Symptoms of Epididymitis
The typical presentation of epididymitis includes gradual onset of unilateral testicular pain, scrotal swelling, tenderness, and symptoms of lower urinary tract infection, with pain relief when the testicle is elevated (positive Prehn sign). 1
Clinical Presentation
Cardinal Symptoms
- Unilateral testicular pain and tenderness (gradually developing)
- Scrotal swelling
- Palpable swelling of the epididymis
- Lower urinary tract symptoms:
- Dysuria
- Urinary frequency
- Urgency
- Fever (in some cases)
- Pain relief when testicle is elevated (Prehn sign)
Physical Examination Findings
- Swollen, tender epididymis and/or testis
- Testis in normal anatomic position
- Intact ipsilateral cremasteric reflex
- Possible reactive hydrocele as inflammation progresses 1
Diagnostic Considerations
Key Differential Diagnosis
Testicular torsion is the most critical differential diagnosis that must be ruled out, as it requires immediate surgical intervention within 6-8 hours. The following table highlights key differences:
| Feature | Epididymitis | Testicular Torsion |
|---|---|---|
| Onset | Gradual | Sudden |
| Pain relief with elevation | Yes (Prehn sign) | No |
| Cremasteric reflex | Present | Absent |
| Testicular position | Normal | High-riding |
| Doppler ultrasound | Increased blood flow | Decreased/absent blood flow |
Diagnostic Testing
- Gram-stained smear of urethral exudate for diagnosis of urethritis and presumptive diagnosis of gonococcal infection
- Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis
- Examination of first-void urine for leukocytes
- Ultrasound with Doppler (imaging modality of choice) showing:
Etiology Based on Age and Risk Factors
- Children (<14 years): Reflux of urine into ejaculatory ducts is the most common cause 3
- Young adults (14-35 years): Sexually transmitted infections, primarily N. gonorrhoeae and C. trachomatis 2, 3
- Men who practice insertive anal intercourse: Enteric organisms in addition to STIs 3
- Older men (>35 years): Enteric bacteria from urinary tract infections, often associated with bladder outlet obstruction 2, 3
Treatment
Antimicrobial Therapy
Treatment should be initiated empirically based on the most likely causative organisms:
For epididymitis likely caused by gonococcal or chlamydial infection (sexually active men <35 years):
For epididymitis likely caused by enteric organisms (men >35 years or with insertive anal intercourse):
Supportive Measures
- Bed rest
- Scrotal elevation
- Analgesics until fever and local inflammation subside
- Adequate fluid intake 2, 1
Follow-Up and Complications
Follow-Up
- Improvement should be seen within 3 days of starting treatment
- Failure to improve requires reevaluation of diagnosis and therapy
- Microbiologic re-examination 7-10 days after completing therapy 2, 1
Potential Complications
- Abscess formation
- Testicular ischemia (rare)
- Infertility
- Chronic scrotal pain
- Global testicular infarction (rare but serious complication requiring surgical management) 1, 5, 6
Management of Sex Partners
- Sex partners of patients with confirmed or suspected N. gonorrhoeae or C. trachomatis should be referred for evaluation and treatment
- Contact tracing should include partners from the 60 days preceding symptom onset
- Patients should avoid sexual intercourse until they and their partners complete treatment and are symptom-free 2
Special Considerations
- Hospitalization should be considered for:
- Severe pain suggesting other diagnoses (torsion, infarction, abscess)
- Febrile patients
- Patients who might be noncompliant with treatment 2
- Chronic epididymitis (symptoms >3 months) may require specialized management approaches and can significantly impact quality of life 7, 6