Epididymitis

Overview

The epididymis is a tightly coiled tube approximately 20 feet long when unraveled, located behind each testicle. It plays a crucial role in the male reproductive system by storing sperm as they mature and transporting them from the testicle to the vas deferens during ejaculation. When this structure becomes inflamed, the condition is called epididymitis.

Epididymitis can develop suddenly (acute) or gradually (chronic). Acute epididymitis typically causes significant pain and swelling that develops over one to two days, while chronic epididymitis involves milder discomfort that persists for six weeks or longer. The inflammation can result from bacterial infections, viral infections, or non-infectious causes such as trauma or urine reflux.

Understanding epididymitis is important because early treatment can prevent complications and reduce discomfort significantly. While the condition can be alarming due to the sensitive nature of the affected area, most men recover completely with appropriate antibiotic therapy and supportive care. The key is recognizing symptoms early and seeking medical attention to rule out other serious conditions like testicular torsion, which requires emergency treatment.

Symptoms

Epididymitis symptoms typically develop gradually over a day or two, though they can sometimes appear suddenly:

Primary Symptoms

• Pain in testicles - Usually starts in one testicle, may radiate to groin
• Swelling of scrotum - Affected side becomes enlarged and tender
• Mass in scrotum - Firm, tender area behind testicle
• Warmth and redness of the scrotum
• Tenderness when touched or during movement
• Heavy feeling in the affected testicle

Urinary Symptoms

• Painful urination - Burning or stinging sensation
• Retention of urine - Difficulty starting or maintaining stream
• Frequent urge to urinate
• Blood in urine (hematuria)
• Discharge from penis (if STI-related)

Associated Symptoms

• Sharp abdominal pain - Lower abdomen or pelvic area
• Groin pain - Radiating from affected testicle
• Side pain - Flank discomfort on affected side
• Lower body pain - General discomfort below waist
• Fever and chills (if infection present)
• Nausea (in severe cases)

Chronic Epididymitis Symptoms

• Dull, persistent ache in testicle
• Intermittent pain that comes and goes
• Mild swelling that persists
• Discomfort during physical activity
• Pain during or after ejaculation

Causes

Epididymitis can result from various infectious and non-infectious causes:

Bacterial Infections

• Sexually transmitted infections (STIs):
  • Chlamydia trachomatis (most common in men under 35)
  • Neisseria gonorrhoeae (gonorrhea)
  • Often occurs 2-8 weeks after exposure
• Urinary tract bacteria:
  • E. coli (most common in older men)
  • Klebsiella
  • Pseudomonas
  • Enterococcus
• Tuberculosis:
  • Rare in developed countries
  • Should be considered in endemic areas
  • Often chronic presentation

Non-Infectious Causes

• Urine reflux:
  • Backflow of urine into epididymis
  • Can occur with heavy lifting or straining
  • More common with bladder outlet obstruction
• Trauma:
  • Direct injury to scrotum
  • Sports injuries
  • Post-surgical complications
• Medication-induced:
  • Amiodarone (heart medication)
  • Rare but well-documented cause

Other Causes

• Viral infections:
  • Mumps (in unvaccinated individuals)
  • Less common than bacterial causes
• Fungal infections:
  • Rare, mainly in immunocompromised patients
• Autoimmune conditions:
  • Vasculitis
  • Behçet's disease
• Congenital abnormalities:
  • Ectopic ureter
  • Other urological anomalies

Risk Factors

Several factors increase the likelihood of developing epididymitis:

Age-Related Risk Factors

• Young adults (14-35 years):
  • Higher risk of STI-related epididymitis
  • Multiple sexual partners
  • Unprotected sexual activity
• Older men (over 35):
  • Higher risk of urinary tract-related causes
  • Prostate enlargement
  • Bladder outlet obstruction
• Children:
  • Often related to urinary abnormalities
  • May indicate underlying congenital issues

Medical Risk Factors

• Recent urinary tract infection
• Prostate infection or enlargement
• History of epididymitis
• Uncircumcised males
• Immunosuppression (HIV, diabetes, medications)
• Structural abnormalities of urinary tract

