1000-2000 5 ьшò

orchiectomy in severe cases refractory to antibiotics

Surgery to correct underlying anatomic abnormality or obstruction

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Intractable pain

Sepsis

Abscess

Persistent vomiting

Scheduled surgery

Purulent drainage

Most cases can be managed with outpatient care.

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

Routine follow-up in 1 week. Follow up within 72 hours if symptoms fail to improve with treatment for reevaluation of diagnosis and therapy (3)[A].

Swelling and tenderness after antibiotic course should be evaluated for abscess, tumor, infarction, cancer, TB, and fungal epididymitis (3)[A].

In noninfectious epididymitis, follow up in 4 weeks to assess efficacy of NSAIDs and lifestyle changes.

DIET

If constipation is contributing to pain or chemical epididymitis, then consider constipation prevention (high-fiber diet) and/or treatment.

PATIENT EDUCATION

Stress completing course of antibiotics, even when asymptomatic.

Early recognition and treatment of UTI or prostatitis

Safer sexual practices

If treated for STI, refer sexual partners for evaluation of N. gonorrhoeae or C. trachomatis if sexual contact within 60 days preceding onset of symptoms or most recent sexual partner if >60 days (3)[A].

If noninfectious epididymitis, then educate on noninfectious etiology and

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proper lifestyle changes.

PROGNOSIS

Pain improves within 1 to 3 days, but induration may take several weeks/months to completely resolve.

If bilateral involvement, sterility may result.

In noninfectious epididymitis, symptoms usually resolve in <1 week.

COMPLICATIONS

Recurrent epididymitis

Infertility

Oligospermia

Testicular necrosis or atrophy

Secondary abscess formation

Fournier gangrene (necrotizing synergistic infection)

REFERENCES

1.Trojian TH, Lishnak TS, Heiman D. Epididymitis and orchitis: an overview. Am Fam Physician. 2009;79(7):583–587.

2.McConaghy JR, Panchal B. Epididymitis: an overview. Am Fam Physician. 2016;94(9):723–726.

3.Workowski KA, Bolan GA; for Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1–137.

4.Crawford P, Crop JA. Evaluation of scrotal masses. Am Fam Physician. 2014;89(9):723–727.

5.Rizvi SA, Ahmad I, Siddiqui MA, et al. Role of color Doppler ultrasonography in evaluation of scrotal swellings: pattern of disease in 120 patients with review of literature. Urol J. 2011;8(1):60–65.

ADDITIONALREADING

Somekh E, Gorenstein A, Serour F. Acute epididymitis in boys: evidence of a post-infectious etiology. J Urol. 2004;171(1):391–394.

Tracy CR, Steers WD, Costabile R. Diagnosis and management of epididymitis. Urol Clin North Am. 2008;35(1):101–108; vii.

Wolin LH. On the etiology of epididymitis. J Urol. 1971;105(4):531–533.

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CODES

ICD10

CLINICALPEARLS

With epididymitis, the pain is gradual in onset, and the tenderness is mostly posterior to the testis. With testicular torsion, the symptoms are quite rapid in onset, the testis will be higher in the scrotum and may have a transverse lie, and the cremasteric reflex will be absent. The absence of leukocytes on urine analysis and decreased blood flow on scrotal ultrasound with Doppler will suggest torsion.

Prostatic massage is contraindicated in epididymitis because of the risk for worsening local infection. The potential for sepsis is increased with acute prostatitis.

Noninfectious epididymitis is a clinical diagnosis of exclusion, and infectious causes are much more common but must be considered in certain occupations, such as soldiers and laborers.

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EPISCLERITIS

Daniel J. Schlegel, MD, MHA Tamara K. Oser, MD

Sean M. Oser, MD, MPH

BASICS

Episcleritis is irritation and inflammation of the episclera, a thin layer of tissue covering the sclera. It is not an infection.

Episcleritis is the localized inflammation of the vascular connective tissue superficial to the sclera.

