Epididymitis 

Updated: Jan 22, 2018
Author: Christina B Ching, MD; Chief Editor: Edward David Kim, MD, FACS 

Overview

Practice Essentials

Epididymitis (inflammation of the epididymis; see the image below) is a significant cause of morbidity and is the fifth most common urologic diagnosis in men aged 18-50 years.[1] Epididymitis must be differentiated from testicular torsion, which is a true urologic emergency.

Color Doppler sonogram of the left epididymis in a 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.

Signs and symptoms

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

  • Gradual onset of scrotal pain and swelling, usually unilateral, often developing over several days (as opposed to hours for testicular torsion)

  • Dysuria, frequency, or urgency

  • Fever and chills (in only 25% of adults with acute epididymitis but in up to 71% of children with the condition)

  • Usually, no nausea or vomiting (in contrast to testicular torsion)

  • Urethral discharge preceding the onset of acute epididymitis (in some cases)

The following history findings are associated with chronic epididymitis:

  • Long-standing (>6 weeks) history of pain, either waxing and waning or constant

  • Scrotum that 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 (common)

  • Parotiditis typically preceding the onset of orchitis by 3-5 days

  • Subclinical infections (30-40% of patients)

Physical examination findings may fail to distinguish acute epididymitis from testicular torsion. Physical findings associated with acute epididymitis may include the following:

  • Tenderness and induration occurring first in the epididymal tail and then spreading

  • Elevation of the affected hemiscrotum

  • Normal cremasteric reflex

  • Erythema and mild scrotal cellulitis

  • Reactive hydrocele (in patients with advanced epididymo-orchitis)

  • Bacterial prostatitis or seminal vesiculitis (in postpubertal individuals)

  • With tuberculosis, focal epididymitis, a draining sinus, or beading of the vas deferens

  • In children, an underlying congenital anomaly of the urogenital tract

Findings associated with orchitis may include the following:

  • Testicular enlargement, induration, and a reactive hydrocele (common)

  • Nontender epididymis

  • In 20-40% of cases, association with acute epididymitis

See Presentation for more detail.

Diagnosis

The following laboratory studies may be indicated for suspected epididymitis:

  • Urinalysis: Pyuria or bacteriuria (50%); urine culture indicated for prepubertal and elderly patients

  • Complete blood count: Leukocytosis

  • Gram stain of urethral discharge, if present

  • Urethral culture, nucleic acid hybridization, and nucleic acid amplification tests to facilitate detection of Neisseria gonorrhoeae and Chlamydia trachomatis

  • Performance of (or referral for) syphilis and HIV testing in patients with a sexually transmitted etiology

  • The use of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to differentiate epididymitis from other causes of acute scrotum is under investigation

Although epididymitis may often be an infectious process, cultures commonly fail to demonstrate any identifiable infection.

Imaging studies that may be considered to evaluate structural abnormalities and help distinguish acute epididymitis from testicular torsion include the following:

  • Voiding cystourethrogram (VCUG)

  • Retrograde urethrography

  • Abdominal/pelvic ultrasonography

  • Radionuclide scanning and scintigraphy

  • In tuberculous epididymitis, chest radiography, computed tomography, or excretory urography

Other measures that may be useful for evaluation include the following:

  • Cystourethroscopy

  • Scrotal exploration or aspiration

See Workup for more detail.

Management

Pharmacologic treatment of epididymitis may include the following:

  • In chronic epididymitis, a 4- to 6-week trial of antibiotics effective against bacterial pathogens (especially chlamydiae)

  • When treating epididymitis secondary to Chlamydia trachomatis or Neisseria gonorrhoeae, treatment of all sexual partners

  • In prepubertal patients with epididymitis, antibiotic therapy only for young infants and those with pyuria or positive urine culture findings

In addition to antibiotics (except in viral epididymitis), the mainstays of supportive therapy for acute epididymitis and orchitis are as follows:

  • Reduction in physical activity

  • Scrotal support and elevation

  • Ice packs

  • Anti-inflammatory agents

  • Analgesics, including nerve blocks

  • Avoidance of urethral instrumentation

  • Sitz baths

Surgical options include the following:

  • Epididymotomy: Infrequently performed in patients with acute suppurative epididymitis

  • Epididymectomy: Typically reserved for refractory cases

  • Orchiectomy: Indicated only for patients with unrelenting epididymal pain

  • Skeletonization of the spermatic cord via subinguinal varicocelectomy: Performed in rare cases of refractory pain due to chronic epididymitis and orchialgia

See Treatment and Medication for more detail.

Go to Acute Epididymitis for complete information on emergent management of epididymitis.