Behavioral Risk Factors

• Unprotected sexual intercourse
• Multiple sexual partners
• Sex with partner who has STI
• Anal intercourse (increased bacterial exposure)
• Heavy lifting or straining

Medical Procedures

• Recent urinary catheter use
• Recent urological surgery
• Prostate biopsy
• Cystoscopy or other urological procedures
• Long-term indwelling catheter

Types

Epididymitis can be classified based on duration, cause, and patient age:

By Duration

• Acute Epididymitis:
  • Symptoms last less than 6 weeks
  • Rapid onset over 1-2 days
  • More severe pain and swelling
  • Better response to treatment
• Chronic Epididymitis:
  • Symptoms persist beyond 6 weeks
  • May develop from untreated acute case
  • Milder but persistent discomfort
  • More challenging to treat
• Recurrent Epididymitis:
  • Multiple episodes over time
  • May indicate underlying issue
  • Requires thorough investigation

By Cause

• Bacterial Epididymitis:
  • STI-related (younger men)
  • UTI-related (older men)
  • Most common type
• Non-bacterial Epididymitis:
  • Chemical (urine reflux)
  • Traumatic
  • Idiopathic (unknown cause)
• Tuberculous Epididymitis:
  • Caused by tuberculosis
  • Usually chronic presentation
  • May have minimal symptoms

By Extent

• Epididymitis: Inflammation limited to epididymis
• Epididymo-orchitis: Inflammation extends to testicle
• Bilateral Epididymitis: Both sides affected (rare)

Diagnosis

Accurate diagnosis is crucial to differentiate epididymitis from other scrotal conditions:

Medical History

• Onset and progression of symptoms
• Sexual history and recent partners
• Urinary symptoms
• Recent procedures or catheter use
• Previous episodes
• Current medications

Physical Examination

• Scrotal examination:
  • Tenderness localized to epididymis
  • Swelling of posterior testicle
  • Prehn's sign (relief with elevation)
  • Cremasteric reflex present
• Abdominal examination:
  • Check for bladder distension
  • Assess for hernias
• Rectal examination:
  • Prostate assessment in older men
  • Check for tenderness or enlargement

Laboratory Tests

• Urinalysis:
  • White blood cells indicate infection
  • Bacteria presence
  • Red blood cells may be present
• Urine culture:
  • Identifies specific bacteria
  • Guides antibiotic selection
• STI testing:
  • Urethral swab or urine PCR
  • Test for chlamydia and gonorrhea
  • Consider HIV and syphilis screening
• Blood tests:
  • Complete blood count
  • C-reactive protein
  • Blood cultures if systemic infection suspected

Imaging Studies

• Scrotal ultrasound with Doppler:
  • First-line imaging test
  • Shows increased blood flow to epididymis
  • Rules out testicular torsion
  • Identifies abscess formation
• Nuclear scan:
  • If ultrasound inconclusive
  • Shows increased uptake in epididymitis
• MRI:
  • For complex cases
  • Better soft tissue detail

Differential Diagnosis

Important conditions to rule out:

• Testicular torsion (emergency)
• Torsion of testicular appendix
• Testicular tumor
• Trauma
• Inguinal hernia
• Hydrocele
• Varicocele

Treatment

Treatment focuses on eliminating infection, reducing inflammation, and managing pain:

Antibiotic Therapy

• For STI-suspected cases (age < 35):
  • Ceftriaxone 250-500mg IM single dose PLUS
  • Doxycycline 100mg twice daily for 10-14 days
  • Alternative: Azithromycin if doxycycline contraindicated
• For enteric organism-suspected cases (age > 35):
  • Levofloxacin 500mg daily for 10-14 days OR
  • Ciprofloxacin 500mg twice daily for 10-14 days
  • Consider longer course for prostatitis
• For chronic cases:
  • Extended antibiotic course (4-6 weeks)
  • May require combination therapy

