Epididymitis Clinical Presentation

  • Author: Christina B Ching, MD; Chief Editor: Edward David Kim, MD, FACS   more...
 
Updated: Jun 10, 2011
 

History

The following history findings are associated with acute epididymitis and orchitis:

  • Gradual onset of scrotal pain and swelling, often developing over several days (as opposed to hours, as in testicular torsion)
  • Usually located on 1 side
  • Dysuria, frequency, and/or urgency
  • Fever and chills (in only 25% of adult patients with acute epididymitis but in up to 71% of children with the condition)
  • Usually no nausea or vomiting (as opposed to testicular torsion)
  • Urethral discharge preceding the onset of acute epididymitis (in some cases)

The following history findings are associated with chronic epididymitis:

  • The patient has a long-standing history of pain (>6 wk) that can be described as either waxing and waning or constant
  • The scrotum is not usually swollen but may be indurated in long-standing cases

The following history findings are associated with mumps orchitis:

  • Fever, malaise, and myalgia are common
  • Parotiditis typically precedes the onset of orchitis by 3-5 days
  • Subclinical infections occur in 30-40% of patients

Younger patients or any patient with a sexually transmitted epididymitis may note symptoms related to urethritis.

A recent history of endourethral instrumentation or urinary tract infection is more common in older patients with epididymitis.

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Physical Examination

Acute epididymitis

Tenderness and induration first occur in the epididymal tail, which may be the first site of reflux via the vas deferens. It then appears to spread to the body, head, and even the spermatic cord (funiculitis) or the ipsilateral testis (epididymo-orchitis). Acute epididymitis is bilateral in 5-10% of affected patients.

When checking for the Prehn sign during an examination, the affected hemiscrotum is elevated. This action relieves the pain of epididymitis but exacerbates the pain of torsion (positive Prehn sign). The elevation takes the weight of the testis off the epididymal suspension.

Physical examination findings may fail to distinguish acute epididymitis from testicular torsion. A normal cremasteric reflex indicates that testicular torsion is less likely.

Erythema and mild scrotal cellulitis may be present, while a reactive hydrocele is common in patients with advanced epididymo-orchitis, complicating scrotal examination. Postpubertal individuals with acute epididymitis frequently have associated bacterial prostatitis and/or seminal vesiculitis.

TB can cause focal epididymitis, a draining sinus, or beading of the vas deferens with extensive involvement. Orchitis rarely occurs without epididymitis in TB.

In children, epididymitis may be related to an underlying congenital anomaly of the urogenital tract, such as urethral abnormalities, an ectopic ureter, an ectopic vas deferens, detrusor sphincter dyssynergia, or vesicoureteral reflux.

Orchitis

Testicular enlargement, induration, and a reactive hydrocele are common. The epididymis is not tender. Orchitis is found in association with acute epididymitis in 20-40% of cases.

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Contributor Information and Disclosures
Author

Christina B Ching, MD  Resident Physician, Department of Urology, Cleveland Clinic Foundation

Christina B Ching, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Student Association/Foundation, and American Urological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Edmund S Sabanegh Jr, MD  Chairman, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation

Edmund S Sabanegh Jr, MD is a member of the following medical societies: American Medical Association, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Society for the Study of Male Reproduction, Society of Reproductive Surgeons, and Southwest Oncology Group

Disclosure: Nothing to disclose.

Specialty Editor Board

Erik T Goluboff, MD  Professor, Department of Urology, College of Physicians and Surgeons, Columbia University College of Physicians and Surgeons; Director of Urology, Allen Pavilion, New York Presbyterian Hospital

Erik T Goluboff, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Urological Association, Medical Society of the State of New York, New York Academy of Medicine, Phi Beta Kappa, and Society for Basic Urologic Research

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

J Stuart Wolf Jr, MD, FACS  The David A Bloom Professor of Urology, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS  Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association

Disclosure: Lilly Consulting fee Advisor; Astellas Consulting fee Speaking and teaching; Watson Consulting fee Speaking and teaching; Allergan Consulting fee Speaking and teaching

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Michael Franks, MD, and Badrinath R Konety, MD, to the development and writing of the source article.

References

  1. Siegel A, Snyder H, Duckett JW. Epididymitis in infants and boys: underlying urogenital anomalies and efficacy of imaging modalities. J Urol. Oct 1987;138(4 Pt 2):1100-3. [Medline].

  2. Santillanes G, Gausche-Hill M, Lewis RJ. Are antibiotics necessary for pediatric epididymitis?. Pediatr Emerg Care. Mar 2011;27(3):174-8. [Medline].

  3. Siu W, Ohl DA, Schuster TG. Long-term follow-up after epididymectomy for chronic epididymal pain. Urology. Aug 2007;70(2):333-5; discussion 335-6. [Medline].

  4. Viswaroop BS, Kekre N, Gopalakrishnan G. Isolated tuberculous epididymitis: a review of forty cases. J Postgrad Med. Apr-Jun 2005;51(2):109-11, discussion 111. [Medline].

  5. Trei JS, Canas LC, Gould PL. Reproductive tract complications associated with Chlamydia trachomatis infection in US Air Force males within 4 years of testing. Sex Transm Dis. Sep 2008;35(9):827-33. [Medline].

  6. Nusbaum MR, Wallace RR, Slatt LM, Kondrad EC. Sexually transmitted infections and increased risk of co-infection with human immunodeficiency virus. J Am Osteopath Assoc. Dec 2004;104(12):527-35. [Medline].

  7. Waldert M, Klatte T, Schmidbauer J, Remzi M, Lackner J, Marberger M. Color Doppler sonography reliably identifies testicular torsion in boys. Urology. May 2010;75(5):1170-4. [Medline].

 
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Cross-section illustration of a testicle and epididymis. A: Caput or head of the epididymis. B: Corpus or body of the epididymis. C: Cauda or tail of the epididymis. D: Vas deferens. E: Testicle. Illustration by David Schumick, BS, CMI. Reprinted with the permission of the Cleveland Clinic Center for Medical Art and Photography © 2009. All Rights Reserved.
Color Doppler sonogram of the left epididymis in a patient with acute epididymitis. The image demonstrates increased blood flow in the epididymis resulting from the active inflammation.
Scrotal sonogram demonstrating the presence of a hydrocele and an enlarged epididymis in a patient with epididymitis. The echogenic white area is the normal testicle surrounded by the hydrocele.
Scrotal sonogram showing the testes adjacent to the inflamed epididymis with a reactive hydrocele.
 
 
 
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