Painful scrotumの鑑別としてはEpididymitis & orchitis ,Torsion of testicle,
Torsion of testicular appendixがあるが、通常Torsion of testicular appendixは20歳以前に見られ、
陰嚢に圧痛はない。Epididymitis & orchitis とTorsion of testicleの鑑別には、一般にカラードップラー
エコーが感度86-100％、特異度100％と有用だが、この症例では発熱がみられ、尿道からの分泌物が
確認できたため、グラム染色にて淋菌と確認できた。（写真）
Epididymitis
Epididymitis is an inflammation or infection of the epididymis. This can occur as the result of trauma
or infection. Symptoms of epididymitis include discomfort in the region of the testicle. This pain and
tenderness is often referred into the groin and occasionally into the abdomen. Initially , tenderness is
well localized to the epididymis, but progression of inflammation results in the physical examination
findings of a single ,large testicular mass( epididymoorchitis) difficult to differentiate from testicular
torsion or carcinoma. Sexually transmitted pathogens are the organisms most often responsible for
epididymitis in the patient younger than 35 years. Chlamydia trachomatis is responsible for nearly 50
-60% of cases, while Neisseria gonorrhoeae is the second most common organism responsibile for
epididymitis. In patients older than 35 years, coliform bacteria predominate, as there is often
underlying obstructive urinary disease. However, sexually transmitted pathogens are still a
consideration. Infrequently, one will encounter chemical epididymitis, which represents an
inflammatory process due to the reflux of sterileurine.
Management and treatment
Depends on availability of results of the stained smears of urethral secretions and urine
Results available
Smear of urethral secretions shows a mean of > or = 4 polymorphonuclear leucocytes (PMNs)/field (x
1000) in 5 fields and gram- negative intracellular diplococci
treat for epididymitis due to N. gonorrhoeae and C. trachomatis:
ceftriaxone 250 mg IM in a single dose(a)
PLUS
doxycycline 100 mg orally x 2/day for at least 10 days OR tetracycline 500 mg orally x 4/day for at
least 10 days
Smear of urethral secretions shows a mean of > or = 4 PMNs/field (x 1000) but no gram- negative
intracellular diplococci
treat for C. trachomatis epididymitis alone
Preferred:
doxycycline 100 mg orally x 2/day for at least 10 days OR tetracycline 500 mg orally x 4/day for at
least 10 days
Smear of urethral secretions shows a mean of < 4 PMNs/field (x 1000) but the stain of unspun urine
shows PMNs and one or more bacteria/field (x 1000)
treat as for a urinary tract infection
Neither smear nor urine shows PMNs
defer antimicrobial treatment and immediately re-evaluate for torsion of the testicle
Results not available
Urethral discharge detected
treat for epididymitis due to N. gonorrhoeae and C. trachomatis and await results:
ceftriaxone 250 mg IM in a single dose(a)
PLUS
doxcycline 100 mg orally x 2/day for at least 10 days OR tetracycline 500 mg orally x 4/day for at
least 10 days
No urethral discharge detected
immediate referral for microbiologic evaluation and additional tests, as needed, if torsion of the
testicle is a possibility
