Patient Presentation
A 9-year-old male came to clinic with a 2-day history of left scrotal discomfort. He had played in a soccer tournament the day it began and denied any trauma to the genital area. He initially thought it was due to chaffing of his undergarment during the tournament, but the discomfort had increased and was now mildly painful. It had awoken him up in the night, but he did not tell his parents until the morning of evaluation. He said there was no swelling or redness to the testicle and that he hadn’t noticed any changes in the pain with movement of the testicle. He denied any problems with the right testicle and scrotum. He denied any masses or swellings in the genital area and also denied any dysuria or discharge from his penis. He had had an upper respiratory infection the week before. He denied anyone inappropriately touching him or sexual contact.
The past medical history was negative for any genitourinary problems including no kidney problems or urinary tract infections. The family history was negative for genitourinary abnormalities. The review of systems was negative for fever, chills, nausea, emesis or diarrhea.
The pertinent physical exam showed a male with normal vital signs including a temperature of 98.8F and normal growth parameters at the 75-90%. He was Tanner I for pubic hair and testicular size. His testicles were symmetrically located in the scrotum when observed without obvious erythema or masses to the scrotum. The phallus was circumcised and normal. The left testicle showed mild pain with palpation of the epididymis and possibly the testicle itself, but it was more prominent over the epididymis. There were no obvious masses of the testicle or along the cord. There was no change in pain with testicular elevation. No inguinal hernias were palpated.
The diagnosis of acute epididymitis with possible orchitis was made. The laboratory evaluation included a urinalysis that was normal and the urine culture was pending. The pediatrician discussed the patient with the on-call urologist who was comfortable with treating him with supportive care and monitoring without further evaluation or empiric antibiotics. The patient’s clinical course showed that he had similar pain for another 48 hours and then this declined until he was pain free by 6 days after the onset. He never was febrile nor had any urinary symptoms, and it was felt this was possibly due to a post-viral infection.
Discussion
In acute epididymitis there is usually an insidious onset of a painful epididymis with swelling and inflammation. Often the testicle itself is also involved and this condition is called epididymo-orchitis. The term epididymitis will be used here. Epididymitis is a common cause of acute scrotal pain with about 1/3 of prepubescent boys presenting with this problem. Some studies show a bimodal distribution of infancy and prepuberty, while others show a peak in prepuberty or late adolescence. With epididymitis, there is normal placement of the testes and normal cremasteric reflex. Scrotal edema may occur and there may also be dysuria. The exact mechanism is not known but may be because of “…urinary outflow obstruction which leads to reflux of urine into the ejaculatory duct.” The actual cause if often not identified (< 10% is cited) but is likely viral infections, post-infection inflammation or trauma in younger boys, but in adolescents and adults sexually transmitted infections are more common. Common pathogens in younger males are adenovirus, enterovirus and Mycoplasma. In adolescents, Neisseria gonorrhea and Chlamydia trachomatis may occur. E. coli is also common if there are associated anatomic abnormalities. As some studies have found that epididymal aspirates correlate with urine culture, urine culture is used as a marker for bacterial analysis.
Learning Point
As some studies have found that epididymal aspirates correlate with urine culture, urine culture is used as a marker for bacterial analysis. Assessment includes evaluation of other causes of scrotal swelling or testicular pain (see Questions for Further Discussion below) and usually a urine culture, and testing for sexually transmitted infections (STIs) in the appropriate age range. Testing for both gonorrhea and chlamydia is recommended as concomitant STIs may occur together. Treatment for younger, prepubescent males is mainly supportive including ice, rest and anti-inflammatory medication. Antibiotics are often not recommended in this age group unless there is a higher risk of a serious bacterial infection such as an anatomic abnormality, neonatal age, or being immunocompromised. For adolescents and young adults, empiric treatment with antibiotics against common infections, and definitive treatment for positive urine culture or STI testing is recommended. Although in general there are good outcomes for epididymitis occurring in the pediatric age range, testicular abscess or infarction can occur.
Questions for Further Discussion
1. What causes scrotal swelling? A review can be found here
2. What causes testicular pain? A review can be found here
3. What is a spermatocele?
Related Cases
- Disease: Epididymitis | Testicular Disorders
- Symptom/Presentation: Scrotal Pain
- Specialty: Nephrology / Urology
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Testicular Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Cristoforo TA. 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. 2021;37(12):e1675-e1680. doi:10.1097/PEC.0000000000001018
Norton SM, Saies A, Browne E, et al. Outcome of acute epididymo-orchitis: risk factors for testicular loss. World J Urol. 2023;41(9):2421-2428. doi:10.1007/s00345-023-04500-1
Hoffmann K, Gopal M. Paediatric acute epididymo-orchitis temporally related to SARS-CoV-2 infection: A case series and review of the literature. Journal of Pediatric Urology. 2024;20(1):91-94. doi:10.1016/j.jpurol.2023.09.017
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

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