Epididymitis in Children

Epididymitis in ChildrenOne of the great aspects of working in my ED is being surrounded by a multitude of amazing and brilliant teammates. One, Dr. Christyn Magill, recently provoked this Morsel of knowledge: just because it ends in “-itis” does not mean it needs antibiotics! Excellent point! We have covered this previously with Sinusitis, but another excellent example of this notion is Epididymitis!! Let us take a moment to review how Epididymitis in Children:


Acute Scrotal Pain


Acute Epididymitis in Children

  • Epididymitis is not rare in children.
    • Older literature described it as a rare condition, but newer research shows greater frequency of disease than previously known. [Nistal, 2016; Redshaw, 2014]
    • Majority of cases occur in prepubertal / early adolescent boys (11-14 years). [Redshaw, 2014; Santillanes, 2011]
    • Comprises up to 35-65% of all acute scrotal pain cases. [Nistal, 2016]
  • Epididymitis is often considered to be due to an infection.
    • Older males often have reflux of urine due to prostatic hypertrophy.
    • Young males (<35 years) often have an associated sexually transmitted disease.
    • What about the children who are not sexually active?
  • In young children, the INCIDENCE of infection is LOW. [Nistal, 2016; Santillanes, 2011]
    • Of ~1,500 patients with acute epididymitis, only ~15% had positive urine cultures. [Cristoforo, 2016]
    • Unfortunately, >85% still received antibiotics. [Cristoforo, 2016; Santillanes, 2011]
    • In the end, the majority are classified as idiopathic. [Redshaw, 2014; Min Joo, 2013]
      • True etiology is still not fully understood.
      • May be due to:
        • Inflammation from adjacent torsion of appendix of testis
        • Reflux of sterile urine
        • Viral illness (ex, Mumps, Coxsackie B, influenza, EBV)
        • Anatomic abnormalities (likely in younger patients)
        • Trauma
  • Epididymitis is usually a unilateral process. [Nistal, 2016]
    • The right side is affected more often.
    • Hydrocele is usually observed along with local symptoms of inflammation.


Epididymitis: Evaluation/Management

  • 1st, don’t overlook the potential for torsion as the etiology!
    • Distinguishing epididymitis from testicular torsion clinically can be difficult. [Redshaw, 2014]
    • Have low threshold for obtaining Ultrasound.
  • If history, exam, and U/S are consistent with epididymitis, consider the age:
    • Young boys who are not sexually active
      • Low risk for infectious etiology. [Cristoforo, 2016; Santillanes, 2011]
        • May wish to treat based on abnormal urinalysis.
        • Could also wait until Urine Culture results, as rates of true infections are slow low. [Cristoforo, 2016; Santillanes, 2011]
      • Treat with NSAIDs, scrotal support, and rest
    • Sexually active boys
      • At risk for STDs!
      • Consider testing and starting empiric therapy.
      • Also can use NSAIDs, scrotal support, and rest (and AVOIDING SEX!).


Moral of the Morsel

  • Don’t overlook torsion! Think of epididymitis as the potential cause of acute scrotal pain in young boys, but check that ultrasound!
  • Just because it has “-itis” at the end of the word, does not mean it is an antibiotic deficiency!
    • There is an abundance of antibiotics given to boys with epididymitis who have a low risk for infection. Don’t add to the problem. (see C. Difficile)
    • Check a Urine Culture (maybe even resist the urge to react to a urinalysis) and educate the family.



Cristoforo TA1. Evaluating the Necessity of Antibiotics in the Treatment of Acute Epididymitis in Pediatric Patients: A Literature Review of Retrospective Studies and Data Analysis. Pediatr Emerg Care. 2017 Jan 17. PMID: 28099292. [PubMed] [Read by QxMD]

Nistal M1, Paniagua R2, González-Peramato P1, Reyes-Múgica M3. Perspective in Pediatric Pathology, Chapter 24. Testicular Inflammatory Processes in Pediatric Patients. Pediatr Dev Pathol. 2016 Nov/Dec;19(6):460-470. PMID: 27575254. [PubMed] [Read by QxMD]

Redshaw JD1, Tran TL2, Wallis MC3, deVries CR4. Epididymitis: a 21-year retrospective review of presentations to an outpatient urology clinic. J Urol. 2014 Oct;192(4):1203-7. PMID: 24735936. [PubMed] [Read by QxMD]

Joo JM1, Yang SH, Kang TW, Jung JH, Kim SJ, Kim KJ. Acute epididymitis in children: the role of the urine test. Korean J Urol. 2013 Feb;54(2):135-8. PMID: 23550228. [PubMed] [Read by QxMD]

Santillanes G1, Gausche-Hill M, Lewis RJ. Are antibiotics necessary for pediatric epididymitis? Pediatr Emerg Care. 2011 Mar;27(3):174-8. PMID: 21346680. [PubMed] [Read by QxMD]

Sakellaris GS1, Charissis GC. Acute epididymitis in Greek children: a 3-year retrospective study. Eur J Pediatr. 2008 Jul;167(7):765-9. PMID: 17786475. [PubMed] [Read by QxMD]

Somekh E1, Gorenstein A, Serour F. Acute epididymitis in boys: evidence of a post-infectious etiology. J Urol. 2004 Jan;171(1):391-4; discussion 394. PMID: 14665940. [PubMed] [Read by QxMD]

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ALiEM Book Club: The Tennis Partner

“Gripping… The Tennis Partner is a sincere and self-effacing book by a physician who well knows that there are things in the human heart that no electrocardiogram can detect.” – Times Literary Supplement

Abraham Verghese, a board-certified physician and a professor at Stanford University is a critically acclaimed, best-selling author. The Tennis Partner is an autobiographical memoir written by Verghese during a time of great turmoil in his life – an unraveling marriage while balancing a brand new attending position in El Paso, TX. He writes about his friendship with David Smith, a young Australian medical student that he meets. The book illuminates the intertwined worlds of of medicine and relationships, but above all else the capacity humans have towards each other in both a healing and hurtful manner.


