Symptoms of Epididymitis
The primary symptoms of epididymitis include gradual onset of posterior scrotal pain, swelling and tenderness of the epididymis, and possible accompanying urinary symptoms such as dysuria and urinary frequency. 1, 2
Clinical Presentation
Cardinal Symptoms
- Gradual onset of testicular pain (unlike the sudden onset in testicular torsion)
- Swelling of the epididymis (typically starting at the lower pole and progressing upward)
- Tenderness on examination
- Scrotal erythema and warmth
- Pain relief with scrotal elevation (positive Prehn sign)
Associated Symptoms
- Urinary symptoms:
- Dysuria
- Increased urinary frequency
- Urgency
- Urethral discharge (particularly in cases of sexually transmitted infections)
- Low-grade fever
- General malaise
- Normal testicular position (unlike the high-riding testis in testicular torsion)
- Present cremasteric reflex (absent in testicular torsion)
Differentiating from Testicular Torsion
Distinguishing epididymitis from testicular torsion is critical as the latter requires immediate surgical intervention 1:
| 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 |
Age-Related Considerations
The symptoms may vary slightly based on age and likely causative organisms 2, 3:
In men under 35 years:
- More likely to have symptoms related to sexually transmitted infections
- Chlamydia trachomatis and Neisseria gonorrhoeae are common causative agents
- May have concurrent urethritis
In men over 35 years:
- More likely to have symptoms related to urinary tract infections
- May have additional symptoms of bladder outlet obstruction
- E. coli is the most common causative organism
Complications and Chronic Symptoms
If left untreated, epididymitis can lead to 1:
- Persistent swelling or tenderness
- Abscess formation
- Testicular ischemia
- Infertility
- Chronic scrotal pain
Common Pitfalls in Diagnosis
Missing testicular torsion: Any acute scrotal pain, especially with sudden onset, should be considered testicular torsion until proven otherwise, as this requires emergency surgical intervention within 6-8 hours to prevent permanent damage.
Incomplete evaluation: Only about 50% of men diagnosed with epididymitis are tested for gonorrhea and chlamydia, despite these being common causative organisms, especially in younger men 3.
Overlooking underlying conditions: In older men, epididymitis is often associated with urinary tract abnormalities or bladder outlet obstruction that should be evaluated.
Confusing isolated orchitis with epididymitis: While epididymitis and orchitis often co-exist (epididymo-orchitis), isolated epididymitis is more common than isolated orchitis 4.
By recognizing these symptoms and understanding the key differences between epididymitis and other acute scrotal conditions, clinicians can make timely and accurate diagnoses, leading to appropriate treatment and improved outcomes.