Usually a self-limited condition, typically resolving within 3 weeks

Most cases resolve without treatment.

Topical lubricants and/or topical corticosteroid treatment may relieve symptoms while awaiting spontaneous resolution.

DESCRIPTION

Edema and injection confined to the episcleral tissue Two types

–Simple (diffuse scleral involvement—more common)

–Nodular (focal area[s] of involvement—less common)

EPIDEMIOLOGY

Slight female predominance (~60–65%)

Incidence

May occur at any age

Peak incidence in 40s to 50s

Community incidence not well-known (~20 to 50 cases/100,000 person-years)

Prevalence

Not historically well-known; a recent community study found a prevalence of 53 cases/100,000 persons.

ETIOLOGYAND PATHOPHYSIOLOGY

Etiology: usually idiopathic, but other causes may be found (either nonimmune or immune)

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Pathophysiology:

–Nonimmune (e.g., dry eye syndrome, with histology showing widespread vasodilation, edema, lymphocytic infiltration)

–Immune (systemic vasculitis or rheumatologic disease)

COMMONLYASSOCIATED CONDITIONS

Usually not associated with another condition

Less commonly associated conditions include the following:

–Rheumatoid arthritis

–Vasculitis

–Inflammatory bowel disease

–Ankylosing spondylitis

–Systemic lupus erythematosus

–Gout

–Herpes zoster

–Hypersensitivity disorders Rosacea

Contact dermatitis

Penicillin sensitivity

Erythema multiforme

DIAGNOSIS

Episcleritis is a clinical diagnosis (1,2)[C].

HISTORY

History should elicit potential causative factors, recurrence, or associated systemic disease (2)[C].

Pain is often absent; when present, it is usually mild and localized to the eye (1,2)[C].

Mild tearing may be present (2)[C].

PHYSICALEXAM

Check visual acuity; decreased vision is very unusual with episcleritis, and its presence should raise suspicion for another condition such as scleritis (1,2) [C].

The white sclera will have a pink or purplish hue. Focal hyperemia (2,3)[C]

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Pupils equal and reactive (2)[C]

Superficial episcleral vascular dilation (1,2)[C]

Episcleral edema (1,2)[C]

–Diffuse in simple episcleritis

–Focal in nodular episcleritis

Tenderness over involved area may be present (2)[C] but is usually absent (3) [C].

Superficial episcleral vascular hyperemia blanches with topical phenylephrine (1,3)[C].

ALERT

Recurrent episodes, difficulty confirming the diagnosis, or worsening symptoms require prompt ophthalmology referral (2)[C].

DIFFERENTIALDIAGNOSIS

Scleritis

Bacterial conjunctivitis

Viral conjunctivitis

Herpes (ulcerative) keratitis

Superficial keratitis

Increased intraocular pressure (ocular hypertension)

DIAGNOSTIC TESTS & INTERPRETATION

Most patients with episcleritis do not require any further lab work or diagnostic studies (4)[C].

TREATMENT

MEDICATION

Treatment for episcleritis typically consists of symptomatic relief. The goal is to suppress the inflammation, which will, in turn, relieve the discomfort or pain. In most cases, treatment is not needed.

First Line

Topical lubricants such as artificial tears are typically used for initial management of symptomatic episcleritis (2)[C].

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Second Line

Topical corticosteroids are useful when discomfort is not sufficiently controlled by conservative measures (2,4,5)[C].

–Fluorometholone 0.1% drops 4 times daily; if not effective, may increase frequency

–Prednisolone 0.5–1% eye drops

Refractory episcleritis may be treated with oral NSAIDs (4)[C].

ISSUES FOR REFERRAL

Recurrent episodes, uncertain diagnosis, and/or worsening symptoms should prompt ophthalmology referral. Rarely, episcleritis may progress to scleritis in which case ophthalmology referral is also recommended.

ADDITIONALTHERAPIES

Topical NSAIDs have not been shown to have a significant benefit over artificial tears (6)[B].

When episcleritis results from viral infection, appropriate antiviral therapy is indicated (5)[C].

