Diagnostic Assessment — Right Testis - Epididymitis
Example 1 of 1 · fictitious patient (Veteran CP)
Diagnostic Assessment
Right Testis - Epididymitis
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran CP, date of birth 19 February 1987, Australian Army, Driver (Transport Operator), enlisted 10 April 2006, medically discharged 06 September 2019. Operational service: Afghanistan, 02 March 2011 to 25 October 2011 (warlike); Middle East Area of Operations, 14 February 2015 to 30 August 2015 (warlike).
Occupational History
As a transport operator the veteran drove heavy trucks on long convoys and loaded and unloaded his own cargo, including ammunition boxes, water pallets, rations and engineer stores, often by hand and in loads of 20 to 40 kilograms. Convoy drivers spend long periods seated with whole-body vibration, frequently restrict their fluid intake or delay urination because there is no safe opportunity to stop, and are exposed to heat, dehydration and dust.
Climbing on and off truck trays and tailgates carries a risk of falls and straddle injuries. On operations drivers work from patrol bases with limited sanitation and medical support, may share food with partner forces, and have restricted access to pathology, imaging and specialist care.
History
Veteran CP, a transport operator in the Australian Army, developed acute right epididymitis on 16 July 2011 during warlike service in Afghanistan, after urethral catheterisation for heat stroke, an Escherichia coli urinary tract infection, a chlamydial urethritis, brucellosis, a pre-existing urethral stricture, a blow to the scrotum and a day of heavy lifting with a full bladder. Effective treatment was delayed, and the condition worsened to a right epididymo-orchitis with abscess, confirmed on ultrasound on 04 August 2011.
Timeline
- 18 Sep 2009 — On a peacetime exercise the veteran slipped while climbing over the tailgate of his truck and fell astride the tailgate edge, injuring his perineum. He had blood at the urethral opening and bruising of the perineum. A urologist confirmed a partial bulbar urethral injury, managed with a suprapubic catheter for three weeks. Urethrography in March 2010 showed a short bulbar urethral stricture, and he was followed with periodic flow studies. "straddle injury, bulbar urethral stricture"
- 14 Feb 2011 — Pre-deployment medical examination recorded a normal genital examination, with no scrotal pain or swelling, and a urine dipstick negative for leucocytes and nitrites. A urinary flow study showed a reduced peak flow of 11 mL/s from the known urethral stricture. He was assessed as fit to deploy to Afghanistan. "genitals normal, peak flow 11"
- 26 Jun 2011 — During warlike service in Afghanistan the veteran ate meals with partner force soldiers at a patrol base, including locally produced unpasteurised milk and soft cheese. Over the following weeks he developed intermittent fevers and night sweats, initially attributed to heat. "unpasteurised dairy, partner force meals"
- 04 Jul 2011 — After a convoy in temperatures above 45 degrees Celsius the veteran collapsed with a core temperature of 41.2 degrees Celsius and confusion. He was treated for heat stroke at the role 3 hospital, where an indwelling urethral catheter was inserted with difficulty past the stricture and remained in place for 48 hours. On 10 July 2011 he reported dysuria and frequency, and urine culture grew more than 100 million per litre Escherichia coli. Trimethoprim was commenced. "heat stroke, IDC, E. coli UTI"
- 15 Jul 2011 — On 14 July 2011 the veteran was struck in the right scrotum by the corner of a falling ammunition box while unloading at a patrol base. On 15 July 2011 he unloaded 30 kilogram ammunition boxes by hand for about six hours during a convoy resupply, without the opportunity to empty his bladder for most of that time because of security restrictions. "scrotal blow, six hours lifting"
- 16 Jul 2011 — The veteran presented to the patrol base medic with right scrotal pain beginning that morning, swelling and tenderness of the right epididymis, a temperature of 38.4 degrees Celsius and dysuria. The testis was in a normal position with a positive cremasteric reflex. A medical officer by telehealth diagnosed acute right epididymitis. The urine sample sent with the next convoy was positive for Chlamydia trachomatis on PCR, from contact during mid-tour leave on 03 June 2011, and Brucella serology later returned positive. "acute R epididymitis, chlamydia positive"
- 04 Aug 2011 — Ceftriaxone and doxycycline were not held at the patrol base, and the veteran remained on trimethoprim alone for 12 days while continuing driving and loading duties. On 02 August 2011, after again loading stores by hand, he developed increasing pain and fever, and a repeat urine culture on 28 July 2011 had grown Escherichia coli resistant to trimethoprim. He was evacuated to the role 3 hospital, where ultrasound on 04 August 2011 showed right epididymo-orchitis with a 2.5 cm epididymal abscess, which was drained surgically. "epididymo-orchitis with abscess, drained"
- 12 Mar 2012 — A urologist in Australia recorded persisting right scrotal pain and a thickened, tender right epididymis eight months after the infection, and diagnosed chronic epididymitis following the acute infection and abscess. Brucellosis had been treated with doxycycline and rifampicin for six weeks. Urethrotomy for the stricture was performed on 18 April 2012. "chronic R epididymitis, urethrotomy planned"
Symptoms
At onset the veteran had right scrotal pain developing over a morning, swelling and tenderness of the right epididymis, fever, burning on passing urine and frequency. The pain was worse with walking, lifting and sitting in his truck, and was eased by scrotal support. Over the following two weeks the pain and swelling increased, and he developed high fevers and rigors.