Complications

Complications associated with acute epididymitis and bacterial orchitis include the following:

  • Scrotal abscess and pyocele

  • Testicular infarction: Cord swelling can limit testicular artery blood flow

  • Fertility problems

  • Testicular atrophy

  • Cutaneous fistulization from rupture of an abscess through the tunica vaginalis (seen especially in tuberculosis)

  • Recurrence, chronic epididymitis, and orchialgia

With regard to the last item above, true local pain can be distinguished from referred pain by spermatic cord injection with 1% lidocaine. Refractory pain that is not improved by analgesics has also been managed by denervation of the spermatic cord.

With regard to fertility problems, sterility is uncommon after acute epididymitis, although the true incidence is unknown. Disturbances in the sperm quality secondary to leukocytospermia and inflammation are usually transient. More important is the far less common azoospermia, which is caused by the epididymal duct obstruction observed in men with untreated or improperly treated epididymitis. The incidence of this condition is unknown.

Complications associated with mumps orchitis include the following:

  • Hypogonadotropic hypogonadism can occur as a result of testicular atrophy, which is observed in 30-50% of patients

  • Sterility occurs in 7-13% of affected patients; orchitis affects the testicular interstitium more than the Leydig and Sertoli cells, but sperm counts, mobility, and morphology can be affected

  • Orchialgia may develop

  • Mumps orchitis is not associated with the development of testicular tumors

Patient education

The patient should limit activity, and the scrotum should be immobilized.

Stress that the course of antibiotics needs to be completed, and also stress the need for screening tests for and treatment of comorbid sexually transmitted diseases for the patient and his sexual partners.

For patient education information, see the Men's Health Center, the Infections Center, and the Sexual Health Center, as well as Epididymitis, Inflammation of the Testicle (Orchitis), Mumps, and Sexually Transmitted Diseases (STDs).

Anatomy

The epididymis is a coiled tubular structure located along the posterior aspect of the testis, connecting the efferent ducts of the testis to the vas deferens. It allows for the storage, maturation, and transport of sperm

The image below is a diagram of the testis and epididymis.

Cross-section illustration of a testicle and epidi 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.

Etiology

The exact etiology of acute epididymitis is unclear; however, it is believed to be caused by the retrograde passage of urine from the prostatic urethra to the epididymis via the ejaculatory ducts and vas deferens. Obstruction of the prostate or urethra and congenital anomalies create a predisposition for reflux. Normally, the oblique angle of the ejaculatory ducts through the dense prostatic tissue prevents reflux. Fifty-six percent of men older than 60 years who have epididymitis exhibit concurrent bladder outlet obstruction (BOO), such as a urethral stricture or benign prostatic hyperplasia (BPH).

Reflux may also be induced by Valsalva maneuvers or strenuous exertion. This can be seen in athletes such as weight lifters. Epididymitis is commonly found to develop during strenuous exertion in conjunction with a full bladder.

Instrumentation and indwelling catheters are common risk factors for acute epididymitis.

Epididymitis may be accompanied by urethritis or prostatitis.

Acute epididymo-orchitis

Infection that is severe and extends to the adjacent testicle is termed acute epididymo-orchitis.[20]  The etiology of acute epididymo-orchitis varies with the age of the patient and may be a bacterial, nonbacterial infectious, noninfectious, or idiopathic process.

Infections with urinary coliforms (eg, E coli, Pseudomonas species, Proteus species, Klebsiella species) are the most common cause in children and in men older than 35 years. Ureaplasma urealyticum, Corynebacterium species, Mycoplasma species, and Mima polymorpha have also been isolated. Systemic Haemophilus influenzae and Neisseria meningitides infections are rare. In men who are the insertive partner during anal intercourse, infections with coliform bacteria are also a common etiology.[2]

Chlamydia is the most common cause in sexually active men younger than 35 years (accounting for up to 50% of cases, although laboratory evidence of chlamydia may be absent in up to 90% of cases).[3] Infections with the following pathogens also occur in this population:

  • N gonorrhoeae
  • Treponema pallidum
  • Trichomonas species
  • Gardnerella vaginalis

Tuberculous epididymitis can occur in endemic areas and is still the most common form of urogenital tuberculosis (TB). It is believed to spread hematogenously and often involves the kidneys.

Epididymo-orchitis may develop following bacillus Calmette-Guérin (BCG) treatment for superficial bladder cancer (at a rate of 0.4%).

Viral epididymitis is thought to be the predominant etiology of pediatric epididymitis. It is defined by the absence of pyuria. Although mumps is the most common viral cause of epididymitis, coxsackievirus A, varicella, and echoviral infections have also been identified.

