Epididymitis

Epididymitis is the inflammation of the epididymis and is commonly associated with genitourinary tract infections. Epididymitis is a clinical diagnosis, with patients typically presenting with a gradual onset of pain and swelling of the affected scrotum and a positive Prehn sign. Urinalysis and testing for sexually transmitted infections (STIs) can help confirm the diagnosis. Testicular torsion is the most important differential diagnosis of epididymitis; if it cannot be ruled out clinically, an urgent ultrasound must be performed. The treatment for epididymitis includes empiric antibiotic therapy based on the most likely source of infection and symptomatic management, e.g., scrotal elevation and NSAIDs.

• Acute epididymitis: an inflammation of the epididymis, usually as a result of an infection
  • Urinary tract infections
    • Most common cause among older men and children
    • Pathogens: E. coli (most common), Pseudomonas (common), Proteus mirabilis, Klebsiella pneumoniae
  • Sexually transmitted infections
    • Most common cause among young males (usually < 35 years of age)
    • Pathogens: Chlamydia trachomatis; (common), Neisseria gonorrhoeae (common), Treponema pallidum, Trichomonas vaginalis, Gardnerella vaginalis
• Chronic epididymitis (> 6-week course of the disease)
  • Recurrent and/or untreated acute epididymitis
  • Tuberculosis (usually associated with renal tuberculosis)
  • Rare, noninfectious causes
    • Amiodarone-induced epididymitis
    • Autoimmune diseases (e.g., Behcet disease): associated with granuloma formation in seminiferous tubules

• Acute epididymitis
  • Unilateral scrotal pain and swelling; , which develops over several days and radiates to the ipsilateral flank ^[1]
  • Tenderness along the posterior testis
  • Positive Prehn sign: reduced pain when the affected hemiscrotum is elevated
  • Scrotal skin overlying the epididymis may appear red, shiny, and edematous
  • Low-grade fever (especially among children)
  • Symptoms of lower urinary tract infection (e.g., dysuria, frequency, urgency), including urethritis (urethral discharge)
• Chronic epididymitis
  • Recurrent bouts of scrotal pain
  • Swelling is minimal when compared to acute epididymitis
  • Thickened epididymis

The following recommendations are consistent with the 2021 CDC STI guidelines. ^[2]

General principles

• Epididymitis is a clinical diagnosis.
• Urine and urethral studies help tailor antibiotic therapy and identify the causative organism.
• Imaging is primarily used to rule out testicular torsion but can confirm epididymitis if the diagnosis is uncertain.

Testicular torsion is the most important differential diagnosis of epididymitis and must be ruled out first! Consult urology if the diagnosis remains unclear.

Routine laboratory studies ^[2][3][4]

• Urinalysis: to identify pyuria and/or bacteriuria
• Urine culture: to identify the causative organism and assess for antibiotic resistance ^[4]
• Nucleic acid amplification testing (NAAT) for Chlamydia trachomatis and Neisseria gonorrhea; (urine sample or urethral swab) ^[4]
• Gram stain of urethral secretions: to identify urethritis and gonococcal infections

Testing for HIV and syphilis is recommended for all patients with acute epididymitis. ^[2]

Additional laboratory studies

Not usually indicated

• Nonspecific elevated acute phase reactants, e.g., leukocytosis, ↑ ESR, ↑ CRP may be present. ^[4][5]
• In patients with persistent clinical features despite antibiotic treatment, consider testing for alternate diagnoses, e.g., neoplasms, abscess, infarction, fungal organisms. ^[2]
• Consider TB workup in patients with chronic epididymitis and recent TB exposure. ^[2]

Duplex ultrasound of the scrotum ^[2]

• May be used to rule out testicular torsion and scrotal abscess
• Findings: An enlarged, hyperemic epididymis with increased blood flow indicates epididymitis.
• Consult urology for further radiological evaluation in patients with chronic epididymitis. ^[6]

• Testicular torsion
• Hydrocele
• Varicocele
• Inguinal hernia
• See “Differential diagnosis of scrotal pain.”

The differential diagnoses listed here are not exhaustive.

The following recommendations apply to acute epididymitis and are consistent with the 2021 CDC STI guidelines. Consult urology regarding the management of chronic epididymitis. ^[2][6]

Antibiotic treatment

• Indicated for all patients with acute epididymitis
• Start empiric antibiotic treatment based on the most likely causative organism. ^[2]
  • Patients with a suspected UTI source; (e.g., enteric organisms): fluoroquinolone, e.g., levofloxacin ^[4]
  • Patients with a suspected STI source (e.g., chlamydia or gonorrhea): ceftriaxone PLUS doxycycline
  • Patients who practice insertive anal sex: Cover both STIs and enteric organisms, e.g., ceftriaxone PLUS levofloxacin .
• Adjust antibiotic therapy once the causative organism is identified.
• If symptoms do not improve within 72 hours after starting treatment, reconsider other diagnoses.

If an STI is suspected, patients should abstain from sex until they and any partners have been successfully treated. Refer all sexual partners from the previous 60 days before symptom onset for evaluation, testing, and presumptive treatment. ^[2]

Symptomatic management

Indicated for all patients as needed

• Scrotal elevation
• NSAIDs
• Avoidance of aggravating activities
• Application of a cold pack

Surgical intervention

• Not generally indicated
• Exceptions include intrascrotal abscesses and some cases of chronic epididymitis

Disposition ^[2]

• Outpatient management is usually sufficient for patients with acute epididymitis.
• Consider inpatient treatment and/or consult urology:
  • For acutely ill patients (fever, high CRP, severe pain)
  • For older patients and patients with diabetes
  • If complications are suspected, e.g., intrascrotal abscess or necrotizing fasciitis

• Epididymal abscess ^[7]
• Epididymo-orchitis: the spread of infection from the epididymis to the testicle
• Testicular infarction
• Infertility

We list the most important complications. The selection is not exhaustive.