Epididymitis

Overview

The epididymis is a long, tightly coiled tube located behind each testicle that connects the testicle to the ductus deferens and stores sperm.

Acute epididymitis is inflammation of the epididymis, causing pain and swelling of the scrotum. Most cases are caused by sexually transmitted bacterial infections occurring in men age 19 to 35 years old.

Chronic epididymitis refers to inflammation characterized by persistent testicular pain in the absence of scrotal swelling. This condition is usually more difficult to treat and may result in long-term pain.

Causes and Risk Factors

Side view of epididymis behind testicleEpididymitis is usually caused by a bacterial infection that starts in the urethra, bladder, or prostate and ultimately spreads to the epididymis. Depending on the patient’s age, the most common causes of epididymitis are sexually transmitted infection, an enlarged prostate gland, or urinary tract infections.

Causal Factors

In heterosexual men under age 35, acute epididymitis is most often caused by a sexually transmitted infection with chlamydia or gonorrhea. These bacteria frequently cause serious infections of the genitals and reproductive systems of men and women. Men who practice anal intercourse may develop epididymitis caused by enteric bacteria found in the lower gastrointestinal tract, such as E. coli. Unprotected sexual intercourse or sexual intercourse with multiple partners increases the risk of these infections.

In men over age 35, the most common cause of acute epididymitis is an enlargement of the prostate gland. This condition, known as benign prostatic hypertrophy, obstructs the normal flow of urine from the bladder and causes urinary tract infections, which may later spread to the epididymis.

Less commonly, epididymitis occurs in children. In pediatric patients, epididymitis is usually related to a urinary tract infection, congenital abnormality of the genitourinary system, or the presence of foreskin on an uncircumcised penis.

Other factors increasing the risk of epididymitis include urinary tract surgeries, use of a urinary catheter for bladder drainage, or medical conditions causing suppression of the immune system, such as HIV. Uncommonly, a noninfectious type of epididymitis is the consequence of testicular trauma or use of a heart medication called amiodarone.

Complications

Major complications of acute epididymitis include chronic epididymitis, infertility, and testicular abscess. Chronic epididymitis is an outcome of inadequately treated acute epididymitis or recurrent infection. Some patients experience chronic epididymitis after vasectomy, a procedure to cut the ductus deferens as permanent birth control for men.

Symptoms

Patients with acute epididymitis usually complain of one-sided testicular pain, tenderness, and scrotal swelling. Other symptoms may include a cloudy discharge from the tip of the penis, frequent urination, and burning with urination.

Chronic epididymitis is distinguished by the presence of pain for longer than 6 weeks and the absence of swelling.

Diagnosis and Treatment

Male urinary tractIn acute epididymitis, the physical examination shows tenderness and swelling of the scrotum, discharge from the penis, enlarged groin lymph nodes, and fever.

Diagnostic Tests

  • Discharge from the urethra is checked for chlamydia, gonorrhea, or other infectious organisms. The fluid is also examined under a microscope to detect an elevation of white blood cells, a sign of infection in the urethra.
  • Urine specimens are tested for a urinary tract infection.
  • Blood tests may show an elevated white blood cell count indicative of infection.
  • An ultrasound might be performed to check for other scrotal conditions like testicular torsion, abscess, or tumor.

Treatment of Acute Epididymitis

The goals are to cure the infection, prevent transmission of the infection to others, and prevent infertility or chronic pain. Treatment includes the following:

  • Antibiotics are started immediately without waiting for the laboratory test results. When chlamydia or gonorrhea is the likely cause, patients are treated with two antibiotics: ceftriaxone as a single intramuscular injection and doxycycline given orally for 10 days. Men who have sex with men and engage in insertive anal intercourse are treated with an additional antibiotic to treat enteric organisms found in feces.
  • Anti-inflammatory medications, such as ibuprofen.
  • Bed rest.
  • Elevation of the scrotum.
  • Prevention of transmission of infection to others.
  • Evaluation and treatment of sexual partners.

Treatment of Chronic Epididymitis

Usually, chronic epididymitis is more difficult to treat and may require 4 to 6 weeks of antibiotics. Unfortunately, some patients experience persistent pain for many years. As a last resort, doctors may consider surgery to remove the epididymis (epididymectomy).

Prevention

Sexually active individuals can decrease their risk of sexually transmitted infections by using condoms for intercourse and having sex with only one partner at a time.

Anyone with urethral discharge, scrotal swelling or testicular pain should refrain from sexual activity and seek immediate medical treatment to prevent transmission of the infection to others and avoid long-term complications.

Sources

  • Epididymitis. Sexually Transmitted Diseases Treatment Guidelines, 2010. Center for Disease Control and Prevention website. http://www.cdc.gov/std/treatment/2010/epididymitis.htm. Accessed April 23, 2014.
  • Geisler WM. Chapter 326. Disease Caused by Chlamydiae. In: Goldman L, Schafer AI, eds. Goldman’s Cecil Medicine, 24e. Philadelphia, PA: Elsevier Saunders; 2012.
  • Nickel JC. Chapter 11. Inflammatory Conditions of the Male Genitourinary Tract: Prostatitis, and Related Conditions, Orchitis, Epididymitis. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology, 10e. Philadelphia, PA: Elsevier Saunders; 2011.