Other rare infections (eg, brucellosis,[21]  coccidioidomycosis, blastomycosis, cytomegalovirus [CMV], candidiasis, CMV in human immunodeficiency virus [HIV] infection, nontuberculous mycobacteria) have been implicated in epididymitis but usually occur in immunocompromised hosts.

Roughly 1 in 1000 men who undergo vasectomy describe a postvasectomy pain syndrome of chronic, dull, aching pain in the epididymis and testicle. The pain is most likely secondary to chronic epididymal congestion of sperm and fluid that continues to be produced after the vasectomy. The epididymis can become distended from back pressure of this fluid, particularly following the close-ended vasectomy technique. When sperm extravasates from the end of the vas deferens, such as can occur in the open-ended vasectomy technique, a sperm granuloma may develop, with a resulting inflammatory reaction.

Men older than 40 years may have BOO (eg, BPH) or a urogenital malformation that predisposes them to urethrovasal reflux and the development of epididymitis. Such reflux can also be induced iatrogenically after certain surgical procedures, such as transurethral resection of the ejaculatory ducts, resulting in epididymitis. It can also be a result of heavy physical activity such as weight lifting.

In children, infection is less common an etiology. One study of a pediatric emergency department found only 4 (4.1%) of 97 children diagnosed with epididymitis had a positive urine culture.[4] Children may have various congenital abnormalities or functional voiding problems that increase the risk of reflux into the ejaculatory ducts. For example, epididymitis may be related to urethral abnormalities, an ectopic ureter, an ectopic vas deferens, detrusor sphincter dyssynergia, or vesicoureteral reflux. In rare cases, children with anorectal malformations and resulting rectourinary fistulae may have resulting bacterial causes of epididymitis.[5]

Acute epididymo-orchitis has been described in 12-19% of individuals with Behçet syndrome. It is also associated with Henoch-Schönlein purpura in the pediatric population, most likely as part of a systemic inflammatory process. Up to 38% of patients with Henoch-Schönlein have scrotal involvement (range, 2-38%).

Amiodarone epididymitis is secondary to high drug concentrations, usually in the head of the epididymis, and can occur in up to 3-11% of patients taking the drug. This is a dose-dependent phenomenon and typically occurs at dosages greater than 200 mg daily. Epididymal levels of the drug are up to 300 times those of the serum, resulting in antiamiodarone HCl antibodies that subsequently attack the epididymis, resulting in the symptoms of epididymitis. Histologic analysis reveals focal fibrosis and lymphocytic infiltration of epididymal tissues.

Sarcoidosis affects the genitourinary system in up to 5% of cases, typically presenting with epididymal nodules. Trauma to the scrotum can also be a precipitating event, while some cases are idiopathic.

Etiology of chronic epididymitis

The etiology of chronic epididymitis includes the following:

  • Inadequate treatment of acute epididymitis

  • Recurrent epididymitis

  • Association with a granulomatous reaction (most commonly Mycobacterium tuberculosis)

  • Association with a chronic disease process such as Behçet syndrome

Etiology of acute orchitis

Causes of acute orchitis include the following:

  • Viral: Mumps orchitis was once the most common etiology; however, since the introduction of the mumps vaccine in 1985, this has been virtually eliminated

  • Bacterial and pyogenic infections: Infections with E coli, Klebsiella species, Pseudomonas species, Staphylococcus species, and Streptococcus species are unusual

  • Granulomatous: T pallidum, M tuberculosis, Mycobacterium leprae, Actinomyces, and fungal diseases are rare

  • Trauma

  • Idiopathic

With regard to a viral etiology, roughly one third of postpubertal boys with mumps have concomitant orchitis. Coxsackievirus type A, varicella, and echoviral, adenoviral, enteroviral, influenzal, and parainfluenzal infections are rare.

Epidemiology

An estimated 1 in 1000 men develop epididymitis annually, and acute epididymitis accounts for more than 600,000 medical visits per year in the United States. Epididymitis is the most common cause of intrascrotal inflammation. Incidence is less than 1 case in 1,000 males per year. However, chronic epididymitis may account for up to 80% of patients presenting with scrotal pain in the outpatient setting.

Age-related demographics

Epididymitis is the fifth most common urologic diagnosis in men ages 18-50 years. The average age of a patient with chronic epididymitis is 49 years. Patients often experience symptoms for 5 years before diagnosis.

Acute epididymitis most commonly occurs in men aged 20-59 years (43% in men aged 20-39 y and 29% in men aged 40-59 y). Childhood (prepubertal) epididymitis is rare; testicular torsion is more common in this age group.

