What is epididymitis

Epididymitis is inflammation (swelling) of the epididymis. The epididymis is a tightly coiled tube at the back of each testicle that stores immature sperm while they mature. Epididymitis is often caused by an infection and is usually treated with antibiotics.

Epididymitis often occurs at the same time as orchitis, which is inflammation of the testes themselves. If the testicles are also affected, it may be called epididymo-orchitis. The occurrence of these conditions in isolation is rare, with epididymitis and orchitis normally occurring together. In the US, it is estimated that there are 600,000 cases of this condition each year, occurring most commonly in the 19-35 year old age group.

Epididymitis presents as the gradual onset of posterior scrotal pain that may be accompanied by urinary symptoms such as dysuria (painful urination) and urinary frequency. Physical findings include a swollen and tender epididymis with the testis in an anatomically normal position. Although the cause is largely unknown, reflux of urine into the ejaculatory ducts is considered the most common cause of epididymitis in children younger than 14 years.

Epididymitis is most often caused by a bacterial infection, including sexually transmitted infections (STIs) caused by Neisseria gonorrhoeae and Chlamydia trachomatis are the most common pathogens in sexually active males 14 to 35 years of age. Because untreated acute epididymitis can lead to infertility and chronic scrotal pain, recognition and therapy are vital to reduce patient morbidity.

The annual incidence of acute epididymitis is approximately 1.2 per 1,000 boys two to 13 years of age (mean age = 11 years) ¹; about one-fourth of this group has recurrence within five years ¹. Among adult men, 43% of epididymitis cases occur between 20 and 30 years of age ². In one series, epididymitis occurred with orchitis (epididymo-orchitis) in 58% of patients ³.

Symptoms of epididymitis may include:

• sudden or gradual pain in one or both of your testicles (balls)
• the bag of skin containing your testicles (scrotum) feeling tender, warm and swollen
• a build-up of fluid around your testicle (a hydrocele) that feels like a lump or swelling

You may have other symptoms depending on the cause – for example, difficulty peeing, or a white, yellow or green discharge from the tip of the penis.

A single intramuscular dose of ceftriaxone with 10 days of oral doxycycline is the treatment of choice in this age group (14 to 35 years of age). In men who practice insertive anal intercourse, an enteric organism is also likely, and ceftriaxone with 10 days of oral levofloxacin or ofloxacin is the recommended treatment regimen. In men older than 35 years, epididymitis is usually caused by enteric bacteria transported by reflux of urine into the ejaculatory ducts secondary to bladder outlet obstruction; levofloxacin or ofloxacin alone is sufficient to treat these infections.

Epididymitis recovery time

You should start to feel better within 48 to 72 hours of starting an antibiotic. Resting, supporting the scrotum with an athletic strap, applying ice packs and taking pain medication can help relieve discomfort. Epididymitis improves within two to three days of antibiotic treatment, but residual pain may persist for several weeks ⁴. All patients treated for a sexually transmitted infection should instruct their partners to also be treated ⁴.

Don’t have sex if you have gonorrhea or chlamydia until you’ve finished the full course of treatment.

Your doctor is likely to recommend a follow-up visit to check that the infection has cleared.

Table 1. Selected Differential Diagnosis of Acute Scrotal Pain

Epididymis

The epididymides (singular – epididymis) are tightly coiled tubes about 6 meters long. Each epididymis is connected to ducts within a testis. It emerges from the top of the testis, descends along the posterior surface of the testis, and then courses upward to become the ductus deferens (vas deferens).

When sperm cells reach the epididymis, they are nonmotile. As rhythmic peristaltic contractions help move these cells through the epididymis, the cells mature. Following this aging process, the sperm cells can move independently and fertilize oocytes. However, sperm cells usually do not move independently until after ejaculation.

Figure 1. Male reproductive system

Figure 2. Epididymis

Figure 3. Inside testicles

Acute epididymitis

In acute epididymitis, pain and scrotal swelling of the epididymis are present for less than six weeks.

