1000-2000 5 ьшò

placebo patch.

Botulinum toxin Afor chronic lateral epicondylitis

–Injections into the forearm extensor muscles (60 units) can be performed in the outpatient setting.

SURGERY/OTHER PROCEDURES

Elbow surgery may be indicated in refractory cases:

–Involves débridement and tendon release

–Can be performed open or arthroscopically

–Improvements in VAS, DASH scores, and grip strength seen in 5-year study

(4)[B]

Denervation of the lateral humeral epicondyle

–Transection of the posterior cutaneous nerve of the forearm with implantation into the triceps may help with chronic symptoms and pain.

COMPLEMENTARY& ALTERNATIVE MEDICINE

Acupuncture: effective for short-term pain relief for lateral epicondyle pain

ONGOING CARE

PROGNOSIS

Good: majority resolve with conservative care

REFERENCES

1.Pattanittum P, Turner T, Green S, et al. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. Cochrane Database Syst Rev. 2013;(5):CD003686.

2.Krogh TP, Bartels EM, Ellingsen T, et al. Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med. 2013;41(6):1435–1446.

3.Mi B, Liu G, Zhou W, et al. Platelet rich plasma versus steroid on lateral epicondylitis: meta-analysis of randomized clinical trials. Phys Sportsmed. 2017;45(2):97–104.

4.Han SH, Lee JK, Kim HJ, et al. The result of surgical treatment of medial

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epicondylitis: analysis with more than a 5-year follow-up. J Shoulder Elbow

Surg. 2016;25(10):1704–1709.

ADDITIONALREADING

Cullinane FL, Boocock MG, Trevelyan FC. Is eccentric exercise an effective treatment for lateral epicondylitis? Asystematic review. Clin Rehabil. 2014;28(1):3–19.

Dingemanse R, Randsdorp M, Koes BW, et al. Evidence for the effectiveness of electrophysical modalities for treatment of medial and lateral epicondylitis: a systematic review. Br J Sports Med. 2014;48(12):957–965.

Green S, Buchbinder R, Barnsley L, et al. Acupuncture for lateral elbow pain.

Cochrane Database Syst Rev. 2002;(1):CD003527.

Lin YC, Wu WT, Hsu YC, et al. Comparative effectiveness of botulinum toxin versus non-surgical treatments for treating lateral epicondylitis: a systematic review and meta-analysis [published online ahead of print May 1, 2017]. Clin Rehabil. 2017. doi:10.1177/0269215517702517.

Mattie R, Wong J, McCormick Z, et al. Percutaneous needle tenotomy for the treatment of lateral epicondylitis: a systemic review of the literature. PMR. 2017;9(6):603–611.

Ozden R, Uruç V, Doğramaci Y, et al. Management of tennis elbow with topical glyceryl trinitrate. Acta Orthop Traumatol Turc. 2014;48(2):175–180.

SEE ALSO

Algorithm: Pain in Upper Extremity

CODES

ICD10

M77.00 Medial epicondylitis, unspecified elbow

M77.10 Lateral epicondylitis, unspecified elbow

M77.01 Medial epicondylitis, right elbow

CLINICALPEARLS

Medial epicondylitis (golfer’s elbow) is characterized by pain and tenderness

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at the tendinous origins of the wrist flexors at the medial epicondyle.

Lateral epicondylitis (tennis elbow) is characterized by pain and tenderness at the tendinous origins of the wrist extensors at the lateral epicondyle.

Left untreated, symptoms typically last between 6 months and 2 years Most patients improve using conservative treatment with bracing, activity modification, and physical therapy.

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EPIDIDYMITIS

David B. McCaleb, MD Holly L. Baab, MD

BASICS

Acute epididymitis: scrotal pain for <6 weeks

Chronic epididymitis: scrotal pain for ≥3 months

DESCRIPTION

Inflammation (infectious or noninfectious) of epididymis resulting in scrotal pain and swelling, induration of the posterior epididymis, eventual scrotal wall edema, involvement of the adjacent testicle, and hydrocele formation

Epididymitis with involvement of testis is named epididymo-orchitis.

Classification: infectious (bacterial, viral, fungal, parasitic) versus noninfectious (chemical, traumatic, autoimmune, idiopathic, industrial, noninfectious, vasoepididymal reflux syndrome, vasal reflux syndrome); chronic versus acute

System(s) affected: reproductive

EPIDEMIOLOGY

Predominant age: usually younger, sexually active men or older men with UTIs; in older men, commonly secondary to bladder outlet obstruction

Predominant sex: male only

Pediatric Considerations

In prepubertal boys: Epididymitis is found to be the most common cause of acute scrotum—more common than testicular torsion.

