanent cure. The urine held for 4 to 5 hours should be free from pus cells and gonococci. Microscopic and cultural examination of the urine and secretions from accessory sexual glands must not reveal gonococci. The serologic test for syphilis must be negative. Finally urethroscopy should reveal normal texture of the urethral lining.