Acute epididymitis generally presents as unilateral pain and inflammation in the scrotum. The cause is highly dependent on age. In boys younger than 14 years, the cause is largely unknown but may be related to anatomic abnormalities causing reflux of infected or sterile urine into the ejaculatory ducts ⁶. Epididymitis in this age group may also be part of a postinfectious syndrome, mainly from Mycoplasma pneumoniae, enteroviruses, and adenoviruses ⁷. Henoch-Schönlein purpura may present as an acute scrotum and bilateral vasculitic epididymitis in children two to 11 years of age ².

Chlamydia trachomatis and Neisseria gonorrhoeae are the most common causes in sexually active males 14 to 35 years of age ⁴. In those older than 35 years, acute epididymitis is most commonly caused by the retrograde flow of infected urine (bacteriuria) into the ejaculatory duct in the setting of bladder outlet obstruction, usually secondary to prostatic hypertrophy ². Enteric bacteria must be considered in men who practice insertive anal intercourse, regardless of age ⁴. In patients with human immunodeficiency virus infection (HIV), epididymitis may be caused by concomitant infections, such as from Cytomegalovirus, Salmonella, toxoplasmosis, Ureaplasma urealyticum, Corynebacterium, Mycoplasma, and mycobacteria ⁴. Noninfectious acute epididymitis may be an adverse reaction to a medication or caused by reflux of sterile urine into the vas deferens because of bladder outlet obstruction or an underlying systemic disease (e.g., sarcoidosis, Behçet syndrome) ⁴.

Chronic epididymitis

Chronic epididymitis is defined as symptoms of discomfort and/or pain at least 3 months in duration in the scrotum, testicle, or epididymis, localized to one or each epididymis on clinical examination. Symptoms of chronic epididymitis might come on gradually and is usually characterized by pain in the absence of scrotal swelling ⁸. The cause of chronic epididymitis can be associated with inflammatory, infectious, or obstructive factors but, in many cases, no identifiable etiology can be identified ⁹.

Men diagnosed with chronic epididymitis generally present with either unilateral or bilateral scrotal pain that can be localized to either a normal- or abnormal-feeling epididymis ⁹. Many patients with chronic epididymitis also have associated testicular pain. Chronic testicular pain, or “chronic orchalgia,” has been defined as “intermittent or constant testicular pain three months or longer in duration that significantly interferes with the daily activities of the patient so as to prompt him to seek medical attention”¹⁰. In many cases, however, the patient will present with epididymal pain and discomfort only, particularly in the chronic stage of the condition.

Definition and Classification of Chronic Epididymitis

Definition: A 3-month or longer history of symptoms of discomfort/pain in the scrotum/testicle or epididymis that are localized to one or both epididymides on clinical examination.

Classification:

1. Inflammatory chronic epididymitis: pain and discomfort associated with abnormal swelling and induration
   • Infective (eg, chlamydia)
   • Postinfective (eg, after acute bacterial epididymitis)
   • Granulomatous (eg, tuberculosis)
   • Drug-induced (eg, amiodarone)
   • Associated with a known syndrome (eg, Behçet’s disease)
   • Idiopathic (ie, no identifiable etiology for inflammation)
2. Obstructive chronic epididymitis: pain or discomfort associated with congenital, acquired, or iatrogenic obstruction of epididymis or vas deferens (eg, congenital obstruction or surgical scarring after vasectomy)
3. Chronic epididymalgia: pain or discomfort in a normal-feeling epididymis associated with no identifiable etiology (ie, epididymis is normal but tender on palpation)

The average age of a patient presenting to our urology clinic with chronic epididymitis was 49 ± 15 years (range, 21–83 years). The patients had an average symptom duration of 4.9 ± 7 years (range, 0.25–29 years). Sixty-four percent of patients had pain in the scrotum often, usually, or always. At the time the subjects were surveyed, the average pain score was 4.7 ± 2.1 on a scale of 0 (no pain) to 10 (pain as bad as imaginable). Pain was localized to the right side in 44%, to the left side in 34%, and bilateral in 22% of the cases. The symptom complex associated with chronic epididymitis’ moderate to severe discomfort or pain seemed to have a significant impact on patient quality of life. Patients thought about the condition frequently, it affected their daily activities, and they were not satisfied with their quality of life.