After the abscess was drained the acute symptoms settled, but he has had persisting right scrotal aching since, worse with prolonged sitting, driving, lifting and sexual activity, with flares of pain and swelling two or three times a year. He now reports daily right scrotal discomfort and avoids heavy lifting.
Imaging
- 17 Mar 2010 — Retrograde urethrogram: "Short bulbar urethral stricture of about 1 cm with moderate narrowing."
- 04 Aug 2011 — Scrotal ultrasound with Doppler: "Enlarged hyperaemic right epididymis with a 2.5 cm complex fluid collection in keeping with abscess. Hyperaemia of the right testis consistent with orchitis. Normal testicular perfusion, no torsion."
- 12 Mar 2012 — Scrotal ultrasound: "Thickened heterogeneous right epididymis with resolved abscess. Normal right testis."
Onset Date
The most likely date of onset of this condition is 16 Jul 2011.
At that date the veteran was on warlike service in Afghanistan as a transport operator at a patrol base. Twelve days earlier he had been catheterised for heat stroke, and he was being treated for an Escherichia coli urinary tract infection. Two days earlier his right scrotum had been struck by a falling ammunition box, and the day before he had unloaded 30 kilogram ammunition boxes by hand for six hours with a full bladder. Right scrotal pain began on the morning of 16 July 2011.
This date is appropriate because his pre-deployment examination of 14 February 2011 recorded a normal genital examination and a clear urine dipstick, and he presented to the medic with right scrotal pain and epididymal swelling on the day the pain began.
For the causative factors, the 60 days before onset run from 17 May 2011 to 16 Jul 2011, and include the sexual contact of 03 Jun 2011 from which chlamydia was acquired. The 30 days before onset run from 16 Jun 2011 to 16 Jul 2011 and include the urethral catheterisation of 04 to 06 Jul 2011. The 14 days before onset run from 02 Jul 2011 to 16 Jul 2011 and include the Escherichia coli urinary tract infection diagnosed on 10 Jul 2011. The 7 days before onset run from 09 Jul 2011 to 16 Jul 2011 and include the scrotal blow on 14 Jul 2011. The 24 hours before onset include the six hours of lifting on 15 Jul 2011. The urethral stricture, present since 2010, and brucellosis, acquired from dairy food eaten from 26 Jun 2011, were present at onset.
For the worsening factors, the period after onset runs from 16 Jul 2011 to the clinical worsening on 02 Aug 2011, confirmed as an abscess on ultrasound on 04 Aug 2011. The 14 days before the worsening run from 19 Jul 2011 to 02 Aug 2011 and include the persisting trimethoprim-resistant Escherichia coli infection cultured on 28 Jul 2011. The 24 hours before the worsening include the manual loading of stores on 02 Aug 2011. Throughout that period effective antibiotics were not available at his patrol base.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Testis - Epididymitis (ICD-10-AM N45.9), acute right epididymitis that progressed to epididymo-orchitis with abscess and then to chronic epididymitis. No Statement of Principles has been determined for epididymitis.
Epididymitis is inflammation of the epididymis, the coiled tube at the back of the testis in which sperm mature. In men under 35 it is most commonly caused by sexually transmitted infection with Chlamydia trachomatis or Neisseria gonorrhoeae, and in older men or men with urinary tract abnormalities by coliform bacteria such as Escherichia coli spreading from infected urine. Urethral strictures, catheterisation and instrumentation, reflux of urine into the ejaculatory ducts during straining, scrotal trauma and systemic infections such as brucellosis are also recognised causes. It presents with scrotal pain and swelling, tenderness of the epididymis, fever and urinary symptoms. Delayed or ineffective treatment can lead to spread to the testis, abscess formation, testicular damage, and chronic epididymal pain.
