History
The following history findings are associated with acute epididymitis and orchitis:
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Gradual onset of scrotal pain and swelling, often developing over several days (as opposed to hours, as in testicular torsion)
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Usually located on 1 side
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Dysuria, frequency, and/or urgency
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Fever and chills (in only 25% of adult patients with acute epididymitis but in up to 71% of children with the condition)
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Usually no nausea or vomiting (as opposed to testicular torsion)
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Urethral discharge preceding the onset of acute epididymitis (in some cases)
The following history findings are associated with chronic epididymitis:
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The patient has a long-standing history of pain (>6 wk) that can be described as either waxing and waning or constant
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The scrotum is not usually swollen but may be indurated in long-standing cases
The following history findings are associated with mumps orchitis:
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Fever, malaise, and myalgia are common
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Parotiditis typically precedes the onset of orchitis by 3-5 days
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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.
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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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.
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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.
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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.
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Scrotal sonogram showing the testes adjacent to the inflamed epididymis with a reactive hydrocele.