In a comprehensive demographic analysis, compared with control patients, men diagnosed with chronic epididymitis had more sexual partners, used sexually transmitted disease protection less often, and had a higher incidence of past sexually transmitted disease. Patients with chronic epididymitis had more general self-reported musculoskeletal, neurologic, and infectious and/or inflammatory medical problems, including a history of urinary tract infections, than did men without this condition. Depression appeared to be a major problem in patients presenting with chronic epididymitis. Surprisingly, a history of vasectomy did not have a major association with a diagnosis of this condition (see Etiology, below), but that could be because this was a small, case-control study.

No comprehensive attempt has been made by past researchers to determine the cause and pathogenesis of chronic epididymitis. Based on experience and review of the literature, some doctors would suggest that the cause of this condition can be associated with inflammatory, infectious, or obstructive factors; however, in many cases, no etiology can be identified. There is some evidence that chronic epididymitis may be infective (eg, chlamydia) ¹¹ and, although there are no studies to confirm this, there seems to be a postinfective chronic epididymitis (ie, after an episode of acute bacterial epididymitis, the inflammation and discomfort persist). Granulomatous epididymitis (eg, tuberculous or bacillus Calmette-Guérin) has been well described ¹². Drug-induced epididymitis (eg, amiodarone) is also a well-recognized entity ¹³, as is chronic epididymitis associated with other generalized diseases (eg, Behçet’s disease) ¹⁴. However, many patients present with an inflammatory type of epididymitis (pain and/or discomfort associated with inflammatory swelling and/or induration of the epididymis) for which no identifiable etiology is apparent.

Chronic epididymitis can be associated with obstruction distal to the epididymis (eg, vas deferens). It has been well described as occurring after vasectomy ¹⁵ and can also be seen in patients with congenital abnormalities of the lower urinary tract.

Many patients, however, present with chronic pain and/or discomfort of varying intensity associated with a normal epididymis that can sometimes be exquisitely tender on palpation. Often, these patients have no identifiable etiology for the pain (although it is tempting to believe that these patients may have a neuropathic type of epididymal pain).

Chronic Epididymitis Treatment

Conservative Therapy

Many urologists suggest watchful waiting for patients in whom symptoms are mild and/or transitory. Empathy and reassurance (particularly that the pain and/or induration of the epididymis does not represent a cancer) is all some patients require. If future studies determine the natural history of this condition, we may be able to reassure some patients that it is a condition that “burns out” over time. Scrotal support, local heat therapy, and avoidance of aggravating activities may also be useful suggestions.

Medical Therapy

Initial treatment of idiopathic chronic epididymitis includes a two-week course of nonsteroidal anti-inflammatory drugs with scrotal icing and elevation. If symptoms do not improve, adding a tricyclic antidepressant or neuroleptic such as gabapentin (Neurontin) may be helpful. As with most chronic pain syndromes, treatment of chronic epididymitis will likely require a combination of modalities individualized to the patient ².

Surgical Therapy

There are more data related to the potential benefits of epididymectomy in patients with chronic epididymitis and epididymo-orchitis. In the 89 patients identified with chronic or recurrent epididymitis in Mittemeyer and colleagues’ armed forces study ¹⁶, 61 underwent epididymectomy and eventually returned to active duty. Davis and colleagues ¹⁰ reported a clinical series of patients with chronic orchalgia, although many appeared to have at least an associated diagnosis of chronic epididymitis. Thirty-one patients underwent surgical therapy (orchidectomy [n = 24], epididymectomy [n = 10], orchidopexy [n = 5], or hydrocelectomy [n = 1]) and, based on this experience, the authors recommended inguinal orchidectomy as the procedure of choice for testicular pain when conservative measures were unsuccessful. In this study, only 1 of the 10 patients treated with epididymectomy had significant pain relief.