In a study from Spain, epididymitis accounted for 28.4% of cases of acute, intense scrotal pain in adults presenting to an emergency department at one hospital. Orchiepididymitis comprised 28.7% of cases. The mean age of these patients was 40.2 ± 17.3 years.[6]

Structural urologic abnormalities are common in children and in men older than 40 years with acute epididymitis. Adults usually have BOO or urethral stricture or may have had previous urologic surgery on their urethra, altering their anatomy and predisposing them to infection. Children may have urethral abnormalities, such as a prostatic utricle, urethral duplication, posterior urethral valves, or urethrorectal fistula, or other anomalies, such as an ectopic ureter, ectopic vas deferens, detrusor sphincter dyssynergia, or vesicoureteral reflux.

Siegel et al found that 47% of prepubertal boys with epididymitis had associated urogenital abnormalities, including ectopic vas deferens or ureters, and urethral abnormalities.[7]

Mumps orchitis occurs in 20-40% of postpubertal boys with mumps but is rare in prepubertal boys.

Prognosis

Hongo et al reported that older age; previous history of diabetes mellitus and fever; and higher white blood cell count, C-reactive protein level, and blood urea nitrogen level were independently associated with severity in Japanese patients with epididymitis. These authors created an algorithm that proved to have 98.8-100% specificity for predicting severe epididymitis.[8]

Pain improves within 1-3 days, but induration may take several weeks or months to resolve. Infection of the epididymis can lead to the formation of an epididymal abscess. In addition, progression of the infection can lead to involvement of the testicle, causing epididymo-orchitis or a testicular abscess. Sepsis is a potential consequence of severe infection. Bilateral epididymitis may result in sterility due to occlusion of the ductules from peritubular fibrosis.

Patients with epididymitis secondary to a sexually transmitted disease have 2-5 times the risk of acquiring and transmitting HIV.[9] All sexual partners of patients with epididymitis secondary to a sexually transmitted disease need referral to ensure that they receive adequate testing and treatment.

 

Presentation

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.

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.

 

DDx

Diagnostic Considerations

Epididymitis must be differentiated from testicular torsion, which is a true urologic emergency. Idiopathic scrotal pain and orchialgia can be misdiagnosed as epididymitis. With a proper evaluation and careful physical examination, however, these entities can be distinguished from each other and a proper diagnosis obtained.

Other conditions to consider in the differential diagnosis of epididymitis include the following:

  • Scrotal hernia

  • Inguinal hernia

  • Idiopathic scrotal edema

  • Reactive hydrocele

  • Pyocele

  • Henoch-Schönlein purpura

  • Behçet disease

  • Polyarteritis nodosa

  • Vasculitis

  • Referred or radicular pain

  • Epididymal cyst

  • Epididymal congestion following vasectomy

  • Spermatocele

  • Testicular tumor (hemorrhage into tumor)

  • Tunica vaginalis tumors: Mesothelioma

  • Varicocele

  • Urinary tract infection

Differential Diagnoses

 

Workup

Approach Considerations

The following laboratory studies may be indicated for suspected epididymitis:

  • Urinalysis - Pyuria or bacteriuria (50%); urine culture indicated for prepubertal[4] and elderly patients

  • Complete blood count (CBC) - Leukocytosis

  • Gram stain of urethral discharge, if present

  • Urethral culture, nucleic acid hybridization, and nucleic acid amplification tests (these tests aid in detection of N gonorrhoeae and C trachomatis)

  • Performance of (or referral for) syphilis and HIV testing in patients found positive for C trachomatis or N gonorrhoeae infection

  • The use of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to differentiate epididymitis from other causes of acute scrotum is currently under investigation

If mumps orchitis is clinically suspected but the diagnosis is in doubt, use immunofluorescent antibody testing to confirm the diagnosis. Urinalysis and culture findings are negative in mumps orchitis.

Amiodarone plasma levels or antibodies are not helpful in the diagnosis of amiodarone-induced epididymitis.

Imaging studies

Use imaging studies (see the images below) to help distinguish acute epididymitis from the more ominous testicular torsion. However, clinical judgment must guide interpretation of imaging results, as they are neither 100% sensitive nor specific.

Scrotal sonogram demonstrating the presence of a h 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 th Scrotal sonogram showing the testes adjacent to the inflamed epididymis with a reactive hydrocele.