The opening chapter of the book starts with a narrated experience of a medical resident being hauled off to the Talbott-Marsh clinic in Atlanta, GA, a drug and alcohol rehab program specifically designed for physicians, which sets the scene for the rest of the book.

The reader is then introduced to the book’s protagonist Dr. Abraham Verghese, a foreign medical graduate and a newcomer to El Paso. He quickly befriends David Smith, an Australian medical student on his medicine ward service with whom he starts to share a ritual of routine play and practice in tennis, a game they both love and feel passionate towards. Their friendship builds during these interactions and Verghese is initially unaware of David’s dark past of drug addiction. Verghese is also going through a period of turmoil and change as his marriage disintegrates; their tennis matches become an escape for them both. This bond between doctor and intern grows increasingly rich and complex until David’s dark past emerges again.

There are signs of it along the way as David’s relationships with women have a frantic, tortured quality; the confidence and poise he exhibits on the court is strangely lacking off of the court. David spirals out of control as he starts to abuse drugs again, and almost everything Verghese has come to trust and believe is threatened. Verghese finds himself forced to choose between his role as a friend and that of an authority figure.

The last few chapters lead us through the ups and downs of David’s drug usage and finally tragically concludes with Verghese visiting the morgue as he is asked to identify David’s body after his suicide. The book final chapter has Verghese relieve both the ups and downs of his memories and friendship with David, and how he comes to terms with the loss.

Analysis and Clinical Application

I spent a long time talking with the patient. If I overdid it, it was to impress on David how this alone – being a doctor – should have been enough. There was so much to learn and perfect and polish and understand in medicine. Why had doctoring not been enough for David? – Page 259

The book tackles the complex subject of addiction and recovery. Verghese doesn’t pretend to understand the roots of Smith’s trouble and never presses him about details to gain further insight. Instead, he relies on the tools he uses daily as a physician – his detail oriented methodology and careful observation of his patients to describe how he discovers and watches his friend’s self destruction.

“Abraham,” David said, “I’ve decided to try to get into an emergency medicine residency after the internship”.

I was surprised at how acutely disappointed I was to hear him say that. I thought it was the wrong choice for him, given his past problems with cocaine. ER work was hectic, stressful, quick highs, lengthy lows – not unlike cocaine – Page 212

The Tennis Partner dives into the difficulty with those practicing the specialty of medicine; the way the medical profession fosters loneliness, discourages the expression of emotion, leaves individuals to battle their demons alone. He discusses how physicians encourage their patients to express themselves but how it is not considered a strength but in fact a weakness if the same is done with physician colleagues.

The story of David illustrates how frustrating and often hopeless it is to try to rehabilitate the addicted, and particularly, how far we are from understanding the causes or successful treatment of addiction. At the same time, important questions of professionalism, medical and personal ethics, and the blurring of personal and professional boundaries are explored.

My dark path, no matter how many times I relive it, would never have led to suicide. There was too much I believed in, too many things I held sacred. My escape from the dark path came from reaching out, primarily to him (David), but also to my parents, my brothers, my friends, a network of human connections – Page 340

Verghese leaves the readers with hope as he chooses a different path from David’s, however demonstrates the difficulty all physicians face in finding their own wellness in both their work and home lives.

Wellness in Medicine

The issues of wellness, burnout, and resiliency have snowballed across nearly all health professions. Emergency Medicine (EM) specifically was singled out as one of the specialties with highest risk for burnout. Continuing to bring awareness to this issue with blog posts such as Healthy in EM, the ALiEM Wellness Think Tank, EM Wellness Week are only some of the initiatives ongoing, and continued work in the field will bring about greater and greater culture change.

Please contact us at ALiEM if interested in any of the above initiatives in the topics of wellness, resiliency, and burnout within medicine, and especially Emergency Medicine.

 Book Club Questions:

  1. Do you think David might have been a happier and healthier person had he chosen a different profession instead of medicine?
  2. Is there something about medicine that attracts addiction-prone individuals or that causes clinicians to turn to drugs?
  3. David’s addiction sponsor Jim states, “David is responsible for David. You aren’t responsible for David. Don’t get caught in that trap. No one can make him do anything. No one made him use. No one can stop him from using but himself”. How can a true friend deny responsibility for his friend in crisis? Do you agree with Verghese’s decision to betray David’s trust by reporting him when he found out the truth?

Author information

Fareen Zaver, MD

Fareen Zaver, MD

Chief Operating Officer, Chief Resident Incubator 2017-18
Lead Editor/Co-Founder of ALiEM Approved Instructional Resources - Professional (AIR-Pro)
Champion, 2016-17 ALiEM Chief Resident Incubator
Board Member, 2016-17 ALiEM Wellness Think Tank
Clinical Lecturer, Emergency Physician
University of Calgary Emergency Department

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Sesión PAC: ¿Nos atrevemos a infiltrar?

Nuestra sesión del mes de marzo nos la dio Mª Jesús Bolaños, médica del PAC de Hernani, y trató sobre la realización de infiltraciones en nuestras consultas. Repasamos juntos la aplicación de esta técnica en las patologías más habituales en nuestro ámbito. Yo creo que somos muchos los que tenemos nuestras reservas para hacerlo habitualmente y no está mal darle una vuelta a este asunto, tal vez nos haya servido para considerar la opción de utilizarla en alguna que otra ocasión.
Mila esker Mª Jesús! Nos vemos en abril.