Incidence

Common (600,000 cases annually in the United States) (1)

1 in 1,000 adult males per year

1.2 in 1,000 boys age 2 to 13 years per year (2)

Prevalence

Common

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ETIOLOGYAND PATHOPHYSIOLOGY

Infectious epididymitis

–Retrograde passage of urine or urinary bacteria from the prostate or urethra to the epididymis via the ejaculatory ducts and the vas deferens, rarely, hematogenous spread

–Causative organism is identified in 80% of patients and varies according to patient age.

Noninfectious epididymitis

–Often no etiology is found; however, can be instigated by trauma, autoimmune disease, or vasculitis

–Thought to likely be secondary to reflux of sterile urine causing a chemical inflammation rather than infectious

–Can develop as a sequelae of strenuous exercise with a full bladder when urine is pushed through internal urethral sphincter (located at proximal end of prostatic urethra) or prolonged periods of sitting

–Reflux of urine through orifice of ejaculatory ducts at verumontanum may occur with history of urethritis/prostatitis, as inflammation may produce rigidity in musculature surrounding orifice to ejaculatory ducts, holding them open.

–Exposure of epididymis to foreign fluid may produce inflammatory reaction

within 24 hours. <14 years of age

–Cause largely unknown although likely anatomic abnormalities resulting in urine reflux such as vesicoureteral reflux, ectopic ureter, or anorectal malformation (recto-urethral fistula)

–May also be part of postinfectious syndrome from Mycoplasma pneumoniae, enterovirus, or adenovirus

–Henoch-Schönlein purpura may present as acute scrotum.

14 to 35 years of age

–Usually Chlamydia trachomatis (serous urethral discharge) or Neisseria gonorrhoeae (purulent discharge) in sexually active males

–With anal intercourse, likely Escherichia coli or Haemophilus influenza

>35 years

–Commonly enteric bacteria but occasionally Staphylococcus aureus or

Staphylococcus epidermidis

–In elderly men, often with distal urinary tract obstruction, benign prostatic hyperplasia (BPH), UTI, or catheterization

–Tuberculosis (TB), if sterile pyuria, nodularity of vas deferens

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(hematogenous spread), and recent infection. TB is the most common granulomatous disease affecting the epididymitis (3).

–Sterile urine reflux after transurethral prostatectomy

–Granulomatous reaction following BCG intravesical therapy for bladder cancer

Amiodarone may cause noninfectious epididymitis; resolves with decreasing drug dosage

Syphilis, blastomycosis, coccidioidomycosis, and cryptococcosis are rare causes, but brucellosis can be a common cause in endemic areas.

RISK FACTORS

UTI

Prostatitis

Indwelling urethral catheter

Urethral instrumentation or transurethral surgery

Urethral or meatal stricture

Transrectal prostate biopsy

Prostate brachytherapy (seeds) for prostate cancer

Anal intercourse

High-risk sexual activity

Strenuous physical activity

Prolonged sedentary periods

Bladder obstruction (BPH, prostate cancer)

HIV-immunosuppressed patient

Severe Behçet disease

Presence of foreskin

Constipation Noninfectious epididymitis

–Increased intra-abdominal pressure (due to frequent physical strain) Military recruits, especially who begin physically unprepared

Laborers; restaurant kitchen workers

Full bladder during intense physical exertion

GENERALPREVENTION

Safer sexual practices

Mumps vaccination

Antibiotic prophylaxis for urethral manipulation

Early treatment of prostatitis/BPH

Vasectomy or vasoligation during transurethral surgery

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Avoid vigorous rectal exam with acute prostatitis.

Emptying the bladder prior to physical exertion

Physically conditioning the body prior to engaging in regular intense physical exertion

Treat constipation.

COMMONLYASSOCIATED CONDITIONS

Prostatitis/urethritis/orchitis

Hemospermia

Constipation UTI

DIAGNOSIS

HISTORY

Gradual onset of scrotal pain, sometimes radiating to the groin region over 1 to 2 days

Urethral discharge or symptoms of UTI, such as frequency of urination, dysuria, cloudy urine, or hematuria

Progresses posterior-lying epididymis—body/head of epididymis

Entire hemiscrotum becoming swollen and red; the testis becomes indistinguishable from the epididymis; the scrotal wall becomes thick and indurated; and reactive hydrocele may occur.

Noninfectious epididymitis

–Unilateral scrotal pain and swelling preceded by several hours of intense physical exertion. Patient may recall full bladder prior to exertion.

–No symptoms of infection

Pediatric Considerations

Bacteremia from H. influenzae infection may produce acute epididymitis.

In adolescent males, particularly age >13 years, must rule out testicular torsion.

History not helpful in distinguishing epididymitis from testicular torsion

Geriatric Considerations

Diabetics with sensory neuropathy may have no pain despite severe infection/abscess.