Do not allow studies to delay intervention or exploration if testicular torsion is suspected because testicular viability drops significantly with delay. In addition, the clinical evaluation is paramount and imaging studies should be used if the examination findings are indeterminate. Confirmatory imaging is unnecessary in a patient with a clear history consistent with epididymitis; ultrasonographic results are positive in only 69% of patients with clinical epididymitis.

Radiologic studies are recommended in children who have bacteruria and acute epididymitis in order to evaluate for structural abnormalities (found in >50% of these patients). In infants with bacteruria and epididymitis, in whom anatomical abnormalities are more common than in older children, a voiding cystourethrogram (VCUG) and abdominal ultrasonography are recommended. Retrograde urethrography is also indicated to evaluate for urethral stricture disease as symptoms dictate.

Radiologic studies for mumps orchitis are not indicated, although a reactive hydrocele is common. Patients with tuberculous epididymitis[10] require a full workup for systemic TB. This may include chest radiography, renal function tests, or computed tomography (CT) or excretory urography.

Along with radiologic evaluation, cystourethroscopy may be indicated to evaluate for structural abnormalities in children, as radiographic and clinical suspicion dictates.

Go to Epididymis Imaging for complete information on this topic.

Scrotal exploration or aspiration

Scrotal exploration or aspiration of the epididymis is rarely needed. If it is needed, it is performed by a urologist. Perform a scrotal exploration if torsion or tumor cannot be ruled out and for the complications of acute epididymitis and orchitis (eg, abscess, pyocele, testicular infarction). Diagnosis of intrascrotal disorders is often confirmed during orchiectomy.

Laboratory Findings in Acute Epididymitis and Nonviral Orchitis

The WBC count may be elevated with a left shift (10,000-30,000 cells/μL). A midstream urine culture and Gram stain are useful in guiding therapy. Urinalysis findings are positive for pyuria in only 25% of patients and are sterile in 40-90% of patients.

Obtain a urethral swab culture (before void, after prostate massage) for gonorrheal and chlamydial infections if the patient is in the at-risk age group or if the patient is older than 40 years and not monogamous. Gonorrheal infections often demonstrate gram-negative diplococci on smear, while chlamydial infections can be established in two thirds of cases when only WBCs are seen on smear. A chlamydia polymerase chain reaction (PCR) assay is highly specific and sensitive for chlamydial infection.

Perform blood cultures if the patient is systemically ill.

It is recommended that pediatric patients be evaluated for underlying congenital anomalies via abdominopelvic ultrasonography, voiding cystourethrography, and, in some cases, cystoscopy, especially when the urine culture result is positive. Debate is ongoing as to whether further work-up is necessary only in those with recurrent episodes or also after a first episode of epididymitis or epididymo-orchitis.

Ultrasonography

Color Doppler ultrasonography

Color Doppler ultrasonography is important in the diagnostic workup of epididymitis, not only for diagnosing epididymitis but to rule out testicular torsion. The sensitivity for torsion in color Doppler ultrasonography is 82-100%, and the specificity is 88.9-100%.[11] The sensitivity of color Doppler ultrasonography for epididymitis is 92-100%.[12, 13] This test is the most widely available; however, it is examiner-dependent. The effectiveness of the examination can be limited by pain and patient size (eg, infants). It should also be reserved for patients with indeterminate examination, history, or laboratory workup findings.

Increased blood flow occurs with epididymitis (see the image below); no flow occurs with torsion. Testicular tumors can also appear hyperemic.[14]

Color Doppler sonogram of the left epididymis in a 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.

The examination may reveal epididymal enlargement or a reactive hydrocele of mixed echogenicity (inhomogeneous echogenicity). Use ultrasonography to help detect a scrotal abscess, as well as complications of epididymitis and bacterial or pyogenic orchitis.

Chronic epididymitis is characterized by an enlarged testis and epididymitis, as well as by a thickened tunica vaginalis with a heterogeneous echo pattern and the presence of course calcifications. The testicle may be atrophic and hypoechoic or heterogeneous from testicular infarction secondary to compromise of the testicular blood flow due to intratesticular edema.

Go to Epididymis Imaging for complete information on this topic.

Contrast-enhanced ultrasonography

One of the sequelae of epididymitis is segmental, and even global testicular infarction. Contrast-enhanced ultrasonography may help distinguish this situation.[15]

Radionuclide Scanning and Scintigraphy

Sensitivity for torsion is 90-100% in technetium-99m (99m Tc) scanning, and specificity is 89-97%. Use99m Tc scanning with imaging every 2 seconds for 2 minutes after injection of the tracer.

Acute epididymitis is characterized by increased tracer uptake, while torsion is characterized by defective uptake in the scrotum. Late torsion may result in inflammation that resembles epididymitis.