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Episcleritis is usually self-limited (up to 21 days) and does not typically require follow-up.

PROGNOSIS

Most patients have no ocular complications.

Prognosis for episcleritis is excellent, with most patients making a full recovery.

COMPLICATIONS

Associated complications are rare, even at tertiary care referral centers, where referral bias likely overestimates their community incidence. When complications do occur, they tend not to be severe.

Anterior uveitis may occur in 4–16% of cases (1,5)[C]. Decreased vision may occur in 0–4% of cases (1,5)[C].

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Ocular hypertension has been reported in 0–3.5% of cases (1,5)[C].

REFERENCES

1.Sainz de la Maza M, Molina N, Gonzalez-Gonzalez LA, et al. Clinical characteristics of a large cohort of patients with scleritis and episcleritis. Ophthalmology. 2012;119(1):43–50.

2.Cronau H, Kankanala RR, Mauger T. Diagnosis and management of red eye in primary care. Am Fam Physician. 2010;81(2):137–144.

3.Galor A, Thorne JE. Scleritis and peripheral ulcerative keratitis. Rheum Dis Clin North Am. 2007;33(4):835–854.

4.Kirkwood BJ, Kirkwood RA. Episcleritis and scleritis. Insight. 2010;35(4):5– 8.

5.Berchicci L, Miserocchi E, Di Nicola M, et al. Clinical features of patients with episcleritis and scleritis in an Italian tertiary care referral center. Eur J Ophthalmol. 2014;24(3):293–298.

6.Williams CP, Browning AC, Sleep TJ, et al. Arandomised, double-blind trial of topical ketorolac vs artificial tears for the treatment of episcleritis. Eye (Lond). 2005;19(7):739–742.

ADDITIONALREADING

Daniel Diaz J, Sobol EK, Gritz DC. Treatment and management of scleral disorders. Surv Ophthalmol. 2016;61(6):702–717.

CODES

ICD10

H15.109 Unspecified episcleritis, unspecified eye

H15.129 Nodular episcleritis, unspecified eye

H15.102 Unspecified episcleritis, left eye

CLINICALPEARLS

Episcleritis typically is a benign, self-limited disorder.

Often not painful and presents without decrease in visual acuity Although treatment is often not needed, when employed, the goal is

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symptomatic relief while awaiting spontaneous resolution.

Topical lubricants and/or topical corticosteroid treatment may relieve symptoms.

Associated complications are uncommon and not severe but may include anterior uveitis, decreased vision, and ocular hypertension.

Episcleritis can be an early presentation of scleritis, which is more severe. Accurate diagnosis of episcleritis is important.

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EPISTAXIS

Rebecca Wetzel, DO Brian E. Neubauer, MD

BASICS

DESCRIPTION

Hemorrhage from the nose involving either the anterior or posterior mucosal surfaces

Intractable or refractory epistaxis: recurrent or persistent despite appropriate packing or multiple episodes during a short period, each requiring medical attention

Synonym(s): nosebleed

EPIDEMIOLOGY

Incidence

Very common in the United States

Estimated lifetime prevalence: ~60%

Bimodal, with peaks in children up to 15 years and in adults >50 years, particularly ages 70 to 79 years

Most common in males <49 years

Rare in children age <2 years

~6% of patients require medical or surgical intervention; accounts for ~1 in 200 ER visits

ETIOLOGYAND PATHOPHYSIOLOGY

Local versus systemic disease. Most nosebleeds are due to local causes.

Anterior: 90–95% of all cases (Kiesselbach plexus)

Posterior: 5–10% of cases (Woodruff plexus); usually branches of sphenopalatine arteries: may be asymptomatic or may present with other symptoms (hematemesis, hemoptysis)

Idiopathic

Local inflammation/irritation

–Infection (viral URI, sinusitis, TB, syphilis)

–Irritant inhalation (smoking, rhinitis)

–Topical steroid or antihistamine use

–Septal deviation (more air movement on one side)

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