Supportive Care

• Pain management:
  • NSAIDs (ibuprofen, naproxen)
  • Acetaminophen for additional relief
  • Stronger pain medication if severe
• Scrotal support:
  • Athletic supporter or briefs
  • Elevation when lying down
  • Reduces pain and swelling
• Ice application:
  • 15-20 minutes at a time
  • Use cloth barrier
  • Several times daily
• Rest:
  • Bed rest for 1-2 days if severe
  • Avoid heavy lifting
  • Gradual return to activities

Additional Measures

• Sexual abstinence until treatment complete
• Partner notification and treatment if STI
• Sitz baths for comfort
• Stool softeners if straining painful
• Adequate hydration

Surgical Treatment

Surgery is rarely needed but may be considered for:

• Abscess formation requiring drainage
• Chronic pain unresponsive to medical therapy
• Epididymectomy (removal of epididymis) in severe cases
• Vasectomy for recurrent epididymitis

Follow-up Care

• Re-evaluation in 48-72 hours if no improvement
• Complete antibiotic course even if symptoms improve
• Repeat STI testing after treatment
• Urological evaluation for recurrent cases

Prevention

Many cases of epididymitis can be prevented through lifestyle modifications and safe practices:

Sexual Health Practices

• Practice safe sex with condom use
• Limit number of sexual partners
• Regular STI screening
• Prompt treatment of STIs
• Partner notification and treatment
• Abstain during treatment

Urinary Health

• Treat urinary infections promptly
• Complete prescribed antibiotics
• Stay well hydrated
• Empty bladder regularly
• Good genital hygiene
• Wipe front to back (for female partners)

Medical Care

• Proper catheter care if needed
• Sterile technique for procedures
• Address prostate problems
• Manage chronic conditions
• Mumps vaccination

Lifestyle Modifications

• Avoid heavy lifting when full bladder
• Use proper lifting techniques
• Wear protective gear during sports
• Avoid prolonged sitting
• Maintain healthy weight

Complications

While most cases resolve without issues, untreated or severe epididymitis can lead to complications:

Local Complications

• Scrotal abscess:
  • Collection of pus in scrotum
  • Requires surgical drainage
  • May damage surrounding tissue
• Chronic epididymitis:
  • Persistent pain beyond 3 months
  • Difficult to treat
  • May require pain management
• Epididymal cyst:
  • Fluid-filled sac formation
  • Usually benign
  • May require removal if large
• Testicular atrophy:
  • Shrinkage of affected testicle
  • Due to reduced blood flow
  • May affect hormone production

Fertility Complications

• Reduced fertility:
  • Scarring can block sperm transport
  • Usually only if bilateral
  • May require assisted reproduction
• Azoospermia:
  • Complete absence of sperm
  • If both sides severely affected
  • Rare complication
• Anti-sperm antibodies:
  • Immune response to sperm
  • Can affect fertility

Systemic Complications

• Sepsis:
  • Spread of infection to bloodstream
  • Medical emergency
  • Requires hospitalization
• Fournier's gangrene:
  • Rare but serious
  • Necrotizing infection
  • Requires emergency surgery

Psychological Impact

• Anxiety about fertility
• Sexual dysfunction
• Depression from chronic pain
• Relationship stress

When to See a Doctor

Timely medical attention is crucial for proper treatment and preventing complications:

See a Doctor Within 24 Hours For:

• Gradual onset testicular pain
• Scrotal swelling or redness
• Pain with urination
• Discharge from penis
• Blood in urine
• Lower abdominal pain with scrotal symptoms

Schedule an Appointment If:

• Mild testicular discomfort persists
• Recurrent episodes of pain
• Previous epididymitis not fully resolved
• Concerns about fertility
• Need STI screening

Follow-up Care

• No improvement after 48-72 hours of antibiotics
• Symptoms worsen despite treatment
• Completion of antibiotic course
• Partner needs treatment
• Chronic pain management

Red Flags During Treatment

• Increasing pain despite medication
• Spreading redness or swelling
• New fever or chills
• Difficulty urinating
• Abscess formation