The study’s usefulness is limited by availability, cost, and difficulty with interpretation. Hydrocele and abscess cause false-positive results. Spontaneous detorsion and intermittent torsion may cause false-negative results.

Radionuclide scintigraphy is used to assess testicle perfusion, yet it provides little anatomic information. Decreased perfusion suggests torsion. Increased or normal perfusion suggests epididymitis but also may be reported with actual torsion.

 

Treatment

Approach Considerations

In chronic epididymitis, a 4- to 6-week trial of antibiotics for bacterial pathogens, especially against chlamydial infections, is appropriate.

With epididymitis secondary to Chlamydia trachomatis or Neisseria gonorrhoeae, treatment of all sexual partners is necessary in order to limit the rate of recurrence and to achieve maximal cure rates. Reinforce the advisability of condom use in the prevention of sexually transmitted disease.

If an enteric organism is the suspected cause of epididymo-orchitis, fluoroquinolones are the preferred antibiotic, as they have excellent penetration into the testes.[16]

Given the low incidence of urinary tract infections in boys with epididymitis, antibiotic therapy in prepubertal patients can be reserved for young infants and those with pyuria or positive urine culture findings. Because predicting a positive urine culture result is difficult, urine cultures should be obtained on all pediatric patients with epididymitis.[17]

Obtain immediate consultation with a urologist upon suspicion of testicular torsion, scrotal abscess, or failed medical treatment.

Orchiectomy is indicated only for patients with unrelenting epididymal pain, although up to 50% of patients still report phantom postoperative pain. Conduct an epididymotomy infrequently in patients with acute suppurative epididymitis. In rare cases, refractory pain due to chronic epididymitis and orchialgia has been managed with skeletonization of the spermatic cord via subinguinal varicocelectomy. Viral mumps has no surgical indications.

Go to Acute Epididymitis for complete information on this topic.

Antibiotics

Guidelines from the Centers for Disease Control and Prevention (CDC) recommend the following regimen for acute epididymitis most likely caused by sexually transmitted chlamydia and gonorrhea[1, 2] :

  • Ceftriaxone 250 mg IM in a single dose plus
  • Doxycycline 100 mg orally twice a day for 10 days

For acute epididymitis most likely caused by sexually-transmitted chlamydia and gonorrhea and enteric organisms (eg, in men who practice insertive anal sex), CDC recommendations are as follows:

  • Ceftriaxone 250 mg IM in a single dose plus
  • Levofloxacin 500 mg orally once a day for 10 days or
  • Ofloxacin 300 mg orally twice a day for 10 days

For acute epididymitis most likely caused by enteric organisms (eg, cases that develop after prostate biopsy, vasectomy, and other urinary-tract instrumentation procedures, with sexually transmitted organisms ruled out) CDC recommendations are as follows:

  • Levofloxacin 500 mg orally once daily for 10 days or
  • Ofloxacin 300 mg orally twice a day for 10 days

Supportive Therapy

In addition to antibiotics (except in viral epididymitis), the mainstays of supportive therapy for acute epididymitis and orchitis are as follows:

  • Reduction in physical activity

  • Scrotal support and elevation

  • Ice packs

  • Nonsteroidal anti-inflammatory drugs

  • Analgesics, including nerve blocks

  • Avoidance of urethral instrumentation

  • Sitz baths

Epididymectomy and Epididymotomy

Epididymectomy

Epididymectomy was once reported to offer a limited chance (at best 50%) of relieving pain caused by chronic epididymitis.

However, a study by Siu et al found that 70% of patients who underwent epididymectomy in the face of chronic epididymal pain (in the setting of postvasectomy pain, obstruction due to radical retropubic prostatectomy or hernia repair, epididymal cysts, or chronic epididymitis) reported pain resolution.[10] In this same study, 91% of patients reported satisfaction with their decision for surgery.

Inhibition of adhesion and fibrosis after epididymectomy for chronic epididymitis improves pain relief, according to a study of 43 patients who still had pain despite conservative treatment.[18] A synthetic physical barrier (hyaluronic acid [HA]/carboxymethylcellulose [CMC]) was used to inhibit adhesion and fibrosis at the operative site in 22 patients; the remaining 21 underwent epididymectomy alone. At 24-week follow-up, 12 patients (57.1%) in the HA/CMC group were pain free, compared with 3 patients (15.8%) in the surgery-only group. HA/CMC was not associated with any adverse effects.

It has been found that epididymectomy may be more effective in men post vasectomy compared with those who have not undergone vasectomy.[19]

Despite these findings, it is still suggested that surgery be reserved only for refractory cases. Concern is that pain relief is only transient and followed by pain recurrence or transfer of symptoms to the contralateral testicle.