In a series reported by Chen and Ball ¹⁷, epididymectomy successfully ameliorated pain symptoms in 5 of 10 patients with postvasectomy epididymal pain, 6 of 7 with epididymoorchitis, and 4 of 7 with epididymal pain associated with an epididymal cyst. Padmore and colleagues ¹⁸ described a series of 27 men who underwent epididymectomy after empiric long-term and repeated courses of antibiotics and/or anti-inflammatory agents had failed, and reported patient satisfaction to be extremely high in the epididymal cyst group compared with the epididymitis/epididymalgia group (92% vs 43%).

West and colleagues ¹⁵ performed 19 epididymectomies (bilateral [n = 3] and unilateral [n = 13]) in 16 patients who suffered pain after vasectomy. Of the 16 patients, 14 were reported to have excellent initial symptomatic benefit from epididymectomy. Long-term follow-up in 10 patients suggested that the benefits were durable. Poor outcome was predicted in patients with atypical symptoms, including testicular or groin pain, erectile dysfunction, and normal appearance of the epididymis on ultrasound.

Epididymitis complications

Complications of epididymitis include:

• Pus-filled infection (abscess) in the scrotum
• Epididymo-orchitis, if the condition spreads from your epididymis to your testicle
• Rarely, reduced fertility

Epididymitis causes

What causes epididymitis

Epididymitis is usually caused by a bacterial or viral infection, particularly sexually transmitted infections (STIs), commonly chlamydia and gonorrhoea and urinary tract infections (UTIs). Epididymitis may also be caused by injury, vasectomy, or an autoimmune disease.

Epididymitis is usually caused by a sexually transmitted infection (STI), such as chlamydia or gonorrhoea. This is more likely in younger men under 35 years old.

It can also be caused by a urinary tract infection (UTI), but UTIs are less common in men. A UTI is more likely if you have:

• an enlarged prostate gland
• a urinary catheter
• recently had surgery to the groin, prostate gland or bladder

Sometimes a cause can’t be found.

Less common causes of epididymitis

• mumps
• tuberculosis
• taking high doses of amiodarone – a medicine used to treat heart rhythm disorder
• a groin injury
• Behçet’s disease

Risk factors for epididymitis

Certain sexual behaviors that can lead to sexually transmitted infections (STIs) put you at risk of sexually transmitted epididymitis, including having:

• Sex with a partner who has an sexually transmitted infection (STI)
• Sex without a condom
• A history of sexually transmitted infections (STIs)

Risk factors for nonsexually transmitted epididymitis include:

• History of prostate or urinary tract infections
• History of medical procedures that affect the urinary tract, such as insertion of a urinary catheter or scope into the penis
• An uncircumcised penis or an anatomical abnormality of the urinary tract
• Prostate enlargement, which increases the risk of bladder infections and epididymitis

Epididymitis prevention

You can help prevent epididymitis by practising safe sex, and asking your doctor about how to prevent urinary tract infections (UTIs), if you get them regularly.

Epididymitis symptoms

Acute epididymitis generally presents as the gradual onset of posterior scrotal pain and swelling over one to two days. There may be concurrent symptoms of fever, hematuria (blood in urine), dysuria (painful urination) and urinary frequency, and the pain may radiate into the lower abdomen. Elevating the scrotum may alleviate the pain (Prehn sign).

If you have epididymitis, your testicle will be:

• Tender or painful scrotum
• Unusually warm scrotum
• Swollen or firm scrotum
• Testicle pain and tenderness, usually on one side, that usually comes on gradually
• Painful urination or an urgent or frequent need to urinate
• Discharge from the penis
• Pain or discomfort in the lower abdomen or pelvic area
• Blood in the semen
• Less commonly, fever

You might also feel sick, with fever and chills.

If your epididymitis is related to a urinary tract infection (UTI), you might also have abdominal pain, the need to urinate often and a burning feeling when you do urinate.

If you have any pain or swelling of the testicle, you should see a doctor straight away to minimize the risk of complications.

Epididymitis diagnosis

Your doctor will check for enlarged lymph nodes in your groin and an enlarged testicle on the affected side. Your doctor might also do a rectal examination to check for prostate enlargement or tenderness.