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PHYSICALEXAM

Epididymis is markedly tender to palpation.

The tail of the epididymis is larger in comparison with the contralateral side.

Elevation of the testes/epididymis reduces the discomfort (Prehn sign).

Absence of a cremasteric reflex should raise suspicion for testicular torsion.

DIFFERENTIALDIAGNOSIS

Testicular torsion

Torsion of testicular appendages

Urethritis/orchitis

Testicular trauma

Epididymal congestion following vasectomy

Testicular malignancy

Epididymal cyst

Inguinal hernia

Spermatocele

Hydrocele

Hematocele

Varicocele

Epididymal adenomatoid tumor

Epididymal rhabdomyosarcoma

Vasculitis (Henoch-Schönlein purpura)

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

All suspected cases should be evaluated for objective evidence of inflammation by one of the following:

–Urinalysis/urine culture preferably on first-void urine to evaluate for positive leukocyte esterase and bacteriuria

–Urine culture/Gram stain urethral discharge; ≥2 WBC per oil immersion field; evaluate for gonococcal infection.

–Microscopic examination of sediment from a spun first-void urine with ≥10 WBC per high power field

Urine GC/chlamydia testing by NAAT for all suspected cases (3)[A]

CRP>24 mg/Lsuggestive of epididymitis (4)[C]

Urinalysis clear and culture-negative suggest noninfectious epididymitis.

If testicular torsion/mass cannot be excluded (especially in children), Doppler ultrasound is test of choice (2).

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In adult men, Doppler ultrasound: sensitivity and specificity of 100% in evaluation of acute scrotum (5)

Pediatric Considerations

Further radiographic imaging in children should be done to rule out anatomic abnormalities.

Diagnostic Procedures/Other

This is a clinical diagnosis.

TREATMENT

GENERALMEASURES

Bed rest or restriction on activity

Scrotal elevation, athletic scrotal supporter

Ice pack wrapped in towel

Avoid constipation.

Spermatic cord block with local anesthesia in severe cases If noninfectious epididymitis

–No strenuous physical activity and avoidance of any Valsalva maneuvers for several weeks

–Empty bladder prior to strenuous exercises.

MEDICATION

First Line

Sexually active adults <35 years: doxycycline 100 mg PO BID for 10 days (C. trachomatis coverage) PLUS ceftriaxone 250 mg IM × 1 (N. gonorrhoeae coverage) (2)[C],(3)[A]

≥35 years, not suspecting STD etiology with suspected enteric organism (i.e., bacteriuria due to bladder outlet obstruction, prostate biopsy, urinary instrumentation, systemic disease, and/or immunosuppression)

–Levofloxacin 500 mg/day PO for 10 days OR

–Ofloxacin 300 mg PO BID for 10 days (2)[C],(3)[A]

–Note: 2016 FDABlack Box warning on fluoroquinolones due to disabling and potentially permanent side effects. Consider trimethoprim sulfamethoxazole for milder infections.

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Men who practice insertive anal intercourse: ceftriaxone 250 mg IM × 1 plus fluoroquinolone as above (2)[C],(3)[A]

Analgesia:

–NSAIDs (e.g., naproxen or ibuprofen) for mild to moderate pain

–Consider corticosteroid if patient cannot tolerate NSAID.

–Acetaminophen-codeine or acetaminophen-oxycodone for moderate to

severe pain

Septic or toxic patient

– 3rd-generation cephalosporin or aminoglycoside For Behçet, sarcoid, Henoch-Schönlein purpura

– Corticosteroids, such as methylprednisolone, 40 mg/day recommended

Chronic epididymitis: 2-week course of NSAIDs, scrotal icing/elevation. If no improvement, may add TCAor neuroleptic (2).

Second Line

Trimethoprim-sulfamethoxazole (Bactrim, Septra) double-strength PO BID for 10 to 14 days; increasing bacterial resistance may limit effectiveness.

Add rifampin (rifampicin) or vancomycin, as required.

Pediatric Considerations

May be postinfectious inflammatory condition; treat with anti-inflammatories, analgesics.

Antibiotic therapy can be reserved for young infants until positive urine cultures (2).

ISSUES FOR REFERRAL

If suspicion is high for testicular torsion, then urgent referral to urologist for possible surgery (1)[C]

Epididymitis in ages <14 years requires a urology referral due to high incidence of associated urogenital abnormalities.

If medical management fails, should be referred to urologist to rule out anatomic abnormality or chemical epididymitis

SURGERY/OTHER PROCEDURES

Vasostomy to drain infected material if severe or refractory case

Scrotal exploration if unable clinically to distinguish between epididymitis and testicular torsion

Drainage of abscesses, epididymectomy (acute suppurative), or epididymo-

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