The epididymitis began on warlike service in Afghanistan on 16 July 2011 after a combination of infective, mechanical and traumatic causes arising from that service, worsened to an abscess when effective treatment was unavailable, and left the veteran with chronic right epididymitis.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
16 July 2011.
When did the veteran first present to a health / medical provider for this condition?
16 July 2011.
When was the condition confirmed / formally diagnosed?
16 July 2011.
When did the veteran first present to you (or your practice) for this condition?
03 March 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made clinically by a medical officer by telehealth on 16 July 2011 on the basis of acute right scrotal pain with swelling and tenderness confined to the right epididymis, fever and dysuria, with the testis in a normal position and a positive cremasteric reflex, which made torsion unlikely. Urine PCR was positive for Chlamydia trachomatis, urine culture had grown Escherichia coli six days earlier, and Brucella serology was positive.
The worsening was confirmed by scrotal ultrasound with Doppler on 04 August 2011, which showed an enlarged hyperaemic right epididymis with a 2.5 cm abscess and hyperaemia of the right testis, with normal testicular perfusion excluding torsion. The abscess was drained surgically. Chronic epididymitis was diagnosed by a urologist on 12 March 2012, with a thickened, tender epididymis on examination and ultrasound eight months after the acute infection.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
No Statement of Principles has been determined for epididymitis. The claim is therefore decided on the sound medical-scientific evidence of what causes and worsens the condition, without the limits a Statement of Principles would impose, and each recognised cause below has been considered against the veteran's service.
Legislation: the clinical onset of this condition was on 16 July 2011, after 1 July 2004, during continuous full-time service and on warlike service in Afghanistan. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. Where a Statement of Principles exists, the Reasonable Hypothesis standard applies to operational service and the Balance of Probabilities standard to peacetime service; here the onset and the worsening both occurred on warlike service. Each factor must be related to the person's service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Recognised causes on the medical-scientific evidence (no Statement of Principles)
Causative factors
Cause 1: having a sexually transmitted infection of the urethra with Chlamydia trachomatis or Neisseria gonorrhoeae acquired within the 60 days before the clinical onset of epididymitis; — MET
- Urine PCR collected at the onset on 16 July 2011 was positive for Chlamydia trachomatis. The infection was acquired from sexual contact during mid-tour leave from his warlike deployment on 03 June 2011, 43 days before onset. The leave was granted as part of the deployment and the contact occurred while he remained a member on operational service.
Cause 2: having a urinary tract infection with a coliform organism within the 14 days before the clinical onset of epididymitis; — MET
- Urine culture on 10 July 2011 grew more than 100 million per litre Escherichia coli, six days before onset. The infection followed urethral catheterisation for heat stroke on warlike service and was present, and inadequately treated, at onset on 16 July 2011.
Cause 3: having a urethral stricture or other bladder outlet obstruction at the time of the clinical onset of epididymitis; — MET
- A bulbar urethral stricture followed a straddle injury on a truck tailgate on a peacetime exercise on 18 September 2009, and was confirmed on urethrography on 17 March 2010. His peak urinary flow was 11 mL/s on 14 February 2011. Raised voiding pressure behind the stricture drives infected urine into the ejaculatory ducts. The stricture was present at onset on 16 July 2011.
Cause 4: undergoing urethral catheterisation, cystoscopy or other transurethral instrumentation within the 30 days before the clinical onset of epididymitis; — MET
- An indwelling urethral catheter was inserted with difficulty past the stricture at the role 3 hospital on 04 July 2011 during treatment for heat stroke on warlike service, and remained for 48 hours. This was 12 days before onset.
Cause 5: having blunt trauma to the scrotum within the 7 days before the clinical onset of epididymitis; — MET
- On 14 July 2011, two days before onset, the corner of a falling ammunition box struck the veteran's right scrotum while he was unloading at a patrol base on warlike service. Bruising of the right hemiscrotum was noted by the medic on 16 July 2011.
Cause 6: lifting or straining against a closed glottis with a full bladder, with loads of at least 20 kilograms, for at least 2 hours within the 24 hours before the clinical onset of epididymitis; — MET
- On 15 July 2011, the day before onset, the veteran unloaded 30 kilogram ammunition boxes by hand for about six hours during a convoy resupply on warlike service, and security restrictions prevented him from emptying his bladder for most of that time. Straining with a full bladder forces urine, which was infected, retrogradely into the vas deferens and epididymis.