The possibility of fertility sequelae should also be discussed with the patient.

 

Medication

Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Ceftriaxone (Rocephin)

This is a third-generation cephalosporin with broad-spectrum gram-negative activity. Ceftriaxone has lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. It arrests bacterial growth by binding to 1 or more penicillin-binding proteins.

Doxycycline (Doryx, Vibramycin)

Doxycycline is used to treat C trachomatis infection. It inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.

Azithromycin (Zithromax)

Azithromycin acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl transfer ribonucleic acid (tRNA) from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected.

Azithromycin concentrates in phagocytes and fibroblasts, as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues. Azithromycin is used for the treatment of gonococcal infections, chlamydia, or both.

Ofloxacin (Floxin)

Ofloxacin penetrates the prostate well and is effective against C trachomatis. It is no longer recommended to use fluoroquinolones to treat gonococcal infections secondary to a high rate of resistance. Ofloxacin is a pyridine carboxylic acid derivative with broad-spectrum bactericidal effect.

Ciprofloxacin (Cipro)

This agent is for bacterial infections. Ciprofloxacin is no longer recommended for gonococcal and nongonococcal infections, such as chlamydia, given their incomplete coverage and increased rate of resistance.

Trimethoprim-sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)

This is for the empiric treatment of nonspecific bacterial infection.

Levofloxacin (Levaquin)

Levofloxacin is excreted in the urine and is effective against C trachomatis. It is no longer recommended to use fluoroquinolones to treat gonococcal infections secondary to a high rate of resistance. Levofloxacin is a pyridine carboxylic acid derivative with broad-spectrum bactericidal effect.

Ampicillin

Ampicillin is used for the treatment of systemic illness warranting hospitalization. It is a broad-spectrum penicillin, and it interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Ampicillin is an alternative to amoxicillin when the patient is unable to take medication orally.

Until recently, the HACEK bacteria were uniformly susceptible to ampicillin. Recently, however, beta-lactamase–producing strains of HACEK have been identified.

Gentamicin

Gentamicin is used for the treatment of systemic illness warranting hospitalization. It is an aminoglycoside antibiotic for coverage of gram-negative bacteria, including pseudomonal species. It is synergistic with beta-lactamase against enterococci. It interferes with bacterial protein synthesis by binding to the 30S and 50S ribosomal subunits.

Dosing regimens are numerous and are adjusted based on creatinine clearance and changes in the volume of distribution, as well as the body space into which the agent needs to distribute. Gentamicin may be given IV/IM. Each regimen must be followed by at least a trough level drawn on the third or fourth dose, 0.5 hour before dosing; a peak level may be drawn 0.5 hour after a 30-minute infusion.

Antituberculous drugs

Class Summary

These agents are used to treat tuberculous epididymo-orchitis.

Rifampin (Rifadin, Rimactane)

These agents are used to treat tuberculous epididymo-orchitis

Isoniazid (Laniazid, Nydrazid)

This is an isonicotinic acid hydrazide (INH), which is part of the triple-drug regimen.

Pyrazinamide

Pyrazinamide is a pyrazine analog of nicotinamide that may be bacteriostatic or bactericidal against M tuberculosis, depending on the concentration of the drug attained at the site of infection. Its mechanism of action is unknown. Pyrazinamide is part of the triple-drug regimen.

 

Questions & Answers

Overview

What is epididymitis and which true urologic emergency must it be differentiated from?

What are the complications associated with acute epididymitis and bacterial orchitis?

What are the complications associated with mumps orchitis relative to epididymitis?

What should patients be educated about regarding epididymitis?

Which history findings are consistent with acute epididymitis and orchitis?

Which history findings are consistent with chronic epididymitis?

Which history findings are consistent with mumps orchitis/epididymitis?

Which physical findings are associated with acute epididymitis and can distinguish it from testicular torsion?

Which findings are associated with orchitis/epididymitis?

Which lab studies are indicated in the workup of epididymitis?

Which imaging studies are used to evaluate structural abnormalities and help distinguish acute epididymitis from testicular torsion?

Which diagnostic procedures may be indicated in the evaluation of epididymitis?

Which medications are used in the treatment of epididymitis?

Which supportive measures are used in the treatment of acute epididymitis and orchitis?

When is surgery indicated in the treatment of epididymitis and which surgical interventions are used?

What is the anatomy of the epididymis?

What causes epididymitis?

What causes epididymo-orchitis/epididymitis?

