Report on Epididymitis: Pathophysiology and Sonographic Findings

This report provides a comprehensive overview of epididymitis, a testicle infection characterized by inflammation of the epididymis. It details the pathophysiology of the condition, including the role of bacterial infections (such as sexually transmitted infections and urinary tract infections) and the mechanisms leading to inflammation, pain, and potential complications like reduced sperm count. The report further explores the sonographic appearance of epididymitis, highlighting the use of ultrasonography as a key diagnostic tool. It describes the typical findings in ultrasound imaging, such as an enlarged and echogenic epididymis, increased blood flow, and the presence of reactive hydrocele. The report includes sonographic images and references to support the findings, offering a valuable resource for understanding the clinical presentation and diagnostic approach to epididymitis. The report covers causes, symptoms, and diagnostic methods, providing a complete overview of the condition.

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Part A: The Pathophysiology of Epididymitis
Epididymitis is a testicle infection that causes the inflammation of the epididymis. The
epididymis is a tube that is located at the back of the testicles whose function is to store and carry
sperm. When this tube becomes infected by bacteria, it becomes swollen, thereby leading to
inflammation pain in the testicles. It can affect men of all ages, but it is most common in men
between the ages of 14 to 35. Its symptoms include pain in the pelvic area, pressure, pain, and
tenderness in testicles, pain during sexual intercourse, abnormal penile discharge, chills, and
redness in the scrotum. The common causes of epididymitis are sexually transmitted infections
such as gonorrhea and chlamydia and non-sexually transmitted infections such as tuberculosis
(Sullivan and Mieusset, 2016).
A bacterial infection most commonly causes epididymitis. In the case of sexually
transmitted disorders, bacteria are introduced during sex intercourse. They then migrate to
epididymis through the genitourinary tract. In the cases of infection as a result of urinary tract
infection, the retrograde flow of urine along the genitourinary tract leads to infection of the
epididymis. Besides, when the disorder is as a result of repetitive movements, the mobility of the
scrotum together with its contents leads to inflammation of the epididymis or testes. Also,
certain viruses such as mumps have the tendency to infect the epididymis.
The pathophysiology of epididymitis is grouped into two chlamydia trachomatis and
Neisseria gonorrhoeae. The Neisseria gonorrhoeae is the most common pathogens in the patient
who are under the age of 35 years. On the other hand, Enterobacteriaceae and gram-positive
cocci are common in patients who are above 35 years. The older men are usually enteric to

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pathogens causing epididymitis, which is linked to bladder outlet obstruction and systemic
illnesses.
The reflux of urine via orifice of ejaculatory ducts at verumontanum occurs as a result of
inflammation which produces rigidity in the musculature surrounding orifice to ejaculatory ducts
holding them open. Men under the age of 14 years cause largely unknown although likely
anatomic abnormalities leading to the urine-like ectopic ureter, anorectal malformation. This
may also be part of the post-infection syndrome from mycoplasma pneumonia. For men between
14 to 35 years of age, they may have Chlamydia trachomatis, also referred to as severe urethra
discharge or purulent discharge in sexually active men (Rao and Arjun, 2012).
Reduction of sperm count is another pathophysiology of epididymitis. In this case, rare
azoospermia after initial 14-day epididymitis occurs. Wall thickening of the scrotum also occurs,
increased mechanical forces from the obstruction of the cells results into differentiated of
myeloid cells into SMCs. Another pathophysiological process that occurs as a result of
epididymitis infection is replacement of spindle-shaped myeloid cells in normal contractile
tubules by large smooth muscle cells. Acute epididymitis causes pain, and tender swelling of the
epididymis, whereas and the symptoms are unilateral as they develop over a few days (Liang and
Pang, 2012).

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Part B: The sonographic appearance of epididymitis
Ultrasonography is the ideal imaging technique that is commonly used in evaluation of
the scrotal abnormalities. It is provides fine anatomical details of the epididymis and the
surrounding structures in the scrotum (Delaney and Karmazyn, 2013). Ultrasonography of the
testis includes greyscale and color Doppler evaluations of the scrotum.
In the case of epididymitis, the epididymal tail is commonly affected area together with
the reactive hydrocele, which results in the thickening of the scrotal wall as observed during
sonography. Besides, the increased size of heterogeneous echogenicity of the scrotum is
observed (Yusuf and Sidhu, 2013). While performing the sonographic appearance of the
epididymitis, a markedly enlarged, echogenic epididymis is observed. Also, avascular or
hypovascular epididymis is observed a sign (Graumann, Dietz and Stehr, 2010).
The inflammation produces increased blood flow within the epididymis or in the
scrotum. The pulsed wave Doppler interrogation yields an epididymal peak systolic velocity,
which is greater, which suggests the presence of epididymitis disorder. A low resistance pattern
of epididymal waveform also suggests epididymitis infection (Carkaci et al. 2010).
In the cases that I observed while on placement, hypervascular enlarged epididymis
frequently occurred in 5 percent of these cases. In these cases, the size and shape of the
epididymis in both symptomatic and asymptomatic was evaluated. Besides, the gray-scale
appearance of the epididymis was determined and the vascularity of the eipsilateral epididymis
together with the symptomatic scrotum examined with the color flow of Doppler imaging
(Waldert et al. 2010).

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The results of Sonographic appearance of epidymitis in cases I observed while on placement
include:
Figure 1 (Carkaci et al. 2010).
The figure shows longitudinal image of epididymis in 3 patients who were infected with
epididymitis disease. The sonograpic appearance shows diffuse enlargement of the head, body
and the tail of epididymis. Besides, the epididymis appears to be bilobular in shape with
increased echogenicity an indication of epididymitis infection (Lev, et al. 2015).

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Figure 2 (Carkaci et al. 2010)
Figure 2 shows the longitudinal image of heterogeneous increased echogenicity of epididymis
(Carkaci et al. 2010).
Figure 3 (Carkaci et al. 2010).
The figure 3 shows diffusely swollen epididymis and enlarged spermatic cord (Carkaci et al.
2010).

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References
Carkaci, S., Ozkan, E., Lane, D. and Yang, W.T., 2010. Scrotal sonography revisited. Journal of
Clinical Ultrasound, 38(1), pp.21-37.
Delaney, L.R. and Karmazyn, B., 2013, June. Ultrasound of the pediatric scrotum. In Seminars
in Ultrasound, CT and MRI(Vol. 34, No. 3, pp. 248-256). WB Saunders.
Graumann, L.A., Dietz, H.G. and Stehr, M., 2010. Urinalysis in children with
epididymitis. European journal of pediatric surgery, 20(04), pp.247-249.
Lev, M., Ramon, J., Mor, Y., Jacobson, J.M. and Soudack, M., 2015. Sonographic appearances
of torsion of the appendix testis and appendix epididymis in children. Journal of Clinical
Ultrasound, 43(8), pp.485-489.
Sullivan, R. and Mieusset, R., 2016. The human epididymis: its function in sperm
maturation. Human reproduction update, 22(5), pp.574-587.
Taylor, S.N., 2015. Epididymitis. Clinical Infectious Diseases, 61(suppl_8), pp.S770-S773.
Waldert, M., Klatte, T., Schmidbauer, J., Remzi, M., Lackner, J. and Marberger, M., 2010. Color
Doppler sonography reliably identifies testicular torsion in boys. Urology, 75(5), pp.1170-1174.
Yusuf, G.T. and Sidhu, P.S., 2013. A review of ultrasound imaging in scrotal
emergencies. Journal of ultrasound, 16(4), pp.171-178.