Cause 7: having brucellosis at the time of the clinical onset of epididymitis; — MET
- From 26 June 2011 the veteran ate unpasteurised milk and soft cheese with partner force soldiers at a patrol base in Afghanistan, as part of his warlike service duties. He developed fevers and night sweats, and Brucella serology from the onset presentation was positive with a rising titre. Brucellosis was present at onset on 16 July 2011 and was treated with doxycycline and rifampicin after his evacuation.
Worsening factors
Worsening 1: having a urinary tract infection with a coliform organism within the 14 days before the clinical worsening of epididymitis; — MET
- Repeat urine culture on 28 July 2011 grew Escherichia coli resistant to trimethoprim, five days before the clinical worsening on 02 August 2011. The persisting infection followed catheterisation on warlike service and was not adequately treated at the patrol base.
Worsening 2: lifting or straining against a closed glottis with a full bladder, with loads of at least 20 kilograms, for at least 2 hours within the 24 hours before the clinical worsening of epididymitis; — MET
- On 02 August 2011 the veteran loaded stores of 20 to 30 kilograms by hand onto his truck for about three hours on warlike service, without opportunity to empty his bladder, and his pain and fever increased that evening. Ultrasound on 04 August 2011 showed an epididymal abscess and orchitis.
Worsening 3: having an uncorrected urethral stricture or other bladder outlet obstruction at the time of the clinical worsening of epididymitis; — MET
- The service-related bulbar urethral stricture remained uncorrected at the worsening on 02 August 2011 and was not treated until urethrotomy on 18 April 2012.
Worsening 4: inability to obtain appropriate clinical management for epididymitis. — MET
- At the patrol base on warlike service the recommended treatment for epididymitis in a young man, ceftriaxone with doxycycline, was not held, urine culture results took more than a week to return by convoy, and scrotal ultrasound was not available. The veteran remained on trimethoprim alone, to which his organism was resistant, for 12 days while continuing driving and loading duties. Under Brew v Repatriation Commission (1999), this is an inability to obtain appropriate clinical management, and the infection progressed to epididymo-orchitis with abscess.
The % contribution of the causes is 100% and significant.
Sequelae
The epididymitis has led to chronic right epididymitis with persisting scrotal pain, documented by a urologist on 12 March 2012, and to right orchitis at the time of the abscess. Semen analysis in 2014 showed reduced sperm concentration, which the urologist attributed in part to the right epididymal obstruction. Each of these is a sequela of the accepted condition and may be claimed in its own right.
Unintended Consequence
Met. The urethral catheter inserted for heat stroke at the role 3 hospital on 04 July 2011, past a known urethral stricture, introduced the Escherichia coli infection that preceded the epididymitis, and the use of trimethoprim alone, to which the organism was resistant, allowed the infection to progress. These are unintended consequences of treatment provided by the Commonwealth while the veteran was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. When the veteran developed acute epididymitis on warlike service at a patrol base on 16 July 2011, the recommended antibiotics were not held, culture results took more than a week to return by convoy, no ultrasound was available, and he was not evacuated until his condition had deteriorated 17 days later. He continued driving and heavy loading duties throughout. The infection progressed to epididymo-orchitis with a 2.5 cm abscess that required surgical drainage on 04 August 2011, and then to chronic epididymitis. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the circumstances of his operational service prevented him from obtaining the treatment that was clinically appropriate, and that inability materially contributed to the worsening of his epididymitis.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 18 Sep 2009, Hospital admission and urology consultation, Urologist
- 17 Mar 2010, Retrograde urethrogram report, Radiologist
- 14 Feb 2011, Pre-deployment medical examination and urinary flow study, Medical Officer
- 04 Jul 2011, Role 3 hospital admission record, heat stroke, Medical Officer, Afghanistan
- 10 Jul 2011, Urine culture report, Pathology, Afghanistan
- 16 Jul 2011, Patrol base treatment record and telehealth consultation, Medic and Medical Officer, Afghanistan
- 28 Jul 2011, Urine culture and Brucella serology reports, Pathology
- 04 Aug 2011, Scrotal ultrasound and operation report, Radiologist and Surgeon, Role 3 hospital, Afghanistan
- 12 Mar 2012, Specialist consultation and scrotal ultrasound, Urologist
- 18 Apr 2012, Operation report, optical urethrotomy, Urologist