What are the most common causes of acute epididymo-orchitis/epididymitis in children and men older than 35 years?

What is the most common cause of acute epididymo-orchitis/epididymitis in sexually active men younger than 35 years and which pathogens cause infections in this population?

How common is TB epididymitis?

Can epididymo-orchitis/epididymitis be caused by cancer treatment?

What is the most common cause of pediatric epididymitis?

Which rare infections have been implicated in epididymitis?

What is the role of vasectomy in epididymitis?

Can acute epididymo-orchitis/epididymitis be related to surgical procedures or physical activity?

What is the etiology of epididymitis in children?

How common is acute epididymo-orchitis/epididymitis in the setting of Behcet syndrome or Henoch-Schönlein purpura?

What is amiodarone epididymitis and how does it occur?

What is the role of sarcoidosis in the etiology of epididymitis?

What is the etiology of chronic epididymitis?

What are the causes of acute orchitis relative to epididymitis?

How common is orchitis/epididymitis in postpubertal boys with mumps?

What is the incidence of epididymitis?

How common is epididymitis in men ages 18-50 years?

What are the age-related demographics of acute epididymitis?

What are the age-related demographics of urogenital abnormalities in epididymitis?

How common is mumps orchitis in postpubertal boys with mumps?

Which factors have been associated with severity of epididymitis in Japanese men?

What is the prognosis of epididymitis?

What is the risk of acquiring and transmitting HIV in patients with epididymitis?

Presentation

Which history findings are associated with acute epididymitis and orchitis?

Which history findings are associated with chronic epididymitis?

Which history findings are associated with mumps orchitis relative to epididymitis?

Which symptoms may be described by patients with sexually transmitted epididymitis?

What recent history is more common in older patients with epididymitis?

Where do tenderness and induration occur initially in epididymitis, and how does the infection typically spread?

How are physical exam findings for the Prehn sign and cremasteric reflex used to distinguish acute epididymitis from testicular torsion?

Which signs of epididymitis may be observed in the physical exam?

What are the physical exam findings in epididymitis due to TB?

Which urogenital tract anomalies may be associated with epididymitis in children?

What are the physical exam findings of orchitis relative to epididymitis?

DDX

Which conditions should be considered in the differential diagnosis of epididymitis?

What are the differential diagnoses for Epididymitis?

Workup

Which lab studies are indicated in epididymitis?

Which lab study is indicated in mumps orchitis relative to epididymitis?

Are amiodarone plasma levels used in the diagnosis of amiodarone-induced epididymitis?

Which imaging study can be used to distinguish acute epididymitis from testicular torsion?

Which imaging studies are used in the workup of epididymitis in children?

Which imaging studies are used in the workup of TB epididymitis?

Which procedure may be indicated to evaluate structural abnormalities in children with epididymitis?

When is scrotal exploration or aspiration indicated in the workup of epididymitis?

What are the lab findings in acute epididymitis and nonviral orchitis?

Which lab studies are used in the workup of gonorrheal and chlamydial infections in epididymitis?

When is blood culture testing indicated in epididymitis?

Which studies are used to evaluate for underlying congenital anomalies in pediatric patients with epididymitis?

When is color Doppler ultrasonography indicated in the workup of epididymitis and what are its sensitivity and specificity?

How is chronic epididymitis characterized on color Doppler ultrasonography?

Which imaging study is used to detect testicular infarction in the workup of epididymitis?

Which conditions can cause false-positive results in radionuclide scanning for epididymitis?

What is the sensitivity and specificity of radionuclide scanning in epididymitis?

How are acute epididymitis and testicular torsion characterized in radionuclide scanning?

What is the indication for radionuclide scintigraphy in the workup of epididymitis?

Treatment

What is the treatment for chronic epididymitis?

What is the treatment for epididymitis secondary to Chlamydia trachomatis or Neisseria gonorrhoeae?

Which antibiotic is preferred in the treatment of epididymitis due to an enteric organism?

When is antibiotic therapy indicated in prepubertal boys or infants with epididymitis?

When is immediate consultation with a urologist indicated in the setting of epididymitis?

When is surgical intervention indicated in the treatment of epididymitis?

What are the CDC guidelines for treatment of acute epididymitis due to sexually transmitted infection?

What are the CDC treatment guidelines for acute epididymitis due to enteric organisms?

What are the mainstays of supportive therapy for acute epididymitis and orchitis?

How effective is epididymectomy in the treatment of epididymitis?

Medications

Which medications in the drug class Antituberculous drugs are used in the treatment of Epididymitis?

Which medications in the drug class Antibiotics are used in the treatment of Epididymitis?