You’ll usually need some tests first to find out the cause. These may include:

• Sexually transmitted infection (STI) screening. A narrow swab is inserted into the end of your penis to obtain a sample of discharge from your urethra. The sample is checked in the laboratory for gonorrhea and chlamydia.
• A rectal examination – to check for problems with your prostate
• Urine and blood tests. Samples of your urine and blood are analyzed for abnormalities.
• Ultrasound. This imaging test might be used to rule out testicular torsion. Ultrasound with color Doppler can determine if the blood flow to your testicles is lower than normal — indicating torsion — or higher than normal, which helps confirm the diagnosis of epididymitis.

Epididymitis treatment

Antibiotics are needed to treat bacterial epididymitis and epididymo-orchitis. If the cause of the bacterial infection is an sexually transmitted infection (STI), your sexual partner also needs treatment. Take the entire course of antibiotics prescribed by your doctor, even if your symptoms clear up sooner, to ensure that the infection is gone.

You should start to feel better within 48 to 72 hours of starting an antibiotic. Resting, supporting the scrotum with an athletic strap, applying ice packs and taking pain medication can help relieve discomfort.

Your doctor is likely to recommend a follow-up visit to check that the infection has cleared.

If your symptoms don’t go away with treatment, you may need to see a specialist. A few people need surgery.

Epididymitis antibiotics

In children two to 14 years of age without systemic signs (e.g., fever), antibiotics may be reserved for when urinalysis or urine culture results are positive ¹⁹. In patients 14 years and older, empiric antibiotics are recommended based on the most likely causative organism. Goals of treatment include curing microbiologic infection; preventing the spread of Neisseria gonorrhoeae or Chlamydia trachomatis infection to sex partners; and preventing complications from untreated epididymitis, including infertility and chronic pain ²⁰.

To prevent complications and the spread of gonorrhea and chlamydia, the Centers for Disease Control and Prevention recommends beginning treatment before all laboratory test results are available, and basing therapy choice on the risk of chlamydia and gonorrhea or enteric organisms ²⁰. In settings where gonorrhea or chlamydia is likely, intramuscular ceftriaxone (single 250-mg dose) plus oral doxycycline (100 mg twice daily for 10 days) is the recommended regimen ²⁰. In men who practice insertive anal intercourse, an enteric organism is likely in addition to gonorrhea or chlamydia; intramuscular ceftriaxone (single 250-mg dose) plus either oral levofloxacin (Levaquin; 500 mg once daily for 10 days) or oral ofloxacin (300 mg twice daily for 10 days) is the recommended treatment regimen for these patients. In patients older than 35 years, sexually transmitted infections are less likely, and monotherapy with levofloxacin or ofloxacin is sufficient to treat the likely enteric organisms. Because of increased chlamydia resistance, ciprofloxacin is no longer an adequate alternative fluoroquinolone for treatment of epididymitis. Table 2 summarizes antibiotic therapy for acute epididymitis ²⁰.

Table 2. Empiric Antibiotic Therapy for Acute Epididymitis

Follow-up

Acute epididymitis can usually be treated in the outpatient setting with follow-up within one week to evaluate for clinical response to treatment. Rarely, inpatient hospitalization and intravenous antibiotics are required for systemic symptoms, abscess formation, or Fournier gangrene ²¹. Epididymitis improves within two to three days of antibiotic treatment, but residual pain may persist for several weeks ⁴. Children younger than 14 years who are treated for acute epididymitis should be referred to a urologist to evaluate for possible anatomic abnormalities ². Men older than 50 years should be evaluated for urinary tract obstruction due to prostatic enlargement. All patients treated for a sexually transmitted infection should instruct their partners to also be treated ⁴.

Surgery

If an abscess has formed, you might need surgery to drain it. Sometimes, all or part of the epididymis needs to be removed surgically (epididymectomy). Surgery might also be considered if epididymitis is due to underlying physical abnormalities.

Epididymitis home treatment

Epididymitis usually causes considerable pain. To ease your discomfort:

• Rest in bed
• Lie down so that your scrotum is elevated
• Apply cold packs to your scrotum as tolerated
• Wear an athletic supporter
• Avoid lifting heavy objects
• Avoid sexual intercourse until your infection has cleared

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